Exhibit 10.1

      

       

      

      CONTRACT BETWEEN

      

      

      ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

      

      

      and

      

      

      TRIPLE-S SALUD, INC.

      

      

      for

       

        

      PROVISION OF PHYSICAL & BEHAVIORAL HEALTH SERVICES UNDER THE GOVERNMENT HEALTH PLAN PROGRAM

      

      

      Contract No.: 2019-000052

      

      

      Account No.: 256-5325 to 5330

       

        

      
        Page 1 of 324

        
          


      

      TABLE OF CONTENTS

      

      

      	
              ARTICLE 1

            	
              GENERAL PROVISIONS

            	
              7

            
	 	 	 
	
              ARTICLE 2

            	
              DEFINITIONS

            	
              10

            
	 	 	 
	
              ARTICLE 3

            	
              ACRONYMS

            	
              30

            
	 	 	 
	
              ARTICLE 4

            	
              ASES RESPONSIBILITIES

            	
              33

            
	 	 	 
	
              ARTICLE 5

            	
              ELIGIBILITY AND ENROLLMENT

            	
              36

            
	 	 	 
	
              ARTICLE 6

            	
              ENROLLEE SERVICES

            	
              52

            
	 	 	 
	
              ARTICLE 7

            	
              COVERED SERVICES AND BENEFITS

            	
              75

            
	 	 	 
	
              ARTICLE 8

            	
              INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH
                    SERVICES

            	
              130

            
	 	 	 
	
              ARTICLE 9

            	
              PROVIDER NETWORK

            	
              134

            
	 	 	 
	
              ARTICLE 10

            	
              PROVIDER CONTRACTING

            	
              162

            
	 	 	 
	
              ARTICLE 11

            	
              UTILIZATION MANAGEMENT

            	
              179

            
	 	 	 
	
              ARTICLE 12

            	
              QUALITY IMPROVEMENT AND PERFORMANCE PROGRAM

            	
              186

            
	 	 	 
	
              ARTICLE 13

            	
              FRAUD, WASTE, AND ABUSE

            	
              195

            
	 	 	 
	
              ARTICLE 14

            	
              GRIEVANCE AND APPEAL SYSTEM

            	
              203

            
	 	 	 
	
              ARTICLE 15

            	
              ADMINISTRATION AND MANAGEMENT

            	
              217

            
	 	 	 
	
              ARTICLE 16

            	
              PROVIDER PAYMENT MANAGEMENT

            	
              219

            
	 	 	 
	
              ARTICLE 17

            	
              INFORMATION MANAGEMENT AND SYSTEMS

            	
              226

            
	 	 	 
	
              ARTICLE 18

            	
              REPORTING

            	
              238

            
	 	 	 
	
              ARTICLE 19

            	
              ENFORCEMENT – INTERMEDIATE SANCTIONS

            	
              252

            
	 	 	 
	
              ARTICLE 20

            	
              ENFORCEMENT – LIQUIDATED DAMAGES AND OTHER
                    REMEDIES

            	
              258

            
	 	 	 
	
              ARTICLE 21

            	
              CONTRACT TERM

            	
              265

            
	 	 	 
	
              ARTICLE 22

            	
              PAYMENT FOR SERVICES

            	
              266

            
	 	 	 
	
              ARTICLE 23

            	
              FINANCIAL MANAGEMENT

            	
              275

            


      

      

      
        Page 2 of 324

        
          


      

      	
              ARTICLE 24

            	
              PAYMENT OF TAXES

            	
              288

            
	 	 	 
	
              ARTICLE 25

            	
              RELATIONSHIP OF PARTIES

            	
              288

            
	 	 	 
	
              ARTICLE 26

            	
              INSPECTION OF WORK

            	
              288

            
	 	 	 
	
              ARTICLE 27

            	
              GOVERNMENT PROPERTY

            	
              289

            
	 	 	 
	
              ARTICLE 28

            	
              OWNERSHIP AND USE OF DATA AND SOFTWARE

            	
              289

            
	 	 	 
	
              ARTICLE 29

            	
              CRIMINAL BACKGROUND CHECKS

            	
              290

            
	 	 	 
	
              ARTICLE 30

            	
              SUBCONTRACTS

            	
              291

            
	 	 	 
	
              ARTICLE 31

            	
              REQUIREMENT OF INSURANCE LICENSE

            	
              294

            
	 	 	 
	
              ARTICLE 32

            	
              CERTIFICATIONS

            	
              294

            
	 	 	 
	
              ARTICLE 33

            	
              RECORDS REQUIREMENTS

            	
              296

            
	 	 	 
	
              ARTICLE 34

            	
              CONFIDENTIALITY

            	
              298

            
	 	 	 
	
              ARTICLE 35

            	
              TERMINATION OF CONTRACT

            	
              304

            
	 	 	 
	
              ARTICLE 36

            	
              PHASE-OUT AND COOPERATION WITH OTHER
                    CONTRACTORS

            	
              311

            
	 	 	 
	
              ARTICLE 37

            	
              INSURANCE

            	
              312

            
	 	 	 
	
              ARTICLE 38

            	
              COMPLIANCE WITH ALL LAWS

            	
              313

            
	 	 	 
	
              ARTICLE 39

            	
              CONFLICT OF INTEREST AND CONTRACTOR
                    INDEPENDENCE

            	
              314

            
	 	 	 
	
              ARTICLE 40

            	
              CHOICE OF LAW OR VENUE

            	
              315

            
	 	 	 
	
              ARTICLE 41

            	
              ATTORNEY’S FEES

            	
              315

            
	 	 	 
	
              ARTICLE 42

            	
              SURVIVABILITY

            	
              315

            
	 	 	 
	
              ARTICLE 43

            	
              PROHIBITED AFFILIATIONS WITH INDIVIDUALS
                    DEBARRED AND SUSPENDED

            	
              315

            
	 	 	 
	
              ARTICLE 44

            	
              WAIVER

            	
              316

            
	 	 	 
	
              ARTICLE 45

            	
              FORCE MAJEURE

            	
              316

            
	 	 	 
	
              ARTICLE 46

            	
              BINDING

            	
              316

            


      

      

      
        Page 3 of 324

        
          


      

      	
              ARTICLE 47

            	
              TIME IS OF THE ESSENCE

            	
              316

            
	 	 	 
	
              ARTICLE 48

            	
              AUTHORITY

            	
              317

            
	 	 	 
	
              ARTICLE 49

            	
              ETHICS IN PUBLIC CONTRACTING

            	
              317

            
	 	 	 
	
              ARTICLE 50

            	
              CONTRACT LANGUAGE INTERPRETATION

            	
              317

            
	 	 	 
	
              ARTICLE 51

            	
              ARTICLE AND SECTION TITLES NOT CONTROLLING

            	
              317

            
	 	 	 
	
              ARTICLE 52

            	
              LIMITATION OF LIABILITY/EXCEPTIONS

            	
              317

            
	 	 	 
	
              ARTICLE 53

            	
              COOPERATION WITH AUDITS

            	
              318

            
	 	 	 
	
              ARTICLE 54

            	
              OWNERSHIP AND FINANCIAL DISCLOSURE

            	
              318

            
	 	 	 
	
              ARTICLE 55

            	
              AMENDMENT IN WRITING

            	
              320

            
	 	 	 
	
              ARTICLE 56

            	
              CONTRACT ASSIGNMENT

            	
              320

            
	 	 	 
	
              ARTICLE 57

            	
              SEVERABILITY

            	
              320

            
	 	 	 
	
              ARTICLE 58

            	
              ENTIRE AGREEMENT

            	
              321

            
	 	 	 
	
              ARTICLE 59

            	
              INDEMNIFICATION

            	
              321

            
	 	 	 
	
              ARTICLE 60

            	
              NOTICES

            	
              322

            
	 	 	 
	
              ARTICLE 61

            	
              OFFICE OF THE COMPTROLLER

            	
              323

            


      

      

      	
              ATTACHMENT 1:

            	
              DESIGNATED LAWS

            
	 	 
	
              ATTACHMENT 2:

            	
              NETWORK ADEQUACY URBAN AND NON-URBAN AREA MAP

            
	 	 
	
              ATTACHMENT 3:

            	
              GHP UNIVERSAL ENROLLEE GUIDELINES HANDBOOK

            
	 	 
	
              ATTACHMENT 4:

            	
              CPTET CENTERS AND COMMUNITY-BASED ORGANIZATIONS FOR HIV/AIDS

            
	 	 
	
              ATTACHMENT 5:

            	
              MASTER FORMULARY

            
	 	 
	
              ATTACHMENT 6:

            	
              RETAIL PHARMACY REIMBURSEMENT LEVELS

            
	 	 
	
              ATTACHMENT 7:

            	
              UNIFORM GUIDE FOR SPECIAL COVERAGE

            
	 	 
	
              ATTACHMENT 8:

            	
              COST-SHARING

            
	 	 
	
              ATTACHMENT 9:

            	
              ENROLLMENT MANUAL

            


      

      

      
        Page 4 of 324

        
          


      

      	
              ATTACHMENT 10:

            	
              GUIDELINES FOR CO-LOCATION OF BEHAVIORAL HEALTH PROVIDERS IN PMG SETTINGS

            
	 	 
	
              ATTACHMENT 11:

            	
              PER MEMBER PER MONTH PAYMENTS

            
	 	 
	
              ATTACHMENT 12:

            	
              INITIAL DELIVERABLE DUE DATES

            
	 	 
	
              ATTACHMENT 13:

            	
              REFERENCED ASES NORMATIVE LETTERS

            
	 	 
	
              ATTACHMENT 14:

            	
              PROGRAM INTEGRITY PLAN DEVELOPMENT GUIDELINES

            
	 	 
	
              ATTACHMENT 15:

            	
              FORMULARY A-102: EVIDENCE OF LACK OF PROVIDERS AND PROVIDERS REFUSAL TO CONTRACT

            
	 	 
	
              ATTACHMENT 16:

            	
              LIST OF REQUIRED REPORTS

            
	 	 
	
              ATTACHMENT 17:

            	
              EHR ADOPTION PLAN

            
	 	 
	
              ATTACHMENT 18:

            	
              BUSINESS ASSOCIATE AGREEMENT

            
	 	 
	
              ATTACHMENT 19:

            	
              HEALTH CARE IMPROVEMENT PROGRAM (HCIP) MANUAL

            
	 	 
	
              ATTACHMENT 20:

            	
              NETWORK ADEQUACY REQUIREMENTS

            
	 	 
	
              ATTACHMENT 21:

            	
              GUIDELINES FOR REVERSE CO-LOCATION OF PRIMARY CARE PHYSICIANS IN MENTAL HEALTH SETTINGS

            
	 	 
	
              ATTACHMENT 22:

            	
              STERILIZATION CONSENT FORM

            
	 	 
	
              ATTACHMENT 23:

            	
              POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF MEDICAID OVERPAYMENTS TO PROVIDERS

            
	 	 
	
              ATTACHMENT 24:

            	
              CARRIER PATIENT VOLUME CERTIFICATON FORM EP-02-2015

            
	 	 
	
              ATTACHMENT 25:

            	
              HIGH UTILIZERS PROGRAM

            
	 	 
	
              ATTACHMENT 26:

            	
              ENCOUNTER DATA REQUIREMENTS

            
	 	 
	
              ATTACHMENT 27:

            	
              POLICY FOR MEDICATION EXCEPTION REQUESTS

            
	 	 
	
              ATTACHMENT 28:

            	
              HIGH COST HIGH NEED (HCHN) RATE CELL ASSIGNMENT

            
	 	 
	
              ATTACHMENT 29:

            	
              MATERNITY KICK PAYMENT METHODOLOGY

            
	 	 
	
              ATTACHMENT 30:

            	
              TRADING PARTNER AGREEMENT

            


       

      

      
        Page 5 of 324

        
          


      

      THIS CONTRACT, is made and entered into by
          and between the Puerto Rico Health Insurance Administration (Administración de Seguros de Salud de Puerto Rico, hereinafter referred to as “ASES” or “the Administration”), a public corporation of the Government of Puerto Rico (“the Government” or
          “Puerto Rico”), with employer identification number 66-0500678 and (Triple-S Salud, Inc.) (“the Contractor”), a managed care organization duly organized and
          authorized to do business under the laws of Puerto Rico, with employer identification number 66-0555677.

       

      WHEREAS, pursuant to Title XIX of the
          Federal Social Security Act, codified as 42 USC 1396 et seq. (“the Social Security Act”), and Act No. 72 of September 7, 1993 of the Laws of Puerto Rico (“Act 72”), a comprehensive program of medical assistance for needy persons exists in Puerto
          Rico;

       

      WHEREAS, ASES is responsible for health care
          policy, purchasing, planning, and regulation pursuant to Act 72, as amended, and other sources of law of Puerto Rico designated in Attachment 1 to this Contract, and pursuant to this statutory provision, ASES has established a managed care
          program under the medical assistance program, known as “GHP,” “GHP Program,” “the Government Health Plan”, or “MI Salud”;

       

      WHEREAS, the Puerto Rico Health Department
          (“the Health Department”) is the single State agency designated to administer medical assistance in Puerto Rico under Title XIX of the Social Security Act of 1935, as amended, and is charged with ensuring the appropriate delivery of health care
          services under the Medicaid and the Children’s Health Insurance Program (“CHIP”) in Puerto Rico, and ASES manages these programs pursuant to a delegation of authority to ASES;

       

      WHEREAS, GHP serves a mixed population
          including not only the Medicaid and CHIP populations, but also other eligible individuals as established in Act 72;

       

      WHEREAS, ASES seeks to comply with Puerto
          Rico’s public policy objectives of creating an integrated system of physical and Behavioral Health Services, with an emphasis on preventative services and access to quality care;

       

      WHEREAS, ASES issued a Request for Proposals
          (“the RFP”) for physical and Behavioral Health Services on February 9-16, 2018, which, except as provided in Article 58 below, are expressly incorporated as if completely restated herein;

       

      WHEREAS, ASES has received from the
          Contractor a proposal in response to the RFP, “Contractor’s Proposal,” which, except as provided in Article 58 below, is expressly incorporated as if completely restated herein; and,

       

      WHEREAS, ASES accepts the Contractor’s
          Proposal to provide the services contemplated under this Contract for ASES;

       

      NOW, THEREFORE, FOR AND IN CONSIDERATION of the mutual promises, covenants and agreements contained herein, and other good and valuable consideration, the receipt and sufficiency of which are
          hereby acknowledged, ASES and the Contractor (each individually a “Party” and collectively the “Parties”) hereby agree as follows:

       

        

      
        Page 6 of 324

        
          


      

      
        
          	ARTICLE 1	
                  GENERAL PROVISIONS

                


        

      

      

      

      
        
          	

                	1.1	
                  General Provisions

                


        

      

       

      
        
          	

                	1.1.1	
                  The Contractor shall assist the Government by providing and delivering services under the GHP through described tasks, obligations, and responsibilities included in this
                      Contract.

                


        

      

       

      
        
          	

                	1.1.2	
                  The Contractor shall maintain the staff, organizational, and administrative capacity and capabilities necessary to carry out all the duties and responsibilities under
                      this Contract.

                


        

      

       

      
        
          	

                	1.1.3	
                  The Contractor shall not make any changes to the following without explicit prior written approval from the Executive Director of ASES or his or her designee:

                


        

      

       

      
        
          	

                	1.1.3.1	
                  Its business address, telephone number, facsimile number, and e-mail address;

                


        

      

       

      
        
          	

                	1.1.3.2	
                  Its corporate status or nature;

                


        

      

       

      
        
          	

                	1.1.3.3	
                  Its business location;

                


        

      

       

      
        
          	

                	1.1.3.4	
                  Its corporate structure;

                


        

      

       

      
        
          	

                	1.1.3.5	
                  Its ownership, including but not limited to the new owner’s legal name, business address, telephone number, facsimile number, and e-mail address; and/or

                


        

      

       

      
        
          	

                	1.1.3.6	
                  Its incorporation status.

                


        

      

       

      
        
          	

                	1.1.4	
                  The Contractor shall notify ASES within five (5) Business Days of a change in the following:

                


        

      

       

      
        
          	

                	1.1.4.1	
                  Its solvency (as a result of a non-operational event);

                


        

      

       

      
        
          	

                	1.1.4.2	
                  Its corporate officers or executive employees; or

                


        

      

       

      
        
          	

                	1.1.4.3	
                  Its Federal employee identification number or Federal tax identification number.

                


        

      

       

      
        
          	

                	1.1.5	
                  Unless otherwise specified herein, all documentation, including policies and procedures that the Contractor is required to maintain, shall be given prior written approval
                      from ASES. All documentation, including the Deliverables listed in Attachment 12 to this Contract, must be submitted to ASES in English.

                


        

      

       

      
        
          	

                	1.1.6	
                  Unless otherwise specified, the Contractor shall notify ASES and/or the Puerto Rico Medicaid Program of any applicable provisions Immediately.

                


           

          

        

      

      
        Page 7 of 324

        
          


      

      

      
        
          	

                	1.1.7	
                  Pursuant to 42 CFR 438.602(i), the Contractor shall not be located outside of the United States.

                


        

      

       

      
        
          	

                	1.1.8	
                  All Administrative Functions of the Contractor must be located within the United States. The following Administrative Functions must be located in Puerto Rico:

                


        

      

       

      
        
          	

                	1.1.8.1	
                  Care Management;

                


        

      

       

      
        
          	

                	1.1.8.2	
                  Marketing;

                


        

      

       

      
        
          	

                	1.1.8.3	
                  Utilization Management determinations, including Prior Authorization determinations;

                


        

      

       

      
        
          	

                	1.1.8.4	
                  Management of Enrollee and Provider Grievances and Appeals;

                


        

      

       

      
        
          	

                	1.1.8.5	
                  Decision-making authority related to Enrollee Services;

                


        

      

       

      
        
          	

                	1.1.8.6	
                  Decision-making authority related to Provider Services, such as claims dispute resolution and credentialing activities; and

                


        

      

       

      
        
          	

                	1.1.8.7	
                  Network management activities.

                


        

      

       

      
        
          	

                	1.2	
                  Background

                


        

      

       

      
        
          	

                	1.2.1	
                  The Government Health Plan (“GHP”), also known as MI Salud, has the following objectives:

                


        

      

       

      
        
          	

                	1.2.1.1	
                  Ensure appropriate and timely access to Covered Services for Enrollees across Puerto Rico, including facilitating and promoting access to preventive care.

                


        

      

       

      
        
          	

                	1.2.1.2	
                  Require Contractors to provide Island-wide coverage and access to Covered Services Island-wide in all geographic areas of Puerto Rico. This may be achieved through
                      sub-contractual relationships.

                


        

      

       

      
        
          	

                	1.2.1.3	
                  Encourage competition among Contractors resulting in improvements of quality outcomes.

                


        

      

       

      
        
          	

                	1.2.1.4	
                  Require Contractors to partner with Government-owned specialty hospitals.

                


        

      

       

      
        
          	

                	1.2.1.5	
                  Encourage Contractors to partner with local provider entities, such as Primary Medical Groups (PMGs), provider groups, and provider associations to leverage island-based
                      best practices and maintain existing Enrollee-provider relationships.

                


        

      

       

      
        
          	

                	1.2.1.6	
                  Require Contractors to propose and demonstrate cost saving initiatives, programs, and value-based payment models for Provider reimbursement to address High Cost High
                      Needs (HCHN) Program Enrollees in Puerto Rico.

                


           

          

        

      

      
        Page 8 of 324

        
          


      

      

      
        
          	

                	1.2.1.7	
                  Establish HCHN Program cohorts with enhanced Contractor management and cost-saving requirements.

                


        

      

       

      
        
          	

                	1.2.1.8	
                  Promote provider-based care coordination models that address social determinants of health and are likely to reduce health care expenditures.

                


        

      

       

      
        
          	

                	1.2.1.9	
                  Require Contractors to implement best practices to address high utilizers of services that are more appropriately delivered in less costly settings; for example,
                      strategies to decrease non-emergent use of the emergency room.

                


        

      

       

      
        
          	

                	1.3	
                  Groups Eligible for Services Under the GHP

                


        

      

       

      
        
          	

                	1.3.1	
                  The Contractor will be responsible for providing services to all persons determined eligible for the GHP and enrolled in the Contractor’s Plan. The groups to be served
                      under the GHP shall hereinafter be referred to collectively as “Eligible Persons.” The groups are subject to change and currently include:

                


        

      

       

      
        
          	

                	1.3.1.1	
                  Medicaid and CHIP. All Medicaid and CHIP eligibility categories covered in the Puerto Rico Medicaid and CHIP State Plans are eligible to enroll in the GHP and shall be referred to hereinafter as “Medicaid and CHIP Eligibles”, also
                      known as the “Federal population.”

                


        

      

       

      
        
          	

                	1.3.1.2	
                  Other Groups (Non-Medicaid and CHIP Eligibles). The following groups, which receive services under the GHP without any Federal financial participation, will be referred to hereinafter as “Other Eligible Persons.”

                


        

      

       

      
        
          	

                	1.3.1.2.1	
                  The “State Population,” formerly known as the “Commonwealth Population,” is currently comprised of individuals, regardless of age, who meet State eligibility standards
                      established by the Puerto Rico Medicaid Program but do not qualify for Medicaid or CHIP.

                


        

      

       

      
        
          	

                	1.3.1.2.2	
                  Any other group of Other Eligible Persons may be added during the Contract Term as a result of a change in laws or regulations.

                


        

      

       

      
        
          	

                	1.4	
                  Geographic Scope of the Contract

                


        

      

       

      
        
          	

                	1.4.1	
                  The Contractor is responsible for the delivery of services under the GHP Island-wide.

                


           

          

        

      

      
        Page 9 of 324

        
          


      

      

      
        
          	

                	1.5	
                  Delegation of Authority

                


        

      

       

      
        
          	

                	1.5.1	
                  Federal law and Puerto Rico law limit the capacity of ASES to delegate decisions to the Contractor. All decisions relating to public policy and to the administration of
                      the Medicaid, CHIP, and the Puerto Rico government health assistance program included in the GHP rest with the Puerto Rico Medicaid Program and ASES.

                


        

      

       

      
        
          	

                	1.6	
                  Availability of Funds

                


        

      

       

      
        
          	

                	1.6.1	
                  This Contract is subject to the availability of funds on the part of ASES, which in turn is subject to the transfer of Federal, Puerto Rico, and municipal funds to ASES.
                      If available funds are insufficient to meet its contractual obligations, ASES reserves the right to terminate this Contract, pursuant to Section 35.5.

                


        

      

       

      
        
          	

                	1.7	
                  Cooperation, Assistance and Compliance with Special Projects

                


        

      

       

      
        
          	

                	1.7.1	
                  The Contractor shall provide to ASES and any other agency of the Government all necessary cooperation, assistance, and compliance with requirements in the development and
                      implementation of any special project of ASES and any other agency of the Government or the Federal Government. The Contractor acknowledges that this is a sine qua non of this Contract and that it will comply with ASES change requests
                      related to such projects as these are implemented due to State or Federal mandate.

                


        

      

      

      

      
        
          	ARTICLE 2	
                  DEFINITIONS

                


        

      

       

      Whenever capitalized in this Contract, the following terms have the respective meaning set forth below, unless the context clearly requires otherwise.

       

      Act 72: The law of Puerto Rico adopted on September 7, 1993, as
          subsequently amended, which created ASES and empowered ASES to administer certain government health programs.

       

      Act 408: The Puerto Rico Mental Health Code (Act No. 408 of
          October 2, 2000, as amended), which established the public policy and procedures regarding the delivery of Behavioral Health services in Puerto Rico.

       

      Abandoned Call: A call initiated to a Call Center that is ended
          by the caller before any conversation occurs or before a caller is permitted access to a caller-selected option.

       

      Abuse: Provider practices that are inconsistent with sound
          fiscal, business, or medical practices, and that result in unnecessary costs to the GHP Program or in reimbursement for services that are not Medically Necessary or that fail to meet professionally recognized standards for the provision of health
          care. It also includes Enrollee practices that result in unnecessary costs to the GHP.

       

        Access: Adequate availability of Benefits to fulfill the
            needs of Enrollees.

        

        

      
        Page 10 of 324

        
          


      

      Adverse Benefit Determination: The denial or limited
          authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service, requirements for medical necessity appropriateness, setting or effectiveness of a covered
          benefit; the denial, in whole or part, of payment for a service (including in circumstances in which an Enrollee is forced to pay for a service); the failure to provide services in a timely manner (within the timeframes established by this
          Contract or otherwise established by ASES); the failure of the Contractor to act within the timeframes provided in 42 CFR 438.408(b); or the denial of an Enrollee’s request to dispute a financial liability, including cost-sharing, co-payments,
          premiums, deductibles, co-insurance, and other Enrollee financial liabilities. For a resident of a rural area, the denial of an Enrollee's request to exercise his or her right, under 42 CFR 438.52(b)(2)(ii), to obtain services outside the
          network.

       

      Actuarial Report: Actuarial reports the Contractor is required
          to submit in accordance with Article 18 of this Contract.

       

      Administrative Functions: The contractual obligations of the
          Contractor under this Contract, other than providing Covered Services; include, without limitation, Care Management, Utilization Management, Credentialing Providers, Network management, Quality Improvement, Marketing, Enrollment, Enrollee
          services, Claims payment, Information Systems, financial management, and reporting.

       

      Administrative Law Hearing: The Appeal process administered by
          the Government and as required by Federal law, available to Enrollees after they exhaust the Contractor’s Grievance and Appeal System.

       

      Administrative Referral: A Referral of an Enrollee by the
          Contractor to a Provider or facility located outside the PPN, when the Enrollee’s PCP or other PMG physician does not provide a Referral within the required time period.

       

      Adult: An individual age twenty-one (21) or older unless
          otherwise specified.

       

      Advance Directive: A written instruction, such as a living will
          or durable power of attorney, granting responsibility over an individual’s health care, as defined in 42 CFR 489.100, and as recognized under Puerto Rico law under Act 160 of November 17, 2001, as amended, relating to the provision of health care
          when the individual is incapacitated.

       

      ADFAN: Families and Children Administration (Administración de
          Familias y Niños), which is responsible for foster care children in the custody of the Government.

       

      Affiliate: Any person, firm, corporation (including, without
          limitation, service corporation and processional corporation), partnership (including, without limitation, general partnership, limited partnership and limited liability partnership), limited liability company, joint venture, business trust,
          association or other entity or organization that now or in the future directly or indirectly controls, is controlled by, or is under common control with the Contractor.

       

      Agent: An entity that contracts with ASES to perform
          Administrative Functions, including but not limited to: fiscal Agent activities; Outreach, eligibility, and Enrollment activities; and systems and technical support.

       

        

      
        Page 11 of 324

        
          


      

      Aggregate Lifetime Dollar Limit: For purposes of compliance
          with Behavioral Health parity requirements in 42 CFR part 438, subpart K, a dollar limitation on the total amount of specified benefits that may be paid under a contractor.

       

      Ambulatory Services Units: Ambulatory clinics that mainly
          provide health services to children, families, and adults, which are staffed by an interdisciplinary team responsible for the appropriate treatment and referral processes.

       

      Ancillary Services: Professional services, including
          laboratory, radiology, physical therapy, and respiratory therapy, which are provided in conjunction with other medical or hospital care.

       

      Annual Dollar Limit: For purposes of compliance with Behavioral
          Health parity requirements in 42 CFR part 438, subpart K, a dollar limitation on the total amount of specified benefits that may be paid in a twelve (12) month period under a contractor.

       

      Annual Open Enrollment Period: The annual period of three (3)
          months from November 1 through January 31 during which Enrollees have one (1) opportunity to select a different contractor, without cause.

       

      Appeal: An Enrollee request for a review of an Adverse Benefit
          Determination. It is a formal petition by an Enrollee, an Enrollee’s Authorized Representative, or the Enrollee’s Provider, acting on behalf of the Enrollee with the Enrollee’s written consent, to reconsider a decision in the case that the
          Enrollee or Provider does not agree with an Adverse Benefit Determination taken.

       

      ASES: Administración de Seguros de Salud de Puerto Rico (the
          Puerto Rico Health Insurance Administration), the Government entity responsible for oversight and administration of the GHP Program, or its Agent.

       

      ASES Data: All Data created from Information, documents,
          messages (verbal or electronic), reports, or meetings involving, arising out of or otherwise in connection with this Contract.

       

      ASES Information: All proprietary Data and/or Information
          generated from any Data requested, received, created, provided, managed and stored by Contractors, - in hard copy, digital image, or electronic format - from ASES and/or Enrollees (as defined in Article 2) necessary or arising out of this
          Contract, except for the Contractor’s Proprietary Information.

       

      ASSMCA: Administración de Servicios de Salud Mental y Contra la
          Adicción (the Puerto Rico Mental Health and Anti-Addiction Services Administration), the government agency responsible for the planning and establishment of mental health and substance abuse policies and procedures and for the coordination,
          development, and monitoring of all Behavioral Health Services rendered to Enrollees in the GHP.

       

      At Risk: When a Provider agrees to accept responsibility to
          provide, or arrange for, any service in exchange for the Per Member Per Month Payment (PMPM).

       

      Authorized Certifier: The Contractor’s CEO, CFO, or an
          individual with delegated authority to sign for and who reports directly to the CEO and/or CFO.

       

          

      
        Page 12 of 324

        
          


      

      Authorized Representative: A person given written authorization
          by an Enrollee to make health-related decisions on behalf of an Enrollee, including, but not limited to: Enrollment and Disenrollment decisions, filing Complaints, Grievances and Appeals, and the choice of a PCP or PMG.

       

      Auto-Assignment: The assignment of an Enrollee to a PMG and a
          PCP by ASES, the Contractor or the Puerto Rico Medicaid Program.

       

      Auto-Enrollment: The Enrollment of a Potential Enrollee in a GHP
          Plan without any action by the Potential Enrollee, as provided in Article 5 of this Contract.

       

      Basic Coverage: The physical and Behavioral Health Services
          available to all GHP Enrollees (as distinguished from Special Coverage, which is available only to Enrollees with certain diagnoses after a registration process). The GHP Covered Services are listed in Article 7 of this Contract.

       

      Behavioral Health: The umbrella term for mental health
          conditions (including psychiatric illnesses and emotional disorders) and substance use disorders (involving addictive and chemical dependency disorders). The term also refers to preventing and treating co-occurring mental health conditions and
          substance use disorders (“SUDs”).

       

      Behavioral Health Facility: A facility for the delivery of
          outpatient, inpatient or stabilization Behavioral Health Services, which houses at least two (2) Providers. These facilities include:

       

        

      
        
          	(i)	
                  Psychiatric hospitals (or a unit within a general hospital)

                


        

      

      
        
          	(ii)	
                  Emergency or stabilization units

                


        

      

      
        
          	(iii)	
                  Partial hospitalization units

                


        

      

      
        
          	(iv)	
                  Intensive ambulatory services units

                


        

      

      
        
          	(v)	
                  Ambulatory services units/clinics

                


        

      

      
        
          	(vi)	
                  Residential units

                


        

      

      
        
          	(vii)	
                  Addiction service units (detoxification, ambulatory, inpatient, and residential)

                


        

      

       

      Benefits: The services set forth in this Contract, for which
          the Contractor has agreed to provide, arrange, and be held fiscally responsible, including Basic Coverage, dental services, Special Coverage, High Cost High Needs Program, and Administrative Functions.

       

      Blocked Call: A call that cannot be connected Immediately
          because no circuit is available at the time the call arrives or because the telephone system is programmed to block calls from entering the queue when the queue is backed up beyond a defined threshold.

       

      Breach: As defined in 45 CFR 164.402, the acquisition, access,
          use, or disclosure of Protected Health Information in a manner not permitted under 45 CFR 164, subpart E which compromises the security or privacy of such Information.

       

      Business Continuity and Disaster Recovery (“BC-DR”) Plan: A
          documented plan (process) to restore vital and critical Information/health care technology systems in the event of business interruption due to human, technical, or natural causes. The plan focuses mainly on technology systems, encompassing
          critical hardware, operating and application software, and tertiary elements required to support the operating environment. It must support the process requirement to restore vital business Data inside the defined business requirement, including
          an emergency mode operation plan as necessary. The BC-DR also provides for continuity of health care in the event of plan terminations.

       

        

      
        Page 13 of 324

        
          


      

      Business Days: Traditional workdays, including Monday, Tuesday,
          Wednesday, Thursday, and Friday. Puerto Rico Holidays, as defined in the Law for Compliance with the Fiscal Plan, Act No. 26 of April 29, 2017, or any other law enacted during the duration of this Contract regarding this subject, are excluded.

       

      Calendar Days: All seven days of the week.

       

      Call Center: A telephone service facility equipped to handle a
          large number of inbound and outbound calls. This facility must meet all requirements set forth in Section 6.8 of this Contract.

       

      Capitation: A contractual agreement through which a Contractor
          or Provider agrees to provide specified health care services to Enrollees for a fixed amount per month.

       

      Care Management: An Administrative Function comprised of a set
          of Enrollee-centered steps to ensure that an Enrollee with intensive needs, including catastrophic or high-risk conditions, receives the necessary services in a supportive, effective, efficient, timely, and cost-effective manner.

       

      Care Manager: A professional with at least a Bachelor of Arts
          or a Bachelor of Science in a health or Behavioral Health-related field who helps Enrollees access the services they need for their recuperation and for the implementation of their individual treatment plans.

       

      Centers for Medicare & Medicaid Services (“CMS”): The agency
          within the US Department of Health and Human Services with responsibility for the Medicare, Medicaid, and the Children’s Health Insurance Programs (“CHIP”).

       

      Center for the Collection of Municipal Revenues: A municipal
          entity, independent from any other governmental agency, in charge of notifying, assessing, collecting, receiving, and distributing the public funds arising from property tax, state subsidy, electronic lottery and any other fund created by law in
          favor of the municipalities of Puerto Rico.

       

      Certification: As provided in Section 5.1.2 of this Contract, a
          decision by the Puerto Rico Medicaid Program that a person is eligible for services under the GHP Program because the person is Medicaid Eligible, CHIP Eligible, or a member of the State Population. Some public employees and pensioners may enroll
          in GHP without first receiving a Certification.

       

      Children’s Health Insurance Program (“CHIP”): Puerto Rico’s
          Children’s Health Insurance Program established pursuant to Title XXI of the Social Security Act.

       

      CHIP Eligible: A child eligible to enroll in the GHP Program
          because he or she is eligible for CHIP.

       

      Chronic Condition: An ongoing physical, behavioral, or
          cognitive disorder, with a duration of at least twelve (12) months with resulting functional limitations, reliance on compensatory mechanisms (medications,
          special diet, assistive devices, etc.) and service use or need beyond that which is normally considered routine.

       

        

      
        Page 14 of 324

        
          


      

      Claim: Whether submitted manually or electronically, a bill for
          services, a line item of services, or a bill detailing all services for one (1) Enrollee.

       

      Clean Claim: A Claim received by the Contractor for
          adjudication, which can be processed without obtaining additional information from the Provider of the service or from a Third Party. It includes a Claim with errors originating in the Contractor’s Claims system. It does not include a Claim from
          a Provider who is under investigation for Fraud, Waste, or Abuse, or a Claim under review to determine Medical Necessity.

       

      Cold-Call Marketing: Any unsolicited personal contact by the
          Contractor with a Potential Enrollee, for the purposes of Marketing.

       

      Co-Location: An integrated care model in which Behavioral
          Health Services are provided in the same site as Primary Care.

       

      Complaint: An expression of dissatisfaction about any matter
          other than an Adverse Benefit Determination that is resolved at the point of contact rather than through filing a formal Grievance.

       

      Contract: The written agreement between ASES and the
          Contractor; comprised of the Contract, any addenda, appendices, attachments, or amendments thereto.

       

      Contract Term: The duration of time that this Contract is in
          effect, as defined in Article 21 of this Contract.

       

      Contractor: The Managed Care Organization that is a Party of
          this Contract, licensed as an insurer by the Puerto Rico Commissioner of Insurance (“PRICO”), which contracts hereunder with ASES under the GHP program for the provision of Covered Services and Benefits to Enrollees on the basis of PMPM Payments.

       

      Co-Payment: A cost-sharing requirement which is a fixed
          monetary amount paid by the Enrollee to a Provider for certain Covered Services as specified by ASES.

       

      Corrective Action Plan: The detailed written plan required by
          ASES from the Contractor to correct or resolve a deficiency or event causing the assessment of a liquidated damage or sanction against the Contractor.

       

      Cost Avoidance: A method of paying Claims in which the Provider
          is not reimbursed until the Provider has demonstrated that all available health insurance, and other sources of Third Party Liability, have been exhausted.

       

      Countersignature: An authorization provided by the Enrollee’s
          PCP, or another Provider within the Enrollee’s PMG, for a prescription written by another Provider to be dispensed. No Countersignature shall be required if the Provider writing the prescription is within the PPN.

       

      Covered Services: Those Medically Necessary health care
          services (listed in Article 7 of this Contract) provided to Enrollees by Providers, the payment or indemnification of which is covered under this Contract.

       

        

      
        Page 15 of 324

        
          


      

      Credentialing: The Contractor’s determination as to the
          qualification of a specific Provider to render specific health care services.

       

      Credible Allegation of Fraud: Any allegation of Fraud that has
          been verified by another State, the Government, or ASES, or otherwise has been preliminary investigated by the Contractor, as the case may be, and that has indicia of reliability that comes from any source.

       

      Cultural Competency: A set of interpersonal skills that allow
          individuals to increase their understanding, appreciation, acceptance, and respect for cultural differences and similarities within, among, and between groups and the sensitivity to know how these differences influence relationships with
          Enrollees. This requires a willingness and ability to draw on community-based values, traditions and customs, to devise strategies to better meet culturally diverse Enrollee needs, and to work with knowledgeable persons of and from the community
          in developing focused interactions, communications, and other supports.

       

      Daily Basis: Each Business Day.

       

      Data: A series of meaningful electrical signals that may be
          manipulated or assigned.

       

      Data Set: Demographic, health, or other Informational elements
          suitable for specific use.

       

      Deductible: In the context of Medicare, the dollar amount of
          Covered Services that must be incurred before Medicare will pay for all or part of the remaining Covered Services.

       

      Deemed Newborn: A newborn whose mother is Medicaid or CHIP
          Eligible on the date of delivery and is eligible from the date of birth.

       

      Deliverable: A document, manual, or report submitted to ASES by
          the Contractor to exhibit that the Contractor has fulfilled the requirements of this Contract.

       

      Disenrollment: The termination of an individual’s Enrollment in
          the Contractor’s Plan.

       

      Domestic Violence Population: Certain survivors of domestic
          violence referred by the Office of the Women’s Advocate.

       

      Dual Eligible Beneficiary: An Enrollee or Potential Enrollee
          eligible for both Medicaid and Medicare.

       

      Durable Medical Equipment: Equipment, including assistive
          technology, which: (i) can withstand repeated use; (ii) is used to service a health-related or functional purpose; (iii) is ordered by a Health Care Provider to address an illness, injury, or disability; and (iv) is appropriate for use in the
          home, work place, or school.

       

      Early and Periodic Screening, Diagnostic, and Treatment (“EPSDT”)
            Program: A Medicaid-mandated program that covers screening and diagnostic services to determine physical and mental deficiencies in Enrollees less than twenty-one (21) years of age, and health care, prevention, treatment, and other
          measures to correct or ameliorate any deficiencies and Chronic Conditions discovered.

       

        

      
        Page 16 of 324

        
          


      

      Effective Date of Contract: The day the Contract is executed by
          both Parties.

       

      Effective Date of Disenrollment: The date, as defined in
          Section 5.3.3 of this Contract, on which an Enrollee ceases to be covered under the Contractor’s Plan.

       

      Effective Date of Eligibility: The eligibility period specified
          for each population covered under the GHP as described in Section 5.1.3 of the Contract.

       

      Effective Date of Enrollment: shall have the meaning prescribed
          to it in Section 5.2.2 of the Contract.

       

      Electronic Funds Transfer (“EFT”): Transfer of funds between
          accounts using electronic means such as a telephone or computer rather than paper-based payment methods such as cash or checks.

       

      Electronic Health Record (“EHR") System: An electronic record
          of health-related information on an individual that is created, gathered, managed, and consulted upon by authorized health care clinicians and staff and certified by The Office of the National Coordinator’s Authorized Testing and Certification
          Bodies (“ONC-ATCBs”).

       

      Eligible Person: A person eligible to enroll in the GHP
          Program, as provided in Section 1.3.1 of this Contract, by virtue of being Medicaid Eligible, CHIP Eligible, or an Other Eligible Person.

       

      Emergency Medical Condition: As defined in 42 CFR 438.114, a
          medical or Behavioral Health condition, regardless of diagnosis or symptoms, manifesting itself in acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine,
          could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairments of
          bodily functions, serious dysfunction of any bodily organ or part, serious harm to self or other due to an alcohol or drug abuse emergency, serious injury to self or bodily harm to others, or the lack of adequate time for a pregnant women having
          contractions to safely reach a another hospital before delivery. The Contractor may not impose limits on what constitutes an Emergency Medical Condition based only, or exclusively, on diagnoses or symptoms.

       

      Emergency Services: As defined in 42 CFR 438.114, any Physical
          or Behavioral Health Covered Services (as described in Section 7.5.9) furnished by a qualified Provider in an emergency room that are needed to evaluate or stabilize an Emergency Medical Condition or a Psychiatric Emergency that is found to exist
          using the prudent layperson standard.

       

      Encounter: A distinct set of services provided to an Enrollee
          in a face-to-face setting on the dates that the services were delivered, regardless of whether the Provider is paid on a Fee-for-Service, Capitated, salary, or alternative payment methodology basis. Encounters with more than one (1) Provider, and
          multiple Encounters with the same Provider, that take place on the same day in the same location will constitute a single Encounter, except when the Enrollee, after the first Encounter, suffers an illness or injury requiring an additional
          diagnosis or treatment.

       

      Encounter Data: (i) All Data captured during the course of a
          single Encounter that specify the diagnoses, comorbidities, procedures (therapeutic, rehabilitative, maintenance, or palliative), pharmaceuticals, medical devices, and equipment associated with the Enrollee receiving services during the
          Encounter; (ii) The identification of the Enrollee receiving and the Provider(s) delivering the health care services during the single Encounter; and (iii) A unique (i.e., unduplicated) identifier for the single Encounter.

       

      
        Page 17 of 324

        
          


      

      Enrollee: A person who is currently enrolled in the
          Contractor’s GHP Plan, as provided in this Contract, and who, by virtue of relevant Federal and Puerto Rico laws and regulations, is an Eligible Person listed in Section 1.3.1 of this Contract.

       

      Enrollment: The process by which an Eligible Person becomes an
          Enrollee of the Contractor’s Plan.

       

      Experience of Care and Health Outcomes (“ECHO”) Survey: A
          survey constructed to merge the most desirable aspects of the Mental Health Statistics Program’s Consumer Survey (“MHSIP”) and the Consumer Assessment of Behavioral Health Services (“CABHS”) Instrument in order to capture as many unique aspects
          of mental health and substance abuse-related services while limiting redundancy. The survey is a product of nearly six (6) years of research and testing by CAHPS grantees at the Harvard Medical School, with extensive input from behavioral health
          care experts.

       

      External Quality Review Organization (“EQRO”): An organization
          that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs analyses and evaluations on the quality, timeliness, and Access to Covered Services and Benefits that the Contractor furnishes to Enrollees.

       

      Federally Qualified Health Center (“FQHC”): An entity that
          provides outpatient health programs pursuant to Section 1905(l)(2)(B) of the Social Security Act.

       

      Fee-for-Service: A method of reimbursement based on payment for
          specific Covered Services on a service-by-service basis rendered to an Enrollee.

       

      Formulary of Medications Covered (“FMC”): A published subset of
          pharmaceutical products used for the treatment of physical and Behavioral Health conditions developed by the PPA after clinical recommendations from the Pharmacy and Therapeutics (P&T) Committee and financial review from the Pharmacy Benefits
          Financial Committee.

       

      Foster Care Population: Children who are in the custody of the
          Department of Family’s ADFAN Program and enrolled in the GHP.

       

      Fraud: An intentional deception or misrepresentation made by a
          person with the knowledge that the deception could result in some unauthorized benefit or financial gain to him/herself or some other person. It includes any act that constitutes Fraud under applicable Federal or Puerto Rico law.

       

      General Network: The entire group of Providers with Provider
          Contracts with the Contractor, including those that are and those that are not members of the Contractor’s Preferred Provider Network.

       

      GHP Plan: A Managed Care Organization under contract with ASES
          that offers services under the Government Health Plan (“GHP”) Program.

       

      
        Page 18 of 324

        
          


      

      GHP Service Line: The Enrollee support Call Center that the
          Contractor shall operate as described in Section 6.8 of this Contract, containing two components: the Information Service and the Medical Advice Service.

       

      The Government Health Plan (or “the GHP”): The government health
          services program (also referred to as “MI Salud”) offered by the Government, and administered by ASES, which serves a mixed population of Medicaid Eligible, CHIP Eligible, and Other Eligible Persons, and emphasizes integrated delivery of physical
          and Behavioral Health services.

       

      Grievance: An expression of dissatisfaction about any matter
          other than an Adverse Benefit Determination.

       

      Grievance and Appeal System: The overall system that includes
          Complaints, Grievances, and Appeals at the Contractor level, as well as access to the Administrative Law Hearing process.

       

      Health Care Acquired Conditions: A medical condition for which
          an individual was diagnosed that could be identified by a secondary diagnostic code described in Section 1886(d)(4)(D)(iv) of the Social Security Act.

       

      Health Care Provider: An individual engaged in the delivery of
          health care services as licensed or certified by Puerto Rico in which he or she is providing services, including but not limited to physicians, podiatrists, optometrists, chiropractors, psychologists, psychiatrists, licensed Behavioral Health
          practitioners, dentists, physician assistant, physical or occupational therapists and therapists assistants, speech-language pathologists, audiologists, registered or licensed practical nurses (including nurse practitioners, clinical nurse
          specialist, certified registered nurse anesthetists, and certified nurse midwives), licensed certified social workers, registered respiratory therapists, and certified respiratory therapy technicians.

       

      Health Certificate: Certificate issued by a physician after an
          examination that includes Venereal Disease Research Laboratory (“VDRL”) and tuberculosis (“TB”) tests if the individual suffers from a contagious disease that could incapacitate him or her or prevent him or her from doing his or her job, and does
          not represent a danger to public health.

       

      Health Information Exchange (“HIE”): The secure and effective
          electronic transmission (push–pull) of the Protected Health Information of patients between Providers, across organizations, community or hospital system, within a jurisdiction and/or between jurisdictions. HIE is also an entity that provides
          services to enable the electronic sharing of health Information.

       

      Health Information Organization (“HIO”): “An organization that
          oversees and governs services related to the exchange of health-related Information among organizations according to nationally recognized standards,” as defined in The National Alliance for Health Information Technology Report to the Office of
          the National Coordinator for Health Information Technology.

       

      Health Information Technology for Economic and Clinical Health
            (“HITECH”) Act: Public Law 111-5 (2009). When referenced in this Contract, it includes all related rules, regulations, and procedures.

       

      
        Page 19 of 324

        
          


      

      Health Care Effectiveness Data and Information Set (“HEDIS”): A
          set of standardized performance measures developed by the National Committee for Quality Assurance (“NCQA”) to measure and compare MCO performance.

       

      Health Insurance Portability and Accountability Act (“HIPAA”): A
          law enacted in 1996 by the US Congress. When referenced in this Contract, it includes all related rules, regulations, and procedures.

       

      High Cost High Needs (HCHN) Program: A set of contractual
          obligations specific to a cohort of Enrollees, as specified in Section 7.8.3 and Attachment 28 to this Contract, with specific conditions that require specialized care management and a dedicated team of Providers due to the cost or elevated needs
          associated with treatment of the condition.

       

      Immediately: Within twenty-four (24) hours, unless otherwise
          provided in this Contract.

       

      Implementation Date of the Contract: The date on which the
          Contractor shall commence providing Covered Services and other Benefits under this Contract after it has passed a readiness review; the expected implementation date of this Contract is November 1, 2018.

       

      Incident: The attempted or successful unauthorized access, use,
          disclosure, modification, or destruction of Information or interference with system operations in an Information System.

       

      Incurred-But-Not-Reported (“IBNR”): Estimate of unpaid Claims
          liability, including received but unpaid Claims.

       

      Indian: An individual, defined in Title 25 of the U.S.C.
          sections 1603(c), 1603(f), 1603(f) or who has been determined eligible, as an Indian, pursuant to 42 C.F.R. 136.12 or Title V of the Indian Health Care Improvement Act, to receive health care services from Indian Health Care Providers (Indian
          Health Services, an Indian Tribe, Tribal Organization, or Urban Indian Organization-I/T/U) or through Referral under Contract Health Services.

       

      Information: Data to which meaning is assigned, according to
          context and assumed conventions; meaningful fractal Data for decision support purposes.

       

      Information Service: The component of the GHP Service Line, a
          Call Center operated by the Contractor (described in Section 6.9), intended to assist Enrollees with routine inquiries, which shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m. (Atlantic Time), Monday through Friday, excluding
          Puerto Rico holidays.

       

      Information System(s): A combination of computing and
          communications hardware and software that is used in: (i) the capture, storage, manipulation, movement, control, display, interchange and/or transmission of Information, i.e., structured Data (which may include digitized audio and video) and
          documents; and/or (ii) the processing of such Information for the purposes of enabling and/or facilitating a business process or a related transaction.

       

      Initial Auto-Enrollment: The process by which an Eligible Person
          enrolled with a GHP contractor prior to November 1, 2018 is Auto-Enrolled with a contractor by ASES with an effective date of November 1, 2018.

       

      
        Page 20 of 324

        
          


      

      Initial Auto-Enrollment Enrollee: An Eligible Person enrolled
          prior to November 1, 2018 with a GHP contractor who is Auto-Enrolled with a Contractor’s Plan during Initial Auto-Enrollment.

       

      Integration Plan: The service delivery plan under the GHP
          Program, providing physical and Behavioral Health Services in close coordination, to ensure optimum detection, prevention, and treatment of physical and Behavioral Health conditions.

       

      International Statistical Classification of Diseases and Related Health
            Problems Tenth Revision (“ICD-10”): A medical classification list created by the World Health Organization that notes various Medical Records including those used for coding diseases, signs, symptoms, abnormal findings, complaints,
          social circumstances, and external causes of injury or disease.

       

      Island-wide: All geographic areas that comprise the entirety of
          Puerto Rico, including Vieques and Culebra, for which the Contractor is responsible for the delivery of Covered Services.

       

      List of Excluded Individuals and Entities (“LEIE”): A database
          of individuals and entities excluded from Federally-funded health care programs maintained by the Department of Health and Human Services Office of the Inspector General.

       

      List of Medications by Exception (“LME”): List of medications
          that are not included in the FMC, but that have been evaluated and approved by ASES’s Pharmacy and Therapeutics (P&T) Committee to be covered only through an exception process if certain clinical criteria are met. Covered outpatient drugs
          that are not included on the LME may still be covered under an Exception Request in compliance with Section 7.5.12.10.1.2 and Attachment 27 to this Contract, unless statutorily excluded.

       

      MA-10: Form issued by the Puerto Rico Medicaid Program,
          entitled “Notice of Action Taken on Application and/or Recertification,” containing the Certification decision (whether a person was determined eligible or ineligible for Medicaid, CHIP, or the State Population).

       

      Managed Care Organization (“MCO”): An entity that is organized
          for the purpose of providing health care and is licensed as an insurer by the Puerto Rico Commissioner of Insurance (“PRICO”), which contracts with ASES for the provision of Covered Services and Benefits Island-wide on the basis of PMPM Payments,
          under the GHP program.

       

      Marketing: Any communication from the Contractor to any
          Eligible Person or Potential Enrollee that can reasonably be interpreted as intended to influence the individual to enroll in the Contractor’s Plan, or not to enroll in another plan, or to disenroll from another plan.

       

      Marketing Materials: Materials that are produced in any medium,
          by or on behalf of the Contractor that can reasonably be interpreted as intended to market to Potential Enrollees.

       

      Medicaid: The joint Federal/state program of medical assistance
          established by Title XIX of the Social Security Act.

       

      Medicaid Eligible: An individual eligible to receive services
          under Medicaid, who is eligible, on this basis, to enroll in the GHP Program.

       

      
        Page 21 of 324

        
          


      

      Medicaid Fraud Control Unit (“MFCU”): The Unit created by the
          Puerto Rico Department of Justice under Administrative Order 2018-002 to investigate and prosecute Medicaid Provider Fraud as well as patient abuse and neglect in health care facilities, as defined in Section 1903(q) of the Social Security Act,
          found at 42 USC 1396b(q).

       

      Medicaid Management Information System (“MMIS”): Computerized
          system used for the processing, collecting, analyzing, and reporting of Information needed to support Medicaid and CHIP functions. The MMIS consists of all required subsystems as specified in the State Medicaid Manual.

       

      Medical Advice Service: The twenty-four (24) hour emergency
          medical advice toll-free phone line operated by the Contractor through its GHP Service Line service, described in Section 6.8 of this Contract.

       

      Medical Record: The complete, comprehensive record of an
          Enrollee including, but not limited to, x-rays, laboratory tests, results, examinations and notes, accessible at the site of the Enrollee’s PCP, or Network Provider, that documents all health care services received by the Enrollee, including
          inpatient care, outpatient care, Ancillary, and Emergency Services, prepared in accordance with all applicable Federal and Puerto Rico rules and regulations, and signed by the Provider rendering the services.

       

      Medically Necessary Services: Those services that meet the
          definition found in Section 7.2 of this Contract.

       

      Medicare: The Federal program of medical assistance for persons
          age sixty-five (65) and over, certain disabled persons under Title XVIII of the Social Security Act, and persons with End Stage Renal Disease.

       

      Medicare Part A: The part of the Medicare program that covers
          inpatient hospital stays, skilled nursing facilities, home health, and hospice care.

       

      Medicare Part B: The part of the Medicare program that covers
          physician, outpatient, home health, and Preventive Services.

       

      Medicare Part C: The part of the Medicare program that permits
          Medicare recipients to select coverage among various private insurance plans.

       

      Medicare Part D: The part of the Medicare programs that covers
          prescription drugs.

       

      Medicare Platino: A program administered by ASES for Dual
          Eligible Beneficiaries, in which MCOs or other insurers under contract with ASES function as Medicare Part C plans to provide services covered by Medicare, and also to provide a “wrap-around” Benefit of Covered Services and Benefits under the
          GHP.

       

      National Provider Identifier (“NPI”): The 10-digit
          unique-identifier numbering system for Providers created by the Centers for Medicare & Medicaid Services (CMS), through the National Plan and Provider Enumeration System.

       

      
        Page 22 of 324

        
          


      

      Negative Determination or Redetermination Decision: The decision
          by the Puerto Rico Medicaid Program that a person is not initially eligible or no longer eligible for services under the GHP Program (because the person no longer meets the eligibility requirements for Medicaid, CHIP, or Puerto Rico’s government
          health assistance program).

       

      Network Adequacy Standards: The Provider-to-Enrollee Ratios;
          Provider Per Municipality requirements; Required Network Provider requirements, and Time and Distance requirements developed in accordance with 42 CFR 438.68, as defined by ASES in Section 9.4 to measure the adequacy and appropriateness of the
          Contractor’s provider network to meet the needs of the enrolled population.

       

      Network Provider: A Medicaid-enrolled Provider that has a
          Provider Contract with a Contractor under the GHP Program. This term includes Providers in the General Network and Providers in the PPN.

       

      New Enrollee: An Eligible Person who became a Potential Enrollee
          after November 1, 2018.

       

      Non-Emergency Medical Transportation (“NEMT”): A ride, or
          reimbursement for a ride, provided so that an Enrollee with no other transportation resources can receive Covered Services from a Provider. NEMT does not include transportation provided on an emergency basis, such as trips to the emergency room
          in life threatening situations.

       

      Non-Urban Area: For purposes of measuring Network Adequacy,
          defined by ASES as municipalities with populations at or below 49,999 people.

       

      Notice of Adverse Benefit Determination: The written notice
          described in Section 14.4.3, in which the Contractor notifies both the Enrollee and the Provider of an Adverse Benefit Determination.

       

      Notice of Disposition: The notice in which the Contractor
          explains in writing the results and the date of resolution of a Complaint, Grievance, or Appeal to the Enrollee and the Provider.

       

      Office of the Inspector General: The Federal office within the
          Department of Health & Human Services tasked with protecting the integrity of federal health care programs as well as the health and welfare of program beneficiaries.

       

      Office of the Patient Advocate: An office of the Government
          created by Act 11 of April 11, 2001, as amended by Act 77 of June 24, 2013, which is tasked with protecting the patient rights and protections contained in the Patient’s Bill of Rights Act.

       

      Office of the Women’s Advocate: An office of the Government
          created by Act 20 of April 11, 2001, as amended, which is tasked, among other responsibilities, with protecting victims of domestic violence.

       

      Open Enrollment Period: A period of ninety (90) Calendar Days
          during which Enrollees have one (1) opportunity to select a different contractor, without cause, as set forth in Section 5.2.5.

       

      
        Page 23 of 324

        
          


      

      Other Eligible Person: A person eligible to enroll in the GHP
          Program under Section 1.3.1.2 of this Contract who is not Medicaid- or CHIP Eligible. This group is comprised of the State Population and certain public employees and pensioners.

       

      Outreach: Means, among other things, of educating or informing
          the Contractor’s Enrollees about GHP, managed care, and health issues.

       

      Out-of-Network Provider: A Provider that does not have a
          Provider Contract with the Contractor under GHP; i.e., the Provider is not in either the General Network or the PPN.

       

      Overpayment: Any funds that a person or entity receives which
          that person or entity is not entitled to under Title XIX of the Social Security Act as defined in 42 CFR 438.2. Overpayments shall not include funds that have been subject to a payment suspension or that have been identified as a Third Party
          Liability as set forth in Section 23.4.

       

      Patient’s Bill of Rights Act: Act 194 of August 25, 2000, a law
          of Puerto Rico relating to patient rights and protection.

       

      Patient Protection and Affordable Care Act (“PPACA”): Public
          Law 111-148 (2010) and the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152 (2010), including any and all rules and regulations thereunder.

       

      Payment Hold: The situation when a Provider who owes funds to
          Puerto Rico, such Provider cannot be paid until the amounts owed to Puerto Rico are repaid or an acceptable repayment plan is in place, as determined by ASES.

       

      Pediatric Enrollee: An Enrollee aged zero (0) through twenty
          (20) (inclusive) unless otherwise specified.

       

      Performance Improvement Projects (“PIPs”): Projects consistent
          with 42 CFR 438.330.

       

      Per Member Per Month (“PMPM”) Payment: The fixed monthly amount,
          developed in accordance with actuarially sound principles and practices as specified in 42 CFR 438.4, that the Contractor is paid by ASES for each Enrollee to ensure that Benefits under this Contract are provided. This payment is made regardless
          of whether the Enrollee receives Benefits during the period covered by the payment.

       

      Protected Health Information (“PHI”): As defined in 45 CFR
          160.103, individually identifiable health Information that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium.

       

      Pharmacy Benefit Manager (“PBM”): An entity under contract with
          ASES under the GHP Program, responsible for the administration of pharmacy Claims processing, formulary management, drug Utilization review, pharmacy network management, and Enrollee Information Services relating to pharmacy services.

       

      Pharmacy Program Administrator (“PPA”): An entity, under
          contract with ASES, responsible for implementing and offering support to ASES and the contracted PBMs in the negotiation of rebates and development of the Maximum Allowable Cost (“MAC”) List.

       

      
        Page 24 of 324

        
          


      

      Physician Incentive Plan: Any compensation arrangement between
          a Contractor and a physician or PMG that is intended to advance Utilization Management and is governed by 42 CFR 438.3(i).

       

      Plan: The Contractor’s Managed Care Organization offering
          services to Enrollees under the GHP.

       

      Post-Stabilization Services: Covered Services, relating to an
          Emergency Medical Condition or Psychiatric Emergency, that are provided after an Enrollee is stabilized, in order to maintain the stabilized condition or to improve or resolve the Enrollee’s condition.

       

      Potential Enrollee: A person who has been Certified by the
          Puerto Rico Medicaid Program as eligible to enroll in the GHP (whether on the basis of Medicaid eligibility, CHIP eligibility, or eligibility as a member of the State Population), but who has not yet enrolled with the Contractor.

       

      Preferential Turns: The policy of requiring Network Providers to
          give priority in treating Enrollees from the island municipalities of Vieques and Culebra, so that they may be seen by a Provider within a reasonable time after arriving at the Provider’s office. This priority treatment is necessary because of
          the remote locations of these municipalities, and the greater travel time required for their residents to seek medical attention.

       

      Preferred Provider Network (“PPN”): A group of Network Providers
          that (i) GHP Enrollees may access without any requirement of a Referral or Prior Authorization; (ii) provides services to GHP Enrollees without imposing any Co-Payments on Medicaid or CHIP-Eligible populations; and (iii) meets the Network
          requirements described in Article 9 of this Contract.

       

      Prevalent Non-English Language: A non-English language spoken
          by a significant number or percentage of Potential Enrollees and current Enrollees in Puerto Rico, as determined by the Government.

       

      Preventive Services: Health care services provided by a
          physician or other Provider within the scope of his or her practice under Puerto Rico law to detect or prevent disease, disability, Behavioral Health conditions, or other health conditions; and to promote physical and Behavioral Health and
          efficiency.

       

      Primary Care: All health care services and laboratory services
          customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, or other licensed practitioner as authorized by ASES, to the extent the furnishing of those
          services is legally authorized where the practitioner furnishes them.

       

      Primary Care Physician: A licensed medical doctor (MD) who is a
          Provider and who, within the scope of practice and in accordance with Puerto Rico certification and licensure requirements, is responsible for providing all required Primary Care to Enrollees. The PCP is responsible for determining services
          required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary.

       

      Primary Medical Group (“PMG”): A grouping of associated Primary
          Care Physicians and other Providers for the delivery of services to GHP Enrollees using a coordinated care model. PMGs may be organized as Provider care organizations, or as another group of Providers who have contractually agreed to offer a
          coordinated care model to GHP Enrollees under the terms of this Contract.

       

      
        Page 25 of 324

        
          


      

      Prior Authorization: Authorization granted by the Contractor to
          determine whether the service is Medically Necessary. In some instances, this process is a condition for receiving the Covered Service.

       

      Provider: Any physician, hospital, facility, or other Health
          Care Provider who is licensed or otherwise authorized to provide physical or Behavioral Health Services in the jurisdiction in which they are furnished.

       

      Provider Per Municipality Requirements: Required number of
          specified Providers per municipality that must be included in the Contractor’s provider network per Section 9.4.3.3.

       

      Provider-to-Enrollee Ratio: Ratios established in Section 9.4
          as part of the Network Adequacy Standards that are applicable to the Contractor’s General Network and PPN.

       

      Provider Contract: Any written contract between the Contractor
          and a Provider that requires the Provider to order, refer, provide or render Covered Services under this Contract. The execution of a Provider Contract makes the Provider a Network Provider.

       

      Psychiatric Emergency: A set of symptoms characterized by an
          alteration in the perception of reality, feelings, emotions, actions, or behavior, requiring immediate therapeutic intervention in order to avoid immediate damage to the patient, other persons, or property. A Psychiatric Emergency shall not be
          defined on the basis of lists of diagnoses or symptoms.

       

      Puerto Rico Health Department (“the Health Department”): The
          Single State Agency charged with administration of the Puerto Rico Medicaid Program, which (through the Puerto Rico Medicaid Program) is responsible for Medicaid and CHIP eligibility determinations.

       

      Puerto Rico Insurance Commissioner’s Office (“PRICO”): The
          Government agency responsible for regulating, monitoring, and licensing insurance business.

       

      Puerto Rico Medicaid Program: The subdivision of the Health
          Department that conducts eligibility determinations under GHP for Medicaid, CHIP, and the State Population.

       

      Quality Assessment and Performance Improvement Program (“QAPI”):
          A set of programs aimed at increasing the likelihood of desired health outcomes of Enrollees through the provision of health care services that are consistent with current professional knowledge; the QAPI Program includes incentives to comply
          with HEDIS standards, to provide adequate Preventive Services, and to reduce the unnecessary use of Emergency Services.

       

      Quality Management/Quality Improvement (“QM/QI”): The process
          of developing and implementing strategies to ensure the delivery of available, accessible, timely, and Medically Necessary Services that meet optimal clinical standards. This includes the identification of key measures of performance, discovery
          and Data collection processes, identification and remediation of issues, and systems improvement activities.

       

      Recertification: A determination by the Puerto Rico Medicaid
          Program that a person is again eligible for services under the GHP Program.

       

      
        Page 26 of 324

        
          


      

      Reconsideration: The process for an Enrollee to request that
          ASES re-evaluate a denial of a Disenrollment request from a contractor that precedes the Administrative Law Hearing process, as provided by Act 72 of September 7, 1993, as amended.

       

      Redetermination: The periodic re-evaluation of eligibility of an
          individual for Medicaid, CHIP, or the State Population, conducted by the Puerto Rico Medicaid Program.

       

      Referral: A request by a PCP, Psychiatrist, Psychologist, or
          any other type of Provider in the PMG for an Enrollee to be evaluated and/or treated by a different Provider, usually a specialist. Referrals shall be required only for services outside the Contractor’s PPN.

       

      Reinsurance: An agreement whereby the Contractor transfers risk
          or liability for losses, in whole or in part, sustained under this Contract. A Reinsurance agreement may also exist at the Provider level.

       

      Remedy: ASES’s means to enforce the terms of the Contract
          through liquidated damages and other sanctions.

       

      Request for Proposals (“RFP”): The Request for Proposals issued
          by the Government on February 9-16, 2018.

       

      Required Network Providers: Specific Providers or types of
          Providers that must be included in the Contractor’s provider network per Section 9.4.3.4.

       

      Retention Fund: The amount of Withhold by ASES of the monthly
          PMPM Payments otherwise payable to the Contractor in order to incentivize the Contractor to meet performance targets under the Health Care Improvement Program described in Section 12.5.3. This amount shall be equal to the percent of that portion
          of the total PMPM Payment that is determined to be attributable to the Contractor’s administration of the Health Care Improvement Program described in Sections 12.5 and 22.4. Amounts withheld will be reimbursed to the Contractor in whole or in
          part (as set forth in Sections 12.5 and 22.4) in the event of a determination by ASES that the Contractor has complied with the quality standards and criteria established by Section 12.5.

       

      Reverse Co-location: An integrated care model in which physical
          health services are available to Enrollees being treated in Behavioral Health settings.

       

      Runoff Period: The period of time as explained in Section
          35.1.5.

       

      Rural Health Clinic or Center (“RHC”): A clinic that is located
          in an area that has a Provider shortage. An RHC provides primary Care and related diagnostic services and may provide optometric, podiatry, chiropractic, and Behavioral Health Services. An RHC employs, contracts, or obtains volunteer services
          from Providers to provide services.

       

      Serious Emotional Disturbance (“SED”): Children and youth who
          currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder to meet diagnostic criteria in the following ICD-10 codes: F-20 Schizophrenia, F-31 Bipolar Disorder, F-33 Major Depressive Disorder,
          F-41 Other Anxiety Disorders, and F-50 Eating Disorders.

       

      
        Page 27 of 324

        
          


      

      Serious Mental Illness (“SMI”): Individuals eighteen (18) years
          of age or older, who currently or at any time during the past year have had a diagnosable mental, behavioral, or emotional disorder to meet diagnostic criteria in the following categories of ICD-10: F20.0 Paranoid schizophrenia; F20.1
          Disorganized schizophrenia; F20.2 Catatonic schizophrenia; F20.3 Undifferentiated schizophrenia; F20.9 Schizophrenia, unspecified; F25 Schizoaffective Disorder; F28 Other non-organic psychotic disorders; F31.2 Bipolar disorder, current episode
          manic, sever, with psychotic symptoms; F31.5 Bipolar disorder, current episode depressed, severe, with psychotic symptoms; F31.6 Bipolar disorder, current episode mixed, severe, with psychotic symptoms; F33.3 Major Depressive disorder, recurrent,
          severe with psychotic symptoms.

       

      Service Authorization Request: An Enrollee’s request for the
          provision of a service.

       

      Span of Control: Information Systems and telecommunications
          capabilities that the Contractor operates or for which it is otherwise legally responsible according to the terms and conditions of this Contract. The Contractor’s Span of Control also includes systems and telecommunications capabilities
          outsourced by the Contractor.

       

      Special Coverage: A component of Covered Services provided by
          the Contractor, described in Section 7.7, which are more extensive than the Basic Coverage services, and for which Enrollees are eligible only by “registering.” Registration for Special Coverage is based on intensive medical needs occasioned by
          serious illness.

       

      “State Population” (formerly known as the “Commonwealth Population”): A
          group eligible for participation in the GHP as Other Eligible Persons, with no Federal financial participation supporting the cost of their coverage, which is comprised of low-income persons and other groups listed in Section 1.3.1.2.1.

       

      Subcontract: Any written contract between the Contractor and
          Subcontractor to perform a specified part of the Contractor’s obligations under this Contract.

       

      Subcontractor: Any organization or person, including the
          Contractor’s parent, subsidiary or Affiliate, who has a Subcontract with the Contractor to provide any function or service for the Contractor specifically related to securing or fulfilling the Contractor’s obligations to the Government under the
          terms of this Contract. Subcontractors do not include Providers unless the Provider is responsible for services other than providing Covered Services pursuant to a Provider Contract.

       

      Systems Unavailability: As measured within the Contractor’s
          Information Systems’ Span of Control, when a system user does not get the complete, correct full-screen response to an input command within three (3) minutes after pressing the “Enter” or any other function key.

       

      Telecommunication Device for the Deaf (“TDD”): Special telephone devices with keyboard attachments for use by individuals with hearing impairments who are unable to use conventional phones.

       

      Terminal Condition: A condition caused by injury, illness, or
          disease, from which, to a reasonable degree of certainty, will lead to the patient’s death in a period of, at most, six (6) months.

       

      
        Page 28 of 324

        
          


      

      Termination Date of the Contract: The dated designated by ASES
          as the date that services under this Contract shall end, pursuant to Article 35 of this Contract.

       

      Termination Plan: The plan referenced in Article 35.

       

      Third Party: Any person, institution, corporation, insurance
          company, public, private, or governmental entity who is or may be liable in Contract, tort, or otherwise by law or equity to pay all or part of the medical cost of injury, disease, or disability of an Enrollee.

       

      Third Party Liability (“TPL”): Legal responsibility of any
          Third Party to pay for health care services.

       

      Time and Distance Standards: A standardized measure of mileage
          and travel time for Enrollees in Urban and Non-Urban Areas to access a set of identified Network Providers as specified in Section 9.4 and developed by ASES in accordance with 42 CFR 438.68.

       

      Urban Area: For purposes of measuring Network Adequacy, defined
          by ASES as municipalities with populations of at least 50,000 people. Urban Areas are San Juan, Carolina, Trujillo Alto, Caguas, Guaynabo, Bayamón, Toa Alta, Toa Baja, Vega Baja, Rio Grande, Humacao, Arecibo, Ponce, Aguadilla, Mayaguez. ASES will
          notify Contractors if this list of Urban Areas changes.

       

      Utilization: The rate patterns of service usage or types of
          service occurring within a specified time frame.

       

      Utilization Management (“UM”): A service performed by the
          Contractor which seeks to ensure that Covered Services provided to Enrollees are in accordance with, and appropriate under, the standards and requirements established by the Contract, or a similar program developed, established, or administered
          by ASES.

       

      Warm Transfer: A telecommunications mechanism in which the
          person answering the call facilitates the transfer to a Third Party, announces the caller and issue, and remains engaged as necessary to provide assistance.

       

      Waste: Health care spending that can be eliminated without
          reducing quality of care.

       

      Week: The traditional seven-day week, Sunday through Saturday.

       

      Well Baby Care: The battery of screenings (listed in Section
          7.5.3.1) provided to children as part of Puerto Rico’s (“EPSDT”) Program.

       

      Withhold: A percentage of payments or set dollar amounts that
          ASES deducts from its payment to the Contractor as a penalty, or that a Contractor deducts from its payment to a Network Provider, depending on specific predetermined factors.

       

        

      
        Page 29 of 324

        
          


      

      
        
          	ARTICLE 3	
                  ACRONYMS

                


        

      

      

      

      The acronyms included in this Contract stand for the following terms:

       

        

      	
              ACH

            	
              Automated Clearinghouse

            
	
              ACIP

            	
              Advisory Committee on Immunization Practices

            
	
              ADAP

            	
              AIDS Drug Assistance Program

            
	
              ADFAN

            	
              Puerto Rico Administración de Familias y Niños, or Families and Children Administration

            
	
              AHRQ

            	
              Agency for Health Care Research and Quality

            
	
              AICPA

            	
              American Institute of Certified Public Accountants

            
	
              ASES

            	
              Administración de Seguros de Salud, or Puerto Rico Health Insurance Administration

            
	
              ASSMCA

            	
              Puerto Rico Mental Health and Anti-Addiction Services Administration or Administración de Servicios de Salud Mental y Contra la Adicción

            
	
              ASUME

            	
              Minor Children Support Administration

            
	
              BC-DR

            	
              Business Continuity and Disaster Recovery

            
	
              CAHPS

            	
              Consumer Assessment of Health Care Providers and Systems

            
	
              CEO

            	
              Chief Executive Officer

            
	
              CFO

            	
              Chief Financial Officer

            
	
              CFR

            	
              Code of Federal Regulations

            
	
              CHIP

            	
              Children's Health Insurance Program

            
	
              CLIA

            	
              Clinical Laboratory Improvement Amendment

            
	
              CMS

            	
              Centers for Medicare & Medicaid Services

            
	
              CPTET

            	
              Centro de Prevención y Tratamiento de Enfermedades Transmisibles, or Communicable Diseases Prevention and Treatment Center

            
	
              DME

            	
              Durable Medical Equipment

            
	
              DOJ

            	
              The Puerto Rico Department of Justice

            
	DSM	
              Diagnostic and Statistical Manual for Mental Disorders

            
	
              ECHO

            	
              Experience of Care and Health Outcomes Survey

            
	
              ECM

            	
              Electronic Claims Management

            
	
              EDI

            	
              Electronic Data Interchange

            
	
              EFT

            	
              Electronic Funds Transfer

            
	
              EIN

            	
              Employer Identification Number

            
	
              EMTALA

            	
              Emergency Medical Treatment and Labor Act

            


      

      

      
        Page 30 of 324

        
          


      

      	
              EPLS

            	
              Excluded Parties List System

            
	
              EPSDT

            	
              Early and Periodic Screening, Diagnostic, and Treatment

            
	
              EQRO

            	
              External Quality Review Organization

            
	
              ER

            	
              Emergency Room

            
	
              FAR

            	
              Federal Acquisition Regulation

            
	
              FMC

            	
              Formulary of Medications Covered

            
	
              FDA

            	
              Food and Drug Administration

            
	
              FFS

            	
              Fee-for-Service

            
	
              FQHC

            	
              Federally Qualified Health Center

            
	
              FTP

            	
              File Transfer Protocol

            
	
              GHP

            	
              Government Health Plan

            
	
              HEDIS

            	
              The Health Care Effectiveness Data and Information Set

            
	
              HCIP

            	
              Health Care Improvement Program

            
	
              HHS

            	
              US Department of Health & Human Services

            
	
              HHS-OIG

            	
              US Department of Health & Human Services Office of the Inspector General

            
	
              HIE

            	
              Health Information Exchange

            
	
              HIO

            	
              Health Information Organization

            
	
              HIPAA

            	
              Health Insurance Portability and Accountability Act of 1996

            
	
              HITECH

            	
              The Health Information Technology for Economic and Clinical Health Act of 2009, 42 USC 17391 et. seq

            
	
              IBNR

            	
              Incurred-But-Not-Reported

            
	
              ICD-10

            	
              International Statistical Classification of Diseases and Related Health
                      Problems (10th edition)

            
	
              LEIE

            	
              List of Excluded Individuals and Entities

            
	
              LME

            	
              List of Medications by Exception

            
	
              MAC

            	
              Maximum Allowable Cost

            
	
              M-CHAT

            	
              Modified Checklist for Autism in Toddlers

            
	
              MCO

            	
              Managed Care Organization

            
	
              MD

            	
              Medical Doctor

            
	
              MHSIP

            	
              Mental Health Statistics Improvement Program

            
	
              MMIS

            	
              Medicaid Management Information System

            
	
              NCQA

            	
              National Committee for Quality Assurance

            
	
              NEMT

            	
              Non-Emergency Medical Transportation

            


      

      

      
        Page 31 of 324

        
          


      

      	
              NPI

            	
              National Provider Identifier

            
	
              NPL

            	
              National Provider List

            
	
              NPPES

            	
              National Plan and Provider Enumeration System

            
	
              NQMC

            	
              National Quality Measures Clearinghouse

            
	
              ONCHIT

            	
              Office of the National Coordinator for Health Information Technology

            
	
              P&T

            	
              Pharmacy and Therapeutics

            
	
              PBM

            	
              Pharmacy Benefit Manager

            
	
              PCP

            	
              Primary Care Physician

            
	
              PHI

            	
              Protected Health Information

            
	
              PIP

            	
              Performance Improvement Projects

            
	
              PMG

            	
              Primary Medical Group

            
	
              PPA

            	
              Pharmacy Program Administrator

            
	
              PPACA

            	
              Patient Protection and Affordable Care Act

            
	
              PPN

            	
              Preferred Provider Network

            
	
              PRHIEC

            	
              Puerto Rico Health Information Exchange Corporation

            
	
              QAPI

            	
              Quality Assessment Performance Improvement Program

            
	
              RFP

            	
              Request for Proposals

            
	
              Rh

            	
              Rhesus

            
	
              RHC

            	
              Rural Health Clinic/Center

            
	
              SAMHSA

            	
              Substance Abuse and Mental Health Services Administration

            
	
              SAS

            	
              Statements on Auditing Standards

            
	
              SMI

            	
              Serious Mental Illness

            
	
              SED

            	
              Serious Emotional Disturbance

            
	
              SSN

            	
              Social Security Number

            
	
              SUDs

            	
              Substance Use Disorders

            
	
              TDD

            	
              Telecommunication Device for the Deaf

            
	
              TPL

            	
              Third Party Liability

            
	
              UM

            	
              Utilization Management

            
	
              US or USA

            	
              United States of America

            
	
              USC

            	
              United States Code

            


       

      

      
        Page 32 of 324

        
          


      

      
        
          	ARTICLE 4	
                  ASES RESPONSIBILITIES

                


        

      

       

      
        
          	

                	4.1	
                  General Provision

                


        

      

       

      
        
          	

                	4.1.1	
                  ASES will be responsible for administering the GHP. ASES will administer contracts, monitor Contractors’ performance, and provide oversight of all aspects of the
                      Contractors’ operations.

                


        

      

       

      
        
          	

                	4.2	
                  Legal Compliance

                


        

      

       

      
        
          	

                	4.2.1	
                  ASES will comply with, and will monitor the Contractor’s compliance with, all applicable Puerto Rico and Federal laws and regulations, including but not limited to those
                      listed in Attachment 1 to this Contract.

                


        

      

       

      
        
          	

                	4.3	
                  Coordination with Contractor’s Key Staff

                


        

      

       

      
        
          	

                	4.3.1	
                  ASES will make diligent, good-faith efforts to facilitate effective and continuous communication and coordination with the Contractor in all areas of the GHP operations.

                


        

      

       

      
        
          	

                	4.3.2	
                  Specifically, ASES will designate individuals within ASES who will serve as liaisons to corresponding individuals on the Contractor’s staff, including:

                


        

      

       

      
        
          	

                	4.3.2.1	
                  A program integrity staff member;

                


        

      

       

      
        
          	

                	4.3.2.2	
                  A quality oversight staff member;

                


        

      

       

      
        
          	

                	4.3.2.3	
                  A financial management staff member;

                


        

      

       

      
        
          	

                	4.3.2.4	
                  A Grievance and Appeal System staff member; and

                


        

      

       

      
        
          	

                	4.3.2.5	
                  An Information Systems coordinator.

                


        

      

       

      
        
          	

                	4.4	
                  Information Systems and Reporting

                


        

      

       

      
        
          	

                	4.4.1	
                  ASES reserves the right to modify, expand, or delete the requirements contained in Article 17 with respect to the Data that Contractor is required to submit to ASES, or
                      to issue new requirements, subject to consultation with Contractor and to cost negotiation, if necessary. Unless otherwise stipulated in the Contract or mutually agreed upon by the Parties, the Contractor shall have ninety (90)
                      Calendar Days from the day on which ASES issues notice of a required modification, addition, or deletion, to comply with the modification, addition, or deletion. Any payment made by ASES that is based on data submitted by the
                      Contractor is contingent upon the Contractor’s compliance with the Certification requirements contained in 42 CFR 438.606.

                


        

      

       

      
        
          	

                	4.4.2	
                  ASES will make available a secure FTP server, accessible via the Internet, for receipt of electronic files and reports from the Contractor. The Contractor shall provide a
                      similar system for ASES to transmit files and reports deliverable by ASES to the Contractor. When such systems are not operational, ASES and the Contractor shall agree mutually on alternate methods for the exchange of files.

                


        

      

       

      
        Page 33 of 324

        
          


      

      
        
          	

                	4.4.3	
                  ASES will deliver to the Contractor the following information:

                


        

      

       

      
        
          	

                	4.4.3.1	
                  On a Daily Basis:

                


        

      

       

      
        
          	

                	4.4.3.1.1	
                  Certifications and Negative Redetermination Decisions;

                


        

      

       

      
        
          	

                	4.4.3.1.2	
                  Enrollment rejections and errors.

                


        

      

       

      
        
          	

                	4.4.3.2	
                  On a Daily and monthly Basis: Eligibility Data (including Certification and Negative Redetermination Decisions); and

                


        

      

       

      
        
          	

                	4.4.3.3	
                  On a monthly Basis: PMPM Payments.

                


        

      

       

      
        
          	

                	4.5	
                  Readiness Review

                


        

      

       

      
        
          	

                	4.5.1	
                  ASES shall conduct readiness reviews of the Contractor’s operations three (3) months before the start of a new managed care program and when the Contractor will provide
                      or arrange for the provision of Covered Services to new eligibility groups. Such review will include, at a minimum, one (1) on-site review, at dates and times to be determined by ASES. These reviews may include, but are not limited
                      to, desk and on-site reviews of documents provided by the Contractor, walk-through(s) of the Contractor’s facilities, Information System demonstrations, and interviews with the Contractor’s staff. ASES will conduct the readiness
                      review to confirm that the Contractor is capable and prepared to perform all Administrative Functions and to provide high-quality services to GHP Enrollees.

                


        

      

       

      
        
          	

                	4.5.2	
                  The Contractor shall submit policies and procedures and other Deliverables specified by ASES in accordance with Attachment 12 to this Contract. The Contractor shall make
                      any changes requested by ASES to policies and procedures or other Deliverables in the timeframes specified by ASES.

                


        

      

       

      
        
          	

                	4.5.3	
                  ASES’s review will document the status of the Contractor’s compliance with the program standards set forth in this Contract. A multidisciplinary team appointed by ASES
                      will conduct the readiness review. The scope of the readiness review will include, but not be limited to, the review and/or verification of:

                


        

      

       

      
        
          	

                	4.5.3.1	
                  Provider Network composition and Access;

                


        

      

       

      
        
          	

                	4.5.3.2	
                  Staff;

                


        

      

       

      
        
          	

                	4.5.3.3	
                  Provider Credentialing;

                


        

      

       

      
        Page 34 of 324

        
          


      

      
        
          	

                	4.5.3.4	
                  Call Center;

                


        

      

       

      
        
          	

                	4.5.3.5	
                  Care Management;

                


        

      

       

      
        
          	

                	4.5.3.6	
                  Marketing Materials;

                


        

      

       

      
        
          	

                	4.5.3.7	
                  Content of Provider contracts;

                


        

      

       

      
        
          	

                	4.5.3.8	
                  EPSDT plan;

                


        

      

       

      
        
          	

                	4.5.3.9	
                  Enrollee services capability;

                


        

      

       

      
        
          	

                	4.5.3.10	
                  Comprehensiveness of Quality and Utilization Management strategies;

                


        

      

       

      
        
          	

                	4.5.3.11	
                  Policies and procedures for the Grievance and Appeal System;

                


        

      

       

      
        
          	

                	4.5.3.12	
                  Financial management, including financial reporting and monitoring and financial solvency;

                


        

      

       

      
        
          	

                	4.5.3.13	
                  Contractor litigation history, current litigation, audits and other government investigations both in Puerto Rico and in other jurisdictions;

                


        

      

       

      
        
          	

                	4.5.3.14	
                  Information Systems management, including claims management, encounter data and enrollment information management, systems performance, interfacing capabilities, and
                      security management functions and capabilities; and

                


        

      

       

      
        
          	

                	4.5.3.15	
                  All other matters which ASES may deem reasonable in order to determine the Contractor’s compliance with the requirements of this Contract.

                


        

      

       

      
        
          	

                	4.5.4	
                  The readiness review may assess the Contractor’s ability to meet any requirements set forth in this Contract and the documents referenced herein.

                


        

      

       

      
        
          	

                	4.5.5	
                  Potential Enrollees may not be enrolled in a GHP Plan until ASES has determined that the Contractor is capable of meeting these standards. A Contractor’s failure to pass
                      the readiness review may result in immediate Contract termination. If the Contract is terminated in accordance with this Section 4.5.5 of this Contract, ASES shall not make any payments to the Contractor and shall have no liability
                      for any costs incurred by the Contractor.

                


        

      

       

      
        
          	

                	4.5.6	
                  ASES will provide the Contractor with a summary of findings from the readiness review, as well as areas requiring remedial action with the timeframes to correct the
                      findings.

                


           

          

        

        
          Page 35 of 324

          
            


        

      

      
        
          	ARTICLE 5	
                  ELIGIBILITY AND ENROLLMENT

                


        

      

       

      
        
          	

                	5.1	
                  Eligibility

                


        

      

       

      
        
          	

                	5.1.1	
                  The Government has sole authority to determine eligibility for the GHP, as provided in Federal law and Puerto Rico’s State Plan, with respect to the Medicaid and CHIP
                      Eligibles; and, with respect to the Other Eligible Persons listed in Section 1.3.1.2, as provided in Article VI, Section 5 of Act 72 and other Puerto Rico law and regulation.

                


        

      

       

      
        
          	

                	5.1.2	
                  The Puerto Rico Medicaid Program’s determination that a person is eligible for the GHP is contained on Form MA-10, titled “Notification of Action Taken on Application
                      and/or Recertification.” A person who has received an MA-10 shall be referred to hereinafter as a “Potential Enrollee.” The Potential Enrollee may access Covered Services using the MA-10 as a temporary Enrollee ID Card from the first
                      day of the eligibility period specified on the MA-10 even if the person has not received an Enrollee ID Card. Only Medicaid, CHIP, and State Enrollees receive an MA-10 and may access Covered Services with the MA-10 as a temporary
                      Enrollee ID Card.

                


        

      

       

      
        
          	

                	5.1.3	
                  Effective Date of Eligibility. ASES shall provide the Effective Date of Eligibility for services under the GHP to the Contractor for all Potential Enrollees as follows:

                


        

      

       

      
        
          	

                	5.1.3.1	
                  Effective Date of Eligibility for Medicaid and CHIP Eligibles (see Section 1.3.1.1) is the eligibility period specified on the Form MA-10 which is the first day of the
                      month in which the Potential Enrollee submits its eligibility application with the Medicaid Program Office and they shall be eligible to be enrolled as of that date. For Medicaid and Chip populations, the eligibility period specified
                      on the MA-10 may be retroactive up to three (3) months before the first day of the month in which the Potential Enrollee submits its eligibility application with the Medicaid Program Office. Retroactive eligibility is calculated
                      independently for each of the three (3) months for which retroactive eligibility may be granted and during which services may be retroactively covered.

                


        

      

       

      
        
          	

                	5.1.3.2	
                  Effective Date of Eligibility for the State Population (see Section 1.3.1.2.1) is








                      the eligibility period specified on the Form MA-10 and they shall be eligible to be enrolled as of that date.

                


        

      

       

      
        
          	

                	5.1.3.3	
                  Public employees and pensioners (see Section 1.3.1.2) shall be eligible to enroll in the GHP according to policies determined by the Government and their eligibility,
                      Enrollment and Disenrollment processes and timeframes shall be determined through such policies. The Puerto Rico Medicaid Program and ASES do not play a role in determining the eligibility for public employees and pensioners, except
                      in cases where the employee or pensioner seeks coverage based on income and the Medicaid Program evaluates whether income eligibility standards are met.

                


        

      

       

      
        Page 36 of 324

        
          


      

      
        
          	

                	5.1.3.4	
                  Effective Date of Eligibility for Enrollees that have been Recertified is the date immediately following the expiration of the twelve (12) month period.

                


        

      

       

      
        
          	

                	5.1.4	
                  Termination of Eligibility

                


        

      

       

      
        
          	

                	5.1.4.1	
                  A Medicaid, CHIP, or State Enrollee who is determined ineligible for the GHP after a Redetermination conducted by the Puerto Rico Medicaid Program shall remain eligible
                      for services under the GHP until the eligibility expiration date specified in the MA-10 issued by the Puerto Rico Medicaid Program for the current period of eligibility. This rule applies unless the Enrollee notifies the Puerto Rico
                      Medicaid Program that their circumstances of eligibility have changed or as otherwise stated in Attachment 9 to this Contract.

                


        

      

       

      
        
          	

                	5.1.4.2	
                  An Enrollee who is a public employee or pensioner (see Section 1.3.1.2) shall remain eligible until disenrolled from the GHP by the applicable Government agency.

                


        

      

       

      
        
          	

                	5.1.5	
                  ASES Notice to Contractor

                


        

      

       

      
        
          	

                	5.1.5.1	
                  ASES will receive a file with Certification and Negative Redetermination Decision Data from the Puerto Rico Medicaid Program on a Daily Basis concerning the Enrollment
                      status of the Medicaid, CHIP, and State Populations, and shall notify the Contractor of a Certification or Negative Redetermination Decision within one (1) Business Day of receiving notice of it via said file. ASES shall forward these
                      Data to the Contractor in an electronic format agreed to between the Parties (the “Daily Update/Carrier Eligibility File Format”).

                


        

      

       

      
        
          	

                	5.1.5.2	
                  The applicable Government agency will directly notify the Contractor of the Enrollment and Disenrollment status of public employees and pensioners.

                


        

      

       

      
        
          	

                	5.2	
                  Enrollment

                


        

      

       

      
        
          	

                	5.2.1	
                  The Contractor shall coordinate with ASES as necessary for all Enrollment and Disenrollment functions.

                


        

      

       

      
        
          	

                	5.2.1.1	
                  The Contractor shall accept all Potential Enrollees into its Plan without restrictions, unless otherwise authorized by ASES. The Contractor shall not discriminate against
                      individuals eligible to enroll on the basis of religion, race, color, national origin, sex, sexual orientation, gender identity, or disability, and will not use any policy or practice that has the effect of discriminating on the basis
                      of religion, race, color, national origin, sex, sexual orientation, gender identity, or disability on the basis of health, health status, pre-existing condition, or need for health care services.

                


        

      

       

      
        Page 37 of 324

        
          


      

      
        
          	

                	5.2.1.2	
                  The Contractor shall maintain adequate capacity to ensure prompt and voluntary Enrollment of all Potential Enrollees on a Daily Basis and in the order in which they apply or are Auto-Enrolled by ASES per Section 5.2.4.

                


        

      

       

      
        
          	

                	5.2.1.3	
                  The Contractor shall provide Potential Enrollees with specific Information allowing for prompt, voluntary, and reliable Enrollment.

                


        

      

       

      
        
          	

                	5.2.1.4	
                  The Contractor guarantees the maintenance, functionality, and reliability of all systems necessary for Enrollment and Disenrollment.

                


        

      

       

      
        
          	

                	5.2.2	
                   Effective Date of Enrollment

                


        

      

       

      
        
          	

                	5.2.2.1	
                  Except as provided below, Enrollment, whether chosen or automatic, will be effective (hereinafter referred to as the “Effective Date of Enrollment”) the same date as the
                      period of eligibility specified on the MA-10.

                


        

      

       

      
        
          	

                	5.2.2.1.1	
                  The Effective Date of Enrollment for all Initial Auto-Enrollment Enrollees is November 1, 2018.

                


        

      

       

      
        
          	

                	5.2.2.2	
                  Changes in Enrollment requested by the Enrollee received during the first twenty (20) Calendar Days of the month will be effective the first Calendar Day of the following
                      month (e.g., requests received January 10th will be effective February 1st).


                      Changes in Enrollment received after the first twenty (20) Calendar Days of the month will be effective the first Calendar Day of the second month following the request to change Enrollment (e.g., requests received January 25th will be effective March 1st).

                


        

      

       

      
        
          	

                	5.2.2.3	
                  Effective Date of Enrollment for Newborns. The Effective Date of Enrollment for a newborn whose mother is Medicaid or CHIP Eligible on the date of delivery (Deemed Newborn) is the date of his or her birth. The Effective Date of
                      Enrollment for a newborn whose mother is a State Population Enrollee is the Effective Date of Eligibility established by the Puerto Rico Medicaid Program. A newborn shall be Auto-Enrolled pursuant to the procedures set forth in
                      Section 5.2.6.

                


        

      

       

      
        Page 38 of 324

        
          


      

      
        
          	

                	5.2.3	
                  Term of Enrollment. The Term of Enrollment with Contractor shall be a period of twelve (12)
                      consecutive months for all GHP Enrollees, unless a different contractor is selected during the applicable Open Enrollment Period described in Section 5.2.5, and except in cases in which the Puerto Rico Medicaid Program has designated
                      an eligibility period shorter than twelve (12) months for an Enrollee who is a Medicaid or CHIP Eligible or a member of the State Population, in which case that same period shall also be considered the Enrollee’s Term of Enrollment.
                      Such a shortened eligibility period may apply, at the discretion of the Puerto Rico Medicaid Program, when an Enrollee is pregnant, is homeless, or anticipates a change in status (such as receipt of unemployment benefits or in family
                      composition). Notwithstanding this Section, Section 5.3.3 controls the Effective Date of Disenrollment.

                


        

      

       

      
        
          	

                	5.2.3.1	
                  Deemed Newborns have a Term of Enrollment of up to thirteen (13) months.

                


        

      

       

      
        
          	

                	5.2.3.2	
                  Pregnant Enrollees with a Term of Enrollment that expires during pregnancy or within sixty (60) Calendar Days of the post-partum period shall have an extended Term of
                      Enrollment that expires on the last day of the month after sixty (60) Calendar days counted from the beginning of the post-partum period.

                


        

      

       

      
        
          	

                	5.2.3.3	
                  Except as otherwise provided in this Section 5.2, and notwithstanding the Term of Enrollment provided in Section 5.2.3, Enrollees shall remain enrolled in the
                      Contractor’s Plan until the occurrence of an event listed in Section 5.3 (Disenrollment).

                


        

      

       

      
        
          	

                	5.2.4	
                  Auto-Enrollment. ASES shall apply an algorithm developed in accordance with the requirements
                      in 42 CFR 438.54 to conduct Initial Auto-Enrollment prior to November 1, 2018. The Contractor shall have the policies and procedures necessary, and as shall be approved in writing by ASES, to comply with Initial Auto-Enrollment as of
                      the Effective Date of the Contract for the Medicaid and CHIP Eligibles and members of the State Population, excluding State Employees eligible under Law 95.

                


        

      

       

      
        
          	

                	5.2.4.1	
                  The Foster Care Population and Domestic Violence Population will be Auto-Enrolled in one contractor’s plan and are not eligible to enroll into another contractor’s plan.

                


        

      

       

      
        
          	

                	5.2.5	
                  Open Enrollment Periods

                


        

      

       

      
        
          	

                	5.2.5.1	
                  Initial Auto-Enrollment Enrollees. Initial Auto-Enrollment Enrollees will have one (1)
                      opportunity to change contractors without cause during their Open Enrollment Period, which shall begin on November 1, 2018 and end on January 31, 2019.

                


        

      

       

      
        
          	

                	5.2.5.2	
                  New Enrollees. New Enrollees to the GHP will have the opportunity to select a contractor
                      during the Medicaid eligibility process with the Puerto Rico Medicaid Program. If the New Enrollee does not select a contractor, the Puerto Rico Medicaid Program will select a contractor on behalf of the New Enrollee. New Enrollees
                      shall be permitted to select a different contractor once without cause, regardless of how the initial selection of contractor was made, during their Open Enrollment Period, which shall begin on the New Enrollee’s Effective Date of
                      Enrollment.

                


        

      

       

      
        Page 39 of 324

        
          


      

      
        
          	

                	5.2.5.3	
                  All Enrollees. All Enrollees will have the opportunity to select a contractor without cause during the Annual Open Enrollment period.

                


        

      

       

      
        
          	

                	5.2.5.3.1	
                  If a New Enrollee’s Open Enrollment Period in Section 5.2.5.2 coincides with the Annual Open Enrollment Period, the Open Enrollment Period in Section 5.2.5.2 controls.

                


        

      

       

      
        
          	

                	5.2.5.4	
                  When an Enrollee ceases to be part of the Domestic Violence or Foster Care Populations but continues to be an Eligible Person, the Enrollee may select a new contractor
                      during an Open Enrollment Period.

                


        

      

       

      
        
          	

                	5.2.5.5	
                  When an Enrollee ceases to be eligible for the Platino Program but continues to be an Eligible Person, the Enrollee may select a new contractor during an Open Enrollment
                      Period.

                


        

      

       

      
        
          	

                	5.2.5.6	
                  If the Enrollee does not make a change in contractor during the Open Enrollment Period, the Enrollee will remain enrolled with his/her current contractor.

                


        

      

       

      
        
          	

                	5.2.6	
                  Enrollment Procedures for All Enrollees Except Newborns

                


        

      

       

      
        
          	

                	5.2.6.1	
                  Upon receipt of notices in accordance with Section 5.1.5 of this Contract, the Contractor shall comply with the Auto-Enrollment process and issue to the Enrollee a notice
                      informing the Enrollee of the PMG and PCP they are assigned to and their rights to change the PMG or PCP without cause during the applicable Open Enrollment Period. Effective November 1, 2018, such changes may be requested through
                      ASES’s designated enrollment counselor.

                


        

      

       

      
        
          	

                	5.2.6.2	
                  The Contractor shall issue to the Enrollee an Enrollee ID Card and a notice of Enrollment, as well as an Enrollee Handbook and Provider Directory either in paper or
                      electronic form, subject to the requirements of Section 6.10.8 and 6.10.9; or, such notice of Enrollment, an ID Card, an Enrollee Handbook, and a Provider Directory may be sent to the Enrollee via surface mail or electronically,
                      subject to the requirements of Section 6.10.8 and 6.10.9 within five (5) Business Days of Enrollment.

                


        

      

       

      
        Page 40 of 324

        
          


      

      
        
          	

                	5.2.6.3	
                  The notice of Enrollment that the Contractor issues will clearly state the Effective Date of Enrollment that applies per Section 5.2.2. The notice of Enrollment will
                      explain that the Enrollee is entitled to receive Covered Services through the Contractor. The notice will inform the Enrollee of his or her limited right to disenroll, per Section 5.3 of this Contract. The notice shall advise the
                      Enrollee of the Enrollee’s right to select a different PCP or to change PMGs, as described in Section 5.4, and will encourage the Enrollee to pursue this option if he or she is dissatisfied with care or services.

                


        

      

       

      
        
          	

                	5.2.6.3.1	
                  All Enrollees must be notified at least annually of their disenrollment rights as set forth in Section 5.3 and 42 CFR 438.56. Such notification must clearly explain the
                      process for exercising this disenrollment right, as well as the alternatives available to the Enrollee based on their specific circumstance.

                


        

      

       

      
        
          	

                	5.2.7	
                  Procedures for Auto-Enrollment of Newborns

                


        

      

       

      
        
          	

                	5.2.7.1	
                  The Contractor shall notify ASES and the Puerto Rico Medicaid Program in writing of any Enrollees who are expectant mothers Immediately at the moment of diagnosis of the
                      pregnancy or at least sixty (60) Calendar Days before the expected date of delivery.

                


        

      

       

      
        
          	

                	5.2.7.2	
                  The Contractor shall promptly, upon learning that an Enrollee is an expectant mother, mail a newborn Enrollment packet to the expectant mother (i) instructing her to
                      register the newborn with the Puerto Rico Medicaid Program within ninety (90) Calendar Days of birth by providing evidence of the newborn’s birth; (ii) notifying an expectant mother that is a Medicaid or CHIP Enrollee that the Deemed
                      Newborn will be Auto-Enrolled in the GHP; (iii) informing an expectant mother that is a Medicaid or CHIP Enrollee that unless she visits the Contractor’s office to select a PMG and PCP, the Deemed Newborn will be Auto-Assigned to the
                      mother’s PMG and to a PCP who is a pediatrician; and (iv) informing the expectant mother that she will have ninety (90) Calendar Days after the date in which the Puerto Rico Medicaid Program notifies that the Deemed Newborn has been
                      registered to disenroll from Plan or to change the child’s PMG and PCP, without cause.

                


        

      

       

      
        
          	

                	5.2.7.3	
                  The Contractor shall provide assistance to any expectant mother or guardian who contacts the Contractor wishing to make a PCP and PMG selection for her newborn and record
                      that selection, per Section 5.4.

                


        

      

       

      
        
          	

                	5.2.7.4	
                  If the mother or guardian has not made a PCP and PMG selection at the time of the Deemed Newborn’s birth, the Contractor shall, within one (1) Business Day of the birth,
                      Auto-Assign the Deemed Newborn to a PCP who is a pediatrician and to the Contact Member’s PMG.

                


        

      

       

      
        Page 41 of 324

        
          


      

      
        
          	

                	5.2.7.5	
                  Within one (1) Business Day of acknowledging, either by concurrent review or hospital notification of the birth of a Deemed Newborn to a Medicaid or CHIP Enrollee, the
                      Contractor shall ensure the submission of a newborn notification form to ASES and to the Puerto Rico Medicaid Program; such form shall be given prior written approval by ASES and the Puerto Rico Medicaid Program.

                


        

      

       

      
        
          	

                	5.2.7.6	
                  The Contractor shall participate in any meeting, working group, or other mechanism requested by ASES in order to ensure coordination among the Contractor, ASES, and the
                      Puerto Rico Medicaid Program in order to implement Deemed Newborn Auto-Enrollment.

                


        

      

       

      
        
          	

                	5.2.8	
                  Contractor Notification Procedures Related to Redeterminations and Open Enrollment Periods

                


        

      

       

      
        
          	

                	5.2.8.1	
                  The Contractor shall inform Enrollees who are Medicaid- and CHIP Eligibles and members of the State Population of an impending Redetermination through written notices.
                      Such notices shall be provided ninety (90) Calendar Days, sixty (60) Calendar Days, and thirty (30) Calendar Days before the scheduled date of the Redetermination.

                


        

      

       

      
        
          	

                	5.2.8.1.1	
                  The written notices shall inform the Enrollee that, if he or she is Recertified, his or her Term of Enrollment with the Contractor’s Plan will automatically renew unless
                      a different contractor is selected during the Open Enrollment Period described in Section 5.2.5.3. The written notices must also specify that the Enrollee may change his or her PMG and/or PCP selection without cause during the
                      applicable Open Enrollment Period.

                


        

      

       

      
        
          	

                	5.2.8.2	
                  The Contractor shall provide Enrollees and their representatives with sixty (60) Calendar Days written notice before the start of the Open Enrollment Period described in
                      Section 5.2.5.3 of the right to disenroll or to change PMG or PCP without cause during such Open Enrollment Period.

                


        

      

       

      
        
          	

                	5.2.8.3	
                  Upon the receipt of written request from ASES, the Contractor shall provide a report for a specific period of time containing documentation that the Contractor has
                      furnished the notices required in this Section 5.2.7.

                


        

      

       

      
        Page 42 of 324

        
          


      

      
        
          	

                	5.2.8.4	
                  The form letters used for the notices in this Section 5.2.8 shall fall within the requirements in Section 6.2.1 that the Contractor seek advance written approval from
                      ASES of certain documents.

                


        

      

       

      
        
          	

                	5.2.9	
                  Specific Contractor Responsibilities Regarding Dual Eligible Beneficiaries. At the time of
                      Enrollment, the Contractor shall provide Potential Enrollees who are Medicaid-eligible and are also eligible for Medicare Part A or Medicare Part A and Part B (“Dual Eligible Beneficiaries”) with the information about their Covered
                      Services and Co-Payments that is listed in Section 6.13. Members of the State Population (see section 1.3.1.2.1) who are Medicare-eligible shall not be considered Dual Eligible Beneficiaries.

                


        

      

       

      
        
          	

                	5.3	
                  Disenrollment

                


        

      

       

      
        
          	

                	5.3.1	
                  Disenrollment occurs only when the Medicaid Program determines that an Enrollee is no longer eligible for the GHP; or when Disenrollment is requested by the Contractor or
                      Enrollee, and approved by ASES, as provided in Sections 5.3.4 and 5.3.5. The Foster Care Population and Domestic Violence Populations may not disenroll from their Auto-Enrolled GHP Plan.

                


        

      

       

      
        
          	

                	5.3.2	
                  All Disenrollments will be processed by ASES, and ASES will issue notification to the Contractor. Such notice shall be delivered via file transfer to the Contractor on a
                      Daily Basis simultaneously with Information on Potential Enrollees within five (5) Calendar Days of a final determination on Disenrollment.

                


        

      

       

      
        
          	

                	5.3.2.1	
                  Disenrollment decisions and processing are the responsibility of the Puerto Rico Medicaid Program and ASES; however, notice to Enrollees of Disenrollment shall be issued
                      by the Contractor. The Contractor shall issue such notice in person or via surface mail to the Enrollee within five (5) Business Days of a final Disenrollment decision, as provided in Sections 5.3.4 and 5.3.5.

                


        

      

       

      
        
          	

                	5.3.2.2	
                  Each notice of Disenrollment shall include information concerning:

                


        

      

       

      
        
          	

                	5.3.2.2.1	
                  The Effective Date of Disenrollment;

                


        

      

       

      
        
          	

                	5.3.2.2.2	
                  The reason for the Disenrollment;

                


        

      

       

      
        
          	

                	5.3.2.2.3	
                  The Enrollee’s right to request a Reconsideration from ASES and of ASES’s Administrative Law Hearing process, as provided by Act 72 of September 7, 1993;

                


        

      

       

      
        
          	

                	5.3.2.2.4	
                  The right to re-enroll in the GHP upon receiving a Recertification from the Puerto Rico Medicaid Program, if applicable; and

                


        

      

       

      
        Page 43 of 324

        
          


      

      
        
          	

                	5.3.2.2.5	
                  Disenrollment shall occur according to the timeframes in Section 5.3.3 (the “Effective Date of Disenrollment”).

                


        

      

       

      
        
          	

                	5.3.3	
                  The Effective Date of Disenrollment is as follows:

                


        

      

       

      
        
          	

                	5.3.3.1	
                  Except as otherwise provided in this Section 5.3, Disenrollment will take effect as of the Effective Date of Disenrollment specified in the daily eligibility file sent to
                      the Contractor by ASES as set forth in Attachment 9 to this Contract.

                


        

      

       

      
        
          	

                	5.3.3.2	
                  When Disenrollment is effectuated at the Contractor’s or the Enrollee’s request, as provided in Sections 5.3.4 and 5.3.5 of this Contract, Disenrollment shall take effect
                      no later than the first day of the second month following the month that the Contractor or Enrollee requested the Disenrollment. If ASES fails to make a decision on the Enrollee’s request before this date, the Disenrollment will be
                      deemed granted. If the Enrollee’s request is denied by ASES, the Enrollee may request, verbally or in writing, a Reconsideration by ASES and the Reconsideration process shall be completed in time to permit the Disenrollement (if
                      approved) to take effect in accordance with this timeframe.

                


        

      

       

      
        
          	

                	5.3.3.3	
                  If an Enrollee is no longer eligible under the GHP, and Disenrollment under this Section 5.3.3 falls:

                


        

      

       

      
        
          	

                	5.3.3.3.1	
                  When the Enrollee is an inpatient at a hospital, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of the month in which the
                      Enrollee is discharged from the hospital, or the last day of the month following the month in which Disenrollment would otherwise be effective, whichever occurs earlier;

                


        

      

       

      
        
          	

                	5.3.3.3.2	
                  During a month in which a Medicaid, CHIP or State Enrollee is pregnant, or on the date the pregnancy ends, ASES shall postpone the Effective Date of Disenrollment so that
                      it occurs on the last day of the month in which the 60-day post-partum period ends;

                


        

      

       

      
        
          	

                	5.3.3.3.3	
                  When the Enrollee is in the process of appealing a denial of a Disenrollment request by ASES through either ASES’s Reconsideration process, ASES’s Administrative Law
                      Hearing process (after exhausting the Reconsideration process), or the Puerto Rico Medicaid Department’s dedicated hearing process on Disenrollments due to loss of eligibility, as applicable, then ASES shall postpone the Effective
                      Date of Disenrollment until a decision is rendered after the hearing; or

                


        

      

       

      
        Page 44 of 324

        
          


      

      
        
          	

                	5.3.3.3.4	
                  During a month in which an Enrollee is diagnosed with a Terminal Condition, ASES shall postpone the Effective Date of Disenrollment so that it occurs on the last day of
                      the following month.

                


        

      

       

      
        
          	

                	5.3.3.4	
                  For the public employees and pensioners who are Other Eligible Persons referred to in Section 1.3.1.2.2, Disenrollment shall occur according to the timeframes set forth
                      in a Normative Letter issued by ASES annually.

                


        

      

       

      
        
          	

                	5.3.4	
                  Disenrollment Initiated by the Contractor

                


        

      

       

      
        
          	

                	5.3.4.1	
                  The Contractor has a limited right to request that an Enrollee be disenrolled without the Enrollee’s consent. The Contractor shall notify ASES upon identification of an
                      Enrollee who it knows or believes meets the criteria for Disenrollment.

                


        

      

       

      
        
          	

                	5.3.4.2	
                  The Contractor shall submit Disenrollment requests to ASES, and the Contractor shall honor all Disenrollment determinations made by ASES. ASES’s decision on the matter
                      shall be final, conclusive, and not subject to appeal by the Contractor.

                


        

      

       

      
        
          	

                	5.3.4.3	
                  The following are acceptable reasons for the Contractor to request Disenrollment:

                


        

      

       

      
        
          	

                	5.3.4.3.1	
                  The Enrollee’s continued Enrollment in the Contractor’s Plan seriously impairs the ability to furnish services to either this particular Enrollee or other Enrollees;

                


        

      

       

      
        
          	

                	5.3.4.3.2	
                  The Enrollee demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and is not caused by a presenting illness;

                


        

      

       

      
        
          	

                	5.3.4.3.3	
                  The Enrollee’s use of services is fraudulent or abusive (for example, the Enrollee has loaned his or her Enrollee ID Card to other persons to seek services);

                


        

      

       

      
        
          	

                	5.3.4.3.4	
                  The Enrollee is placed in a long-term care nursing facility or intermediate care facility for the intellectually disabled;

                


        

      

       

      
        
          	

                	5.3.4.3.5	
                  The Enrollee’s Medicaid or CHIP eligibility category changes to a category ineligible for the GHP; or

                


        

      

       

      
        
          	

                	5.3.4.3.6	
                  The Enrollee has died or moved out of Puerto Rico, thereby making him or her ineligible for Medicaid or CHIP or is otherwise ineligible for the GHP.

                


        

      

       

      
        Page 45 of 324

        
          


      

      
        
          	

                	5.3.4.4	
                  ASES will approve a Disenrollment request by the Contractor, in ASES’s discretion, only if ASES determines:

                


        

      

       

      
        
          	

                	5.3.4.4.1	
                  That it is impossible for the Contractor to continue to provide services to the Enrollee without endangering the Enrollee or other GHP Enrollees; and

                


        

      

       

      
        
          	

                	5.3.4.4.2	
                  That an action short of Disenrollment, such as transferring the Enrollee to a different PCP or PMG, will not resolve the problem.

                


        

      

       

      
        
          	

                	5.3.4.5	
                  The Contractor may not request Disenrollment for any discriminatory reason including, but not limited, to the following:

                


        

      

       

      
        
          	

                	5.3.4.5.1	
                  Adverse changes in an Enrollee’s health status;

                


        

      

       

      
        
          	

                	5.3.4.5.2	
                  Missed appointments;

                


        

      

       

      
        
          	

                	5.3.4.5.3	
                  Utilization of medical services;

                


        

      

       

      
        
          	

                	5.3.4.5.4	
                  Diminished mental capacity;

                


        

      

       

      
        
          	

                	5.3.4.5.5	
                  Pre-existing medical condition;

                


        

      

       

      
        
          	

                	5.3.4.5.6	
                  The Enrollee’s attempt to exercise his or her rights under the Grievance and Appeal System; or

                


        

      

       

      
        
          	

                	5.3.4.5.7	
                  Uncooperative or disruptive behavior resulting from the Enrollee’s special needs.

                


        

      

       

      
        
          	

                	5.3.4.6	
                  The request of one (1) PMG to have an Enrollee assigned to a different PMG, per Section 5.4, shall not be sufficient cause for the Contractor to request that the Enrollee
                      be disenrolled from the Plan. Rather, the Contractor shall, if possible, assign the Enrollee to a different and available PMG within the Plan.

                


        

      

       

      
        
          	

                	5.3.4.7	
                  When requesting Disenrollment of an Enrollee for reasons described in Section 5.3.4.3, the Contractor shall document at least three (3) interventions over a period of
                      ninety (90) Calendar Days that occurred through treatment and Care Management to resolve any difficulty leading to the request. The Contractor shall also provide evidence of having given at least one (1) written warning to the
                      Enrollee, with a certified return receipt requested, regarding implications of his or her actions.

                


        

      

       

      
        
          	

                	5.3.4.8	
                  If the Enrollee has demonstrated abusive or threatening behavior as defined by ASES, only one (1) Contractor intervention, and a subsequent written attempt to resolve the
                      difficulty, are required.

                


        

      

       

      
        Page 46 of 324

        
          


      

      
        
          	

                	5.3.4.9	
                  In the event that the Contractor seeks Disenrollment of an Enrollee, the Contractor shall notify the Enrollee of the availability of ASES’s Reconsideration process and
                      Administrative Law Hearing process, as provided by Act 72 of September 7, 1993, as amended.

                


        

      

       

      
        
          	

                	5.3.4.10	
                  The Contractor shall maintain policies and procedures to comply with the Puerto Rico Patients’ Bill of Rights Act and with the Medicaid Regulations of 42 CFR 438.100, to
                      ensure that the Enrollee’s exercise of Grievance rights does not adversely affect the services provided to the Enrollee by the Contractor or by ASES.

                


        

      

       

      
        
          	

                	5.3.5	
                  Disenrollment Initiated by the Enrollee

                


        

      

       

      
        
          	

                	5.3.5.1	
                  All Enrollees must be notified at least annually of their disenrollment rights as set forth in Section 5.3 and 42 CFR 438.56. Such notification shall clearly explain the
                      process for exercising this disenrollment right, as well as the coverage alternatives available to the Enrollee based on their specific circumstance.

                


        

      

       

      
        
          	

                	5.3.5.2	
                  An Enrollee wishing to request Disenrollment must submit an oral or written request to ASES or to the Contractor. If the request is made to the Contractor, the Contractor
                      shall forward the request to ASES, within five (5) Business Days of receipt of the request, with a recommendation of the action to be taken.

                


        

      

       

      
        
          	

                	5.3.5.3	
                  An Enrollee may request Disenrollment from the Contractor’s Plan without cause once during the applicable Open Enrollment Period in accordance with Section 5.2.5.

                


        

      

       

      
        
          	

                	5.3.5.4	
                  An Enrollee may request Disenrollment from the Contractor’s Plan for cause at any time. ASES shall determine whether the reason constitutes a valid cause. The following
                      constitute cause for Disenrollment by the Enrollee:

                


        

      

       

      
        
          	

                	5.3.5.4.1	
                  The Enrollee moves outside of Puerto Rico;

                


        

      

       

      
        
          	

                	5.3.5.4.2	
                  The Contractor’s Plan does not, due to moral or religious objections, cover the health service the Enrollee seeks.

                


        

      

       

      
        
          	

                	5.3.5.4.3	
                  The Enrollee needs related services to be performed at the same time, and not all related services are available within the network. The Enrollee’s PCP or another
                      Provider in the Contractor’s Network have determined that receiving services separately would subject the Enrollee to unnecessary risk.

                


        

      

       

      
        
          	

                	5.3.5.4.4	
                  Other acceptable reasons for Disenrollment at Enrollee request, per 42 CFR 438.56(d)(2), including, but not limited to, poor quality of care, lack of Access to Covered
                      Services, or lack of Providers experienced in dealing with the Enrollee’s health care needs; and

                


        

      

       

      
        Page 47 of 324

        
          


      

      
        
          	

                	5.3.5.4.5	
                  The Enrollee has become eligible for a Platino Program, or has experienced a change in his or her eligibility as a member of the Domestic Violence or Foster Care
                      Populations.

                


        

      

       

      
        
          	

                	5.3.5.5	
                  If the Contractor fails to refer a Disenrollment request within the timeframe specified in Section 5.3.3, or if ASES fails to make a Disenrollment determination so that
                      the Enrollee may be disenrolled by the first day of the second month following the month when the Disenrollment request was made, per Section 5.3.3, the Disenrollment shall be deemed approved for the effective date that would have
                      been established had ASES or the Contractor complied with Section 5.3.3.

                


        

      

       

      
        
          	

                	5.3.5.6	
                  ASES shall make the final decision on Enrollees’ requests for Disenrollment. ASES may approve or disapprove the request based on the reasons specified in the Enrollee’s
                      request, or upon any relevant Information provided to ASES by the Contractor about the Disenrollment request.

                


        

      

       

      
        
          	

                	5.3.5.7	
                  If the Enrollee’s request for Disenrollment under this Section is denied, the Contractor shall provide the Enrollee with a notice of the decision in a format and content
                      consistent with Section 14.5.15. The notice shall include the grounds for the denial and shall inform the Enrollee of his or her right to use the Reconsideration process, and to have access to an Administrative Law Hearing after first
                      exhausting ASES’s Reconsideration process.

                


        

      

       

      
        
          	

                	5.3.5.8	
                  Use of the Contractor’s Grievance and Appeal System. ASES may at its option require that the
                      Enrollee seek redress through the Contractor’s Grievance and Appeal System before ASES makes a determination on the Enrollee’s request for Disenrollment. The Contractor shall Immediately inform ASES of the outcome of the Grievance
                      process. ASES may take this Information into account in making a determination regarding the request for Disenrollment. The Grievance process shall be completed in time to permit the Disenrollment (if approved) to be effective in
                      accordance with the timeframe specified in Section 5.3.3; if the process is not completed within the specified timeframe, then the Disenrollment will be deemed approved by ASES.

                


        

      

       

      
        
          	

                	5.3.6	
                  Disenrollment During Termination Hearing Process. If ASES notifies the Contractor of its
                      intention to terminate the Contract as provided in Article 35, ASES may allow Enrollees to disenroll Immediately without cause. In the event of such a Termination, ASES must provide Enrollees with the notice required by 42 CFR 438.10,
                      listing their options for receiving services following the Termination Date of the Contract.

                


        

      

       

      
        Page 48 of 324

        
          


      

      
        
          	

                	5.3.7	
                  ASES shall ensure, through the obligations of the Contractor under this Contract that Enrollees receive the notices contained in Section 5.2.7 (Re-Enrollment Procedures).
                      While these notices shall be issued by the Contractor, per Section 5.2.7, ASES shall provide the Contractor with the information on Certifications and Negative Redetermination Decisions (see Section 5.1.5.1) needed for the Contractor
                      to carry out this responsibility.

                


        

      

       

      
        
          	

                	5.3.8	
                  Enrollment Database

                


        

      

       

      
        
          	

                	5.3.8.1	
                  The Contractor shall maintain an Enrollment database that includes all Enrollees, and contains, for each Enrollee, the Information specified in the Carrier Billing
                      File/Carrier Eligibility File format.

                


        

      

       

      
        
          	

                	5.3.8.2	
                  The Contractor shall notify the Puerto Rico Medicaid Program Immediately when the Enrollment database is updated to reflect a change in the place of residence of an
                      Enrollee.

                


        

      

       

      
        
          	

                	5.3.8.3	
                  The Contractor shall secure any authorization required from Enrollees under the laws of Puerto Rico in order to allow the US Department of Health and Human Services, the
                      Medicaid Fraud Control Unit, ASES, and its Agents to review Enrollee Medical Records, in order to evaluate the Information and determine quality, appropriateness, timeliness, and cost of services performed under this Contract;
                      provided that such authorization shall be limited by the Contractor’s obligation to observe the confidentiality of Enrollees’ Protected Health Information, as provided in Article 34.

                


        

      

       

      
        
          	

                	5.3.9	
                  Notification to ASES and the PBM of New Enrollees and of Completed Disenrollments

                


        

      

       

      
        
          	

                	5.3.9.1	
                  The Contractor shall notify ASES and the PBM of new Enrollees and of completed Disenrollments on a routine Daily Basis; or at any time, if requested by ASES. Such
                      notification will be made through electronic transmissions.

                


        

      

       

      
        
          	

                	5.3.9.2	
                  The notification will include all new Enrollees as of the Business Day before the notification is issued, and will be sent no later than the following Business Day after
                      the Enrollment process has been completed (as signified by issuance of the Enrollee ID Card, either in person or by surface mail) or the Disenrollment process has been completed (as signified by the issuance of a Disenrollment
                      notice).

                


        

      

       

      
        
          	

                	5.3.10	
                  In the event that the Contractor must update information previously submitted to ASES about a new Enrollment, including a change in coverage code, or that the Contractor
                      must add a new Enrollee who was previously omitted, such update must occur the next Business Day after the information is updated or a new Enrollee is added. ASES reserves the authority not to accept any new additions or corrections
                      to a particular month’s Enrollment Data after two (2) Business Days past the date on which ASES notifies the Contractor of the rejected
                        subscriptions, as set forth in Attachment 9 to this Contract.

                


        

      

       

      
        Page 49 of 324

        
          


      

      
        
          	

                	5.4	
                  Change of a Primary Medical Group (“PMG”) and Primary Care Physician (“PCP”)

                


        

      

       

      
        
          	

                	5.4.1	
                  Change of a PMG and PCP

                


        

      

       

      
        
          	

                	5.4.1.1	
                  During the ninety (90) Calendar Days period following the Effective Date of Enrollment (the Open Enrollment Period), the Enrollee can change his/her Auto-Assigned or
                      selected PMG and PCP without cause. The Contractor can offer counseling and assistance to the Enrollee in selecting a different PCP and PMG. Enrollees under the Foster Care Population and Domestic Violence Population classification
                      are not assigned to a PCP or PMG.

                


        

      

       

      
        
          	

                	5.4.1.2	
                  The Contractor shall advise certain Enrollees to choose a physician other than, or in addition to, a general practice physician as their PCP, as follows:

                


        

      

       

      
        
          	

                	5.4.1.2.1	
                  Female Enrollees age twelve (12) and older will be recommended to choose an obstetrician/gynecologist as a PCP.

                


        

      

       

      
        
          	

                	5.4.1.2.2	
                  Enrollees under twenty-one (21) years of age will be recommended to choose a pediatrician as a PCP.

                


        

      

       

      
        
          	

                	5.4.1.2.3	
                  Enrollees with conditions that are included in HCHN Program in Section 7.8.3 will be recommended to choose an internist or other appropriate specialist as a PCP.

                


        

      

       

      
        
          	

                	5.4.1.3	
                  Per Section 5.2.7, following the Contractor’s notice to an expectant mother of a Deemed Newborn’s upcoming Auto-Enrollment in the Contractor’s Plan, the Contractor shall
                      record any notice it receives from the mother or guardian concerning the selection of a PCP or PMG for the Deemed Newborn. The Contractor shall ensure that such selections take effect as of the date of the Deemed Newborn’s birth.

                


        

      

       

      
        
          	

                	5.4.1.4	
                  In order to comply with the PMG Capitation payment process, if an Enrollee changes PCP/PMG during the first five (5) Calendar Days of the month, the change will be
                      effective in the next subsequent month of the change. If Enrollee changes PCP/PMG after the fifth (5th) day of the month, the change will be effective in
                      the second (2nd) subsequent month of the change. The Enrollee can still receive services until the change is effective from the originally assigned
                      PCP/PMG

                


        

      

       

      
        Page 50 of 324

        
          


      

      
        
          	

                	5.4.1.5	
                  The Contractor shall permit Enrollees to change their PMG or PCP at any time with cause. The following shall constitute cause for change of PMG or PCP:

                


        

      

       

      
        
          	

                	5.4.1.5.1	
                  The Enrollee’s religious or moral convictions conflict with the services offered by Providers in the PMG;

                


        

      

       

      
        
          	

                	5.4.1.5.2	
                  The Enrollee needs related services to be provided concurrently; not all services are available within the Preferred Provider Network associated with a PMG; and the
                      Enrollee’s PCP or any other Provider has determined that receiving the services separately could expose the Enrollee to an unnecessary risk; or

                


        

      

       

      
        
          	

                	5.4.1.5.3	
                  Other reasons, including a deterioration of the Provider-Enrollee relationship where the Enrollee no longer feels comfortable receiving services from the Provider, poor
                      quality of care, unavailability of appointments, inaccessibility to Covered Services, and inaccessibility to Providers with the experience to address the health care needs of the Enrollee.

                


        

      

       

      
        
          	

                	5.4.1.6	
                  The Contractor shall permit Enrollees to change their PMG and/or PCP for any reason, within certain timeframes:

                


        

      

       

      
        
          	

                	5.4.1.6.1	
                  During the ninety (90) Calendar Days following the Effective Date of Enrollment (Open Enrollment Period);

                


        

      

       

      
        
          	

                	5.4.1.6.2	
                  At least every twelve (12) months, following the ninety (90) Calendar Days after the Effective Date of Enrollment; or

                


        

      

       

      
        
          	

                	5.4.1.6.3	
                  At any time, during time periods in which the Contractor is subject to intermediate sanctions, as defined in 42 CFR 438.702(a)(3).

                


        

      

       

      
        
          	

                	5.4.1.7	
                  A Contractor may change an Enrollee’s PMG at the request of the PCP or another Provider within that PMG, in limited situations, when appropriately documented, as follows:

                


        

      

       

      
        
          	

                	5.4.1.7.1	
                  The Enrollee’s continued participation in the PMG seriously impairs the PMG’s ability to furnish services to either this particular Enrollee or other Enrollees;

                


        

      

       

      
        Page 51 of 324

        
          


      

      
        
          	

                	5.4.1.7.2	
                  The Enrollee demonstrates a pattern of disruptive or abusive behavior that could be construed as non-compliant and that is not caused by a presenting illness; or

                


        

      

       

      
        
          	

                	5.4.1.7.3	
                  The Enrollee’s use of services is fraudulent or abusive (for example, the Enrollee has loaned his or her Enrollee ID Card to other persons to seek services).

                


        

      

       

      
        
          	

                	5.5	
                  Transition of Care During Contractor Change

                


        

      

       

      
        
          	

                	5.5.1	
                  The Contractor must ensure continued access to services during an Enrollee’s transition from one Contractor to another by complying with the following:

                


        

      

       

      
        
          	

                	5.5.1.1	
                  Ensure the Enrollee has access to services consistent with the access they previously had, and is permitted to retain their current Provider for ninety (90) Calendar Days
                      if that Provider is not a Network Provider;

                


        

      

       

      
        
          	

                	5.5.1.2	
                  Refer Enrollee to appropriate Network Providers;

                


        

      

       

      
        
          	

                	5.5.1.3	
                  Fully and timely comply with requests for historical utilization data from the new contractor or other entity in compliance with Federal and State laws;

                


        

      

       

      
        
          	

                	5.5.1.4	
                  Ensure that the Enrollee’s new Provider is able to obtain copies of the Enrollee’s medical records, as appropriate;

                


        

      

       

      
        
          	

                	5.5.1.5	
                  Comply with any other necessary procedures specified by CMS or ASES to ensure continued access to services to prevent serious detriment to the Enrollee’s health or reduce
                      the risk of hospitalization or institutionalization.

                


        

      

      

      

      
        
          	ARTICLE 6	
                  ENROLLEE SERVICES

                


        

      

       

      
        
          	

                	6.1	
                  General Provisions

                


        

      

       

      
        
          	

                	6.1.1	
                  The Contractor shall have policies and procedures, prior approved by ASES and submitted in accordance with Attachment 12 to this Contract, that explain how it will ensure
                      that Enrollees and Potential Enrollees:

                


        

      

       

      
        
          	

                	6.1.1.1	
                  Are aware of their rights and responsibilities;

                


        

      

       

      
        
          	

                	6.1.1.2	
                  How to obtain physical and Behavioral Health Services;

                


        

      

       

      
        
          	

                	6.1.1.3	
                  What to do in an emergency or urgent medical situation;

                


        

      

       

      
        Page 52 of 324

        
          


      

      
        
          	

                	6.1.1.4	
                  How to request a Grievance, Appeal, or Administrative Law Hearing;

                


        

      

       

      
        
          	

                	6.1.1.5	
                  How to report suspected Incident of Fraud, Waste, and Abuse;

                


        

      

       

      
        
          	

                	6.1.1.6	
                  Have basic information on the basic features of managed care; and

                


        

      

       

      
        
          	

                	6.1.1.7	
                  Understand the Contractor’s responsibilities to coordinate Enrollee care.

                


        

      

       

      
        
          	

                	6.1.2	
                  The Contractor’s informational materials must convey to Enrollees and Potential Enrollees that GHP is an integrated program that includes both physical and Behavioral
                      Health Services, and must also explain the concepts of Primary Medical Groups and Preferred Provider Networks.

                


        

      

       

      
        
          	

                	6.1.3	
                  The information conveyed in the Contractor’s written materials shall conform with ASES’s Universal Enrollee Handbook, included as Attachment 3 to this Contract.

                


        

      

       

      
        
          	

                	6.1.4	
                  The Contractor shall convey Information to Enrollees and Potential Enrollees via written materials and via telephone, internet, and face-to-face communications, and shall
                      allow Enrollees to submit questions and to receive responses from the Contractor.

                


        

      

       

      
        
          	

                	6.1.5	
                  The Contractor shall ensure that the informational materials disseminated to all GHP Enrollees accurately identify differences among the categories of Eligible Persons.

                


        

      

       

      
        
          	

                	6.1.6	
                  The Contractor shall provide Enrollees with at least thirty (30) Calendar Days written notice of any significant change in policies concerning Enrollees’ Disenrollment
                      rights (see Section 5.3), right to change PMGs or PCPs (see Section 5.4), or any significant change to any of the items listed in the Enrollee Handbook (Section 6.4) or Enrollee Rights and Responsibilities (section 6.5), regardless of
                      whether ASES or the Contractor caused the change to take place. This Section 6.1.6 shall not be construed as giving the Contractor the right to change its policies and procedures without prior written approval from ASES.

                


        

      

       

      
        
          	

                	6.1.7	
                  The Contractor shall use the definitions for managed care terminology set forth by ASES in all of its written and verbal communications with Enrollees, in accordance with
                      42 CFR 438.10(c)(4)(i).

                


        

      

       

      
        
          	

                	6.1.8	
                  The Contractor shall provide instructions to Enrollees and Potential Enrollees on how to access continued services pursuant to its transition of care process as specified
                      in Section 5.5 and in accordance with 42 CFR 438.62.

                


        

      

       

      
        Page 53 of 324

        
          


      

      
        
          	

                	6.2	
                  ASES Approval of All Written Materials

                


        

      

       

      
        
          	

                	6.2.1	
                  The Contractor shall submit to ASES for review and prior written approval all materials meant for distribution to Enrollees, including but not limited to, Enrollee
                      Handbooks, Provider Directories, ID cards and, upon request, any other additional, but not required, materials and Information provided to Enrollees designed to promote health and/or educate Enrollees.

                


        

      

       

      
        
          	

                	6.2.2	
                  All materials must be submitted to ASES in paper and electronic file media, in the format prescribed by ASES. The Contractor shall submit the reading level and the
                      methodology used to measure it concurrent with all submissions of written materials and include a plan that describes the Contractor’s intent for the use of the materials.

                


        

      

       

      
        
          	

                	6.2.3	
                  ASES reserves the right to notify the Contractor to discontinue or modify written materials after approval.

                


        

      

       

      
        
          	

                	6.2.4	
                  Except as otherwise provided below, written materials described in this Article 6 must be submitted to ASES for review at least forty-five (45) Calendar Days before their
                      printing and distribution, as required by Act 194 of August 2000. This requirement applies to:

                


        

      

       

      
        
          	

                	6.2.4.1	
                  The materials described in this Article 6 distributed to all Enrollees, including the Enrollee Handbook;

                


        

      

       

      
        
          	

                	6.2.4.2	
                  Policy letters, coverage policy statements, or other communications about Covered Services under the GHP distributed to Enrollees; and

                


        

      

       

      
        
          	

                	6.2.4.3	
                  Standard letters and notifications, such as the notice of Enrollment required in Section 5.2.6.3, the notice of Redetermination required in Section 5.2.8.1, and the
                      notice of Disenrollment required in Section 5.3.2. The Contractor shall use model Enrollee notices developed by ASES whenever available.

                


        

      

       

      
        
          	

                	6.2.5	
                  The Contractor shall provide ASES with advance notice of any changes made to written materials that will be distributed to all Enrollees. Notice shall be provided to ASES
                      at least forty-five (45) Calendar Days before the effective date of the change. Within fifteen (15) Business Days of receipt of the materials, ASES will respond to the Contractor’s submission with either an approval of the materials,
                      recommended modifications, or a notification that more review time is required. If the Contractor receives no response from ASES within fifteen (15) Business Days of ASES’s receipt of the materials, the materials shall be deemed
                      approved. Except as otherwise provided in this Section 6.2.5, the Contractor may distribute the revised written materials only upon written approval of the changes from ASES.

                


        

      

       

      
        Page 54 of 324

        
          


      

      
        
          	

                	6.3	
                  Requirements for Written Materials

                


        

      

       

      
        
          	

                	6.3.1	
                  The Contractor shall maintain written policies and procedures governing the development and distribution of written materials including how the Contractor will meet the
                      requirements in this Section 6.3, with such policies and procedures to be submitted in accordance with Attachment 12 to this Contract for prior written approval from ASES. The Contractor shall, at a minimum, have policies and
                      procedures regarding the process for developing/creating, proofing, approving, publishing, and mailing the (i) Enrollee Handbook, (ii) Provider Directory, and (iii) form letters within contractual standards and timeframes. The
                      Contractor shall include a separate set of policies and procedures for the items listed above.

                


        

      

       

      
        
          	

                	6.3.2	
                  The Contractor shall make all written materials available through auxiliary aids and services or alternative formats, and in a manner that takes into consideration the
                      Enrollee’s or Potential Enrollee’s special needs, including Enrollees and Potential Enrollees who are visually impaired or have limited reading proficiency. The Contractor shall notify all Enrollees and Potential Enrollees that
                      Information is available in alternative formats, and shall instruct them on how to access those formats. Consistent with Section 1557 of PPACA and 42 CFR 438.10(d)(3), all written materials must also include taglines in the prevalent
                      languages, as well as large print, with a font size of no smaller than 18 point, to explain the availability of written and oral translation to understand the Information provided and the toll-free and TTY/TDD telephone number of the
                      GHP Service Line.

                


        

      

       

      
        
          	

                	6.3.3	
                  Once an Enrollee has requested a written material in an alternative format or language, the Contractor shall at no cost to the Enrollee or Potential Enrollee (i) make a
                      notation of the Enrollee or Potential Enrollee’s preference in the Contractor’s system and (ii) provide all subsequent written materials to the Enrollee or Potential Enrollee in such format unless the Enrollee or Potential Enrollee
                      requests otherwise.

                


        

      

       

      
        
          	

                	6.3.4	
                  Except as provided in Sections 1.1.5 and 6.4 (Enrollee Handbook) and subject to Section 6.3.8, the Contractor shall make all written information available in Spanish or
                      other applicable Prevalent Non-English Language, as defined in Section 6.3.8 below, with a language block in English, explaining that (i) Enrollees may access an English translation of the Information if needed, and (ii) the
                      Contractor will provide oral interpretation services into any language other than Spanish or English, if needed. Such translation or interpretation shall be provided by the Contractor at no cost to the Enrollee. The language block and
                      all other content shall comply with 42 CFR 438.10(d)(2) and Section 1557 of PPACA.

                


        

      

       

      
        
          	

                	6.3.5	
                  If oral interpretation services are required in order to explain the Benefits covered under the GHP to a Potential Enrollee who does not speak either English or Spanish,
                      the Contractor must, at its own cost, make such services available in a third language, in compliance with 42 CFR 438.10(d)(4).

                


        

      

       

      
        Page 55 of 324

        
          


      

      
        
          	

                	6.3.6	
                  All written materials shall be worded such that they are understandable to a person who reads at the fourth (4th) grade level.

                


        

      

       

      
        
          	

                	6.3.7	
                  All written materials must be clearly legible with a minimum font of size twelve (12) point with the exception of Enrollee ID cards and unless otherwise approved in
                      writing by ASES.

                


        

      

       

      
        
          	

                	6.3.8	
                  Within ninety (90) Calendar Days of a notification from ASES that ASES has identified a Prevalent Non-English Language other than Spanish or English (with “Prevalent
                      Non-English Language” defined as a language that is the primary language of more than five percent (5%) of the population of Puerto Rico), all written materials provided to Enrollees and Potential Enrollees shall be translated into
                      and made available in such language.

                


        

      

       

      
        
          	

                	6.3.9	
                  The Contractor shall provide written notice to Enrollees of any material changes to written materials previously distributed to Enrollees at least thirty (30) Calendar
                      Days before the effective date of the change.

                


        

      

       

      
        
          	

                	6.4	
                  Enrollee Handbook Requirements

                


        

      

       

      
        
          	

                	6.4.1	
                  The Contractor shall produce at its sole cost, and shall mail or make electronically available, subject to the requirements of Section 6.10.8 and 6.10.9, to all new
                      Enrollees, an Enrollee Handbook including information on physical health, Behavioral Health, and all other Covered Services offered under the GHP. The Contractor shall distribute the Enrollee Handbook either simultaneously with the
                      notice of Enrollment referenced in Section 5.2.5.3 or within five (5) Calendar Days of sending the notice of Enrollment via surface mail.

                


        

      

       

      
        
          	

                	6.4.2	
                  Upon request of an Enrollee or his/her Authorized Representative for a replacement or additional copy of the Enrollee Handbook, the Contractor shall send an Enrollee
                      Handbook within ten (10) Calendar Days. The Contractor shall give the person requesting an Enrollee Handbook the option to get the Information from the Contractor’s website or to receive a printed document.

                


        

      

       

      
        
          	

                	6.4.3	
                  The Contractor shall either:

                


        

      

       

      
        
          	

                	6.4.3.1	
                  Mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9, to all Enrollees an Enrollee Handbook on at least an annual basis, after
                      the initial distribution of the Enrollee Handbook at Enrollment; or

                


        

      

       

      
        
          	

                	6.4.3.2	
                  At least annually, as required by 42 CFR 438.10, mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9, to all Enrollees a
                      Handbook supplement that includes Information on the following:

                


        

      

       

      
        Page 56 of 324

        
          


      

      
        
          	

                	6.4.3.2.1	
                  The Contractor’s service area;

                


        

      

       

      
        
          	

                	6.4.3.2.2	
                  Benefits covered under the GHP;

                


        

      

       

      
        
          	

                	6.4.3.2.3	
                  Any cost-sharing imposed by the Contractor; and

                


        

      

       

      
        
          	

                	6.4.3.2.4	
                  To the extent available, quality and performance indicators, including Enrollee satisfaction.

                


        

      

       

      
        
          	

                	6.4.3.3	
                  The Contractor is not required to mail an Enrollee Handbook to an Enrollee who may have been disenrolled and subsequently reenrolled if Enrollee was provided an Enrollee
                      Handbook within the past year. The Contractor is also not required to mail an Enrollee Handbook to new Enrollees under the age of twenty-one (21) if an Enrollee Handbook has been mailed within the past year to a member of that
                      Enrollee’s household. However, this exception does not apply to pregnant Enrollees under the age of twenty-one (21).

                


        

      

       

      
        
          	

                	6.4.4	
                  The Contractor shall use the Universal Beneficiary Guide, provided by ASES and included as Attachment 3 to this Contract, as a model for its Enrollee Handbook; however,
                      the Contractor shall ensure that its Enrollee Handbook meets all the requirements listed in this Section 6.4.

                


        

      

       

      
        
          	

                	6.4.5	
                  Pursuant to the requirements set forth in 42 CFR 438.10, the Enrollee Handbook shall include, at a minimum, the following:

                


        

      

       

      
        
          	

                	6.4.5.1	
                  A table of contents;

                


        

      

       

      
        
          	

                	6.4.5.2	
                  An explanation of the purpose of the Enrollee ID Card and a warning that transfer of the card to another person constitutes Fraud;

                


        

      

       

      
        
          	

                	6.4.5.3	
                  Information about the role of the PCP and how to choose a PCP;

                


        

      

       

      
        
          	

                	6.4.5.4	
                  Information about the PMG, how to choose a PMG, and which Benefits may be accessed through the PMG;

                


        

      

       

      
        
          	

                	6.4.5.5	
                  Information about the PPN associated with the Enrollee’s PMG, and the benefits of seeking services within the PPN;

                


        

      

       

      
        
          	

                	6.4.5.6	
                  Information about the circumstances under which Enrollees may change to a different PMG;

                


        

      

       

      
        
          	

                	6.4.5.7	
                  Information about what to do when family size changes, including the responsibility of new mothers who are Medicaid Eligible to register their newborn with the Puerto
                      Rico Medicaid Program and to apply for the Enrollment of the newborn;

                


        

      

       

      
        Page 57 of 324

        
          


      

      
        
          	

                	6.4.5.8	
                  Appointment procedures;

                


        

      

       

      
        
          	

                	6.4.5.9	
                  Information on the amount, duration and scope of Benefits and Covered Services, including how the scope of Benefits and services differs between Medicaid and CHIP
                      Eligibles and Other Eligible Persons. This must include Information on the EPSDT Benefit and how Enrollees under the age of twenty-one (21) and entitled to the EPSDT Benefit may access component services;

                


        

      

       

      
        
          	

                	6.4.5.10	
                  An explanation of how physical health and Behavioral Health services are integrated under the GHP, and how to access specialized Behavioral Health Services;

                


        

      

       

      
        
          	

                	6.4.5.11	
                  Information on how to access local resources for Non-Emergency Medical Transportation (“NEMT”);

                


        

      

       

      
        
          	

                	6.4.5.12	
                  An explanation of any service limitations or exclusions from coverage, including any restrictions on the Enrollee’s freedom of choice among network Providers;

                


        

      

       

      
        
          	

                	6.4.5.13	
                  Information on where and how Enrollees may access Benefits not available from or not covered by the Contractor’s Plan;

                


        

      

       

      
        
          	

                	6.4.5.14	
                  The Medical Necessity definition used in determining whether services will be covered (see Section 7.2);

                


        

      

       

      
        
          	

                	6.4.5.15	
                  A description of all pre-certification, Prior Authorization, or other requirements for treatments and services;

                


        

      

       

      
        
          	

                	6.4.5.16	
                  The policy on Referrals for specialty care and for other Covered Services not provided by the Enrollee’s PCP;

                


        

      

       

      
        
          	

                	6.4.5.17	
                  Information on how to obtain after-hours coverage;

                


        

      

       

      
        
          	

                	6.4.5.18	
                  An explanation of cost-sharing, including:

                


        

      

       

      
        
          	

                	6.4.5.18.1	
                  The differences in cost-sharing responsibilities between Medicaid- and CHIP Eligibles and Other Eligible Persons, and

                


        

      

       

      
        
          	

                	6.4.5.18.2	
                  The cost-sharing responsibilities of Dual Eligible Beneficiaries, as well as the other information for Dual Eligible Beneficiaries listed in Section 6.13;

                


        

      

       

      
        Page 58 of 324

        
          


      

      
        
          	

                	6.4.5.19	
                  Notice of all appropriate mailing addresses and telephone numbers to be utilized by Enrollees seeking Information or authorization, including the Contractor’s toll-free
                      telephone line and website address;

                


        

      

       

      
        
          	

                	6.4.5.20	
                  A description of Utilization Management policies and procedures used by the Contractor;

                


        

      

       

      
        
          	

                	6.4.5.21	
                  A description of Enrollee rights and responsibilities as described in Section 6.5;

                


        

      

       

      
        
          	

                	6.4.5.22	
                  The policies and procedures for Disenrollment, including when Disenrollment may be requested without Enrollee consent by the Contractor and Information about Enrollee’s
                      right to request Disenrollment, and including notice of the fact that the Enrollee will lose Access to services under the GHP if the Enrollee chooses to disenroll;

                


        

      

       

      
        
          	

                	6.4.5.23	
                  Information on Advance Directives, including the right of Enrollees to file directly with ASES or with the Puerto Rico Office of the Patient Advocate, Complaints
                      concerning Advance Directive requirements listed in Section 7.10 of this Contract;

                


        

      

       

      
        
          	

                	6.4.5.24	
                  A statement that additional Information, including the Provider Guidelines (see Section 10.2.1 of the Contract) and Information on the structure and operations of the GHP
                      and Physician Incentive Plans, shall be made available to Enrollees and Potential Enrollees upon request;

                


        

      

       

      
        
          	

                	6.4.5.25	
                  Information on the extent to which, and how, after-hours and emergency coverage are provided, including:

                


        

      

       

      
        
          	

                	6.4.5.25.1	
                  What constitutes an Emergency Medical Condition and a Psychiatric Emergency;

                


        

      

       

      
        
          	

                	6.4.5.25.2	
                  The fact that Prior Authorization is not required for Emergency Services;

                


        

      

       

      
        
          	

                	6.4.5.25.3	
                  Notice that:

                


        

      

       

      
        
          	

                	6.4.5.25.3.1	
                  Under no circumstances will a Medicaid or CHIP Enrollee be charged a Co-Payment for the treatment of any Emergency Medical Condition or Psychiatric Emergency;

                


        

      

       

      
        
          	

                	6.4.5.25.3.2	
                  No Co-Payments shall be charged for Medicaid and CHIP children under twenty-one (21) years under any circumstances.

                


        

      

       

      
        Page 59 of 324

        
          


      

      
        
          	

                	6.4.5.25.3.3	
                  For Medicaid or CHIP Enrollees, Co-Payments may apply to non-emergency services provided in an emergency room pursuant to Attachment 8 to this Contract on Cost-Sharing;
                      and

                


        

      

       

      
        
          	

                	6.4.5.25.3.4	
                  For Other Eligible Persons, Co-Payments apply to Emergency Services outside the Enrollee’s PPN, but the Enrollee may avoid a Co-Payment by using the GHP Service Line (see
                      Section 6.8).

                


        

      

       

      
        
          	

                	6.4.5.25.4	
                  The process and procedures for obtaining Emergency Services, including the use of the 911 telephone systems or its local equivalent;

                


        

      

       

      
        
          	

                	6.4.5.25.5	
                  The scope of Post-Stabilization Services offered under the GHP as detailed in Section 7.5.9.4;

                


        

      

       

      
        
          	

                	6.4.5.25.6	
                  The locations of emergency rooms and other locations at which Providers and hospitals furnish Emergency Services and Post-Stabilization Services covered under the GHP;
                      and

                


        

      

       

      
        
          	

                	6.4.5.25.7	
                  The fact that an Enrollee has a right to use any hospital or other setting for Emergency Services;

                


        

      

       

      
        
          	

                	6.4.5.26	
                  An explanation of the Redetermination process, including:

                


        

      

       

      
        
          	

                	6.4.5.26.1	
                  Disenrollment as a consequence of a Negative Redetermination Decision; and

                


        

      

       

      
        
          	

                	6.4.5.26.2	
                  The Re-Enrollment period that follows a new Certification.

                


        

      

       

      
        
          	

                	6.4.5.27	
                  Information on the Contractor’s Grievance and Appeal System policies and procedures, as described in Article 14 of this Contract. This description must include the
                      following:

                


        

      

       

      
        
          	

                	6.4.5.27.1	
                  The right to file a Grievance and Appeal with the Contractor;

                


        

      

       

      
        
          	

                	6.4.5.27.2	
                  The requirements and timeframes for filing a Grievance or Appeal with the Contractor;

                


        

      

       

      
        
          	

                	6.4.5.27.3	
                  The availability of assistance in filing a Grievance or Appeal with the Contractor;

                


        

      

       

      
        
          	

                	6.4.5.27.4	
                  The toll-free numbers that the Enrollee can use to file a Grievance or an Appeal with the Contractor by phone;

                


        

      

       

      
        
          	

                	6.4.5.27.5	
                  The right to an Administrative Law Hearing after exhaustion of the Contractor’s Grievance and Appeal System, the method for obtaining a hearing, and the rules that govern
                      representation at the hearing;

                


        

      

       

      
        Page 60 of 324

        
          


      

      
        
          	

                	6.4.5.27.6	
                  Notice that if the Enrollee files an Appeal or a request for an Administrative Law Hearing and requests continuation of services, the Enrollee may be required to pay the
                      cost of services furnished while the Appeal is pending, if the final decision is adverse to the Enrollee;

                


        

      

       

      
        
          	

                	6.4.5.27.7	
                  Any Appeal rights that ASES chooses to make available to Providers to challenge the failure of the Contractor to cover a service;

                


        

      

       

      
        
          	

                	6.4.5.27.8	
                  Instructions on how an Enrollee can report suspected Fraud, Waste, or Abuse, and protections that are available for whistleblowers;

                


        

      

       

      
        
          	

                	6.4.5.27.9	
                  Information on the family planning services and supplies, including the extent to which, and how, Enrollees may obtain such services or supplies from out-of-network
                      providers, and that an Enrollee cannot be required to obtain a referral before choosing a family planning Provider;

                


        

      

       

      
        
          	

                	6.4.5.27.10	
                  Information on non-coverage of counseling or referral services based on Contractor’s moral or religious objections, as specified in Section 7.13 and how to access these
                      services from ASES; and

                


        

      

       

      
        
          	

                	6.4.5.27.11	
                  Instructions on how to access oral or written translation services, Information in alternative formats, and auxiliary aids and services, as specified in Sections 6.3 and
                      6.11.

                


        

      

       

      
        
          	

                	6.4.5.28	
                  A description of the model of care for treatment of Enrollees with each HCHN condition.

                


        

      

       

      
        
          	

                	6.4.6	
                  The Enrollee Handbook in both English and Spanish shall be submitted to ASES for review and prior written approval. Submission of the Enrollee Handbook by the Contractor
                      shall be in accordance with the timeframes specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	6.4.7	
                  The Contractor shall be responsible for producing the Enrollee Handbook in both English and Spanish.

                


        

      

       

      
        
          	

                	6.5	
                  Enrollee Rights and Responsibilities

                


        

      

       

      
        
          	

                	6.5.1	
                  The Contractor shall have written policies and procedures regarding the rights of Enrollees and shall comply with any applicable Federal and Puerto Rico laws and
                      regulations that pertain to Enrollee rights, including those set forth in 42 CFR 438.100, and in the Puerto Rico Patient’s Bill of Rights Act 194 of August 25, 2000; the Puerto Rico Mental Health Law Act 408 of October 2, 2000, as
                      amended and implemented; and Law 77 of July 24, 2013 which created the Office of the Patient Advocate. These rights shall be included in the Enrollee Handbook. At a minimum, the policies and procedures shall specify the Enrollee’s
                      right to:

                


        

      

       

      
        Page 61 of 324

        
          


      

      
        
          	

                	6.5.1.1	
                  Receive information pursuant to 42 CFR 438.10;

                


        

      

       

      
        
          	

                	6.5.1.2	
                  Be treated with respect and with due consideration for the Enrollee’s dignity and privacy;

                


        

      

       

      
        
          	

                	6.5.1.3	
                  Have all records and medical and personal information remain confidential;

                


        

      

       

      
        
          	

                	6.5.1.4	
                  Receive information on available treatment options and alternatives, presented in a manner appropriate to the Enrollee’s condition and ability to understand;

                


        

      

       

      
        
          	

                	6.5.1.5	
                  Participate in decisions regarding his or her health care, including the right to refuse treatment;

                


        

      

       

      
        
          	

                	6.5.1.6	
                  Be free from any form of restraint or seclusion as a means of coercion, discipline, convenience, or retaliation, as specified in 42 CFR 482.13(e) and other Federal
                      regulations on the use of restraints and seclusion;

                


        

      

       

      
        
          	

                	6.5.1.7	
                  Request and receive a copy of his or her Medical Records pursuant to 45 CFR Parts 160 and 164, subparts A and E, and request to amend or correct the record as specified
                      in 45 CFR 164.524 and 164.526;

                


        

      

       

      
        
          	

                	6.5.1.8	
                  Choose an Authorized Representative to be involved as appropriate in making care decisions;

                


        

      

       

      
        
          	

                	6.5.1.9	
                  Provide informed consent;

                


        

      

       

      
        
          	

                	6.5.1.10	
                  Be furnished with health care services in accordance with 42 CFR 438.206 through 438.210;

                


        

      

       

      
        
          	

                	6.5.1.11	
                  Freely exercise his or her rights, including those related to filing a Grievance or Appeal, and that the exercise of these rights will not adversely affect the way the
                      Enrollee is treated;

                


        

      

       

      
        
          	

                	6.5.1.12	
                  Receive Information about Covered Services and how to access Covered Services and Network Providers;

                


        

      

       

      
        Page 62 of 324

        
          


      

      
        
          	

                	6.5.1.13	
                  Be free from harassment by the Contractor or its Network Providers with respect to contractual disputes between the Contractor and its Providers;

                


        

      

       

      
        
          	

                	6.5.1.14	
                  Participate in understanding physical and Behavioral Health problems and developing mutually agreed-upon treatment goals;

                


        

      

       

      
        
          	

                	6.5.1.15	
                  Not be held liable for the Contractor’s debts in the event of insolvency; not be held liable for the Covered Services provided to the Enrollee for which ASES does not pay
                      the Contractor; not be held liable for Covered Services provided to the Enrollee for which ASES or the Contractor’s Plan does not pay the Provider that furnishes the services; and not be held liable for payments of Covered Services
                      furnished under a contract, Referral, or other arrangement to the extent that those payments are in excess of the amount the Enrollee would owe if the Contractor provided the services directly; and

                


        

      

       

      
        
          	

                	6.5.1.16	
                  Only be responsible for cost-sharing in accordance with 42 CFR 447.50 through 42 CFR 447.56 and as permitted by the Puerto Rico Medicaid and CHIP State Plans and Puerto
                      Rico law as applicable to the Enrollee.

                


        

      

       

      
        
          	

                	6.6	
                  Provider Directory

                


        

      

       

      
        
          	

                	6.6.1	
                  The Contractor shall develop, maintain, and mail or make electronically available, subject to the requirements of Sections 6.10.8 and 6.10.9 to all new Enrollees a
                      Provider Directory in a manner reasonably calculated to reach Enrollees within five (5) Calendar Days of sending the notice of Enrollment referenced in Section 5.2.5.3.

                


        

      

       

      
        
          	

                	6.6.1.1	
                  The Contractor is not required to mail a Provider Directory to an Enrollee who may have been disenrolled and subsequently reenrolled if Enrollee was provided a Provider
                      Directory within the past year. The Contractor is also not required to mail a Provider Directory to new Enrollees under the age of twenty-one (21) if a Provider Directory has been mailed to a member of that Enrollee’s household.
                      However, this exception does not apply to pregnant Enrollees under the age of twenty-one (21).

                


        

      

       

      
        
          	

                	6.6.2	
                  The Contractor shall update the paper Provider Directory once a month, and distribute it to Enrollees upon Enrollee request.

                


        

      

       

      
        
          	

                	6.6.3	
                  The Contractor shall make the Provider Directory available on its website in a machine readable file and format as specified by CMS.

                


        

      

       

      
        
          	

                	6.6.4	
                  The Provider Directory shall include the names, provider group affiliations, locations, office hours, telephone numbers, websites, cultural and linguistic capabilities,
                      completion of Cultural Competency training, and accommodations for people with physical disabilities of current Network Providers. This includes, at a minimum, Information sorted by PCPs; specialists; dentists; FQHCs and RHCs;
                      Behavioral Health Providers/clinics, including detox clinics; pharmacies; hospitals, including locations of emergency settings and Post-Stabilization Services, with the name, location, hours of operation, and telephone number of each
                      facility/setting. The Provider Directory shall also identify all Network Providers that are not accepting new patients. Any subcontractors of ASES, such as the PBM, will collaborate with the Contractor to provide information in a
                      format mutually agreed upon for the generation of the Provider Directory.

                


        

      

       

      
        Page 63 of 324

        
          


      

      
        
          	

                	6.6.5	
                  The Provider Directory shall include all Network Providers grouped by PMG.

                


        

      

       

      
        
          	

                	6.6.6	
                  The Provider Directory must be indexed alphabetically and by specialty.

                


        

      

       

      
        
          	

                	6.6.7	
                  The Contractor shall submit the Provider Directory to ASES for review and prior written approval in the timeframe specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	6.6.8	
                  The Contractor shall update and amend the Provider Directory on its website within three (3) Calendar Days of any changes as well as produce and distribute annual updates
                      to all Enrollees. The Contractor shall maintain on its website an updated Provider Directory that includes all identified Information above and that is searchable by Provider type, distance from Enrollee’s address, and/or whether the
                      Network Provider is accepting new patients. Information on how to access this Information shall be clearly stated in both the Enrollee and Provider sections of the website.

                


        

      

       

      
        
          	

                	6.6.9	
                  On a monthly basis, the Contractor shall submit to ASES any changes and edits to the Provider Directory. Such changes shall be submitted electronically in the format
                      specified by ASES.

                


        

      

       

      
        
          	

                	6.7	
                  Enrollee Monthly Utilization Report

                


        

      

       

      
        
          	

                	6.7.1	
                  The Contractor shall send a quarterly utilization report to Enrollees in accordance with Act 114 of July 30, 2010.

                


        

      

       

      
        
          	

                	6.8	
                  Enrollee Identification (ID) Card

                


        

      

       

      
        
          	

                	6.8.1	
                  The Contractor shall furnish to all new Enrollees an Enrollee ID card made of durable plastic material. The card shall be mailed to the Enrollee via surface mail within
                      five (5) Business Days of sending the notice of Enrollment referenced in Section 5.2.5.3.

                


        

      

       

      
        
          	

                	6.8.2	
                  The Enrollee ID Card must, at a minimum, include the following information:

                


        

      

       

      
        
          	

                	6.8.2.1	
                  The “GHP” logo;

                


        

      

       

      
        Page 64 of 324

        
          


      

      
        
          	

                	6.8.2.2	
                  The Enrollee’s name;

                


        

      

       

      
        
          	

                	6.8.2.3	
                  A designation of the Enrollee as a Medicaid Eligible, a CHIP Eligible, or an Other Eligible Person;

                


        

      

       

      
        
          	

                	6.8.2.4	
                  The Enrollee’s Medicaid or CHIP identification number, if applicable;

                


        

      

       

      
        
          	

                	6.8.2.5	
                  The Enrollee’s Plan group number, when applicable;

                


        

      

       

      
        
          	

                	6.8.2.6	
                  The Effective Date of Enrollment in the GHP;

                


        

      

       

      
        
          	

                	6.8.2.7	
                  The Master Patient Identifier, which shall not be altered in format or content by the Contractor;

                


        

      

       

      
        
          	

                	6.8.2.8	
                  The applicable Co-Payment levels for various services outside the Enrollee’s PPN and the assurance that no Co-Payment will be charged for a Medicaid Eligible Person and
                      for CHIP children under twenty-one (21) years under any circumstances;

                


        

      

       

      
        
          	

                	6.8.2.9	
                  The PCP’s and the PMG’s names;

                


        

      

       

      
        
          	

                	6.8.2.10	
                  The name and telephone number(s) of the Contractor;

                


        

      

       

      
        
          	

                	6.8.2.11	
                  The twenty-four (24) hour, seven (7) day a Week toll-free GHP Service Line Medical Advice Service phone number;

                


        

      

       

      
        
          	

                	6.8.2.12	
                  A notice that the Enrollee ID Card may under no circumstances be used by a person other than the identified Enrollee; and

                


        

      

       

      
        
          	

                	6.8.2.13	
                  Instructions to obtain Emergency Services

                


        

      

       

      
        
          	

                	6.8.3	
                  The Contractor shall reissue the Enrollee ID Card in the following situations and timeframes:

                


        

      

       

      
        
          	

                	6.8.3.1	
                  Within ten (10) Calendar Days of notice if an Enrollee reports a lost, stolen, or damaged ID Card and requests a replacement;

                


        

      

       

      
        
          	

                	6.8.3.2	
                  Within ten (10) Calendar Days of notice if an Enrollee reports a name change;

                


        

      

       

      
        
          	

                	6.8.3.3	
                  Within twenty (20) Calendar Days of the effective date of a change of PMG or change or addition of a PCP, as provided in Section 5.4.

                


        

      

       

      
        
          	

                	6.8.4	
                  The Contractor may charge a fee of five dollars ($5.00) to replace lost, damaged, or stolen Enrollee ID Cards; provided, however, that the Contractor may not charge a
                      replacement fee because of a name change or change of PMG or PCP, and that the Contractor may not charge a replacement fee in any circumstance for Medicaid and CHIP Eligibles.

                


        

      

       

      
        Page 65 of 324

        
          


      

      
        
          	

                	6.8.5	
                  The Contractor shall submit a front and back sample Enrollee ID Card to ASES for review and prior written approval according to the timeframe specified in Attachment 12
                      to this Contract.

                


        

      

       

      
        
          	

                	6.8.6	
                  The Contractor must require an Enrollee to surrender his or her ID Card in each of the following events:

                


        

      

       

      
        
          	

                	6.8.6.1	
                  The Enrollee disenrolls from the GHP;

                


        

      

       

      
        
          	

                	6.8.6.2	
                  The Enrollee requests a change to his or her PCP or PMG, and is therefore issued a new Enrollee ID Card; or

                


        

      

       

      
        
          	

                	6.8.6.3	
                  The Enrollee requests a new ID card because his or her existing card is damaged.

                


        

      

       

      
        
          	

                	6.9	
                  GHP Service Line (Toll Free Telephone Service)

                


        

      

       

      
        
          	

                	6.9.1	
                  The Contractor shall operate a toll-free telephone number, “GHP Service Line” equipped with caller identification and automatic call distribution equipment capable of
                      handling the high expected volume of calls. The GHP Service Line shall have two components:

                


        

      

       

      
        
          	

                	6.9.1.1	
                  An Information Service to respond to questions, concerns, inquiries, and Complaints regarding the GHP from the Enrollee, Enrollee’s family, or Enrollee’s Authorized
                      Representative; and

                


        

      

       

      
        
          	

                	6.9.1.2	
                  A Medical Advice Service to advise Enrollees about how to resolve non-emergency medical or Behavioral Health concerns.

                


        

      

       

      
        
          	

                	6.9.2	
                  The Contractor shall establish, operate, monitor, and support an automated call distribution system for the GHP Service Line that supports, at a minimum:

                


        

      

       

      
        
          	

                	6.9.2.1	
                  Capacity to handle the high call volume;

                


        

      

       

      
        
          	

                	6.9.2.2	
                  A daily analysis of the quantity, length, and types of calls received;

                


        

      

       

      
        
          	

                	6.9.2.3	
                  A daily analysis of the amount of time it takes to answer the call, including Blocked and Abandoned Calls;

                


        

      

       

      
        
          	

                	6.9.2.4	
                  The ability to measure average waiting time; and

                


        

      

       

      
        
          	

                	6.9.2.5	
                  The ability to monitor calls from a remote location by a Third Party, such as ASES.

                


        

      

       

      
        
          	

                	6.9.3	
                  Hours of Operation

                


        

      

       

      
        
          	

                	6.9.3.1	
                  The Information Service shall be fully staffed between the hours of 7:00 a.m. and 7:00 p.m. (Atlantic Time). Monday through Friday, excluding Puerto Rico holidays. The
                      Contractor shall have an automated system available between the hours of 7:00 p.m. and 7:00 a.m. (Atlantic Time) Monday through Friday and during all hours on weekends and holidays. This automated system must provide callers with
                      operating instructions on what to do in case of an emergency and shall include, at a minimum, a voice mailbox for callers to leave messages. The Contractor shall ensure that the voice mailbox has the required capacity to receive all
                      messages. A Contractor’s representative shall reply to one hundred percent (100%) of messages by the next Business Day.

                


        

      

       

      
        Page 66 of 324

        
          


      

      
        
          	

                	6.9.3.2	
                  The Medical Advice Service shall be fully staffed and available to Enrollees twenty-four (24) hours per day, seven (7) days per Week.

                


        

      

       

      
        
          	

                	6.9.4	
                  Staffing

                


        

      

       

      
        
          	

                	6.9.4.1	
                  The Contractor shall be responsible for the required staffing of the GHP Service Line with individuals who are able to communicate effectively with GHP Enrollees.

                


        

      

       

      
        
          	

                	6.9.4.2	
                  The Contractor shall make key staff responsible for operating the GHP Service Line available to meet with ASES staff on a regular basis, as requested by ASES, to review
                      reports and all other obligations under the Contract relating to GHP Service Line.

                


        

      

       

      
        
          	

                	6.9.4.3	
                  All staff shall be hired and must complete a training program at least fifteen (15) Calendar Days before the staff provides GHP Service Line services. Such training
                      program shall include, but will not be limited to, systems, policies and procedures, and telephone scripts.

                


        

      

       

      
        
          	

                	6.9.4.4	
                  For the Information Service, the Contractor shall ensure that Call Center attendants receive the necessary training to respond to Enrollee questions, concerns, inquiries,
                      and Complaints from the Enrollee or the Enrollee’s family relating to this Contract regarding topics, including but not limited to Covered Services (both physical and Behavioral Health), Grievances and Appeals, the Provider Network,
                      and Enrollment and Disenrollment.

                


        

      

       

      
        
          	

                	6.9.4.5	
                  For the Medical Advice Service, the Contractor shall ensure that Call Center attendants are registered nurses with the necessary training to advise Enrollees about
                      appropriate steps they should take to resolve a physical or Behavioral Health complaint or concern.

                


        

      

       

      
        
          	

                	6.9.4.6	
                  The Contractor shall ensure that GHP Service Line Call Center staff is trained to identify Behavioral Health concerns and, where appropriate, to transfer Enrollee callers
                      to the appropriate Call Center representative for assistance.

                


        

      

       

      
        Page 67 of 324

        
          


      

      
        
          	

                	6.9.4.7	
                  The Contractor shall ensure that GHP Service Line Call Center staff is trained to identify situations in which an Enrollee may need services that are offered through the
                      Department of Health rather than through the GHP, and GHP Service Line staff shall provide the Enrollee with Information on where to access these services.

                


        

      

       

      
        
          	

                	6.9.4.8	
                  The Contractor shall ensure that GHP Service Line Call Center staff is trained to provide to Medicaid and CHIP Eligible Enrollees Information on how to access local NEMT
                      resources to enable an Enrollee without available transportation to receive Medically Necessary Services.

                


        

      

       

      
        
          	

                	6.9.4.9	
                  The Contractor shall ensure that GHP Service Line Call Center staff are trained to process and fulfill requests by Enrollees and Potential Enrollees to receive, by
                      surface mail, the Enrollee Handbook, the Provider Directory, or the Provider Guidelines. The Contractor shall fulfill such requests by mailing the requested document within five (5) Business Days of the request.

                


        

      

       

      
        
          	

                	6.9.5	
                  The Contractor may provide the Information Service and the Medical Advice Service as separate phone lines with a “Warm Transfer” capability, or as separate dialing
                      options within one (1) phone line.

                


        

      

       

      
        
          	

                	6.9.6	
                  The Contractor shall have the capability of making out-bound calls.

                


        

      

       

      
        
          	

                	6.9.7	
                  The GHP Service Line shall be equipped to handle calls in Spanish and English, as well as, through a Telecommunication Device for the Deaf (TDD) for calls from Enrollees
                      who are hearing-impaired. For callers who speak neither English nor Spanish, the Contractor shall provide interpreter services free of charge to Enrollees. The Contractor shall not permit Enrollees’ family members, especially minor
                      children, or friends, to provide oral interpreter services, unless specifically requested by the Enrollee.

                


        

      

       

      
        
          	

                	6.9.8	
                  All calls shall be recorded, identifying the date and time, the type of call, the reason for the call, and the resolution of the call.

                


        

      

       

      
        
          	

                	6.9.9	
                  The Contractor shall generate a call identification number for each phone call made by an Enrollee to the Medical Advice Service. Enrollees who use this service to seek
                      advice on their health condition before visiting the emergency room will not be responsible for any Co-Payment otherwise imposed for emergency room visits (as provided under Section 7.11.4) outside the Enrollee’s PPN, provided that
                      the Enrollee presents his or her GHP Service Line call identification number at the emergency room. Under no circumstance will a Co-Payment be imposed on a Medicaid or CHIP Eligible Enrollee for treatment of an Emergency Medical
                      Condition or Psychiatric Emergency (regardless of whether the Enrollee uses the Medical Advice Service). The Medical Advice Service does not apply to emergency services obtained outside of Puerto Rico; however, Enrollees should be
                      able to access both the Medical Advice Service and the Information Service lines from the US.

                


        

      

       

      
        Page 68 of 324

        
          


      

      
        
          	

                	6.9.10	
                  The Contractor shall develop GHP Service Line policies and procedures, including staffing, training, hours of operation, Access and response standards,
                      transfers/Referrals, monitoring of calls via recording and other means, and compliance with other performance standards to be prior approved in writing by ASES.

                


        

      

       

      
        
          	

                	6.9.11	
                  The Contractor shall develop GHP Service Line quality criteria and protocols. These protocols shall, at a minimum:

                


        

      

       

      
        
          	

                	6.9.11.1	
                  Measure and monitor the accuracy of responses and phone etiquette in GHP Service Line (including through recording phone calls) and take corrective action as necessary to
                      ensure the accuracy of responses and appropriate phone etiquette by staff;

                


        

      

       

      
        
          	

                	6.9.11.2	
                  Provide for quality calibration sessions between the Contractor’s staff and ASES;

                


        

      

       

      
        
          	

                	6.9.11.3	
                  Require that, on a monthly basis, the average speed of answer is at least eighty percent (80%) of calls answered within thirty (30) seconds;

                


        

      

       

      
        
          	

                	6.9.11.4	
                  Require that, on a monthly basis, the Blocked Call rate does not exceed three percent (3%); and

                


        

      

       

      
        
          	

                	6.9.11.5	
                  Require that, on a monthly basis, the rate of Abandoned Calls does not exceed five percent (5%).

                


        

      

       

      
        
          	

                	6.9.12	
                  The above standards serve as minimum requirements for each GHP Service Line service. The Contractor may elect to establish more rigorous performance standards. The
                      Contractor may elect to establish different quality criteria for the Medical Advice Service than for the Information Service; provided, however, the standards governing the Medical Advice Service are stricter than the standards for
                      the Information Service.

                


        

      

       

      
        
          	

                	6.9.13	
                  The Contractor must develop and implement a GHP Service Line Outreach Program to educate Enrollees about the GHP Service Line service and to encourage its use. The
                      Outreach program shall include, at a minimum, the following components:

                


        

      

       

      
        
          	

                	6.9.13.1	
                  A section on GHP Service Line in the Enrollee Handbook;

                


        

      

       

      
        
          	

                	6.9.13.2	
                  Contact information for GHP Service Line on the Enrollee ID Card and on the Contractor’s website; and

                


        

      

       

      
        Page 69 of 324

        
          


      

      
        
          	

                	6.9.13.3	
                  Informational flyers on the GHP Service Line to be placed in the offices of the Contractor and the Network Providers.

                


        

      

       

      
        
          	

                	6.9.14	
                  All documents and communication materials included in this Outreach program must explain that (i) by using the Medical Advice Service before visiting the emergency room,
                      and presenting their call identification number at the emergency room, Enrollees can avoid any emergency room Co-Payments otherwise applicable under Section 7.11.4 of this Contract for services outside the PPN; and (ii) in no event
                      will Co-Payments be imposed for services to treat an Emergency Medical Condition or Psychiatric Emergency for Medicaid or CHIP Eligibles. All written materials included in the Outreach Program must be written at a fourth (4th) grade reading level and must be available in Spanish and English.

                


        

      

       

      
        
          	

                	6.9.15	
                  The Contractor shall prepare scripts addressing the questions expected to arise most often for both the Information Service and the Medical Advice Service. The Contractor
                      shall submit these scripts to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract. It is the responsibility of the Contractor to maintain and update these scripts and to
                      ensure that they are developed at the fourth (4th) grade reading level. The Contractor shall submit revisions to the script to ASES for written approval
                      prior to use.

                


        

      

       

      
        
          	

                	6.9.16	
                  The Contractor shall submit the following written materials referred to in this Section 6.8 to ASES for review and prior written approval according to the timeframe
                      specified in Attachment 12 to this Contract:

                


        

      

       

      
        
          	

                	6.9.16.1	
                  GHP Service Line policies and procedures;

                


        

      

       

      
        
          	

                	6.9.16.2	
                  GHP Service Line quality criteria and protocols;

                


        

      

       

      
        
          	

                	6.9.16.3	
                  GHP Service Line Outreach Program; and

                


        

      

       

      
        
          	

                	6.9.16.4	
                  Scripts and training materials for GHP Service Line Call Center employees.

                


        

      

       

      
        
          	

                	6.10	
                  Internet Presence/Website

                


        

      

       

      
        
          	

                	6.10.1	
                  The Contractor shall provide on its website general and up-to-date information about the GHP and about the Contractor’s Plan, including the Provider Network, customer
                      services, GHP Service Line, and its Grievance and Appeal System. The Enrollee Handbook and the Provider Directory shall be available on the website. All information must be written at a fourth (4th) grade level and must be available in Spanish and English.

                


        

      

       

      
        
          	

                	6.10.2	
                  The Contractor shall maintain an Enrollee portal that allows Enrollees to access a searchable Provider Directory that shall be updated within three (3) Business Days of
                      any change to the Provider Network.

                


        

      

       

      
        Page 70 of 324

        
          


      

      
        
          	

                	6.10.3	
                  The website must have the capability for Enrollees to submit questions and comments to the Contractor and receive responses. The Contractor shall reply to Enrollee
                      questions within two (2) Business Days.

                


        

      

       

      
        
          	

                	6.10.4	
                  The website must comply with the Marketing policies and procedures and with requirements for written materials described in Sections 6.2 and 6.3 of this Contract and must
                      be consistent with applicable Puerto Rico and Federal laws.

                


        

      

       

      
        
          	

                	6.10.5	
                  The Contractor shall submit website screenshots, active website URLs, and provide ASES access to website development portals upon request, for review and approval of
                      information on the website relating to the GHP Program according to the timeframe specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	6.10.6	
                  The Contractor’s website shall provide secured online access to the Enrollee’s historical and current information.

                


        

      

       

      
        
          	

                	6.10.7	
                  The Contractor’s website shall prominently feature a link to the ASES website, www.ases.pr.gov.

                


        

      

       

      
        
          	

                	6.10.8	
                  Any Enrollee Information required under 42 CFR 438.10, including the Enrollee Handbook, Provider Directory, FMC and LME, and Enrollee notices, may not be provided
                      electronically or on the Contractor’s website unless such Information (1) is readily accessible, (2) is placed on the Contractor’s website in a prominent location, (3) is provided in a form that can be electronically retained and
                      printed, and (4) includes notice to the Enrollee that the Information is available in paper form without charge and can be provided upon request within five (5) Business Days.

                


        

      

       

      
        
          	

                	6.10.9	
                  The Enrollee Handbook, Provider Directory, FMC and LME may be provided electronically instead of paper form if all required elements of Section 6.10.8 are satisfied.
                      However, the Contractor must provide the Enrollee Handbook, Provider Directory, and FMC and LME in paper form upon request by the Enrollee at no charge and within five (5) Business Days. If the Enrollee Handbook is provided by e-mail,
                      the Contractor must first obtain the Enrollee’s agreement to receive the Enrollee Handbook by e-mail. If the Enrollee Handbook is posted on the Contractor’s website, the Contractor must first advise the Enrollee in paper or electronic
                      form that the information is available on the internet, and must include the applicable website address, provided that Enrollees with disabilities who cannot access this information online are provided auxiliary aids and services upon
                      request and at no cost.

                


        

      

       

      
        
          	

                	6.11	
                  Cultural Competency

                


        

      

       

      
        
          	

                	6.11.1	
                  In accordance with 42 CFR 438.206, the Contractor shall have a comprehensive written Cultural Competency plan describing how the Contractor will ensure that services are
                      provided in a culturally competent manner to all Enrollees. The Cultural Competency plan must describe how the Providers, individuals, and systems within the Contractor’s Plan will effectively provide services to people of all diverse
                      cultural and ethnic backgrounds, disabilities, and regardless of gender, sexual orientation, gender identity, or religion in a manner that recognizes values, affirms, and respects the worth of the individual Enrollees and protects and
                      preserves the dignity of each individual.

                


        

      

       

      
        Page 71 of 324

        
          


      

      
        
          	

                	6.11.2	
                  The Contractor shall submit the Cultural Competency plan to ASES for review and approval according to the timeframe specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	6.11.3	
                  The Contractor may distribute a summary of the Cultural Competency plan, rather than the entire document, to Providers if the summary includes Information on how the
                      Provider may access the full Cultural Competency plan on the Contractor’s website. This summary shall also detail how the Provider can request a hard copy from the Contractor at no charge to the Provider.

                


        

      

       

      
        
          	

                	6.12	
                  Interpreter Services

                


        

      

       

      
        
          	

                	6.12.1	
                  The Contractor shall provide oral interpreter services to any Enrollee or Potential Enrollee who speaks any language other than English or Spanish as his or her primary
                      language, regardless of whether the Enrollee or Potential Enrollee speaks a language that meets the threshold of a Prevalent Non-English Language. This also includes the use of auxiliary aids and services such as TTY/TDD and the use
                      of American Sign Language. The Contractor is required to notify its Enrollees of the availability of oral interpretation services and to inform them of how to access oral interpretation services. There shall be no charge to an
                      Enrollee or Potential Enrollee for interpreter services or other auxiliary aids.

                


        

      

       

      
        
          	

                	6.13	
                  Enrollment Outreach

                


        

      

       

      
        
          	

                	6.13.1	
                  The Contractor shall participate in any Enrollment Outreach activities as prescribed by ASES or the Puerto Rico Medicaid Program.

                


        

      

       

      
        
          	

                	6.14	
                  Special Enrollee Information Requirements for Dual Eligible Beneficiaries

                


        

      

       

      
        
          	

                	6.14.1	
                  The Contractor shall inform a Potential Enrollee who is a Dual Eligible Beneficiary:

                


        

      

       

      
        
          	

                	6.14.1.1	
                  That the Dual Eligible Beneficiary is eligible for services under the GHP with the limits stated in Section 7.12 of this Contract;

                


        

      

       

      
        
          	

                	6.14.1.2	
                  That the GHP Plan will cover Medicare Part B Deductibles and co-insurance subject to the requirements in Section 23.5.1, but not Medicare Part A Deductibles;

                


        

      

       

      
        
          	

                	6.14.1.3	
                  That the Dual Eligible Beneficiary may not be simultaneously enrolled in the GHP and in a Medicare Platino plan, for the reason that the Platino plan already includes GHP
                      Benefits; and

                


        

      

       

      
        Page 72 of 324

        
          


      

      
        
          	

                	6.14.1.4	
                  That as an Enrollee in the Contractor’s Plan, the Dual Eligible Beneficiary may access Covered Services only through the PMG, not through the Medicare Provider List.

                


        

      

       

      
        
          	

                	6.15	
                  Marketing

                


        

      

       

      
        
          	

                	6.15.1	
                  For purposes of this section only, “Contractor” shall also include Contractor’s Subcontractors and Network Providers to the extent that such Subcontractors and Network
                      Providers are conducting Marketing activities.

                


        

      

       

      
        
          	

                	6.15.2	
                  Prohibited Activities. The Contractor is prohibited from engaging in the following
                      activities:

                


        

      

       

      
        
          	

                	6.15.2.1	
                  Directly or indirectly engaging in door-to-door, telephone, e-mail, texting or other Cold-Call Marketing activities;

                


        

      

       

      
        
          	

                	6.15.2.2	
                  Offering any favors, inducements or gifts, promotions, or other insurance products that are designed to induce Enrollment in the Contractor’s Plan;

                


        

      

       

      
        
          	

                	6.15.2.3	
                  Distributing plans and materials that contain statements that ASES determines are inaccurate, false, or misleading. Statements considered false or misleading include, but
                      are not limited to, any assertion or statement (whether written or oral) that the Contractor’s Plan is endorsed by the Federal Government or Government, or similar entity;

                


        

      

       

      
        
          	

                	6.15.2.4	
                  Distributing materials that, according to ASES, mislead or falsely describe the Contractor’s Provider Network, the participation or availability of Network Providers, the
                      qualifications and skills of Network Providers (including their bilingual skills); or the hours and location of network services;

                


        

      

       

      
        
          	

                	6.15.2.5	
                  Seeking to influence Enrollment in conjunction with the sale or offering of any private insurance; and

                


        

      

       

      
        
          	

                	6.15.2.6	
                  Asserting or stating in writing or verbally that the Enrollee or Potential Enrollee must enroll in the Contractor’s Plan to obtain or retain Benefits.

                


        

      

       

      
        
          	

                	6.15.2.7	
                  Marketing Contractor’s Plan to Enrollees or Potential Enrollees prior to October 1, 2018.

                


        

      

       

      
        
          	

                	6.15.3	
                  Allowable Activities. The Contractor shall be permitted to perform the following Marketing
                      activities:

                


        

      

       

      
        Page 73 of 324

        
          


      

      
        
          	

                	6.15.3.1	
                  Distribute general information through mass media (i.e., newspapers, magazines and other periodicals, radio, television, the Internet, public transportation advertising,
                      and other media outlets);

                


        

      

       

      
        
          	

                	6.15.3.2	
                  Make telephone calls, mailings and home visits only to Enrollees currently enrolled in the Contractor’s plan, for the sole purpose of educating them about services
                      offered by or available through the Contractor;

                


        

      

       

      
        
          	

                	6.15.3.3	
                  Distribute brochures and display posters at Provider offices that inform patients that the Provider is part of the GHP Provider Network; and

                


        

      

       

      
        
          	

                	6.15.3.4	
                  Attend activities that benefit the entire community, such as health fairs or other health education and promotional activities.

                


        

      

       

      
        
          	

                	6.15.4	
                  If the Contractor performs an allowable activity, the Contractor must conduct that activity Island-wide.

                


        

      

       

      
        
          	

                	6.15.5	
                  All materials shall be in compliance with the informational requirements in 42 CFR 438.10.

                


        

      

       

      
        
          	

                	6.15.6	
                  ASES Approval of Marketing Materials

                


        

      

       

      
        
          	

                	6.15.6.1	
                  The Contractor shall submit a detailed description of its Marketing plan and copies of all Marketing Materials (written and oral) that it or its Subcontractors plan to
                      distribute to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract. This requirement includes, but is not limited to posters, brochures, websites, and any materials that
                      contain statements regarding the Benefit package and Provider Network-related materials. Neither the Contractor nor its Subcontractors shall distribute any Marketing Materials without prior written approval from ASES.

                


        

      

       

      
        
          	

                	6.15.6.1.1	
                  The Contractor may begin Marketing activities using the materials and marketing plan approved by ASES beginning on October 1, 2018.

                


        

      

       

      
        
          	

                	6.15.6.2	
                  The Contractor may not initiate Marketing or distribute Marketing Materials of its GHP Plan until ASES has granted its written authorization for all Contractors to
                      initiate Marketing at the same time.

                


        

      

       

      
        
          	

                	6.15.6.3	
                  The Contractor shall submit any changes to previously approved Marketing Materials and receive written approval from ASES of the changes before distribution.

                


        

      

       

      
        Page 74 of 324

        
          


      

      
        
          	

                	6.15.6.4	
                  The Contractor must comply with ASES’ Normative Letter 18-0807, and any superseding Normative Letters, related to the review and approval of the Contractors Marketing
                      Materials included in Attachment 13 to this Contract.

                


        

      

       

      
        
          	

                	6.15.7	
                  Provider Marketing Materials

                


        

      

       

      
        
          	

                	6.15.7.1	
                  The Contractor is responsible for ensuring that not only its Marketing activities, but also the Marketing activities of its Subcontractors and Providers, meet the
                      requirements of this Section 6.14.

                


        

      

       

      
        
          	

                	6.15.7.2	
                  The Contractor shall collect from its Providers any Marketing Materials they intend to distribute and submit these to ASES for review and written approval prior to
                      distribution.

                


        

      

       

      
        
          	

                	6.15.7.3	
                  The Contractor shall provide for equitable distribution of all Marketing Materials without bias toward or against any group.

                


        

      

      

      

      
        
          	ARTICLE 7	
                  COVERED SERVICES AND BENEFITS

                


        

      

       

      
        
          	

                	7.1	
                  Requirement to Provide Covered Services

                


        

      

       

      
        
          	

                	7.1.1	
                  The Contractor shall at a minimum provide Medically Necessary Covered Services to Enrollees as of the Effective Date of Enrollment (including the retroactive period
                      specified in Section 5.1.3.1) pursuant to the program requirements of the GHP, and the Puerto Rico Medicaid State Plan and CHIP Plan. The Contractor shall not impose any other exclusions, limitations, or restrictions on any Covered
                      Service, and shall not arbitrarily deny or reduce the amount, duration, or scope of a Covered Service solely because of the diagnosis, type of illness, or condition.

                


        

      

       

      
        
          	

                	7.1.1.1	
                  In accordance with Section 2702 of the PPACA and 42 CFR 438.3(g), the Contractor must have mechanisms in place to prevent payment for the following Provider preventable
                      conditions and must require all providers to report on such Provider preventable conditions associated with Claims for payment or Enrollee treatments for which payment would otherwise be made. The Contractor must report all identified
                      Provider preventable conditions to ASES as follows:

                


        

      

       

      
        
          	

                	7.1.1.1.1	
                  All hospital acquired conditions as identified by Medicare other than deep vein thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip
                      replacement surgery in pediatric and obstetric patients for inpatient hospital services; and

                


        

      

       

      
        Page 75 of 324

        
          


      

      
        
          	

                	7.1.1.1.2	
                  Any incorrect surgical or other invasive procedure performed on a patient; any surgical or other invasive procedure performed on the incorrect body part; or any surgical
                      or other invasive procedure performed on the incorrect patient for inpatient and non-institutional services.

                


        

      

       

      
        
          	

                	7.1.2	
                  The Contractor shall not deny Covered Services based on pre-existing conditions, the individual’s genetic Information, or waiting periods.

                


        

      

       

      
        
          	

                	7.1.3	
                  The Contractor shall not be required to provide a Covered Service to a person who is not an Eligible Person.

                


        

      

       

      
        
          	

                	7.1.4	
                  The Contractor shall not be required to pay for a Covered Service if:

                


        

      

       

      
        
          	

                	7.1.4.1	
                  The Enrollee paid the Provider for the service. This rule does not apply in circumstances where a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for
                      Emergency Services provided in the other USA jurisdictions. In such a case, the expenses will be reimbursed under the GHP; or

                


        

      

       

      
        
          	

                	7.1.4.2	
                  The service was provided by a person or entity that does not meet the definition of a Network Provider (with the exception of Medical Emergencies and cases where the
                      service was Prior Authorized by the Contractor).

                


        

      

       

      
        
          	

                	7.1.5	
                  The Contractor shall make a best effort to conduct an initial screening of each Enrollee within ninety (90) days of the Effective Date of Enrollment for all new
                      Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful.

                


        

      

       

      
        
          	

                	7.2	
                  Medical Necessity

                


        

      

       

      
        
          	

                	7.2.1	
                  Based on generally accepted medical practices specific to the medical or Behavioral Health condition of the Enrollee at the time of treatment, Medically Necessary
                      Services are those that relate to (i) the prevention, diagnosis, and treatment of health impairments; (ii) the ability to achieve age-appropriate growth and development; or (iii) the ability to attain, maintain, or regain functional
                      capacity. The scope of Medically Necessary Services must not be any more restrictive than that of Puerto Rico’s Medicaid program. Additionally, Medically Necessary services must be:

                


        

      

       

      
        
          	

                	7.2.1.1	
                  Appropriate and consistent with the diagnosis of the treating Provider and the omission of which could adversely affect the eligible Enrollee’s medical condition;

                


        

      

       

      
        
          	

                	7.2.1.2	
                  Compatible with the standards of acceptable medical practice in the medical community;

                


        

      

       

      
        Page 76 of 324

        
          


      

      
        
          	

                	7.2.1.3	
                  Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;

                


        

      

       

      
        
          	

                	7.2.1.4	
                  Not provided solely for the convenience of the Enrollee or the convenience of the Provider or hospital; and

                


        

      

       

      
        
          	

                	7.2.1.5	
                  Not primarily custodial care (for example, foster care).

                


        

      

       

      
        
          	

                	7.2.2	
                  In order for a service to be Medically Necessary, there must be no other effective and more conservative or substantially less costly treatment, service, or setting
                      available.

                


        

      

       

      
        
          	

                	7.3	
                  Experimental or Cosmetic Procedures

                


        

      

       

      
        
          	

                	7.3.1	
                  In no instance shall the Contractor cover experimental or cosmetic procedures, except as required by the Puerto Rico Patient’s Bill of Rights Act or any other Federal or
                      Puerto Rico law or regulation. Breast reconstruction after a mastectomy and surgical procedures that are determined to be Medically Necessary to treat morbid obesity shall not be regarded as cosmetic procedures.

                


        

      

       

      
        
          	

                	7.4	
                  Covered Services and Administrative Functions

                


        

      

       

      
        
          	

                	7.4.1	
                  Benefits under the GHP are comprised of four categories: (i) Basic and Behavioral Health Coverage, (ii) dental services, (iii) Special Coverage, (iv) High Cost High Needs
                      Program, and (v) Administrative Functions. The scope of these items is covered in Sections 7.5 – 7.8, in the order listed.

                


        

      

       

      
        
          	

                	7.4.2	
                  The Contractor may cover services or settings that are in lieu of those covered under the State plan if ASES has approved the in lieu of service or setting as a medically
                      appropriate and cost effective substitute. If approved by ASES, the Contractor may offer the in lieu of service or setting to Enrollees, as appropriate, but shall not require an Enrollee to use an in lieu of service or setting. The
                      utilization and actual cost of approved in lieu of services or settings will be taken into account in developing the component of the PMPM Payment that represents the covered Medicaid State Plan services or settings, unless a statute
                      or regulation explicitly requires otherwise. Approved in lieu of services or settings will be communicated to Contractors via a Normative Letter or other standard method of communication of formal GHP policy.

                


        

      

       

      
        
          	

                	7.5	
                  Basic and Behavioral Health Coverage

                


        

      

       

      
        
          	

                	7.5.1	
                  Basic and Behavioral Health Coverage is available to all GHP Enrollees, except as provided in the table below. Basic Coverage includes the following categories:

                


           

          

          
            Page 77 of 324

            
              


          

        

      

      	 	
              BASIC COVERAGE 

              SERVICES

            	 	
              GHP ELIGIBILITY

              GROUPS COVERED

            
	 	
              Preventive Services

            	 	
              All

            
	 	
              Diagnostic Test Services

            	 	
              All

            
	 	
              Outpatient Rehabilitation Services

            	 	
              All

            
	 	
              Medical and Surgical Services

            	 	
              All

            
	 	
              Emergency Transportation Services

            	 	
              All (Services outside Puerto Rico available only for Medicaid and CHIP Eligibles)

            
	 	
              Maternity and Pre-Natal Services

            	 	
              All

            
	 	
              Emergency Services

            	 	
              All (Services outside Puerto Rico available only for Medicaid and CHIP Eligibles)

            
	 	
              Hospitalization Services

            	 	
              All

            
	 	
              Behavioral Health Services

            	 	
              All

            
	 	
              Pharmacy Services

            	 	
              All (Note: Claims processing and adjudication Services provided by PBM; not covered under this Contract.)

            


       

      
        
          	

                	7.5.2	
                  Exclusions from Basic Coverage

                


        

      

       

      
        
          	

                	7.5.2.1	
                  The following services are excluded from all Basic Coverage. In addition, exclusions specific to each category of Covered Services are noted in Sections 7.5.3 – 7.5.12
                      below.

                


        

      

       

      
        
          	

                	7.5.2.1.1	
                  Expenses for personal comfort materials or services, such as, telephone use, television, or toiletries;

                


        

      

       

      
        
          	

                	7.5.2.1.2	
                  Services rendered by close family relatives (parents, children, siblings, grandparents, grandchildren, or spouses);

                


        

      

       

      
        
          	

                	7.5.2.1.3	
                  Weight control treatment (obesity or weight gain) for aesthetic reasons. As noted, procedures determined to be Medically Necessary to address morbid obesity shall not be
                      excluded;

                


        

      

       

      
        
          	

                	7.5.2.1.4	
                  Sports medicine, music therapy, and natural medicine;

                


        

      

       

      
        
          	

                	7.5.2.1.5	
                  Services, diagnostic testing, or treatment ordered or rendered by naturopaths, naturists, or iridologists;

                


        

      

       

      
        
          	

                	7.5.2.1.6	
                  Health Certificates, except as provided in Section 7.5.3.2.10 (Preventive Services);

                


        

      

       

      
        Page 78 of 324

        
          


      

      
        
          	

                	7.5.2.1.7	
                  Epidural anesthesia services;

                


        

      

       

      
        
          	

                	7.5.2.1.8	
                  Educational tests or services;

                


        

      

       

      
        
          	

                	7.5.2.1.9	
                  Peritoneal dialysis or hemodialysis services (covered under Special Coverage, not Basic Coverage);

                


        

      

       

      
        
          	

                	7.5.2.1.10	
                  Home Health and Hospice care for Adults;

                


        

      

       

      
        
          	

                	7.5.2.1.11	
                  Services received outside the territorial limits of Puerto Rico, except as provided in Sections 7.5.7.11 (Emergency Transportation) and 7.5.9.3 (Emergency Services);

                


        

      

       

      
        
          	

                	7.5.2.1.12	
                  Expenses incurred for the treatment of conditions resulting from services not covered under the GHP (maintenance prescriptions and required clinical laboratories for the
                      continuity of a stable health condition, as well as any emergencies which could alter the effects of the previous procedure, are covered);

                


        

      

       

      
        
          	

                	7.5.2.1.13	
                  Judicially ordered evaluations for legal purposes;

                


        

      

       

      
        
          	

                	7.5.2.1.14	
                  Travel expenses, even when ordered by the Primary Care Physician;

                


        

      

       

      
        
          	

                	7.5.2.1.15	
                  Psychological, psychometric, and psychiatric tests and evaluations to obtain employment or insurance, or for purposes of litigation;

                


        

      

       

      
        
          	

                	7.5.2.1.16	
                  Eyeglasses, contact lenses and hearing aids for Adults;

                


        

      

       

      
        
          	

                	7.5.2.1.17	
                  Acupuncture services;

                


        

      

       

      
        
          	

                	7.5.2.1.18	
                  Sex change procedures;

                


        

      

       

      
        
          	

                	7.5.2.1.19	
                  Organ and tissue transplants, except skin, bone and corneal transplants.; and

                


        

      

       

      
        
          	

                	7.5.2.1.20	
                  Treatment for infertility and/or related to conception by artificial means including tuboplasty, vasovasectomy, and any other procedure to restore the ability to
                      procreate.

                


        

      

       

      
        
          	

                	7.5.2.1.21	
                  Mechanical respirators and ventilators with oxygen supplies are covered without limits as required by local law to Enrollees under age twenty-one (21). The Contractor
                      must cooperate with ASES and DOH to provide any necessary information as directed by ASES. All Durable Medical Equipment (DME) is not covered; however, DME may be covered on a case-by-case basis under an exceptions process.

                


        

      

       

      
        Page 79 of 324

        
          


      

      
        
          	

                	7.5.3	
                  Preventive Services

                


        

      

       

      
        
          	

                	7.5.3.1	
                  Well Baby Care. The Contractor shall provide the following Preventive Services as Covered
                      Services under the Well Baby Care Program:

                


        

      

       

      
        
          	

                	7.5.3.1.1	
                  One (1) annual comprehensive evaluation by a certified Provider, which complements other services for children and young adults provided pursuant to the periodicity
                      scheme of the American Academy of Pediatrics and Title XIX (EPSDT); and

                


        

      

       

      
        
          	

                	7.5.3.1.2	
                  Other services, as needed.

                


        

      

       

      
        
          	

                	7.5.3.2	
                  Other Preventive Services. The Contractor shall provide the following Preventive Services as
                      Covered Services for all GHP Enrollees:

                


        

      

       

      
        
          	

                	7.5.3.2.1	
                  All immunizations shall be provided for Pediatric Enrollees, and those necessary according to age, gender, and health condition of the Enrollee, including but not limited
                      to: influenza and pneumonia, and vaccines for children and adults with high risk conditions such as pulmonary, renal, diabetes and heart disease, among others.

                


        

      

       

      
        
          	

                	7.5.3.2.1.1	
                  The Puerto Rico Department of Health shall provide and pay for vaccines to Enrollees ages zero (0) and eighteen (18), excluding those in the State Population, through the
                      Children’s Immunization Program. The Contractor shall cover the administration of the vaccines provided by the Puerto Rico Department of Health.

                


        

      

       

      
        
          	

                	7.5.3.2.1.2	
                  The Contractor shall provide and pay for the immunizations of Enrollees in the State Population ages zero (0) and eighteen (18), all Enrollees ages nineteen (19) to
                      twenty (20), and those necessary according to age, gender and health condition of the Enrollee, including but not limited to influenza and pneumonia vaccines for Enrollees over sixty-five (65) years and adults with high risk
                      conditions such as pulmonary, renal, diabetes, and heart disease, among others.

                


        

      

       

      
        Page 80 of 324

        
          


      

      
        
          	

                	7.5.3.2.1.3	
                  The Contractor shall cover the administration of all the vaccines according to the fee schedule established by the Puerto Rico Health Department. The Contractor shall
                      contract with immunization providers, duly certified by the Puerto Rico Department of Health, to provide immunization services.

                


        

      

       

      
        
          	

                	7.5.3.2.1.4	
                  The Contractor shall administer the immunizations without any charge or deductible.

                


        

      

       

      
        
          	

                	7.5.3.2.2	
                  Hearing exam, including hearing screening for newborns prior to their leaving the hospital nursery;

                


        

      

       

      
        
          	

                	7.5.3.2.3	
                  Evaluation and nutritional screening;

                


        

      

       

      
        
          	

                	7.5.3.2.4	
                  Medically Necessary laboratory exams and diagnostic tests, appropriate to the Enrollee’s age, sex, and health condition, including, but not limited to:

                


        

      

       

      
        
          	

                	7.5.3.2.4.1	
                  Prostate and gynecological cancer screening according to accepted medical practice, including Pap smears (for Enrollees over age eighteen (18)), mammograms (for Enrollees
                      age forty (40) and over), and Prostate-Specific Antigen (PSA) tests when Medically Necessary; and

                


        

      

       

      
        
          	

                	7.5.3.2.4.2	
                  Sigmoidoscopy and colonoscopy for colon cancer detection in Adults age fifty (50) years and over, classified in risk groups according to accepted medical practice;

                


        

      

       

      
        
          	

                	7.5.3.2.5	
                  Nutritional, oral, and physical health education;

                


        

      

       

      
        
          	

                	7.5.3.2.6	
                  Reproductive health counseling and family planning. Enrollees shall be free to choose the
                      method of family planning in accordance with 42 CFR 438.210(a)(4)(ii)(C). The Contractor shall cover the following family planning services:

                


        

      

       

      
        
          	

                	7.5.3.2.6.1	
                  Education and Counseling;

                


        

      

       

      
        
          	

                	7.5.3.2.6.2	
                  Pregnancy testing;

                


        

      

       

      
        
          	

                	7.5.3.2.6.3	
                  Infertility assessments;

                


        

      

       

      
        Page 81 of 324

        
          


      

      
        
          	

                	7.5.3.2.6.4	
                  Sterilization services in accordance with 42 CFR 441.200, subpart F.

                


        

      

       

      
        
          	

                	7.5.3.2.6.5	
                  Laboratory services;

                


        

      

       

      
        
          	

                	7.5.3.2.6.6	
                  At least one of every class and category of FDA-approved contraceptive method as specified by ASES’s Normative Letter 15-1012 (Attachment 13);

                


        

      

       

      
        
          	

                	7.5.3.2.6.7	
                  At least one of every class of FDA-approved contraceptive medication as specified in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);

                


        

      

       

      
        
          	

                	7.5.3.2.6.8	
                  Cost and insertion removal of non-oral products, such as long acting reversible contraceptives (LARC) as specified in ASES’s Normative Letter 15-1012 (Attachment 13 to
                      this Contract); and

                


        

      

       

      
        
          	

                	7.5.3.2.6.9	
                  Other FDA-approved contraceptive medications or methods not covered by sections 7.5.3.2.6.6 or 7.5.3.2.6.7 of the Contract, when it is Medically Necessary and approved
                      through a Prior Authorization or through an exception process and the prescribing Provider can demonstrate at least one of the following situations:

                


        

      

       

      
        
          	

                	7.5.3.2.6.9.1	
                  Contra-indication with drugs that are in the ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract) that the Enrollee is already taking, and no other methods
                      available in the ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract) that can be used by the Enrollee;

                


        

      

       

      
        
          	

                	7.5.3.2.6.9.2	
                  History of adverse reaction by the Enrollee to the contraceptive methods covered as specified by ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);

                


        

      

       

      
        
          	

                	7.5.3.2.6.9.3	
                  History of adverse reaction by the Enrollee to the contraceptive medications covered as specified by ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);

                


        

      

       

      
        Page 82 of 324

        
          


      

      
        
          	

                	7.5.3.2.7	
                  Syringes for home medicine administration, if deemed Medically Necessary;

                


        

      

       

      
        
          	

                	7.5.3.2.8	
                  Annual physical exam and follow-up for diabetic patients according to the Diabetic Patient Treatment Guide and Health Department protocols; and

                


        

      

       

      
        
          	

                	7.5.3.2.9	
                  Health Certificates are covered under the GHP, provided that cost sharing and/or deductibles applicable for necessary procedures and laboratory testing related to
                      generating a Health Certificate will be the Enrollee’s responsibility. Such certificates shall include:

                


        

      

       

      
        
          	

                	7.5.3.2.9.1	
                  Venereal Disease Research Laboratory (“VDRL”) tests;

                


        

      

       

      
        
          	

                	7.5.3.2.9.2	
                  Tuberculosis (“TB”) tests; and

                


        

      

       

      
        
          	

                	7.5.3.2.9.3	
                  Any Certification for GHP Enrollees related to eligibility for the Medicaid Program (provided at no charge).

                


        

      

       

      
        
          	

                	7.5.4	
                  Diagnostic Test Services

                


        

      

       

      
        
          	

                	7.5.4.1	
                  The Contractor shall provide the following diagnostic test services as Covered Services:

                


        

      

       

      
        
          	

                	7.5.4.1.1	
                  Diagnostic and testing services for Enrollees under age twenty-one (21) required by EPSDT, as defined in Section 1905(r) of the Social Security Act;

                


        

      

       

      
        
          	

                	7.5.4.1.2	
                  Clinical labs, including but not limited to, any laboratory order for disease diagnostic purposes, even if the final diagnosis is a condition or disease whose treatment
                      is not a Covered Service;

                


        

      

       

      
        
          	

                	7.5.4.1.3	
                  Hi-tech Labs;

                


        

      

       

      
        
          	

                	7.5.4.1.4	
                  X-Rays;

                


        

      

       

      
        
          	

                	7.5.4.1.5	
                  Electrocardiograms;

                


        

      

       

      
        
          	

                	7.5.4.1.6	
                  Radiation therapy (Prior Authorization required);

                


        

      

       

      
        
          	

                	7.5.4.1.7	
                  Pathology;

                


        

      

       

      
        Page 83 of 324

        
          


      

      
        
          	

                	7.5.4.1.8	
                  Arterial gases and Pulmonary Function Test;

                


        

      

       

      
        
          	

                	7.5.4.1.9	
                  Electroencephalograms;

                


        

      

       

      
        
          	

                	7.5.4.1.10	
                  Diagnostic services for Enrollees who present learning disorder symptoms; and

                


        

      

       

      
        
          	

                	7.5.4.1.11	
                  Services related to a diagnostic code included in the Diagnostic and Statistical Manual of Mental Disorders (“DSM IV or DSM V”).

                


        

      

       

      
        
          	

                	7.5.4.2	
                  The following shall not be considered diagnostic test services covered under the GHP:

                


        

      

       

      
        
          	

                	7.5.4.2.1	
                  Polysomnography studies; and

                


        

      

       

      
        
          	

                	7.5.4.2.2	
                  Clinical labs processed outside of Puerto Rico.

                


        

      

       

      
        
          	

                	7.5.5	
                  Outpatient Rehabilitation Services

                


        

      

       

      
        
          	

                	7.5.5.1	
                  The Contractor shall provide the following outpatient rehabilitation services as Covered Services:

                


        

      

       

      
        
          	

                	7.5.5.1.1	
                  Medically Necessary outpatient rehabilitation services for Enrollees under age twenty-one (21), as required by EPSDT, Section 1905(r) of the Social Security Act;

                


        

      

       

      
        
          	

                	7.5.5.1.2	
                  Physical therapy (limited to a maximum of fifteen (15) treatments per Enrollee condition per year, unless Prior Authorization of an additional fifteen (15) treatments is
                      indicated by an orthopedist or physiatrist or chiropractor);

                


        

      

       

      
        
          	

                	7.5.5.1.3	
                  Occupational therapy, without limitations; and

                


        

      

       

      
        
          	

                	7.5.5.1.4	
                  Speech therapy, without limitations.

                


        

      

       

      
        
          	

                	7.5.6	
                  Medical and Surgical Services

                


        

      

       

      
        
          	

                	7.5.6.1	
                  The Contractor shall provide the following medical and surgical services as Covered Services:

                


        

      

       

      
        
          	

                	7.5.6.1.1	
                  Early and Periodic Screening, Diagnostic and Treatment (“EPSDT”) services, as defined in Section 1905(r) of the Social Security Act;

                


        

      

       

      
        
          	

                	7.5.6.1.2	
                  Primary Care Physician visits, including nursing services;

                


        

      

       

      
        
          	

                	7.5.6.1.3	
                  Specialist treatment, once referred by the selected PCP if outside of the Enrollee’s PPN;

                


        

      

       

      
        Page 84 of 324

        
          


      

      
        
          	

                	7.5.6.1.4	
                  Sub-specialist treatment, once referred by the selected PCP if outside of the Enrollee’s PPN;

                


        

      

       

      
        
          	

                	7.5.6.1.5	
                  Physician home visits when Medically Necessary;

                


        

      

       

      
        
          	

                	7.5.6.1.6	
                  Respiratory therapy, without limitations;

                


        

      

       

      
        
          	

                	7.5.6.1.7	
                  Anesthesia services (except for epidural anesthesia);

                


        

      

       

      
        
          	

                	7.5.6.1.8	
                  Radiology services;

                


        

      

       

      
        
          	

                	7.5.6.1.9	
                  Pathology services;

                


        

      

       

      
        
          	

                	7.5.6.1.10	
                  Surgery;

                


        

      

       

      
        
          	

                	7.5.6.1.11	
                  Outpatient surgery facility services;

                


        

      

       

      
        
          	

                	7.5.6.1.12	
                  Nursing services;

                


        

      

       

      
        
          	

                	7.5.6.1.13	
                  Voluntary sterilization of men and women of legal age and sound mind, provided that they have been previously informed about the medical procedure’s implications, and
                      that there is evidence of Enrollee’s written consent by completing the Sterilization Consent Form included as Attachment 22 to this Contract;

                


        

      

       

      
        
          	

                	7.5.6.1.14	
                  Prosthetics, including the supply of all extremities of the human body including therapeutic ocular prosthetics, segmental instrument tray, and spine fusion in scoliosis
                      and vertebral surgery;

                


        

      

       

      
        
          	

                	7.5.6.1.15	
                  Ostomy equipment for outpatient-level ostomized patients;

                


        

      

       

      
        
          	

                	7.5.6.1.16	
                  Transfusion of blood and blood plasma services, without limitations, including the following:

                


        

      

       

      
        
          	

                	7.5.6.1.16.1	
                  Antihemophilic recombinant factor VIII;

                


        

      

       

      
        
          	

                	7.5.6.1.16.2	
                  Antihemophilic recombinant factor IX;

                


        

      

       

      
        
          	

                	7.5.6.1.16.3	
                  Anti-inhibitor coagulant complex (Feiba); and

                


        

      

       

      
        
          	

                	7.5.6.1.16.4	
                  Antihemophilic factor VIII, human/Von Willebrand factor complex.

                


        

      

       

      
        
          	

                	7.5.6.1.17	
                  Services to patients with Level 1 or Level 2 of chronic renal disease (Levels 3 to 5 are included in Special Coverage in Section 7.7).

                


        

      

       

      
        Page 85 of 324

        
          


      

      
        
          	

                	7.5.6.1.17.1	
                  Chronic renal disease Levels 1 and 2 are defined as follows:

                


        

      

       

      
        
          	

                	7.5.6.1.17.1.1	
                  Level 1. GFR (Glomerular Filtration – ml/min. per 1.73m2 per corporal area surface) over 90;
                      slight damage when protein is present in the urine.

                


        

      

       

      
        
          	

                	7.5.6.1.17.1.2	
                  Level 2. GFR between 60 and 89, a slight decrease in kidney function.

                


        

      

       

      
        
          	

                	7.5.6.1.17.2	
                  When GFR decreases to under 60 ml/min per 1.73 m2, the Enrollee must be referred to a nephrologist for proper management. The Enrollee will be registered for Special
                      Coverage.

                


        

      

       

      
        
          	

                	7.5.6.1.18	
                  Skin, bone and corneal transplants.

                


        

      

       

      
        
          	

                	7.5.6.2	
                  While cosmetic procedures shall be excluded from Covered Services, breast reconstruction after a mastectomy and surgical procedures Medically Necessary to treat morbid
                      obesity shall not be considered to be cosmetic procedures.

                


        

      

       

      
        
          	

                	7.5.6.3	
                  Mechanical respirators and ventilators with oxygen supplies are covered without limits as required by local law to Enrollees under age twenty-one (21). All Durable
                      Medical Equipment (DME) is not covered; however, DME may be covered on a case-by-case basis under an exceptions process.

                


        

      

       

      
        
          	

                	7.5.6.4	
                  Abortions are covered in the following instances: (i) life of the mother would be in danger if the fetus is carried to term; (ii) when the pregnancy is a result of rape
                      or incest; and (iii) severe and long lasting damage would be caused to the mother if the pregnancy is carried to term, as certified by a physician.

                


        

      

       

      
        
          	

                	7.5.7	
                  Emergency Transportation Services

                


        

      

       

      
        
          	

                	7.5.7.1	
                  The Contractor shall provide Emergency Transportation Services, including but not limited to, maritime and ground transportation, in emergency situations as Covered
                      Services.

                


        

      

       

      
        
          	

                	7.5.7.2	
                  Emergency transportation services shall be available twenty-four (24) hours a day, seven (7) days per Week throughout Puerto Rico.

                


        

      

       

      
        
          	

                	7.5.7.3	
                  Emergency transportation services do not require Prior Authorization.

                


        

      

       

      
        Page 86 of 324

        
          


      

      
        
          	

                	7.5.7.4	
                  The Contractor shall ensure that adequate emergency transportation is available to transport any Enrollees experiencing an Emergency Medical Conditions or a Psychiatric
                      Emergency, or whose conditions require emergency transportation because of their geographical location.

                


        

      

       

      
        
          	

                	7.5.7.5	
                  The Contractor may not impose limits on what constitutes an Emergency Medical Condition or a Psychiatric Emergency on the basis of lists of diagnoses or symptoms.

                


        

      

       

      
        
          	

                	7.5.7.6	
                  Aerial emergency transportation services are provided and paid for by the Government of Puerto Rico under a separate contract. The Contractor shall coordinate the
                      provision of aerial emergency transportation on behalf of its Enrollees when Medically Necessary utilizing the Provider designated by the Government of Puerto Rico.

                


        

      

       

      
        
          	

                	7.5.7.7	
                  The Contractor shall bear the expenses of providing emergency transportation and shall adhere to Puerto Rico laws and regulations concerning emergency transportation,
                      including applicable fees as established by the Public Service Commission of the Government of Puerto Rico (CSP for its acronym in Spanish).

                


        

      

       

      
        
          	

                	7.5.7.8	
                  The Contractor shall provide Category II and Category III Ambulance Services pursuant to Regulation No. 6737 of the Public Service Commission.

                


        

      

       

      
        
          	

                	7.5.7.8.1	
                  Category II Ambulances are Ambulances utilized for the transportation of ill, injured, hurt, and disabled patients equipped with the specifications set by the Department
                      of Heath of Puerto Rico. Fees paid for Type III ambulances are set by Provision 57.37 of the Public Service Commission.

                


        

      

       

      
        
          	

                	7.5.7.8.2	
                  Category III Ambulances must comply with all the requirements of Category II Ambulances, have advanced stabilization equipment and are specially designed and equipped as
                      established from time to time by the Ambulance Certification Office of the Department of Health of Puerto Rico.

                


        

      

       

      
        
          	

                	7.5.7.9	
                  The Contractor may not retroactively deny a Claim for emergency transportation services because the Enrollee’s condition, which at the time of service appeared to be an
                      Emergency Medical Condition or a Psychiatric Emergency under the prudent layperson standard, was ultimately determined to be a non-emergency.

                


        

      

       

      
        
          	

                	7.5.7.10	
                  In any case in which an Enrollee is transported by ambulance to a facility that is not a Network Provider, and, after being stabilized, is transported by ambulance to a
                      facility that is a Network Provider, all emergency transportation costs, provided that they are justified by prudent layperson standards, will be borne by the Contractor.

                


        

      

       

      
        Page 87 of 324

        
          


      

      
        
          	

                	7.5.7.11	
                  The Contractor shall be responsible for timely payment for emergency transportation services in the other USA jurisdictions for Enrollees who are Medicaid or CHIP
                      Eligibles, if the emergency transportation is associated with an Emergency Service in the other USA jurisdictions covered under Section 7.5.9.3.1.2 of this Contract. If, in an extenuating circumstance, a Medicaid or CHIP Eligible
                      Enrollee incurs out-of-pocket expenses for emergency transportation services provided in the other USA jurisdictions, the Contractor shall reimburse the Enrollee for such expenses in a timely manner, and the reimbursement shall be
                      considered a Covered Service.

                


        

      

       

      
        
          	

                	7.5.7.12	
                  Emergency transportation services will be subject to periodic reviews and/or audits by applicable governmental agencies and ASES to ensure quality of services.

                


        

      

       

      
        
          	

                	7.5.8	
                  Maternity and Pre-Natal Services

                


        

      

       

      
        
          	

                	7.5.8.1	
                  The Contractor shall provide the following maternity and pre-natal services as Covered Services:

                


        

      

       

      
        
          	

                	7.5.8.1.1	
                  Pregnancy testing;

                


        

      

       

      
        
          	

                	7.5.8.1.2	
                  Medical services, during pregnancy and post-partum;

                


        

      

       

      
        
          	

                	7.5.8.1.3	
                  Physician and nurse obstetrical services during vaginal and caesarean section deliveries, and services to address any complication that arises during the delivery;

                


        

      

       

      
        
          	

                	7.5.8.1.4	
                  Treatment of conditions attributable to the pregnancy or delivery, when medically recommended;

                


        

      

       

      
        
          	

                	7.5.8.1.5	
                  Hospitalization for a period of at least forty-eight (48) hours in cases of vaginal delivery, and at least ninety-six hours (96) in cases of caesarean section;

                


        

      

       

      
        
          	

                	7.5.8.1.6	
                  Anesthesia, excluding epidural;

                


        

      

       

      
        
          	

                	7.5.8.1.7	
                  Incubator use, without limitations;

                


        

      

       

      
        
          	

                	7.5.8.1.8	
                  Fetal monitoring services, during hospitalization only;

                


        

      

       

      
        
          	

                	7.5.8.1.9	
                  Nursery room routine care for newborns;

                


        

      

       

      
        
          	

                	7.5.8.1.10	
                  Circumcision and dilatation services for newborns;

                


        

      

       

      
        Page 88 of 324

        
          


      

      
        
          	

                	7.5.8.1.11	
                  Transportation of newborns to tertiary facilities when necessary;

                


        

      

       

      
        
          	

                	7.5.8.1.12	
                  Pediatrician assistance during delivery; and

                


        

      

       

      
        
          	

                	7.5.8.1.13	
                  Delivery services provided in free-standing birth centers.

                


        

      

       

      
        
          	

                	7.5.8.2	
                  The following are excluded from maternity and pre-natal Covered Services:

                


        

      

       

      
        
          	

                	7.5.8.2.1	
                  Outpatient use of fetal monitor;

                


        

      

       

      
        
          	

                	7.5.8.2.2	
                  Treatment services for infertility and/or related to conception by artificial means;

                


        

      

       

      
        
          	

                	7.5.8.2.3	
                  Services, treatments, or hospitalizations as a result of a provoked non-therapeutic abortion or associated complications are not covered. The following are considered to
                      be provoked abortions:

                


        

      

       

      
        
          	

                	7.5.8.2.3.1	
                  Dilatation and curettage (CPT Code 59840);

                


        

      

       

      
        
          	

                	7.5.8.2.3.2	
                  Dilatation and expulsion (CPT Code 59841);

                


        

      

       

      
        
          	

                	7.5.8.2.3.3	
                  Intra-amniotic injection (CPT Codes 59850, 59851, 59852);

                


        

      

       

      
        
          	

                	7.5.8.2.3.4	
                  One or more vaginal suppositories (e.g., Prostaglandin) with or without cervical dilatation (e.g., Laminar), including hospital admission and visits, fetus birth, and
                      secundines (CPT Code 59855);

                


        

      

       

      
        
          	

                	7.5.8.2.3.5	
                  One or more vaginal suppositories (e.g., Prostaglandin) with dilatation and curettage/or evacuation (CPT Code 59856); and

                


        

      

       

      
        
          	

                	7.5.8.2.3.6	
                  One or more vaginal suppositories (e.g., Prostaglandin) with hysterectomy (omitted medical expulsion) (CPT Code 59857); and

                


        

      

       

      
        
          	

                	7.5.8.2.4	
                  Differential diagnostic interventions up to the confirmation of pregnancy are not covered. Any procedure after the confirmation of pregnancy will be at the Contractor’s
                      own risk.

                


        

      

       

      
        
          	

                	7.5.8.3	
                  The Contractor shall implement a pre-natal and maternal program, aimed at preventing complications during and after pregnancy, and advancing the objective of lowering the
                      incidence of low birth weight and premature deliveries.

                


        

      

       

      
        Page 89 of 324

        
          


      

      
        
          	

                	7.5.8.3.1	
                  The program shall include, at a minimum, the following components:

                


        

      

       

      
        
          	

                	7.5.8.3.1.1	
                  A pre-natal care card, used to document services utilized;

                


        

      

       

      
        
          	

                	7.5.8.3.1.2	
                  Counseling regarding HIV testing;

                


        

      

       

      
        
          	

                	7.5.8.3.1.3	
                  Pregnancy testing;

                


        

      

       

      
        
          	

                	7.5.8.3.1.4	
                  A RhoGAM injection for all pregnant women who have a negative Rhesus (“Rh”) factor according to the established protocol;

                


        

      

       

      
        
          	

                	7.5.8.3.1.5	
                  Alcohol screening of pregnant women with the 4P-Plus instrument;

                


        

      

       

      
        
          	

                	7.5.8.3.1.6	
                  Smoking cessation counseling and treatment;

                


        

      

       

      
        
          	

                	7.5.8.3.1.7	
                  Post-partum depression screening using the Edinburgh post-natal depression scale;

                


        

      

       

      
        
          	

                	7.5.8.3.1.8	
                  Post-partum counseling and Referral to the WIC program;

                


        

      

       

      
        
          	

                	7.5.8.3.1.9	
                  Dental evaluation during the second trimester of gestation; and

                


        

      

       

      
        
          	

                	7.5.8.3.1.10	
                  Educational workshops regarding pre-natal care topics (importance of pre-natal medical visits and post-partum care), breast-feeding, stages of childbirth, oral and
                      Behavioral Health, family planning, and newborn care, among others.

                


        

      

       

      
        
          	

                	7.5.8.3.2	
                  The Contractor shall ensure that eighty-five percent (85%) of pregnant Enrollees receive services under the Pre-Natal and Maternal Program. The Contractor shall submit
                      its pre-natal and Maternal Program maternal wellness plan to ASES according to the timeframe specified in Attachment 12 to this Contract, and shall submit reports quarterly concerning the usage of services under this program.

                


        

      

       

      
        
          	

                	7.5.8.4	
                  The Contractor shall provide reproductive health and family planning counseling. Such services shall be provided voluntarily and confidentially, including circumstances
                      where the Enrollee is under age eighteen (18). Family planning services will include, at a minimum, the following:

                


        

      

       

      
        Page 90 of 324

        
          


      

      
        
          	

                	7.5.8.4.1	
                  Education and counseling;

                


        

      

       

      
        
          	

                	7.5.8.4.2	
                  Pregnancy testing;

                


        

      

       

      
        
          	

                	7.5.8.4.3	
                  Infertility assessment;

                


        

      

       

      
        
          	

                	7.5.8.4.4	
                  Sterilization services in accordance with 42 CFR 441.200, subpart F;

                


        

      

       

      
        
          	

                	7.5.8.4.5	
                  Laboratory services;

                


        

      

       

      
        
          	

                	7.5.8.4.6	
                  Cost and insertion/removal of non-oral products, such as long acting reversible contraceptives (LARC) as specified by ASES’s Normative Letter 15-1012 (Attachment 13 to
                      this Contract);

                


        

      

       

      
        
          	

                	7.5.8.4.7	
                  At least one of every class and category of FDA-approved contraceptive medication as specified in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract);

                


        

      

       

      
        
          	

                	7.5.8.4.8	
                  At least one of every class and category of FDA-approved contraceptive method as specified in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract); and

                


        

      

       

      
        
          	

                	7.5.8.4.9	
                  Other FDA-approved contraceptive medications or methods not covered by sections 7.5.8.4.7 or 7.5.8.4.8 of the Contract, when it is Medically Necessary and approved
                      through a Prior Authorization or through an exception process and the prescribing Provider can demonstrate at least one of the following situations:

                


        

      

       

      
        
          	

                	7.5.8.4.9.1	
                  Contra-indication with drugs that are in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract) that the Enrollee is already taking, and no other methods
                      available in the ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract) that can be used by the Enrollee.

                


        

      

       

      
        
          	

                	7.5.8.4.9.2	
                  History of adverse reaction by the Enrollee to the contraceptive methods covered as specified by ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract); or

                


        

      

       

      
        
          	

                	7.5.8.4.9.3	
                  History of adverse reaction by the Enrollee to the contraceptive medications that are in ASES’s Normative Letter 15-1012 (Attachment 13 to this Contract).

                


        

      

       

      
        Page 91 of 324

        
          


      

      
        
          	

                	7.5.8.5	
                  Maternity services, including family planning and postpartum services must be covered for a sixty (60) Calendar Day period, beginning on the day the pregnancy ends. These
                      services will also be covered for any remaining days in the month in which the sixtieth (60th) day falls.

                


        

      

       

      
        
          	

                	7.5.9	
                  Emergency Services

                


        

      

       

      
        
          	

                	7.5.9.1	
                  The Contractor shall cover and pay for Emergency Services where necessary to treat an Emergency Medical Condition or a Behavioral Health Emergency. The Contractor shall
                      ensure that Medical and Behavioral Health Emergency Services are available twenty-four (24) hours a day, seven (7) days per Week. The Contractor shall ensure that emergency rooms and other Providers qualified to furnish Emergency
                      Services have appropriate personnel to provide physical and Behavioral Health Services. All Emergency Services must be billed appropriately to the Contractor based on the applicable treatment and site of care. No Prior Authorization
                      will be required for Emergency Services, and the Contractor shall not deny payment for treatment if a representative of the Contractor instructed the Enrollee to seek Emergency Services.

                


        

      

       

      
        
          	

                	7.5.9.2	
                  Emergency Services shall include, but are not limited to, the following:

                


        

      

       

      
        
          	

                	7.5.9.2.1	
                  Emergency room visits, including medical attention and routine and necessary services;

                


        

      

       

      
        
          	

                	7.5.9.2.2	
                  Trauma services;

                


        

      

       

      
        
          	

                	7.5.9.2.3	
                  Operating room use;

                


        

      

       

      
        
          	

                	7.5.9.2.4	
                  Respiratory therapy;

                


        

      

       

      
        
          	

                	7.5.9.2.5	
                  Specialist and sub-specialist treatment when required by the emergency room physician;

                


        

      

       

      
        
          	

                	7.5.9.2.6	
                  Anesthesia;

                


        

      

       

      
        
          	

                	7.5.9.2.7	
                  Surgical material;

                


        

      

       

      
        
          	

                	7.5.9.2.8	
                  Laboratory tests and X-Rays;

                


        

      

       

      
        
          	

                	7.5.9.2.9	
                  Post-Stabilization Services, as provided in Section 7.5.9.4 below;

                


        

      

       

      
        Page 92 of 324

        
          


      

      
        
          	

                	7.5.9.2.10	
                  Care as necessary in the case of a Psychiatric Emergency in an emergency room setting;

                


        

      

       

      
        
          	

                	7.5.9.2.11	
                  Drugs, medicine and intravenous solutions used in the emergency room; and

                


        

      

       

      
        
          	

                	7.5.9.2.12	
                  Transfusion of blood and blood plasma services, without limitations, including:

                


        

      

       

      
        
          	

                	7.5.9.2.12.1	
                  Antihemophilic recombinant factor VIII;

                


        

      

       

      
        
          	

                	7.5.9.2.12.2	
                  Antihemophilic recombinant factor IX;

                


        

      

       

      
        
          	

                	7.5.9.2.12.3	
                  Anti-inhibitor coagulant complex (Feiba); and

                


        

      

       

      
        
          	

                	7.5.9.2.12.4	
                  Antihemophilic factor VIII, human/Von Willebrand factor complex.

                


        

      

       

      
        
          	

                	7.5.9.3	
                  Emergency Services Within and Outside Puerto Rico

                


        

      

       

      
        
          	

                	7.5.9.3.1	
                  The Contractor shall make Emergency Services available:

                


        

      

       

      
        
          	

                	7.5.9.3.1.1	
                  For all Enrollees, throughout Puerto Rico and notwithstanding whether the Emergency Services Provider is a Network Provider; and

                


        

      

       

      
        
          	

                	7.5.9.3.1.2	
                  For Medicaid and CHIP Eligibles, in Puerto Rico or in the other USA jurisdictions, when the services are Medically Necessary and could not be anticipated, notwithstanding
                      that Emergency Services Providers outside of Puerto Rico are not Network Providers. The Contractor shall be responsible for fulfilling payment for Emergency Services rendered in the other USA jurisdictions in a timely manner. If, in
                      an extenuating circumstance, a Medicaid or CHIP Eligible Enrollee incurs out-of-pocket expenses for Emergency Services provided in the other USA jurisdictions, the Contractor shall reimburse the Enrollee for such expenses in a timely
                      manner, and the reimbursement shall be considered a Covered Service.

                


        

      

       

      
        
          	

                	7.5.9.3.2	
                  In covering Emergency Services provided by Puerto Rico Providers outside the Contractor’s Network, or by Providers in the other USA jurisdictions, the Contractor shall
                      pay the Provider at least the average rate paid to Network Providers.

                


        

      

       

      
        Page 93 of 324

        
          


      

      
        
          	

                	7.5.9.4	
                  Post-Stabilization Services

                


        

      

       

      
        
          	

                	7.5.9.4.1	
                  The Contractor shall cover Post-Stabilization Services obtained from any Provider, regardless of whether the Provider is in the General Network or PPN, that are
                      administered to maintain the Enrollee’s stabilized condition for one (1) hour while awaiting response on a Prior Authorization request. The attending Emergency Room physician or other treating Provider shall be responsible for
                      determining whether the Enrollee is sufficiently stabilized for transfer or discharge. That determination will be binding for the Contractor with respect to its responsibility for coverage and payment.

                


        

      

       

      
        
          	

                	7.5.9.4.2	
                  An Enrollee who has been treated for an Emergency Medical Condition or Behavioral Health Emergency shall not be held liable for any subsequent screening or treatment
                      necessary to stabilize or diagnose the specific condition in order to stabilize the Enrollee.

                


        

      

       

      
        
          	

                	7.5.9.4.3	
                  Financial Responsibility

                


        

      

       

      
        
          	

                	7.5.9.4.3.1	
                  The Contractor shall be financially responsible for Post-Stabilization Services obtained within or outside the Contractor’s General Network. These services will be
                      subject to Prior Authorization by a Network Provider or any other Contractor representative.

                


        

      

       

      
        
          	

                	7.5.9.4.3.2	
                  The Contractor must limit cost-sharing for Post-Stabilization Services upon inpatient admission to Enrollees to amounts no greater than what the Contractor would charge
                      Enrollee if services were obtained through the Contractor’s General Network.

                


        

      

       

      
        
          	

                	7.5.9.4.3.3	
                  The Contractor shall be financially responsible for Post-Stabilization Services obtained within or outside the Contractor’s Network that are not given Prior Authorization by a Network Provider or other Contractor representative, but are administered to maintain, improve, or resolve the Enrollee’s stabilized
                      condition if:

                


        

      

       

      
        
          	

                	7.5.9.4.3.3.1	
                  The Contractor does not respond to a request for Prior Authorization within one (1) hour;

                


        

      

       

      
        Page 94 of 324

        
          


      

      
        
          	

                	7.5.9.4.3.3.2	
                  The Contractor cannot be contacted; or

                


        

      

       

      
        
          	

                	7.5.9.4.3.3.3	
                  The Contractor and the treating physician cannot reach an agreement concerning the Enrollee’s care, and the participating Network Provider is not available for
                      consultation. In this situation, the Contractor must give the treating physician the opportunity to consult with the participating Network Provider and the treating physician may continue with care of the patient until the Network
                      Provider is reached or one of the criteria in 42 CFR 422.113(c)(3) is met.

                


        

      

       

      
        
          	

                	7.5.9.4.3.4	
                  The Contractor’s financial responsibility for Post-Stabilization Services that it has not Prior Authorized ends when:

                


        

      

       

      
        
          	

                	7.5.9.4.3.4.1	
                  A Network Provider with privileges at the treating hospital assumes responsibility for the Enrollee’s care;

                


        

      

       

      
        
          	

                	7.5.9.4.3.4.2	
                  A Network Provider assumes responsibility for the Enrollee’s care through transfer;

                


        

      

       

      
        
          	

                	7.5.9.4.3.4.3	
                  A Contractor representative and the treating physician reach an agreement concerning the Enrollee’s care; or

                


        

      

       

      
        
          	

                	7.5.9.4.3.4.4	
                  The Enrollee is discharged.

                


        

      

       

      
        
          	

                	7.5.9.5	
                  Coverage of Services Ultimately Determined to be Non-Emergencies. The Contractor shall not retroactively deny a Claim for an emergency screening examination because the condition, which appeared to be an Emergency Medical Condition
                      or a Psychiatric Emergency under the prudent layperson standard, turned out to be non-emergency in nature.

                


        

      

       

      
        
          	

                	7.5.9.6	
                  Enrollee Use of GHP Service Line. The Contractor shall train Emergency Services Providers
                      concerning the GHP Service Line Medical Advice Service, and shall make Providers aware that:

                


        

      

       

      
        
          	

                	7.5.9.6.1	
                  An Enrollee who consults this service before visiting the emergency room shall not be responsible for any Co-Payment, provided that he or she presents his or her GHP
                      Service Line call identification number when he or she arrives at the emergency room;

                


        

      

       

      
        Page 95 of 324

        
          


      

      
        
          	

                	7.5.9.6.2	
                  No Co-Payments shall be charged for Medicaid and CHIP children under twenty-one (21) years of age under any circumstances.

                


        

      

       

      
        
          	

                	7.5.9.6.3	
                  No Co-Payments shall be imposed, or required, to an Enrollee to receive treatment for an Emergency Medical Condition or Psychiatric Emergency who is a Medicaid or CHIP
                      Eligible; and the Contractor shall not deny payment for Emergency Services when the Enrollee seeks Emergency Services at the instruction of the Contractor or its Agent (including a GHP Service Line representative).

                


        

      

       

      
        
          	

                	7.5.9.7	
                  Coverage of All Emergency Medical Conditions and Psychiatric Emergencies

                


        

      

       

      
        
          	

                	7.5.9.7.1	
                  The Contractor shall not deny payment for treatment of an Emergency Medical Condition or a Psychiatric Emergency, including cases in which the absence of immediate
                      medical attention would not have resulted in the outcomes specified in the definition of Emergency Medical Condition or a Psychiatric Emergency in this Contract and in 42 CFR 438.114(a).

                


        

      

       

      
        
          	

                	7.5.9.7.2	
                  The Contractor shall not refuse to cover an Emergency Medical Condition or a Psychiatric Emergency based on the emergency room Provider, hospital, or fiscal Agent not
                      notifying the Enrollee’s PCP or the Contractor of the Enrollee’s screening or treatment within ten (10) Calendar Days following the Enrollee’s presentation for Emergency Services.

                


        

      

       

      
        
          	

                	7.5.10	
                  Hospitalization Services

                


        

      

       

      
        
          	

                	7.5.10.1	
                  The Contractor shall provide hospitalization services, including the following:

                


        

      

       

      
        
          	

                	7.5.10.1.1	
                  Access to a nursery;

                


        

      

       

      
        
          	

                	7.5.10.1.2	
                  Access to a semi-private room (bed available twenty-four (24) hours a day, every Calendar Day of the year, including Puerto Rico holidays);

                


        

      

       

      
        
          	

                	7.5.10.1.3	
                  Access to an isolation room for physical or Behavioral Health reasons;

                


        

      

       

      
        Page 96 of 324

        
          


      

      
        
          	

                	7.5.10.1.4	
                  Food, including specialized nutrition services;

                


        

      

       

      
        
          	

                	7.5.10.1.5	
                  Regular nursing services;

                


        

      

       

      
        
          	

                	7.5.10.1.6	
                  Specialized room use, such as operation, surgical, recovery, treatment and maternity, without limitations;

                


        

      

       

      
        
          	

                	7.5.10.1.7	
                  Drugs, medicine, and contrast agents, without limitations;

                


        

      

       

      
        
          	

                	7.5.10.1.8	
                  Availability of materials such as bandages, gauze, plaster, or any other therapeutic or healing material;

                


        

      

       

      
        
          	

                	7.5.10.1.9	
                  Therapeutic and maintenance care services, including the use of the necessary equipment to offer the service;

                


        

      

       

      
        
          	

                	7.5.10.1.10	
                  Specialized diagnostic tests, such as electrocardiograms, electroencephalograms, arterial gases, and other specialized tests that are available at the hospital and
                      necessary during the Enrollee's hospitalization;

                


        

      

       

      
        
          	

                	7.5.10.1.11	
                  Supply of oxygen, anesthetics, and other gases including administration;

                


        

      

       

      
        
          	

                	7.5.10.1.12	
                  Respiratory therapy, without limitations;

                


        

      

       

      
        
          	

                	7.5.10.1.13	
                  Rehabilitation services while Enrollee is hospitalized, including physical, occupational, and speech therapy;

                


        

      

       

      
        
          	

                	7.5.10.1.14	
                  Outpatient surgery facility use; and

                


        

      

       

      
        
          	

                	7.5.10.1.15	
                  Transfusion of blood and blood plasma services, without limitations, including:

                


        

      

       

      
        
          	

                	7.5.10.1.15.1	
                  Antihemophilic recombinant factor VIII;

                


        

      

       

      
        
          	

                	7.5.10.1.15.2	
                  Antihemophilic recombinant factor IX;

                


        

      

       

      
        
          	

                	7.5.10.1.15.3	
                  Anti-inhibitor coagulant complex (Feiba); and

                


        

      

       

      
        
          	

                	7.5.10.1.15.4	
                  Antihemophilic factor VIII, human/Von Willebrand factor complex.

                


        

      

       

      
        
          	

                	7.5.10.2	
                  Hospitalization for services that would normally be considered outpatient services or for diagnostic purposes only, is not a Covered Service under the GHP.

                


        

      

       

      
        
          	

                	7.5.11	
                  Behavioral Health Services

                


        

      

       

      
        
          	

                	7.5.11.1	
                  Covered Behavioral Health Services include the following:

                


        

      

       

      
        Page 97 of 324

        
          


      

      
        
          	

                	7.5.11.1.1	
                  Evaluation, screening, and treatment of individuals, couples, families and groups;

                


        

      

       

      
        
          	

                	7.5.11.1.2	
                  Outpatient services with psychiatrists, psychologists, and social workers;

                


        

      

       

      
        
          	

                	7.5.11.1.3	
                  Hospital or outpatient services for substance and alcohol abuse disorders;

                


        

      

       

      
        
          	

                	7.5.11.1.4	
                  Behavioral Health hospitalization;

                


        

      

       

      
        
          	

                	7.5.11.1.5	
                  Intensive outpatient services;

                


        

      

       

      
        
          	

                	7.5.11.1.6	
                  Immediate access to Emergency or crisis intervention Services twenty-four (24) hours a day, seven (7) days a Week (services outside of Puerto Rico available only for
                      Medicaid and CHIP Eligibles);

                


        

      

       

      
        
          	

                	7.5.11.1.7	
                  Detoxification services for Enrollees intoxicated with alcohol or illegal substances, whether as a result of substance abuse, a suicide attempt, or accidental poisoning;

                


        

      

       

      
        
          	

                	7.5.11.1.8	
                  Long-lasting injected medicine clinics;

                


        

      

       

      
        
          	

                	7.5.11.1.9	
                  Escort/professional assistance and ambulance services when needed;

                


        

      

       

      
        
          	

                	7.5.11.1.10	
                  Prevention and secondary-education services;

                


        

      

       

      
        
          	

                	7.5.11.1.11	
                  Pharmacy coverage and access to medicine for a maximum of twenty-four (24) hours, in compliance with Act No. 408;

                


        

      

       

      
        
          	

                	7.5.11.1.12	
                  Medically Necessary clinical laboratories;

                


        

      

       

      
        
          	

                	7.5.11.1.13	
                  Treatment for Enrollees diagnosed with Attention Deficit Disorder (with or without hyperactivity). This includes, but is not limited to, neurologist visits and tests
                      related to this diagnosis’s treatment; and

                


        

      

       

      
        
          	

                	7.5.11.1.14	
                  Substance abuse treatment.

                


        

      

       

      
        
          	

                	7.5.11.2	
                  Opiate Addiction Treatment

                


        

      

       

      
        
          	

                	7.5.11.2.1	
                  The Contractor shall provide appropriate services for Enrollees in need of Buprenorphine treatment due to a diagnosis of opiate addiction. The Contractor shall cover all
                      services related to assessment, treatment, and monitoring of opiate addiction including:

                


        

      

       

      
        Page 98 of 324

        
          


      

      
        
          	

                	7.5.11.2.1.1	
                  Prescriptions for Buprenorphine or any other medically appropriate medications included on the FMC;

                


        

      

       

      
        
          	

                	7.5.11.2.1.2	
                  Comprehensive medical examination (CPT Code 99205);

                


        

      

       

      
        
          	

                	7.5.11.2.1.3	
                  Extended office visits (CPT Code 99215);

                


        

      

       

      
        
          	

                	7.5.11.2.1.4	
                  Brief office visit (CPT Code 99211);

                


        

      

       

      
        
          	

                	7.5.11.2.1.5	
                  Psychiatric Diagnostic Interview Exam – New Patient (CPT Code 90801);

                


        

      

       

      
        
          	

                	7.5.11.2.1.6	
                  Individual Therapy with Medical Evaluation and Management (CPT Code 90807);

                


        

      

       

      
        
          	

                	7.5.11.2.1.7	
                  Pharmacologic Management (CPT Code 90862);

                


        

      

       

      
        
          	

                	7.5.11.2.1.8	
                  Drug Urine Toxicology (CPT Code 80100);

                


        

      

       

      
        
          	

                	7.5.11.2.1.9	
                  Blood Test Basic Metabolic Panel (CPT Code 80048);

                


        

      

       

      
        
          	

                	7.5.11.2.1.10	
                  Blood Test CBC (CPT Code 85025);

                


        

      

       

      
        
          	

                	7.5.11.2.1.11	
                  TB Test – Skin (CPT Code 86580), but only in conjunction with the prescription of Buprenorphine for the treatment of opiate addiction;

                


        

      

       

      
        
          	

                	7.5.11.2.1.12	
                  HIV Test (CPT Code 86703), but only in conjunction with the prescription of Buprenorphine for the treatment of opiate addiction;

                


        

      

       

      
        
          	

                	7.5.11.2.1.13	
                  Hepatitis Panel (CPT Code 80074), but only in conjunction with the prescription of Buprenorphine for the treatment of opiate addiction;

                


        

      

       

      
        
          	

                	7.5.11.2.1.14	
                  Individual Counseling (CPT Code 90806);

                


        

      

       

      
        
          	

                	7.5.11.2.1.15	
                  Group Counseling (CPT Code 90853);

                


        

      

       

      
        
          	

                	7.5.11.2.1.16	
                  Mental Health Assessment by Non-Physician Professional (CPT Code H0031); and

                


        

      

       

      
        Page 99 of 324

        
          


      

      
        
          	

                	7.5.11.2.1.17	
                  Alcohol and substance abuse Services, Treatment Plan Development and Modification (CPT Code T007).

                


        

      

       

      
        
          	

                	7.5.11.3	
                  Inpatient Behavioral Health Services are covered in Institutions for Mental Diseases (IMD), as defined in 42 CFR 435.1010, so long as the facility is a hospital providing
                      psychiatric or substance use disorder, inpatient care or a sub-acute facility providing psychiatric or substance use disorder crisis residential services as follows:

                


        

      

       

      
        
          	

                	7.5.11.3.1	
                  Inpatient Behavioral Health Services for Enrollees aged twenty-one (21) through sixty-four (64) are covered in an IMD setting for up to fifteen (15) days within the month
                      for which the PMPM Payment would be made in accordance with 42 CFR 438.6(e). Prospective rate development for the PMPM Payments will account for utilization and cost of short term stays in an IMD in accordance with 42 CFR 438.6(e).

                


        

      

       

      
        
          	

                	7.5.11.3.2	
                  Inpatient Behavioral Health Services for Enrollees aged zero (0) to twenty (20) and aged sixty-five (65) and older are covered in accordance with the State Plan.

                


        

      

       

      
        
          	

                	7.5.11.4	
                  The Contractor shall have Providers trained and certified by the Substance Abuse and Mental Health Services Administration (“SAMHSA”) to provide opiate addiction
                      treatment. The training and certification of the Providers by SAMHSA may be evidenced with either (i) a copy of the letter issued by SAMHSA to the Provider certifying his/her training and certification or (ii) a copy of the Controlled
                      Substance Registration Certification issued by the Drug Enforcement Administration with the identification number assigned to the Provider by SAMHSA. Evidence of SAMHSA certification shall be included in the Provider’s Credentialing
                      file maintained by the Contractor.

                


        

      

       

      
        
          	

                	7.5.11.5	
                  The Contractor shall establish and strengthen relationships (if needed, through memoranda of understanding) with ASSMCA, ADFAN, the Office of the Women’s Advocate, and
                      other government or nonprofit entities, in order to improve the delivery of Behavioral Health Services.

                


        

      

       

      
        
          	

                	7.5.11.6	
                  Behavioral Health Parity

                


        

      

       

      
        
          	

                	7.5.11.6.1	
                  As required by 42 CFR 438.3(n)(1), the Contractor shall provide services in compliance with the requirements in 42 CFR part 438, subpart K regarding parity in Behavioral
                      Health services.

                


        

      

       

      
        Page 100 of 324

        
          


      

      
        
          	

                	7.5.11.6.2	
                  The Contractor shall not have an Aggregate Lifetime or Annual Dollar Limits (see 42 CFR 438.905(b)) on any Behavioral Health service.

                


        

      

       

      
        
          	

                	7.5.11.6.3	
                  As specified in 42 CFR 438.910(b)(1), the Contractor shall not apply any Financial Requirement or Treatment Limitation to Behavioral Health services in any classification
                      (inpatient, outpatient, emergency care, or prescription drugs) that is more restrictive that the predominant Financial Requirement or Treatment Limitation of that type applied to substantially all medical/surgical services in the same
                      classification furnished to Enrollees (whether or not the benefits are furnished by the same Contractor).

                


        

      

       

      
        
          	

                	7.5.11.6.4	
                  In accordance with 42 CFR 438.910(b)(2), the Contractor shall provide Behavioral Health services in all benefit classifications (inpatient, outpatient, emergency care,
                      and prescription drugs).

                


        

      

       

      
        
          	

                	7.5.11.6.5	
                  The Contractor shall not apply any cumulative Financial Requirements (see 42 CFR 438.910(c)(3)) for Behavioral Health services.

                


        

      

       

      
        
          	

                	7.5.11.6.6	
                  In accordance with 42 CFR 438.910(d), the Contractor shall not impose a non-quantitative treatment limitation (NQTL) for Behavioral Health services in any classification
                      (inpatient, outpatient, emergency care, or prescription drugs) unless, under the policies and procedures of the Contractor as written and in operation, any processes, strategies, evidentiary standards, or other factors used in
                      applying the NQTL to Behavioral Health services in the classification are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, or other factors used in applying the NQTL for
                      medical/surgical services in the same classification. NQTLs include, but are not limited to, medical management standards; standards for provider participation, including reimbursement rates; fail-first policies; exclusions based on
                      failure to complete a course of treatment; and restrictions based on geographic location, facility type, provider specialty, other criteria that limit the scope or duration of services; and standards for providing access to
                      out-of-network Providers (see 42 CFR 438.910(d)(2)).

                


        

      

       

      
        
          	

                	7.5.11.6.7	
                  The Contractor shall work with ASES and other Government agencies to ensure that all Enrollees are provided access to a set of services that meets the requirements of 42
                      CFR part 438, subpart K regarding parity in Behavioral Health services, regardless of what Behavioral Health services are provided by the Contractor.

                


        

      

       

      
        Page 101 of 324

        
          


      

      
        
          	

                	7.5.11.6.8	
                  The Contractor shall cooperate with ASES to establish and demonstrate initial and ongoing compliance with 42 CFR part 438, subpart K regarding Behavioral Health parity.
                      This shall include but not be limited to participating in meetings, providing information (documentation, data, etc.) requested by ASES to assess parity compliance, working with ASES to resolve any non-compliance, and notifying ASES
                      of any changes to benefits or limitations that might impact parity compliance.

                


        

      

       

      
        
          	

                	7.5.11.6.9	
                  If requested by ASES, the Contractor shall conduct an analysis to determine compliance with 42 CFR part 438, subpart K regarding Behavioral Health parity and provide the
                      results of the analysis to ASES in the format and timeframes specified by ASES.

                


        

      

       

      
        
          	

                	7.5.11.6.10	
                  As specified in 42 CFR 438.915(a), the Contractor shall make available the criteria for medical necessity determinations for Behavioral Health services to any Enrollee,
                      Potential Enrollee, or Provider upon request.

                


        

      

       

      
        
          	

                	7.5.11.6.11	
                  As specified in 42 CFR 438.915(b), the Contractor shall make available to the Enrollee the reason for any denial by the Contractor of reimbursement or payment for
                      Behavioral Health services to the Enrollee.

                


        

      

       

      
        
          	

                	7.5.12	
                  Pharmacy Services

                


        

      

       

      
        
          	

                	7.5.12.1	
                  The Contractor shall provide pharmacy services under the GHP in accordance with Section 1927 of the Social Security Act and 42 CFR 438.3(s), including the following:

                


        

      

       

      
        
          	

                	7.5.12.1.1	
                  All costs related to prescribed medications for Enrollees, excluding the Enrollee’s Co-Payment where applicable;

                


        

      

       

      
        
          	

                	7.5.12.1.2	
                  Drugs on the Formulary of Medications Covered (FMC);

                


        

      

       

      
        
          	

                	7.5.12.1.3	
                  Drugs included on the LME, but not in the FMC (through the exceptions process explained in Section 7.5.12.10 and Attachment 27 to this Contract); and

                


        

      

       

      
        
          	

                	7.5.12.1.4	
                  In some instances, through the exceptions process, drugs that are not included on either the FMC or the LME.

                


        

      

       

      
        Page 102 of 324

        
          


      

      
        
          	

                	7.5.12.2	
                  The Contractor may not impose restrictions on available prescription drugs beyond those stated in the FMC, LME, or any other drug formulary approved by ASES.

                


        

      

       

      
        
          	

                	7.5.12.3	
                  The following drugs are excluded from the pharmacy component of Covered Services:

                


        

      

       

      
        
          	

                	7.5.12.3.1	
                  Rebetron or any other medication prescribed for the treatment of Hepatitis C treatment (Enrollees to be referred to the Health Department, upon Referral to the Health
                      Department by a Network Provider. This medication is not provided through the GHP); and

                


        

      

       

      
        
          	

                	7.5.12.3.2	
                  Medications delivered directly to Enrollees by a Provider that does not have a pharmacy license, with the exception of medications that are traditionally administered in
                      a doctor’s office, such as injections.

                


        

      

       

      
        
          	

                	7.5.12.4	
                  Prescriptions ordered under the pharmacy services Benefit are subject to the following Utilization controls:

                


        

      

       

      
        
          	

                	7.5.12.4.1	
                  Consistent with the requirements of Section 1927(d)(5) of the Social Security Act, some or all prescription drugs may be subject to Prior Authorization, which shall be
                      implemented and managed by the PBM or the Contractor, according to policies and procedures established by the ASES Pharmacy and Therapeutic (“P&T”) Committee and decided upon in consultation with the Contractor when applicable.

                


        

      

       

      
        
          	

                	7.5.12.4.2	
                  The Contractor shall ensure that Prior Authorization for pharmacy services is provided for the Enrollee in the following timeframes, including outside of normal business
                      hours.

                


        

      

       

      
        
          	

                	7.5.12.4.2.1	
                  The decision whether to grant a Prior Authorization of a prescription must not exceed twenty-four (24) hours from the receipt of the Enrollee’s Service Authorization
                      Request and the standard information needed to make a determination is provided. Such standard information to make a determination includes the following: the prescription, a supporting statement setting forth the clinical
                      justification and medical necessity for the prescribed medication, and expected duration of treatment, as required by the protocol for the medication. The Contractor shall provide notice on a Prior Authorization request by telephone
                      or other telecommunication device in the required timeframes. In circumstances where the Contractor or the Enrollee’s Provider determines that the Enrollee’s life or health could be endangered by a delay in accessing the prescription
                      drug, the Contractor shall provide at least a seventy-two (72) hour supply of the prescription drug unless the drug is statutorily excluded from coverage under Section 1927(d)(2) of the Social Security Act. In such cases, Prior
                      Authorization must be provided as expeditiously as the Enrollee’s health requires, and no later than within twenty-four (24) hours following the Service Authorization Request.

                


        

      

       

      
        Page 103 of 324

        
          


      

      
        
          	

                	7.5.12.4.2.2	
                  The Contractor may extend the time allowed for Prior Authorization decisions, where:

                


        

      

       

      
        
          	

                	7.5.12.4.2.2.1	
                  The Enrollee, or the Provider, requests the extension; or

                


        

      

       

      
        
          	

                	7.5.12.4.2.2.2	
                  The Contractor justifies to ASES a need for the extension in order to collect additional information, such that the extension is in the Enrollee’s best interest.

                


        

      

       

      
        
          	

                	7.5.12.4.3	
                  Prescriptions written by a Provider who is outside the PPN may be filled only upon a Countersignature from the Enrollee’s PCP, or another assigned PCP from the PMG in
                      case of absence or unavailability of the Enrollee’s PCP. A Countersignature request made to the PCP shall be acted upon within three (3) Calendar Days of the request of the prescribing Provider or, if the Enrollee’s health is in
                      danger, within twenty-four (24) hours.

                


        

      

       

      
        
          	

                	7.5.12.4.4	
                  The Contractor shall not require a PCP Countersignature on prescriptions written by a Provider within the PPN.

                


        

      

       

      
        
          	

                	7.5.12.5	
                  The Contractor shall use bioequivalent drugs approved by the Food and Drug Administration (“FDA”), provided they are classified as “AB” and authorized by regulations,
                      unless the Provider notes a contra-indication in the prescription. Nonetheless, the Contractor shall not refuse to cover a drug solely because the bioequivalent drug is unavailable; nor shall the Contractor impose an additional
                      payment on the Enrollee because the bioequivalent is unavailable.

                


        

      

       

      
        Page 104 of 324

        
          


      

      
        
          	

                	7.5.12.6	
                  The Contractor shall observe the following timeframe limits with respect to prescribed drugs:

                


        

      

       

      
        
          	

                	7.5.12.6.1	
                  Medication for critical conditions will be covered for a maximum of thirty (30) Calendar Days and for additional time, where Medically Necessary.

                


        

      

       

      
        
          	

                	7.5.12.6.2	
                  Medication for Chronic Conditions or severe Behavioral Health conditions will be covered for a maximum of thirty (30) Calendar Days, except at the beginning of therapy
                      where, upon a Provider’s recommendation, a minimum of fifteen (15) Calendar Days shall be prescribed in order to reevaluate compliance and tolerance. Under a doctor’s orders, a prescription may be refilled up to five (5) times.

                


        

      

       

      
        
          	

                	7.5.12.6.3	
                  For maintenance drugs that require Prior Authorization, the Prior Authorization will be effective for a term of six (6) months, unless there are contra-indications or
                      side effects, in which case the term may be shorter, or unless associated with a formulary exception request, as set forth in Attachment 27 to this Contract, in which case the term may be approved for up to twelve (12) months.

                


        

      

       

      
        
          	

                	7.5.12.6.4	
                  The prescribing Provider shall re-evaluate pharmacotherapy as to compliance, tolerance, and dosage within ninety (90) Calendar Days of having prescribed a maintenance
                      drug. Dosage changes will not require Prior Authorization. Changes in the drug used may require Prior Authorization.

                


        

      

       

      
        
          	

                	7.5.12.7	
                  Special considerations, including cooperation with Puerto Rico governmental entities other than ASES, govern coverage of medications for the following conditions:

                


        

      

       

      
        
          	

                	7.5.12.7.1	
                  Medications for Treatment of HIV/AIDS

                


        

      

       

      
        
          	

                	7.5.12.7.1.1	
                  The following HIV/AIDS medications are excluded from the ASES FMC: Viread®, Emtriva®, Truvada®, Fuzeon®, Atripla®, Epzicom®, Selzentry®, Intelence®, Isentress/Insentress
                      HD®, Edurant®, Complera®, Stribild®, Descovy®, Triumeq®, Genvoya®, Tivicay® and Odefsey®.

                


        

      

       

      
        
          	

                	7.5.12.7.1.2	
                  Because of an agreement between the Health Department and ASES, Enrollees diagnosed with HIV/AIDS may access the medications listed above through Health Department
                      clinics. The Contractor is not At Risk for the coverage of these medications.

                


        

      

       

      
        Page 105 of 324

        
          


      

      
        
          	

                	7.5.12.7.1.3	
                  The Contractor shall inform Providers about this agreement, and shall require Providers to refer Enrollees for whom these medications are Medically Necessary to CPTET
                      Centers (Centros de Prevención y Tratamiento de Enfermedades Transmisibles) or community-based organizations, where the Enrollee may be screened to determine whether the Enrollee is eligible for the AIDS Drug Assistance Program
                      (“ADAP”).

                


        

      

       

      
        
          	

                	7.5.12.7.1.4	
                  A list of CPTET Centers and community-based organizations that administer these medications is included as Attachment 4 to this Contract.

                


        

      

       

      
        
          	

                	7.5.12.7.2	
                  Medications for Chronic Conditions for Children with Special Health Needs. Directions for
                      prescriptions for chronic use drugs for children with special health needs shall cover therapy for thirty (30) Calendar Days, and if necessary up to five (5) refills of the original prescription, according to medical opinion of a
                      certified Provider. When Medically Necessary, additional prescriptions will be covered.

                


        

      

       

      
        
          	

                	7.5.12.7.3	
                  Medications for Enrollees with Opiate Addictions. See Section 7.5.11.2.1.1 above.

                


        

      

       

      
        
          	

                	7.5.12.8	
                  Except as provided in Section 7.5.12.3.2, all prescriptions must be dispensed by a pharmacy under contract with the PBM that is duly authorized under the laws of the
                      Puerto Rico, and is freely selected by the Enrollee. The PBM shall maintain responsibility for ensuring that the pharmacy services network complies with the terms specified by ASES.

                


        

      

       

      
        
          	

                	7.5.12.9	
                  Prescribed drugs must be dispensed at the time and date, as established by the Puerto Rico Pharmacy Law, when the Enrollee submits the prescription for dispensation.

                


        

      

       

      
        
          	

                	7.5.12.10	
                  Use of FMC Medications. The Contractor shall ensure that drugs on the FMC are used whenever possible.

                


        

      

       

      
        
          	

                	7.5.12.10.1	
                  In the following two categories of exceptional cases, however, the Contractor shall cover drugs not included on the FMC, upon submission of acceptable written
                      documentation of the medical justification for the drug from the Provider, in accordance with Attachment 27 to this Contract.

                


        

      

       

      
        Page 106 of 324

        
          


      

      
        
          	

                	7.5.12.10.1.1	
                  The Contractor shall cover drugs included on the LME (Attachment 5 to this Contract) in lieu of a FMC drug, only as a part of an exceptions process, upon a showing that
                      no drug listed on the FMC is clinically effective for the Enrollee.

                


        

      

       

      
        
          	

                	7.5.12.10.1.2	
                  The Contractor shall cover a drug that is not included on either the FMC or the LME, only as part of an exceptions process, provided that the drug is being prescribed for
                      a use approved by the FDA or for a medically accepted indication, as defined in Section 1927(k)(6) of the Social Security Act for the treatment of the condition.

                


        

      

       

      
        
          	

                	7.5.12.10.2	
                  In addition to demonstrating that the drug is being prescribed for a medically accepted indication, as defined in Section 1927(k)(6) of the Social Security Act and as
                      referenced in Section 7.5.12.10.1.2 above, a Provider prescribing a drug not on the FMC or LME must follow the process in Attachment 27 to this Contract and provide the Contractor with the necessary medical documentation to
                      demonstrate that:

                


        

      

       

      
        
          	

                	7.5.12.10.2.1	
                  The drug does not have any bioequivalent on the market; and

                


        

      

       

      
        
          	

                	7.5.12.10.2.2	
                  The drug is clinically indicated because of:

                


        

      

       

      
        
          	

                	7.5.12.10.2.3	
                  Contra-indication with drugs that are in the FMC or LME that the Enrollee is already taking, and scientific literature’s indication of the possibility of serious adverse
                      health effects related to the taking the drug;

                


        

      

       

      
        
          	

                	7.5.12.10.2.3.1	
                  History of adverse reaction by the Enrollee to drugs that are on the FMC or LME;

                


        

      

       

      
        
          	

                	7.5.12.10.2.3.2	
                  Therapeutic failure of all available alternatives on the FMC or LME; or

                


        

      

       

      
        
          	

                	7.5.12.10.2.3.3	
                  Other special circumstances.

                


        

      

       

      
        Page 107 of 324

        
          


      

      
        
          	

                	7.5.12.11	
                  In the event the Comprehensive Cancer Center of Puerto Rico (“Centro Comprensivo de Cancer”) participates as a covered entity in the 340B Drug Pricing Program, ASES
                      reserves the right to modify coverage and pricing for such 340B eligible cancer drugs.

                


        

      

       

      
        
          	

                	7.5.12.12	
                  Role of Pharmacy Benefit Manager

                


        

      

       

      
        
          	

                	7.5.12.12.1	
                  Pharmacy services are administered primarily by a Pharmacy Benefit Manager (“PBM”) under contract with ASES. The Contractor shall work with the PBM as well as the
                      Pharmacy Program Administrator (“PPA”) selected by ASES as needed, and as provided in this Section 7.5.12.11, in order to ensure the successful provision of pharmacy services.

                


        

      

       

      
        
          	

                	7.5.12.12.2	
                  The Contractor shall be obligated to accept the terms and conditions of the contract that ASES awards to a PBM. The Contractor shall use the procedures, guidelines, and
                      other instructions implemented by ASES through the PBM. The Contractor and the PBM shall coordinate all the required efforts to achieve the integrated model of rendering all Covered Services to Enrollees under the GHP Program.

                


        

      

       

      
        
          	

                	7.5.12.12.3	
                  Among other measures, to enhance cooperation with the PBM, the Contractor shall:

                


        

      

       

      
        
          	

                	7.5.12.12.3.1	
                  Work with the PBM to improve Information flow and to develop protocols for Information-sharing;

                


        

      

       

      
        
          	

                	7.5.12.12.3.2	
                  Establish, in consultation with the PBM, the procedures to transfer funds for the payment of Claims to the pharmacy network according to the payments cycle specified by
                      the PBM; and

                


        

      

       

      
        
          	

                	7.5.12.12.3.3	
                  Coordinate with the PBM to establish customer service protocols concerning pharmacy services.

                


        

      

       

      
        
          	

                	7.5.12.13	
                  Claims Processing and Administrative Services for Pharmacy. The Contractor shall:

                


        

      

       

      
        
          	

                	7.5.12.13.1	
                  Assume the cost of implementing and maintaining online connection with the PBM;

                


        

      

       

      
        
          	

                	7.5.12.13.2	
                  Cover all of its own costs of implementation, including but not limited to payment processes, Utilization review and approval processes, connection and line charges, and
                      other costs incurred to implement the payment arrangements for pharmacy Claims;

                


        

      

       

      
        Page 108 of 324

        
          


      

      
        
          	

                	7.5.12.13.3	
                  Review Claims payments summary reports for each payment cycle and transfer funds required for payment to pharmacies;

                


        

      

       

      
        
          	

                	7.5.12.13.4	
                  Review denials and rejections of Claims;

                


        

      

       

      
        
          	

                	7.5.12.13.5	
                  Maintain an appropriately staffed phone line that is available twenty-four (24) hours a day, seven (7) days a week to provide for the Prior Authorization of drugs,
                      according to the established policies, the FMC, and the LME; and

                


        

      

       

      
        
          	

                	7.5.12.13.6	
                  Electronically submit on a daily basis a list of all Contractor’s Network Providers, and a list of Enrollees to the PBM. Submit the PBM Member History Move file included
                      in Attachment 9 to this Contract whenever an Enrollee previously enrolled with a different contractor selects Contractor as its new Plan.

                


        

      

       

      
        
          	

                	7.5.12.14	
                  Fraud Investigations. The Contractor shall develop tracking mechanisms for detecting Fraud, Waste, and Abuse related to pharmacy services, and shall forward Fraud, Waste, and Abuse Complaints from Enrollees related to
                      pharmacy services to the PBM and to ASES.

                


        

      

       

      
        
          	

                	7.5.12.15	
                  Formulary Management Program

                


        

      

       

      
        
          	

                	7.5.12.15.1	
                  The Contractor shall select two (2) members of its staff to serve on a
                      cross-functional committee, the Pharmacy Benefit Financial Committee, tasked with rebate maximization and/or evaluating recommendations regarding the FMC and LME from the P&T Committee and the PPA and PBM as applicable. The
                      Pharmacy Benefit Financial Committee will also review the FMC and LME from time to time and evaluate additional recommendations on potential cost-saving pharmacy initiatives, under the direction and approval of ASES.

                


        

      

       

      
        
          	

                	7.5.12.15.2	
                  The Contractor shall select a member of its staff to serve on a cross-functional subcommittee tasked with assisting in the evaluation of additional potential cost-saving
                      pharmacy initiatives as needed.

                


        

      

       

      
        
          	

                	7.5.12.15.3	
                  The Contractor shall select two (2) members of its staff to serve as non voting advisors to the P&T Committee. These advisors must be available to answers questions
                      and provide requested information relevant to the tasks performed by P&T Committee.

                


        

      

       

      
        Page 109 of 324

        
          


      

      
        
          	

                	7.5.12.16	
                  Utilization Management and Reports. The Contractor shall:

                


        

      

       

      
        
          	

                	7.5.12.16.1	
                  Perform drug Utilization reviews that meet the standards established by both ASES and Federal authorities, including the operation of a drug utilization review program as
                      required in 42 CFR Part 456, Subpart K;

                


        

      

       

      
        
          	

                	7.5.12.16.2	
                  Develop and distribute protocols that will be subject to ASES approval, when necessary; and

                


        

      

       

      
        
          	

                	7.5.12.16.3	
                  Provide to ASES annually a detailed description of its drug utilization program activities.

                


        

      

       

      
        
          	

                	7.5.12.17	
                  Communication with Providers. The Contractor shall ensure the following communications with Providers:

                


        

      

       

      
        
          	

                	7.5.12.17.1	
                  The Contractor shall advise Providers regarding the use of the FMC as a first option at the moment of prescribing and of the need to observe the exceptions process when
                      filling a prescription for a drug not on the FMC.

                


        

      

       

      
        
          	

                	7.5.12.17.2	
                  The Contractor shall advise Providers that they may not outright deny medication because it is not included on ASES’s FMC or LME. A medication not on the FMC or LME may
                      be provided through the exceptions process described in Section 7.5.12.10 and Attachment 27 to this Contract.

                


        

      

       

      
        
          	

                	7.5.12.17.3	
                  The Contractor shall advise Providers on the availability of the bioequivalent versions of brand-name drugs and that such bioequivalent versions should be prescribed
                      instead of brand-name drugs as available and appropriate.

                


        

      

       

      
        
          	

                	7.5.12.18	
                  Cooperation with the Pharmacy Program Administrator (“PPA”)

                


        

      

       

      
        
          	

                	7.5.12.18.1	
                  The Contractor shall receive updates to the FMC and LME from the PPA. The Contractor shall adhere to these updates.

                


        

      

       

      
        
          	

                	7.5.12.18.2	
                  Any rebates shall be negotiated by the PPA and retained in their entirety by ASES. The Contractor shall neither negotiate, collect, nor retain any pharmacy rebate for
                      Enrollee Utilization of brand drugs included on ASES’s FMC or LME.

                


        

      

       

      
        Page 110 of 324

        
          


      

      
        
          	

                	7.5.12.19	
                  Information on Pharmacy Benefits Coverage. The Contractor shall provide Information on the
                      FMC and LME in electronic or paper form, including which generic or brand medications are covered, and what formulary tier each medication is on. Drug lists that are published on the Contractor’s website must be in a machine readable
                      file and format as specified by CMS.

                


        

      

       

      
        
          	

                	7.5.12.20	
                  The Contractor must submit, on a quarterly basis, all or specifically requested drugs administered by a Provider in his or her office to an Enrollee following the format
                      established by ASES. This report must include the description of the NDC, HCPCS J-Code, as applicable, and the drug dosage, form and quantity. The Contractor must comply with the Normative Letters 16-1129 and 17-0619.

                


        

      

       

      
        
          	

                	7.6	
                  Dental Services

                


        

      

       

      
        
          	

                	7.6.1	
                  The Contractor shall provide the following dental services as Covered Services for Pediatric Enrollees:

                


        

      

       

      
        
          	

                	7.6.1.1	
                  All preventative and corrective services mandated by the EPSDT requirement;

                


        

      

       

      
        
          	

                	7.6.1.2	
                  Orthodontic services to EPSDT eligible children as medically necessary, subject to Prior Authorization, to prevent and restore oral structures to health and function.
                      Orthodontic services for cosmetic purposes are not covered.

                


        

      

       

      
        
          	

                	7.6.1.3	
                  Pediatric Pulp Therapy (Pulpotomy);

                


        

      

       

      
        
          	

                	7.6.1.4	
                  Stainless steel crowns for use in primary teeth following a Pediatric Pulpotomy;

                


        

      

       

      
        
          	

                	7.6.1.5	
                  Anesthesia services, subject to prior authorization, for a child, or Enrollees with physical or mental handicaps in compliance with Federal and State laws. These special
                      conditions include, but are not limited to, (a) autism, (b) severe retardation, (c) severe neurologic impairment, (d) significant attention deficit disorders with hyperactivity, (e) significant or severe mental disorders, (f) disabled
                      or unable to follow commands, and (g) any other circumstance that in the dentist’s professional judgment, impairs cooperation and feasibility to adequately perform the dental procedure. Prior authorization determinations must be made
                      within two (2) Calendar Days.

                


        

      

       

      
        
          	

                	7.6.2	
                  The Contractor shall provide the following dental services as Covered Services for Adults:

                


        

      

       

      
        
          	

                	7.6.2.1	
                  Preventive dental services;

                


        

      

       

      
        Page 111 of 324

        
          


      

      
        
          	

                	7.6.2.2	
                  Restorative dental services;

                


        

      

       

      
        
          	

                	7.6.2.3	
                  One (1) comprehensive oral exam per year;

                


        

      

       

      
        
          	

                	7.6.2.4	
                  One (1) periodical exam every six (6) months;

                


        

      

       

      
        
          	

                	7.6.2.5	
                  One (1) defined problem-limited oral exam;

                


        

      

       

      
        
          	

                	7.6.2.6	
                  One (1) full series of intra-oral radiographies, including bitewings, every three (3) years;

                


        

      

       

      
        
          	

                	7.6.2.7	
                  One (1) initial periapical intra-oral radiography;

                


        

      

       

      
        
          	

                	7.6.2.8	
                  Up to five (5) additional periapical/intra-oral radiographies per year;

                


        

      

       

      
        
          	

                	7.6.2.9	
                  One (1) single film-bite radiography per year;

                


        

      

       

      
        
          	

                	7.6.2.10	
                  One (1) two-film bite radiography per year;

                


        

      

       

      
        
          	

                	7.6.2.11	
                  One (1) panoramic radiography every three (3) years;

                


        

      

       

      
        
          	

                	7.6.2.12	
                  One (1) cleanse every six (6) months;

                


        

      

       

      
        
          	

                	7.6.2.13	
                  One (1) Prophylaxis, every six (6) months;

                


        

      

       

      
        
          	

                	7.6.2.14	
                  Amalgam restoration;

                


        

      

       

      
        
          	

                	7.6.2.15	
                  Resin restorations;

                


        

      

       

      
        
          	

                	7.6.2.16	
                  Root canal;

                


        

      

       

      
        
          	

                	7.6.2.17	
                  Palliative treatment;

                


        

      

       

      
        
          	

                	7.6.2.18	
                  Oral surgery; and

                


        

      

       

      
        
          	

                	7.6.2.19	
                  Anesthesia services, subject to prior authorization, for adults with physical or mental handicaps in compliance with federal and local law.

                


        

      

       

      
        
          	

                	7.7	
                  Special Coverage

                


        

      

       

      
        
          	

                	7.7.1	
                  The Special Coverage Benefit is designed to provide services for Enrollees with special health care needs caused by serious illness. Certain Special Coverage conditions
                      may also be a qualifying condition subject under the HCHN Program (e.g., cancer).

                


        

      

       

      
        
          	

                	7.7.2	
                  The Contractor shall provide ASES with the strategy implemented for the identification of populations with special health care needs in order to identify any ongoing
                      special conditions of Enrollees that require a treatment plan and regular care monitoring by appropriate Providers.

                


        

      

       

      
        Page 112 of 324

        
          


      

      
        
          	

                	7.7.3	
                  The Contractor shall implement a system for screening Enrollees for Special Coverage and registering Enrollees who qualify. The Contractor shall design a form, with prior
                      written approval from ASES, to be used by Providers in submitting a registration for Special Coverage.

                


        

      

       

      
        
          	

                	7.7.4	
                  The registration system for Special Coverage shall emphasize speedy processing of the registration that requires the Contractor, once it receives the notification from
                      the Provider, to register the Enrollee in Special Coverage within seventy-two (72) hours.

                


        

      

       

      
        
          	

                	7.7.5	
                  Once a Provider supplies all the required information for the Contractor to process a registration and the Contractor processes such information, Special Coverage shall
                      take effect retroactively as of the date the Provider reaches a diagnosis, including documentation of test results, for any condition included in Special Coverage. In case Information is submitted to the Contractor after the diagnosis
                      was reached, coverage can be made retroactive up to sixty (60) Calendar Days before the date on which Provider submitted the registration request.

                


        

      

       

      
        
          	

                	7.7.6	
                  According to the timeframes specified in Attachment 12 to this Contract, the Contractor shall submit proposed protocols to be established for Special Coverage to ASES for
                      prior written approval, including:

                


        

      

       

      
        
          	

                	7.7.6.1	
                  Registration procedures;

                


        

      

       

      
        
          	

                	7.7.6.2	
                  Formats established for registration forms;

                


        

      

       

      
        
          	

                	7.7.6.3	
                  Forms of notices to be issued to the Enrollee and to the Provider to inform them of the Contractor’s decision concerning Special Coverage;

                


        

      

       

      
        
          	

                	7.7.6.4	
                  Protocols for the development of a treatment plan;

                


        

      

       

      
        
          	

                	7.7.6.5	
                  Provisions for ensuring that Enrollees with Special Coverage have Immediate Access to specialists appropriate for the Enrollee’s condition and identified needs; and

                


        

      

       

      
        
          	

                	7.7.6.6	
                  A summary of the Contractor’s strategy for the identification of populations with special health care needs.

                


        

      

       

      
        
          	

                	7.7.7	
                  The protocols shall emphasize both the need for a speedy determination and the need for screening evaluations to be conducted by competent Providers with appropriate
                      expertise.

                


        

      

       

      
        Page 113 of 324

        
          


      

      
        
          	

                	7.7.8	
                  The Contractor shall complete, monitor, and routinely update a treatment plan for each Enrollee who is registered for Special Coverage at least every twelve (12) months,
                      or when the Enrollee’s circumstances or needs change significantly, or at the request of the Enrollee. In the event an Enrollee qualifies for both Special Coverage and the HCHN Program, the treatment plan developed under the HCHN
                      program must comply with this provision.

                


        

      

       

      
        
          	

                	7.7.8.1	
                  The treatment plan shall be developed by the Enrollee’s PCP, with the Enrollee’s participation, and in consultation with any specialists caring for the Enrollee. The
                      Contractor shall require, in its Provider Contracts with PCPs, that Special Coverage registration treatment plans be submitted to the Contractor for review and approval in a timely manner.

                


        

      

       

      
        
          	

                	7.7.9	
                  Autism

                


        

      

       

      
        
          	

                	7.7.9.1	
                  The physical and Behavioral Health Services that the autism population needs to access through specialists such as gastroenterologists, neurologists, allergists, and
                      dentists, will be offered through Special Coverage. Attachment 7 to this Contract includes the mandated procedures for this condition.

                


        

      

       

      
        
          	

                	7.7.9.2	
                  The Contractor shall require in its Provider Contracts with PCPs that the PCP carry out the Modified Checklist for Autism in Toddlers (“M-CHAT R/F”) In its last version for the screening of autism spectrum disorders at eighteen (18) or twenty-four (24) months of age, or in any other age range established by
                      the Department of Health. The Contractor and Providers should follow the “Protocolo Uniforme de TEA” government plan version, published by the Department of Health.

                


        

      

       

      
        
          	

                	7.7.9.3	
                  The Contractor shall also require, through its Provider Contracts, that PCPs administer the Ages and Stages Questionnaire (“ASQ”) to the parents of child Enrollees. This
                      questionnaire must be completed when the child is nine (9), eighteen (18), and thirty (30) months old, or at any other age established by the Health Department. Each Contractor shall acquire the license for the exclusive use of the
                      questionnaire for child Enrollees in the GHP and transmit the questionnaire to PCPs and train and educate them in its use.

                


        

      

       

      
        
          	

                	7.7.10	
                  Services provided under Special Coverage shall be subject to Prior Authorization by the Contractor.

                


        

      

       

      
        
          	

                	7.7.11	
                  Special Coverage shall include in its scope the following services, provided, however, that an Enrollee shall be entitled only to those services Medically Necessary to
                      treat the condition that qualified the Enrollee for Special Coverage:

                


        

      

       

      
        Page 114 of 324

        
          


      

      
        
          	

                	7.7.11.1	
                  Coronary and intensive care services, without limit;

                


        

      

       

      
        
          	

                	7.7.11.2	
                  Maxillary surgery;

                


        

      

       

      
        
          	

                	7.7.11.3	
                  Neurosurgical and cardiovascular procedures, including pacemakers, valves, and any other instrument or artificial devices (Prior Authorization required);

                


        

      

       

      
        
          	

                	7.7.11.4	
                  Peritoneal dialysis, hemodialysis, and related services (Prior Authorization required);

                


        

      

       

      
        
          	

                	7.7.11.5	
                  Pathological and clinical laboratory tests that are required to be sent outside Puerto Rico for processing (Prior Authorization required);

                


        

      

       

      
        
          	

                	7.7.11.6	
                  Neonatal intensive care unit services, without limit;

                


        

      

       

      
        
          	

                	7.7.11.7	
                  Radioisotope, chemotherapy, radiotherapy, and cobalt treatments;

                


        

      

       

      
        
          	

                	7.7.11.8	
                  Treatment of gastrointestinal conditions, treatment of allergies, and nutritional services in autism patients;

                


        

      

       

      
        
          	

                	7.7.11.9	
                  The following procedures and diagnostic tests, when Medically Necessary (Prior Authorization required):

                


        

      

       

      
        
          	

                	7.7.11.9.1	
                  Computerized Tomography;

                


        

      

       

      
        
          	

                	7.7.11.9.2	
                  Magnetic resonance test;

                


        

      

       

      
        
          	

                	7.7.11.9.3	
                  Cardiac catheters;

                


        

      

       

      
        
          	

                	7.7.11.9.4	
                  Holter test;

                


        

      

       

      
        
          	

                	7.7.11.9.5	
                  Doppler test;

                


        

      

       

      
        
          	

                	7.7.11.9.6	
                  Stress tests;

                


        

      

       

      
        
          	

                	7.7.11.9.7	
                  Lithotripsy;

                


        

      

       

      
        
          	

                	7.7.11.9.8	
                  Electromyography;

                


        

      

       

      
        
          	

                	7.7.11.9.9	
                  Single-photon Emission Computed Topography (“SPECT”) test;

                


        

      

       

      
        
          	

                	7.7.11.9.10	
                  Orthopantogram (“OPG”) test;

                


        

      

       

      
        
          	

                	7.7.11.9.11	
                  Impedance Plesthymography;

                


        

      

       

      
        Page 115 of 324

        
          


      

      
        
          	

                	7.7.11.9.12	
                  Other neurological, cerebrovascular, and cardiovascular procedures, invasive and noninvasive;

                


        

      

       

      
        
          	

                	7.7.11.9.13	
                  Nuclear imaging;

                


        

      

       

      
        
          	

                	7.7.11.9.14	
                  Diagnostic endoscopies; and

                


        

      

       

      
        
          	

                	7.7.11.9.15	
                  Genetic studies;

                


        

      

       

      
        
          	

                	7.7.11.10	
                  Up to fifteen (15) additional (beyond the services provided under Basic Coverage) physical therapy treatments per Enrollee condition per year when indicated by an
                      orthopedist, physiatrist or chiropractor after Contractor Prior Authorization;

                


        

      

       

      
        
          	

                	7.7.11.11	
                  General anesthesia, including for dental treatment of special-needs children;

                


        

      

       

      
        
          	

                	7.7.11.12	
                  Hyperbaric Chamber;

                


        

      

       

      
        
          	

                	7.7.11.13	
                  Immunosuppressive medicine and clinical laboratories required for the maintenance treatment of post-surgical patients or transplant patients, to ensure the stability of
                      the Enrollee's health, and for emergencies that may occur after said surgery; and

                


        

      

       

      
        
          	

                	7.7.11.14	
                  Treatment for the following conditions after confirmed laboratory results and established diagnosis:

                


        

      

       

      
        
          	

                	7.7.11.14.1	
                  HIV Positive factor and/or Acquired Immunodeficiency Syndrome (“AIDS”) (Outpatient and hospitalization services are included; no Referral or Prior Authorization is
                      required for Enrollee visits and treatment at the Health Department's Regional Immunology Clinics or other qualified Providers);

                


        

      

       

      
        
          	

                	7.7.11.14.2	
                  Aplastic Anemia

                


        

      

       

      
        
          	

                	7.7.11.14.3	
                  Rheumatoid Arthritis

                


        

      

       

      
        
          	

                	7.7.11.14.4	
                  Cancer, not limited to Skin Cancer;

                


        

      

       

      
        
          	

                	7.7.11.14.5	
                  Certain obstetric services, if the Enrollee is active in the Special Coverage Registry.

                


        

      

       

      
        
          	

                	7.7.11.14.6	
                  Adults with Phenylketonuria (PKU);

                


        

      

       

      
        
          	

                	7.7.11.14.7	
                  Pulmonary Hypertension

                


        

      

       

      
        
          	

                	7.7.11.14.8	
                  Tuberculosis;

                


        

      

       

      
        Page 116 of 324

        
          


      

      
        
          	

                	7.7.11.14.9	
                  Leprosy;

                


        

      

       

      
        
          	

                	7.7.11.14.10	
                  Systemic Lupus Erythematosus (SLE);

                


        

      

       

      
        
          	

                	7.7.11.14.11	
                  Cystic Fibrosis;

                


        

      

       

      
        
          	

                	7.7.11.14.12	
                  Hemophilia;

                


        

      

       

      
        
          	

                	7.7.11.14.13	
                  Special conditions of children, including the prescribed conditions in the Special Needs Children Diagnostic Manual Codes (see Attachment 13 to this Contract), except:

                


        

      

       

      
        
          	

                	7.7.11.14.13.1	
                  Psychiatric Disorders; and

                


        

      

       

      
        
          	

                	7.7.11.14.13.2	
                  Intellectual disabilities;

                


        

      

       

      
        
          	

                	7.7.11.14.14	
                  Scleroderma;

                


        

      

       

      
        
          	

                	7.7.11.14.15	
                  Multiple Sclerosis and Amiotrophic Lateral Sclerosis (ALS); and

                


        

      

       

      
        
          	

                	7.7.11.14.16	
                  Chronic renal disease in levels three (3), four (4) and five (5) (Levels 1 and 2 are included in the Basic Coverage); these levels of renal disease are defined as
                      follows:

                


        

      

       

      
        
          	

                	7.7.11.14.16.1	
                  Level 3. GFR








                      (Glomerular Filtration – ml/min. per 1.73m2 per corporal surface area) between 30 and 59, a moderate decrease in kidney function;

                


        

      

       

      
        
          	

                	7.7.11.14.16.2	
                  Level 4. GFR between 15 and 29, a severe decrease in kidney function; and

                


        

      

       

      
        
          	

                	7.7.11.14.16.3	
                  Level 5. GFR under 15, renal failure that will probably require either dialysis or a kidney
                      transplant.

                


        

      

       

      
        
          	

                	7.7.11.15	
                  Required medication for the outpatient treatment of Tuberculosis and Leprosy is included under Special Coverage. Medication for the outpatient treatment or
                      hospitalization for AIDS-diagnosed Enrollees or HIV-positive Enrollees is also included, with the exception of Protease inhibitors which will be provided by CPTET Centers.

                


        

      

       

      
        
          	

                	7.7.12	
                  An Enrollee may register for Special Coverage based on one (1) of the conditions listed in Attachment 7 to this Contract. The Contractor must seek ASES Prior
                      Authorization for any other special condition not listed in Attachment 7 to this Contract, which the Enrollee, PCP, or PMG requests to be the basis of Special Coverage for an Enrollee. The request must include sufficient documentation
                      of the Enrollee’s need for services and the cost-effectiveness of the care option. ASES will consult with the Health Department and issue a decision which will be binding between the Parties.

                


        

      

       

      
        Page 117 of 324

        
          


      

      
        
          	

                	7.7.13	
                  The Contractor must have a mechanism in place to allow Enrollees to directly access a specialist as appropriate for the enrollee’s condition and identified needs, in
                      regards to all services encompassed within the scope of Special Coverage.

                


        

      

       

      
        
          	

                	7.7.14	
                  Except as expressly noted in this Section 7.7, the exclusions applied to Basic Coverage apply to Special Coverage.

                


        

      

       

      
        
          	

                	7.8	
                  Administrative Functions and the High Cost High Needs (HCHN) Program

                


        

      

       

      
        
          	

                	7.8.1	
                  Benefits under the GHP include the Administrative Functions of Care Management and the Wellness Plan (see Section 12.6 of this Contract), which are intended to coordinate
                      care for Enrollees with conditions specified in the HCHN Program or other Enrollees with an identified need for additional coordination.

                


        

      

       

      
        
          	

                	7.8.2	
                  Care Management

                


        

      

       

      
        
          	

                	7.8.2.1	
                  The Contractor shall be responsible for the Care Management of Enrollees who demonstrate the greatest need, including those who have conditions specified in the HCHN
                      Program, further described in Section 7.8.3) and/or who require intensive assistance, including during extended hours as required by the Enrollees’ medical conditions, to ensure integration of physical and Behavioral Health needs.

                


        

      

       

      
        
          	

                	7.8.2.2	
                  Enrollees who present with the following conditions shall be offered Care Management and may elect to opt out of the program:

                


        

      

       

      
        
          	

                	7.8.2.2.1	
                  Enrollees identified with special health care needs and whom qualify for Special Coverage, the HCHN Program, the High Utilizers Program, or have a Chronic Condition not
                      otherwise covered under Special Coverage or the HCHN Program;

                


        

      

       

      
        
          	

                	7.8.2.2.2	
                  Enrollees diagnosed with a Serious Mental Illness (SMI) or a Serious Emotional Disturbance (SED); or

                


        

      

       

      
        
          	

                	7.8.2.2.3	
                  Enrollees who have accessed the emergency room seven (7) or more times within twelve (12) months.

                


        

      

       

      
        
          	

                	7.8.2.3	
                  The Contractor’s Care Management system shall emphasize prevention, continuity of care, and coordination of care, including between settings of care and appropriate
                      discharge planning for short- and long-term hospital and institutional stays. The system will advocate for, and link Enrollees to, services as necessary across Providers, including community and social support Providers, and settings.
                      Care Management functions include:

                


        

      

       

      
        Page 118 of 324

        
          


      

      
        
          	

                	7.8.2.3.1	
                  Assignment of a specific Care Manager to each enrollee qualified for Care Management;

                


        

      

       

      
        
          	

                	7.8.2.3.2	
                  Management of Enrollee to Care Manager ratios that have been reviewed ASES;

                


        

      

       

      
        
          	

                	7.8.2.3.3	
                  Identification of Enrollees who have or may have chronic or severe Behavioral Health needs, including through use of the screening tools M-CHAT for the detection of
                      Autism, ASQ, ASQ-SE, Conners Scale (ADHD screen), DAST-10, GAD, and PC-PTSD, and other tools available for diagnosis of Behavioral Health disorders;

                


        

      

       

      
        
          	

                	7.8.2.3.4	
                  Assessment of an Enrollee’s physical and Behavioral Health needs utilizing a standardized needs assessment within thirty (30) Calendar Days of Referral to Care Management
                      that has been reviewed and given written approval by ASES. The Contractor shall also make its best efforts to perform this needs assessment for all new Enrollees within ninety (90) Calendar Days of the Effective Date of Enrollment,
                      and to comply with all other requirements for such assessments set forth in 42 CFR 438.208(b);

                


        

      

       

      
        
          	

                	7.8.2.3.5	
                  Development of a plan of care within sixty (60) Calendar Days of the needs assessment;

                


        

      

       

      
        
          	

                	7.8.2.3.6	
                  Referrals and assistance to ensure timely Access to Providers;

                


        

      

       

      
        
          	

                	7.8.2.3.7	
                  Coordination of care actively linking the Enrollee to Providers, medical services, residential, social, and other support services where deemed necessary;

                


        

      

       

      
        
          	

                	7.8.2.3.8	
                  Monitoring of the Enrollees needs for assistance and additional services via face-to-face or telephonic contact at least quarterly (based on high- or low-risk);

                


        

      

       

      
        
          	

                	7.8.2.3.9	
                  Continuity and transition of care; and

                


        

      

       

      
        
          	

                	7.8.2.3.10	
                  Follow-up and documentation, including the review and/or revision of a plan of care upon reassessment of need, at least every twelve (12) months, or when the Enrollee’s
                      circumstances or needs change significantly, or at the request of the Enrollee.

                


        

      

       

      
        Page 119 of 324

        
          


      

      
        
          	

                	7.8.2.4	
                  The Contractor shall develop policies and procedures for Care Management that include, at a minimum, the following elements:

                


        

      

       

      
        
          	

                	7.8.2.4.1	
                  The provision of an individual needs assessment and diagnostic assessment;

                


        

      

       

      
        
          	

                	7.8.2.4.2	
                  The development of an individual treatment plan, as necessary, based on the needs assessment;

                


        

      

       

      
        
          	

                	7.8.2.4.3	
                  The establishment of treatment objectives;

                


        

      

       

      
        
          	

                	7.8.2.4.4	
                  The monitoring of outcomes;

                


        

      

       

      
        
          	

                	7.8.2.4.5	
                  A process to ensure that treatment plans are revised as necessary;

                


        

      

       

      
        
          	

                	7.8.2.4.6	
                  A strategy to ensure that all Enrollees or Authorized Representatives, as well as any specialists caring for the Enrollee, are involved in a treatment planning process
                      coordinated by the PCP;

                


        

      

       

      
        
          	

                	7.8.2.4.7	
                  Procedures and criteria for making Referrals to specialists and subspecialists;

                


        

      

       

      
        
          	

                	7.8.2.4.8	
                  Procedures and criteria for maintaining care plans and Referral services when the Enrollee changes Providers;

                


        

      

       

      
        
          	

                	7.8.2.4.9	
                  Capacity to implement, when indicated, Care Management functions such as individual needs assessment, including establishing treatment objectives, treatment follow-up,
                      monitoring of outcomes, or revision of the treatment plan; and

                


        

      

       

      
        
          	

                	7.8.2.5	
                  These procedures must be designed to include consultation and coordination with Enrollee’s PCP.

                


        

      

       

      
        
          	

                	7.8.2.6	
                  The Contractor shall submit its Care Management policies and procedures to ASES for review according to the timeframe specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	7.8.3	
                  High Cost High Needs (HCHN) Program

                


        

      

       

      
        
          	

                	7.8.3.1	
                  The HCHN Program is a coordinated model of care focused on conditions that may require intensive use services, monitoring and interventions by a dedicated team of
                      Providers to ensure compliance with plans of care, and specialized care management services (see Section 7.8.2). Outcomes for Enrollees with select conditions in the HCHN Program will be subject to performance metrics and the
                      affiliated Retention Fund as specified in the Health Care Improvement Program (HCIP) Manual (Attachment 19 to this Contract) and Sections 12.5 and 22.4 of the Contract.

                


        

      

       

      
        Page 120 of 324

        
          


      

      
        
          	

                	7.8.3.2	
                  The Contractor shall design a model of care that assigns Enrollees to an appropriate level of care management and an appropriate team of Providers to treat and manage the
                      health condition. The model of care shall also include transition of care planning when the Enrollee presents at a facility for Emergency Services or post-discharge following an inpatient stay. The model of care shall also include
                      linkages and interventions related to social determinants of health to treat the holistic needs of the Enrollee.

                


        

      

       

      
        
          	

                	7.8.3.3	
                  The Contractor’s Enrollee Handbook must describe in detail the model of care for treatment of Enrollees with each HCHN condition and the models of care are enforceable
                      and auditable by ASES.

                


        

      

       

      
        
          	

                	7.8.3.4	
                  Health conditions subject to the Contractor’s HCHN model of care and the process for identifying Enrollees with these specified health conditions is provided in
                      Attachment 28 to this Contract.

                


        

      

       

      
        
          	

                	7.8.3.5	
                  Contractors will be paid the associated PMPM Payment for Enrollees in the HCHN Program, per specified condition, as provided in Attachment 28 to this Contract.

                


        

      

       

      
        
          	

                	7.9	
                  Early and Periodic Screening, Diagnosis and Treatment Requirements (“EPSDT”)

                


        

      

       

      
        
          	

                	7.9.1	
                  The Contractor shall provide EPSDT services to Pediatric Enrollees in compliance with all requirements found below. EPSDT services must be in compliance with Health
                      Department guidelines and the Mothers, Children and Adolescents Program guidelines. ASES may issue additional guidelines to the Contractor in regards to the applicable EPSDT services.

                


        

      

       

      
        
          	

                	7.9.1.1	
                  The Contractor shall comply with sections 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Social Security Act, and Part 5 of the State Medicaid Manual, which require EPSDT
                      services to include Outreach and education, screening, tracking, and diagnostic and treatment services.

                


        

      

       

      
        
          	

                	7.9.1.2	
                  The Contractor shall develop an EPSDT Plan that includes written policies and procedures for conducting Outreach and education, informing, tracking, and organizing
                      follow-up to ensure compliance with the Well Baby Care periodicity schedules.

                


        

      

       

      
        Page 121 of 324

        
          


      

      
        
          	

                	7.9.1.3	
                  The EPSDT Plan shall emphasize Outreach and compliance monitoring for children and adolescents (young adults), taking into account the multi-lingual, multi-cultural
                      nature of the population, as well as other unique characteristics of this population.

                


        

      

       

      
        
          	

                	7.9.1.4	
                  The EPSDT Plan shall include procedures for follow-up of missed appointments, including missed Referral appointments for problems identified through EPSDT screens and
                      exams. The plan shall also include procedures for Referral, tracking, and follow-up for annual dental examinations and visits. The Contractor shall submit its EPSDT Plan for review and approval according to the timeframe specified in
                      Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	7.9.2	
                  Outreach and Education

                


        

      

       

      
        
          	

                	7.9.2.1	
                  The Contractor’s EPSDT Outreach and education process for Pediatric Enrollees and their families shall include:

                


        

      

       

      
        
          	

                	7.9.2.1.1	
                  The importance of preventive care;

                


        

      

       

      
        
          	

                	7.9.2.1.2	
                  The periodicity schedule and the depth and breadth of services;

                


        

      

       

      
        
          	

                	7.9.2.1.3	
                  How and where to access services, including necessary transportation and scheduling services; and

                


        

      

       

      
        
          	

                	7.9.2.1.4	
                  A statement that services are provided without cost.

                


        

      

       

      
        
          	

                	7.9.2.2	
                  The Contractor shall provide written notification to its families with EPSDT-eligible children when appropriate periodic assessments or needed services are due. The
                      Contractor shall coordinate appointments for care. The Contractor shall follow-up with families with EPSDT-eligible children who have failed to access Well Baby Care services after one hundred and twenty (120) Calendar Days of
                      Enrollment in the GHP.

                


        

      

       

      
        
          	

                	7.9.2.3	
                  The Contractor shall inform its newly enrolled families with EPSDT-Eligible children about the EPSDT Program upon Enrollment with the Plan. This requirement includes
                      informing pregnant women and new mothers, either before or within fourteen (14) Calendar Days after the birth of their children, that EPSDT services are available.

                


        

      

       

      
        
          	

                	7.9.2.4	
                  The Contractor shall provide each PCP, on a monthly basis, with a list of the PCP’s EPSDT-eligible children who have not had an appointment during the initial one hundred
                      and twenty (120) Calendar Days of Enrollment, and/or are not in compliance with the EPSDT periodicity schedule. The Contractor and/or the PCP shall subsequently contact the Enrollees’ parents or guardians to schedule an appointment.

                


        

      

       

      
        Page 122 of 324

        
          


      

      
        
          	

                	7.9.2.5	
                  Outreach and education shall include a combination of written and oral (on the telephone, face-to-face, or films/tapes) methods, and may be done by Contractor personnel
                      or by Providers. All Outreach and education shall be documented and shall be conducted in non-technical language at or below a fourth (4th) -grade reading level. The Contractor shall use accepted methods for informing persons who are blind or deaf, or cannot read or understand the Spanish
                      language.

                


        

      

       

      
        
          	

                	7.9.2.6	
                  The Contractor may provide nominal, non-cash incentives of fifteen dollars ($15) or less to Enrollees and no more than seventy-five dollars ($75) in the aggregate
                      annually per Enrollee, to motivate compliance with periodicity schedules if prior approved in writing by ASES.

                


        

      

       

      
        
          	

                	7.9.3	
                  Screening

                


        

      

       

      
        
          	

                	7.9.3.1	
                  The Contractor is responsible for periodic screens (“EPSDT Checkups”) in accordance with the Puerto Rico Medicaid Program’s periodicity schedule and the American Academy
                      of Pediatrics EPSDT periodicity schedule. Such EPSDT Checkups shall include, but not be limited to, the Well Baby Care checkups described in Section 7.5.3.1.

                


        

      

       

      
        
          	

                	7.9.3.2	
                  The Contractor shall provide an initial health and screening visit to all newly enrolled CHIP Eligible children within ninety (90) Calendar Days and within twenty-four
                      (24) hours of birth to all newborns; and, after the initial Checkup, annually.

                


        

      

       

      
        
          	

                	7.9.3.3	
                  The Contractor must advise the Enrollee child, his or her parents, or his or her legal guardian of his or her right to have an EPSDT Checkup.

                


        

      

       

      
        
          	

                	7.9.3.4	
                  EPSDT Checkups must include all of the following:

                


        

      

       

      
        
          	

                	7.9.3.4.1	
                  A comprehensive health and developmental history;

                


        

      

       

      
        
          	

                	7.9.3.4.2	
                  Developmental assessment, including mental, emotional, and Behavioral Health development;

                


        

      

       

      
        
          	

                	7.9.3.4.3	
                  Measurements (including head circumference for infants);

                


        

      

       

      
        
          	

                	7.9.3.4.4	
                  An assessment of nutritional status;

                


        

      

       

      
        
          	

                	7.9.3.4.5	
                  A comprehensive unclothed physical exam;

                


        

      

       

      
        Page 123 of 324

        
          


      

      
        
          	

                	7.9.3.4.6	
                  Immunizations according to the guidance issued by the Advisory Committee on Immunization Practices (ACIP). All immunizations shall be provided for Pediatric Enrollees,
                      and those necessary according to age, gender, and health condition of the Enrollee, including but not limited to influenza and pneumonia, vaccines for Enrollees over 65 years and vaccines for children and adults with high risk
                      conditions such as pulmonary, renal, diabetes and heart disease, among others.

                


        

      

       

      
        
          	

                	7.9.3.4.6.1	
                  The Puerto Rico Department of Health shall provide and pay for vaccines to Enrollees ages 0-18 through the Children's Immunization Program. The Contractor shall cover the
                      administration of the vaccines provided by the Puerto Rico Department of Health.

                


        

      

       

      
        
          	

                	7.9.3.4.6.2	
                  The Contractor shall provide and pay for the immunizations of Enrollees ages 19-20 and those necessary according to age, gender and health condition of the Enrollee,
                      including but not limited to influenza and pneumonia vaccines for beneficiaries over 65 years and adults with high risk conditions such as pulmonary, renal, diabetes, and heart disease, among others.

                


        

      

       

      
        
          	

                	7.9.3.4.6.3	
                  The Contractor shall cover the administration of all the vaccines according to the fee schedule established by the Puerto Rico Health Department. The Contractor shall
                      contract with immunization providers, duly certified by the Puerto Rico Department of Health, to provide immunization services.

                


        

      

       

      
        
          	

                	7.9.3.4.6.4	
                  The Contractor shall administer the immunizations without any charge or deductible.

                


        

      

       

      
        
          	

                	7.9.3.4.7	
                  Certain laboratory tests;

                


        

      

       

      
        
          	

                	7.9.3.4.8	
                  Anticipatory guidance and health education;

                


        

      

       

      
        
          	

                	7.9.3.4.9	
                  Vision screening;

                


        

      

       

      
        
          	

                	7.9.3.4.10	
                  Tuberculosis;

                


        

      

       

      
        
          	

                	7.9.3.4.11	
                  Hearing screening; and

                


        

      

       

      
        
          	

                	7.9.3.4.12	
                  Dental and oral health assessment.

                


        

      

       

      
        Page 124 of 324

        
          


      

      
        
          	

                	7.9.3.5	
                  Lead screening is a required component of an EPSDT Checkup, and the Contractor shall implement a screening program for the detection of the presence of lead toxicity. The
                      screening program shall consist of two (2) parts: verbal risk assessment (from thirty-six (36) to seventy-two (72) months of age), and blood screening for lead. Regardless of risk, the Contractor shall provide for a blood screening
                      testing for lead for all EPSDT-Eligible children at twelve (12) and twenty-four (24) months of age. Children between twenty-four (24) months of age and seventy-two (72) months of age should receive a blood lead screening testing for
                      lead if there is no record of a previous test.

                


        

      

       

      
        
          	

                	7.9.3.6	
                  The Contractor shall have procedures for Provider Referral to and follow-up with dental service Providers, including annual dental examinations and services by an oral
                      health Provider.

                


        

      

       

      
        
          	

                	7.9.3.7	
                  The Contractor shall have procedures for Provider Referral of children for further diagnostic and/or treatment services to correct or ameliorate defects, physical and
                      mental illnesses, and conditions discovered by the EPSDT checkup. Referral to the Provider conducting the screening or to another Provider may be made, as appropriate, as well as any follow-up appointments.

                


        

      

       

      
        
          	

                	7.9.3.8	
                  The Contractor shall ensure at a minimum fifty percent (50%) compliance during the first Contract year, sixty percent (60%) compliance during the second Contract year,
                      and seventy-five percent (75%) compliance during the third Contract year, with the EPSDT screening requirements, including blood screening for lead and annual dental examinations and services, using the methodology prescribed by CMS
                      to determine the screening rate. ASES may impose penalties, sanctions, and/or fines under Articles 19 and 20 if the Contractor fails to comply with the minimum requirements.

                


        

      

       

      
        
          	

                	7.9.4	
                  Tracking

                


        

      

       

      
        
          	

                	7.9.4.1	
                  The Contractor shall establish a tracking system that provides Information on compliance with EPSDT requirements. This system shall have in a place a
                      reminder/notification system and shall track, at a minimum, the following areas:

                


        

      

       

      
        
          	

                	7.9.4.1.1	
                  Initial newborn Well Baby Care hospital checkups;

                


        

      

       

      
        
          	

                	7.9.4.1.2	
                  Periodic EPSDT checkups as required by the periodicity schedule;

                


        

      

       

      
        
          	

                	7.9.4.1.3	
                  Diagnostic and treatment services, including Referrals; and

                


        

      

       

      
        
          	

                	7.9.4.1.4	
                  Immunizations, lead, tuberculosis, and dental services.

                


        

      

       

      
        Page 125 of 324

        
          


      

      
        
          	

                	7.9.4.2	
                  All Information generated and maintained in the tracking system shall be consistent with Encounter Data requirements as specified in Section 17.3.3 of this Contract.

                


        

      

       

      
        
          	

                	7.9.5	
                  Diagnostic and Treatment Services

                


        

      

       

      
        
          	

                	7.9.5.1	
                  If a suspected problem is detected by a screening examination as described above, the child shall be evaluated as necessary for further diagnosis. This diagnosis is used
                      to determine treatment needs.

                


        

      

       

      
        
          	

                	7.9.5.2	
                  EPSDT requires coverage for all follow-up diagnostic and treatment services deemed Medically Necessary to ameliorate or correct a problem discovered during an EPSDT
                      checkup. Such Medically Necessary diagnostic and treatment services must be provided regardless of whether such services are covered by the State Medicaid Plan, as long as they are Medicaid-coverable Services as defined in Title XIX
                      of the Social Security Act. The Contractor shall provide Medically Necessary, Medicaid-coverable diagnostic and treatment services.

                


        

      

       

      
        
          	

                	7.9.6	
                  EPSDT Reporting is addressed in Section 18.2.4 of this Contract.

                


        

      

       

      
        
          	

                	7.10	
                  Advance Directives

                


        

      

       

      
        
          	

                	7.10.1	
                  In compliance with 42 CFR 438.3 (j), 42 CFR 422.128(a), 42 CFR 422.128(b), 42 CFR 489.102(a), and Law No. 160 of November 17, 2001, the Contractor shall maintain written
                      policies and procedures for Advance Directives. Such Advance Directives shall be included in each Enrollee’s Medical Record. The Contractor shall provide these policies and procedures written at a fourth (4th) grade reading level in English and Spanish to all Enrollees eighteen (18) years of age and older and shall advise Enrollees of:

                


        

      

       

      
        
          	

                	7.10.1.1	
                  Their rights under the laws of Puerto Rico, including the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives;

                


        

      

       

      
        
          	

                	7.10.1.2	
                  The Contractor’s written policies respecting the implementation of those rights, including a statement of any limitation that incorporates the requirements set forth
                      under 42 CFR 422.128(b)(1)(ii) regarding the implementation of Advance Directives as a matter of conscience; and

                


        

      

       

      
        
          	

                	7.10.1.3	
                  The Enrollee’s right to file Complaints concerning noncompliance with Advance Directive requirements directly with ASES or with the Puerto Rico Office of the Patient
                      Advocate.

                


        

      

       

      
        Page 126 of 324

        
          


      

      
        
          	

                	7.10.2	
                  The Information must include a description of Puerto Rico law and must reflect changes in laws as soon as possible and no later than ninety (90) Calendar Days after the
                      effective change.

                


        

      

       

      
        
          	

                	7.10.3	
                  The Contractor shall educate its staff about its policies and procedures on Advance Directives, situations in which Advance Directives may be of benefit to Enrollees, and
                      the staff’s responsibility to educate Enrollees about this tool and assist them in making use of it.

                


        

      

       

      
        
          	

                	7.10.4	
                  The Contractor shall educate Enrollees about their ability to direct their care using Advance Directives and shall specifically designate which staff members or Network
                      Providers are responsible for providing this education.

                


        

      

       

      
        
          	

                	7.11	
                  Enrollee Cost-Sharing

                


        

      

       

      
        
          	

                	7.11.1	
                  The Contractor shall ensure that Providers collect the Enrollee’s cost-sharing portion only as specified in Attachment 8 to this Contract, as developed in accordance with
                      42 CFR 438.108.

                


        

      

       

      
        
          	

                	7.11.2	
                  The Contractor shall ensure that it accurately differentiates the categories of GHP Enrollees in its Marketing Materials and communications, to clarify the cost-sharing
                      rules that are applied to each group. The Contractor shall ensure that the Enrollee’s eligibility category appears on the Enrollee ID Card, so that cost-sharing is correctly determined.

                


        

      

       

      
        
          	

                	7.11.3	
                  The Contractor shall ensure that, in keeping with the Co-Payment policies included in Attachment 8 to this Contract, Medicaid and CHIP Eligibles bear no cost-sharing
                      responsibility under the GHP for services provided within the Contractor’s PPN.

                


        

      

       

      
        
          	

                	7.11.4	
                  As provided in Attachment 8 to this Contract, the Contractor shall impose Co-Payments for services provided in an emergency room outside the Enrollee’s PPN, but only in
                      limited circumstances.

                


        

      

       

      
        
          	

                	7.11.4.1	
                  For Medicaid and CHIP Eligibles, the Contractor shall not impose any Co-Payment for the treatment of an Emergency Medical Condition or a Psychiatric Emergency. The
                      Contractor shall, however, as provided in Attachment 8 to this Contract, impose Co-Payments for services provided in an emergency room to treat a condition that the attending physician determines, at the time of the visit, does not
                      meet the definition of a Psychiatric Emergency or an Emergency Medical Condition and if the Enrollee does not consult the GHP Service Line Medical Advice Line before visiting the emergency room, and provide his or her call
                      identification number at the emergency room. If the Enrollee presents the call identification number, no Co-Payment shall be imposed.

                


        

      

       

      
        Page 127 of 324

        
          


      

      
        
          	

                	7.11.4.2	
                  No Co-Payments shall be charged for Medicaid and CHIP children under twenty-one (21) years of age under any circumstances.

                


        

      

       

      
        
          	

                	7.11.4.3	
                  For Other Eligible Persons, the Contractor shall impose a Co-Payment for any emergency room visit outside the Enrollee’s PPN, if the Enrollee does not consult the GHP
                      Service Line Medical Advice Line before visiting the emergency room, and provide his or her call identification number at the emergency room. If the Enrollee presents the call identification number, no Co-Payment shall be imposed.

                


        

      

       

      
        
          	

                	7.11.5	
                  As provided in 42 CFR 447.53(e), if a Medicaid or CHIP Eligible expresses his or her inability to pay the established Co-Payment at the time of service, the Contractor
                      (through its contracted Providers) shall not deny the service.

                


        

      

       

      
        
          	

                	7.11.6	
                  Enrollees of Indian background, as defined in Article 2, are exempt from all Co-Payments.

                


        

      

       

      
        
          	

                	7.11.7	
                  The Contractor shall ensure that any cost sharing complies with the parity requirements for Financial Requirements in 42 CFR 438.910 addressed in Section 7.5.11.7.

                


        

      

       

      
        
          	

                	7.12	
                  Dual Eligible Beneficiaries

                


        

      

       

      
        
          	

                	7.12.1	
                  Dual Eligible Beneficiaries enrolled in the GHP are eligible, with the limitations provided below, for the Covered Services described in this Article 7, with the addition
                      of some coverage of Medicare cost-sharing.

                


        

      

       

      
        
          	

                	7.12.1.1	
                  Dual Eligible Beneficiaries Who Receive Medicare Part A Only

                


        

      

       

      
        
          	

                	7.12.1.1.1	
                  The Contractor shall provide regular GHP coverage as provided in this Article 7, excluding services covered under Medicare Part A (hospitalization). However, the GHP
                      shall cover hospitalization services after the Medicare Part A coverage limit has been reached.

                


        

      

       

      
        
          	

                	7.12.1.1.2	
                  The Contractor shall not cover the Medicare Part A premium or Deductible.

                


        

      

       

      
        
          	

                	7.12.1.2	
                  Dual Eligible Beneficiaries Who Receive Medicare Part A and Part B

                


        

      

       

      
        
          	

                	7.12.1.2.1	
                  The Contractor shall provide regular GHP coverage as detailed in this Article 7, excluding services covered under Medicare Part A or Part B. However, the GHP shall cover
                      hospitalization services after the Medicare Part A coverage limit has been reached.

                


        

      

       

      
        Page 128 of 324

        
          


      

      
        
          	

                	7.12.1.2.2	
                  The Contractor shall not cover the Medicare Part A premium or Deductible.

                


        

      

       

      
        
          	

                	7.12.1.2.3	
                  The Contractor shall cover Medicare Part B Deductibles and co-insurance in accordance with Section 23.5.1.

                


        

      

       

      
        
          	

                	7.12.1.3	
                  Dual Eligible Beneficiaries enrolled in a Medicare Part C and/or Platino Plan are not eligible for services under this Contract.

                


        

      

       

      
        
          	

                	7.12.1.4	
                  Barbiturates and Benzodiazepines for Dual Eligible Beneficiaries with Medicare Part D are covered by Medicare Part D.

                


        

      

       

      
        
          	

                	7.12.2	
                  Any GHP cost-sharing for Dual Eligible Beneficiaries shall be determined according to Section 7.11 and Attachment 8 to this Contract.

                


        

      

       

      
        
          	

                	7.12.3	
                  The Contractor must enter into a Coordination of Benefits Agreement with Medicare within sixty (60) Calendar Days from the Effective Date of the Contract and participate
                      in the automated claims crossover process in order to appropriately allocate reimbursement for Dual Eligible Beneficiaries. Any crossover claims not appropriately reimbursed by the applicable Medicare program will be considered an
                      Overpayment and shall be reported and returned in accordance with Section 22.1.19.

                


        

      

       

      
        
          	

                	7.12.3.1	
                  ASES may extend the sixty (60) Calendar Day time frame set forth in Section 7.12.3 if the Contractor can provide evidence, satisfactory to ASES, that documents the
                      Contractor’s reasonable efforts to enter into a Coordination of Benefits Agreement with Medicare.

                


        

      

       

      
        
          	

                	7.13	
                  Moral or Religious Objections

                


        

      

       

      
        
          	

                	7.13.1	
                  If, during the course of the Contract period, pursuant to 42 CFR 438.102, the Contractor elects not to provide, not to reimburse for, or not to provide a Referral or
                      Prior Authorization for a service within the scope of the detailed Covered Services, because of an objection on moral or religious grounds, the Contractor shall notify:

                


        

      

       

      
        
          	

                	7.13.1.1	
                  ASES within one hundred and twenty (120) Calendar Days before adopting the policy with respect to any service;

                


        

      

       

      
        
          	

                	7.13.1.2	
                  Enrollees within ninety (90) Calendar Days after adopting the policy with respect to any service; and

                


        

      

       

      
        
          	

                	7.13.1.3	
                  Enrollees and Potential Enrollees before and during Enrollment.

                


        

      

       

      
        
          	

                	7.13.2	
                  The Contractor shall furnish information about the services it does not cover based on a moral or religious objection to ASES with its GHP Program application. The
                      Contractor acknowledges that such objections will be factored into the calculation of rates paid to the Contractor and, when made during the course of the Contract period, may serve as grounds for recalculation of the rates paid.

                


        

      

       

      
        Page 129 of 324

        
          


      

      
        
          	

                	7.13.3	
                  If the Contractor does not cover counseling or referral services because of moral or religious objections and chooses not to furnish information to Enrollees on how and
                      where to obtain such services, ASES must provide that information to Enrollees.

                


        

      

       

      
        
          	

                	7.14	
                  High Utilizers Program – Collaboration with ASES

                


        

      

       

      
        
          	

                	7.14.1	
                  Pursuant to Attachment 25 to this Contract, the Contractor shall collaborate with ASES in its implementation and administration of the High Utilizer Program, including
                      but not limited to, providing data related to physical and Behavioral Health services such as:

                


        

      

       

      
        
          	

                	7.14.1.1	
                  Demographic data.

                


        

      

       

      
        
          	

                	7.14.1.2	
                  Utilization Data from the population.

                


        

      

       

      
        
          	

                	7.14.1.3	
                  Real-time data from the hospitals to know every time that one of the patients in the program or patients identified as prospects for the program enters the hospital.

                


        

      

       

      
        
          	

                	7.14.1.4	
                  Hospital data from the hospitals using the Client contracting relationship with them.

                


        

      

       

      
        
          	

                	7.14.1.5	
                  Authorization data from fast track process for authorizations within Plans.

                


        

      

       

      
        
          	

                	7.14.2	
                  The Contractor shall provide expedited authorization processes and contact personnel as needed to help coordinate the High Utilizer Program’s information and services.

                


        

      

      

      

      
        
          	ARTICLE 8	
                  INTEGRATION OF PHYSICAL AND BEHAVIORAL HEALTH SERVICES

                


        

      

       

      
        
          	

                	8.1	
                  General Provisions

                


        

      

       

      
        
          	

                	8.1.1	
                  The Contractor shall ensure that physical and Behavioral Health Services are fully integrated, to ensure optimal detection, prevention, and treatment of physical and
                      Behavioral Health illness.

                


        

      

       

      
        
          	

                	8.1.2	
                  The Contractor (through contracted PCPs, PMGs, and other Network Providers) shall be responsible, for identifying Enrollees’ needs and coordinating proper Access to both
                      physical and Behavioral Health Services.

                


        

      

       

      
        Page 130 of 324

        
          


      

      
        
          	

                	8.1.3	
                  In implementing an integrated model of service delivery, the Contractor shall observe all the protections of the Mental Health Code (Act No. 408) and the Puerto Rico
                      Patient’s Bill of Rights Act, as well as other applicable Federal and Puerto Rico legislation.

                


        

      

       

      
        
          	

                	8.2	
                  Co-Location of Staff

                


        

      

       

      
        
          	

                	8.2.1	
                  The Contractor shall require the placement of a psychologist or other type of Behavioral Health Provider as part of the PMG’s PPN. The Behavioral Health Provider shall be
                      present and available to provide assessment, screening, consultation, and Behavioral Health Services to Enrollees. The standard minimum criteria for weekly access will be four (4) hours per week for one thousand (1,000) or fewer
                      Enrollees assigned to the PMG and increments of four (4) hours per every additional one thousand (1,000) Enrollees thereafter as detailed in Attachment 10 to this Contract. Total Behavioral Health Provider hours will be determined by
                      the number of Enrollees assigned to the PMG regardless of the Contractor selected by the Enrollee. The Contractor must ensure that each PMG complies with the ASES Guidelines for Co-location of the Behavioral Health Provider in PMG
                      settings established in Attachment 10 to this Contract.

                


        

      

       

      
        
          	

                	8.2.2	
                  The Contractor shall ensure that the PMG provides adequate space and resources for the Behavioral Health Provider to provide care and consultations in a confidential
                      setting.

                


        

      

       

      
        
          	

                	8.2.3	
                  The Behavioral Health Provider housed within the PMG shall conduct screening evaluations (PHQ-9, ASQ, ASQ SE, Conners Scales, DAST-10, GAD, PC-PTSD among others), crisis
                      intervention, and limited psychotherapy (between four (4) and six (6) sessions), according to the needs of the Enrollee). Formal and informal case discussions between the PCP and Behavioral Health Providers are encouraged.
                      Additionally, the Behavioral Health Provider shall evaluate all Enrollees in the HCHN Program, and develop and implement a short term, limited psychotherapy care plan as appropriate. The Contractor shall ensure that the services
                      provided are compliant with Act No. 408.

                


        

      

       

      
        
          	

                	8.3	
                  Reverse Co-location

                


        

      

       

      
        
          	

                	8.3.1	
                  The Contractor shall contract with Short-term Intervention Centers (Stabilization Units) based on the needs of the population, and with a geographic distribution approved
                      by ASES. Based on the needs of the population, ASES has the sole discretion of requiring the Contractor to contract additional Behavioral Health Services Facilities.

                


        

      

       

      
        
          	

                	8.3.2	
                  The Contractor must comply with the ASES Guidelines for Reverse Co-location of the PCP in Behavioral Health Facilities detailed in Attachment 21 of this Contract.

                


        

      

       

      
        Page 131 of 324

        
          


      

      
        
          	

                	8.3.3	
                  The Contractor shall ensure that a PCP is on site or on call as specified in the Guidelines for Reverse Collocation (see Attachment 21 to this Contract) to monitor the
                      physical health of the Enrollees.

                


        

      

       

      
        
          	

                	8.3.4	
                  The Contractor shall ensure that the Behavioral Health Facility provides adequate space and resources for the PCP to provide care and consultations in a confidential
                      setting.

                


        

      

       

      
        
          	

                	8.3.5	
                  In the event that a Behavioral Health Facility does not allow Contractor to place a PCP in the Behavioral Health Facility for the minimum time required, the Contractor
                      shall proceed according to the Guidelines for Reverse Collocation (see Attachment 21 to this Contract).

                


        

      

       

      
        
          	

                	8.4	
                  Referrals

                


        

      

       

      
        
          	

                	8.4.1	
                  GHP Enrollees with Behavioral Health conditions requiring more intensive or continuous care than can be provided within the PMG environment as set forth in Section 8.2,
                      shall be referred to a Behavioral Health Provider for on-going services. In the same way, Enrollees who require more intensive or continuous care than can be provided within the Behavioral Health Facility as set forth in Section 8.3
                      shall be referred to the appropriate physical provider for level of treatment. For any physical urgent care that an Enrollee may have at the Behavioral Health Facility they could be seen by the reverse co-located physician to receive
                      such evaluation. However, Enrollees with SMI shall be assisted by the reverse co-located physician for all acute or chronic physical conditions at the same point of service.

                


        

      

       

      
        
          	

                	8.4.2	
                  An Enrollee may access Behavioral Health services through the following means:

                


        

      

       

      
        
          	

                	8.4.2.1	
                  A Referral from the PCP or other PMG physician;

                


        

      

       

      
        
          	

                	8.4.2.2	
                  Self-referral (walk-in);

                


        

      

       

      
        
          	

                	8.4.2.3	
                  The GHP Service Line Service;

                


        

      

       

      
        
          	

                	8.4.2.4	
                  The telephone Call Center provided by ASSMCA, known as “Linea PAS”;

                


        

      

       

      
        
          	

                	8.4.2.5	
                  Hospitals; and

                


        

      

       

      
        
          	

                	8.4.2.6	
                  Emergency rooms.

                


        

      

       

      
        
          	

                	8.5	
                  Information Sharing

                


        

      

       

      
        
          	

                	8.5.1	
                  To the extent the Contractor utilizes a Subcontractor to provide Behavioral Health services, the Contractor and the Subcontractor shall share documents in their
                      respective possession (including agreements, processes, guidelines and clinical protocols), in order to understand the other’s operations to ensure optimal cooperation and integration of physical and Behavioral Health Services.

                


        

      

       

      
        Page 132 of 324

        
          


      

      
        
          	

                	8.5.2	
                  The Contractor shall develop forms to facilitate electronic communication between physical health and Behavioral Health Providers, such as:

                


        

      

       

      
        
          	

                	8.5.2.1	
                  An information sheet for Enrollees on HIPAA requirements;

                


        

      

       

      
        
          	

                	8.5.2.2	
                  A Referral sheet; and

                


        

      

       

      
        
          	

                	8.5.2.3	
                  An informed consent form.

                


        

      

       

      
        
          	

                	8.5.3	
                  The Contractor shall establish a process for monitoring exchange of Information, documenting receipt of Information and following up on Information not submitted in a
                      timely manner.

                


        

      

       

      
        
          	

                	8.5.4	
                  The Contractor shall require PMG staff to follow-up with Behavioral Health Providers concerning the care of Enrollees referred by the PMG to a Behavioral Health Provider.

                


        

      

       

      
        
          	

                	8.5.5	
                  The Contractor shall ensure that the Providers implement a certified EHR and a HIE platform with the capacity of centralizing the management of the referred EHR for all
                      the PMG Providers including all Behavioral Health Providers. Also, the Contractor shall provide ASES all the necessary data to assure that the Providers comply with the Medicaid encounters patient volume as required by 42 CFR 495.306.
                      The Contractor must submit to ASES the certification document included as Attachment 24 to this Contract within seven (7) Business Days of ASES’s request of the certification.

                


        

      

       

      
        
          	

                	8.6	
                  Staff Education

                


        

      

       

      
        
          	

                	8.6.1	
                  The Contractor shall train PMG and the Behavioral Health Facility staff on the goals and operational details of the integrated model of care, and, as appropriate, the
                      identification of Behavioral Health issues and conditions.

                


        

      

       

      
        
          	

                	8.6.2	
                  The Contractor shall require PMGs to Immediately refer Enrollees to the Behavioral Health Provider located within the PMG (or, if the Provider is not available, to the
                      emergency room) when an Enrollee displays suicidal behavior.

                


        

      

       

      
        
          	

                	8.7	
                  Cooperation with Puerto Rico and Federal Government Agencies

                


        

      

       

      
        
          	

                	8.7.1	
                  The Contractor acknowledges that governmental entities, including ASSMCA and SAMHSA regulate, as applicable, Behavioral Health services under the GHP. The Contractor
                      shall consult such governmental entities where appropriate.

                


        

      

       

      
        Page 133 of 324

        
          


      

      
        
          	

                	8.8	
                  Integration Plan

                


        

      

       

      
        
          	

                	8.8.1	
                  The Contractor shall submit to ASES, for its review and approval, an Integration Plan incorporating the elements in this Article 8, according to the timeframe specified
                      in Attachment 12 to this Contract. The Integration Plan shall cover at a minimum:

                


        

      

       

      
        
          	

                	8.8.1.1	
                  How (1) Reverse Co-location and (2) co-location will be arranged, implemented, and monitored;

                


        

      

       

      
        
          	

                	8.8.1.2	
                  Target dates for full compliance with reverse co-location and co-location;

                


        

      

       

      
        
          	

                	8.8.1.3	
                  Contingency plans for PMGs and Behavioral Health Facilities who do not have appropriate space for co-location or reverse co-location or refuse to participate;

                


        

      

       

      
        
          	

                	8.8.1.4	
                  How Referrals are communicated, implemented, and tracked; and

                


        

      

       

      
        
          	

                	8.8.1.5	
                  Schedule for staff education and measurement of compliance.

                


        

      

      

      

      
        
          	ARTICLE 9	
                  PROVIDER NETWORK

                


        

      

       

      
        
          	

                	9.1	
                  General Provisions

                


        

      

       

      
        
          	

                	9.1.1	
                  The Contractor shall comply with the requirements specified in 42 CFR 438.68, 438.206, 438.207, 438.214 and all applicable Puerto Rico requirements regarding Provider
                      Networks. The Contractor shall have policies and procedures that reflect these requirements that are prior approved in writing by ASES in accordance with the timeframes in Attachment 12 to this Contract. The Contractor shall also:

                


        

      

       

      
        
          	

                	9.1.1.1	
                  Establish and maintain a comprehensive network of Providers capable of serving all Enrollees who enroll in the Contractor’s Plan;

                


        

      

       

      
        
          	

                	9.1.1.2	
                  Pursuant to Section 1932(b)(7) of the Social Security Act, not discriminate against Providers that serve high-risk populations or specialize in conditions that require
                      costly treatment;

                


        

      

       

      
        
          	

                	9.1.1.3	
                  Not discriminate with respect to participation, reimbursement, or indemnification of any Provider acting within the scope of that Provider’s license or certification
                      under applicable Puerto Rico law solely on the basis of the Provider’s license or certification;

                


        

      

       

      
        
          	

                	9.1.1.4	
                  Upon declining to include a Provider or group of Providers that have requested inclusion in the Contractor’s General Network, the Contractor shall give the affected
                      Provider(s) written notice explaining the reason for its decision;

                


        

      

       

      
        Page 134 of 324

        
          


      

      
        
          	

                	9.1.1.5	
                  Be allowed to negotiate different reimbursement amounts for different specialties or for different practitioners in the same specialty;

                


        

      

       

      
        
          	

                	9.1.1.6	
                  Be allowed to establish measures that are designed to maintain quality of services and control of costs and are consistent with its responsibility to Enrollees;

                


        

      

       

      
        
          	

                	9.1.1.7	
                  Not make payment to any Provider who has been barred from participation based on existing Medicare, Medicaid or CHIP sanctions, except for Emergency Services; and

                


        

      

       

      
        
          	

                	9.1.1.8	
                  Provide Enrollees with special health care needs direct access to a specialist, as appropriate for the Enrollee’s health care condition, as specified in 42 CFR
                      438.208(c)(4).

                


        

      

       

      
        
          	

                	9.1.2	
                  The Contractor shall have an adequate network of available Network Providers meeting all Contract requirements in order to (i) ensure timely Access to Covered Services
                      (including complying with all Federal and Puerto Rico requirements concerning timeliness, amount, duration, and scope of services); and (ii) provide sufficient
                      Network Providers to satisfy the demand of Covered Services with adequate capacity and quality service delivery.

                


        

      

        

      

      
        
          	

                	9.1.3	
                  When establishing and maintaining an adequate network of Providers, the Contractor shall consider and comply with each of the following criteria, in accordance with 42
                      CFR 438.206(b)(1):

                


        

      

       

      
        
          	

                	9.1.3.1	
                  Estimated eligible population and number of Enrollees;

                


        

      

       

      
        
          	

                	9.1.3.2	
                  Estimated use of services, considering the specific characteristics of the population and special needs for physical and Behavioral Health care;

                


        

      

       

      
        
          	

                	9.1.3.3	
                  Integration of physical health services and Behavioral Health Services using state facilities, academic medical centers, municipal health services and facilities;

                


        

      

       

      
        
          	

                	9.1.3.4	
                  Number and type of Providers required to offer services taking experience, training, and specialties into account;

                


        

      

       

      
        
          	

                	9.1.3.5	
                  Maximum number of patients per Provider;

                


        

      

       

      
        
          	

                	9.1.3.6	
                  The number of Providers in the PPN and General Network that are not accepting new patients; and

                


        

      

       

    

    
      Page 135 of 324

      
        


    

    
      
        
          	

                	9.1.3.7	
                  Geographic location of Providers and Enrollees, taking into account distance as permitted by law, the duration of trip, the means of transportation commonly used by
                      Enrollees, and whether the facilities provide physical access for Enrollees with physical disabilities or special needs.

                


        

      

       

      
        
          	

                	9.1.3.8	
                  Sufficient family planning Providers to ensure timely access to family planning Covered Services.

                


        

      

       

      
        
          	

                	9.1.4	
                  If the Contractor declines to include individual or groups of Providers in its network, it must give the affected Providers written notice of the reason for its decision.
                      42 CFR 438.12(a) may not be construed to:

                


        

      

       

      
        
          	

                	9.1.4.1	
                  Require the Contractor to contract with Providers beyond the number necessary to meet the needs of its Enrollees;

                


        

      

       

      
        
          	

                	9.1.4.2	
                  Preclude the Contractor from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or

                


        

      

       

      
        
          	

                	9.1.4.3	
                  Preclude the Contractor from establishing measures that are designed to maintain quality of services and control costs and is consistent with its responsibilities to
                      Enrollees.

                


        

      

       

      
        
          	

                	9.1.5	
                  The provider’s facilities must comply with Federal and Puerto Rico laws regarding the physical condition of medical facilities, the Provider’s facilities and must also comply with ASES’s requirements including, but not limited to, accessibility,
                      cleanliness and proper hygiene. ASES reserves the right to evaluate the appropriateness of such facilities to provide the Covered Services. After receiving a written notice from ASES, the Contractor must timely notify the Provider,
                      propose and enforce a corrective plan to be completed within ninety (90) Calendar Days to make the facilities appropriate to provide the Covered Services.

                


        

      

       

      
        
          	

                	9.1.5.1	
                  The Contractor shall collaborate with the Providers to provide integrated GHP physical and Behavioral Health Services in order to achieve a fully integrated and holistic
                      approach to providing Enrollee care.

                


        

      

       

      
        
          	

                	9.1.5.2	
                  The Contractor shall implement procedures in conjunction with the Providers to ensure that each GHP Enrollee has Access to both physical and Behavioral Health outpatient
                      and inpatient services.

                


        

      

       

      
        
          	

                	9.1.5.3	
                  The Contractor shall develop policies and procedures that ensure timely Access to physical and Behavioral Health Services and integration of care.

                


        

      

       

      
        Page 136 of 324

        
          


      

      
        
          	

                	9.1.5.4	
                  The Contractor shall submit its policies and procedures to ASES for prior written approval according to the timeframe set forth in Attachment 12 to this Contract

                


        

      

       

      
        
          	

                	9.1.5.5	
                  The Contractor must sub-contract ASSMCA to be a Behavioral Health Services provider.

                


        

      

       

      
        
          	

                	9.1.6	
                  The Contractor’s Network shall not include a Provider if the Provider, or any person who has an ownership or controlling interest in the Provider, or is an agent or
                      managing employee of the Provider, is included on the List of Excluded Individuals/Entities (“LEIE”) (which is maintained by HHS-OIG), or who are on the Excluded Parties List System (“EPLS”) or on Puerto Rico’s list of excluded
                      Providers. The Contractor shall check LEIE and EPLS upon the Provider’s Enrollment, Re-Enrollment, and on a monthly basis. Upon enrollment and Re-Enrollment the Contractor must also check the SSA Death Master File to make sure the
                      Provider is not deceased and the National Plan and Provider Enumeration System (“NPPES”) to make sure the Provider has a NPI as required in Section 9.1.7.

                


        

      

       

      
        
          	

                	9.1.7	
                  The Contractor shall require that each Provider have a unique National Provider Identifier (“NPI”). When the NPI is reported to ASES, the NPI must be in the NPPES
                      standard format.

                


        

      

       

      
        
          	

                	9.1.8	
                  Ambulatory clinics shall have a sufficient number of Providers to efficiently and promptly provide Behavioral Health Services to Enrollees visiting such clinics,
                      including Vieques and Culebra. Contractor shall provide ASES with a report within the first ten (10) Business Days of each month indicating the number of Enrollees (including walk-ins) receiving Behavioral Health Services therein and
                      the number of Providers providing these services during such period.

                


        

      

       

      
        
          	

                	9.1.9	
                  ASES shall have the right to previously approve Contractor’s clinical protocols to render behavioral health services and substance abuse to Enrollees in ambulatory care.

                


        

      

       

      
        
          	

                	9.1.10	
                  In the event that a determined type of Provider cannot be contracted by the Contractor due to lack of such Providers or due to such Provider’s refusal to contract for
                      this GHP Program, the Contractor must carry out all efforts to contract with those Providers. The Contractor must validate and submit all supporting documents evidencing the lack of Providers or refusal to contract to ASES using Form
                      A-102 provided as Attachment 15 to this Contract. ASES will make a determination based on the evidence submitted if any further action is required of the Contractor.

                


        

      

       

      
        
          	

                	9.1.11	
                  The Contractor is responsible for establishing and monitoring Medical Record guidelines which include documentation of all services provided by the Primary Care Providers
                      as well as any participating Providers in the contracted Provider Network.

                


        

      

       

      
        Page 137 of 324

        
          


      

      
        
          	

                	9.1.12	
                  Direct Relationship

                


        

      

       

      
        
          	

                	9.1.12.1	
                  The Contractor shall ensure that all Network Providers have knowingly and willingly agreed to participate in the Contractor’s General Network.

                


        

      

       

      
        
          	

                	9.1.12.2	
                  The Contractor shall be prohibited from acquiring established networks without contacting each individual Provider to ensure knowledge of the requirements of this
                      Contract and to confirm the Provider’s complete understanding and agreement to fulfill all terms of the Provider Contract.

                


        

      

       

      
        
          	

                	9.1.12.3	
                  ASES reserves the right to confirm and validate, through collection of information, documentation from the Contractor and on-site visits to Network Providers, the
                      existence of a direct relationship between the Contractor and the Network Providers.

                


        

      

       

      
        
          	

                	9.1.13	
                  Contractor Documentation of Adequate Capacity and Services

                


        

      

       

      
        
          	

                	9.1.13.1	
                  Before the Effective Date of this Contract and Immediately upon request by ASES after the Implementation Date of the Contract, the Contractor shall provide documentation
                      demonstrating that it:

                


        

      

       

      
        
          	

                	9.1.13.1.1	
                  Offers an appropriate range of assessment and treatment, preventive, Primary Care, and specialty services that is adequate for the anticipated number of Enrollees and
                      meets ASES’s Network Adequacy standards in accordance with Section 9.4; and

                


        

      

       

      
        
          	

                	9.1.13.1.2	
                  Maintains a Provider Network that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of Enrollees and meets ASES’s
                      Network Adequacy Standards in accordance with Section 9.4.

                


        

      

       

      
        
          	

                	9.1.13.2	
                  The Contractor shall provide documentation of the Network Adequacy Standards stated in this Section 9.4 on an annual basis, and Immediately any time that there has been a
                      significant change in the Contractor’s operations that would affect adequate capacity and services, including:

                


        

      

       

      
        
          	

                	9.1.13.2.1	
                  When there is a change in Benefits, composition of or payments to its Network Providers; or

                


        

      

       

      
        
          	

                	9.1.13.2.2	
                  Upon the Enrollment of a new eligibility group in the Contractor’s Plan.

                


        

      

       

      
        Page 138 of 324

        
          


      

      
        
          	

                	9.2	
                  Provider Qualifications

                


        

      

       

      
        
          	

                	9.2.1	
                  The following requirements apply to Network Providers in the Contractor’s network:

                


           

          

        

      

      	 	
              FQHC

               

               

               

            	 	
              A Federally Qualified Health Center is an entity that provides outpatient care under Section 330 of the Public Health Service Act (42 U.S.C. 254b)
                  and complies with the standards and regulations established by the Federal Government and is an eligible Provider enrolled in the Medicaid Program.

            
	 	
              PHYSICIAN

               

            	 	
              A person with a license to practice medicine as an M.D. or a D.O. in Puerto Rico, whether as a PCP or in the area of specialty under which he or she
                  will provide medical services through a contract with the Contractor; and is a Provider enrolled in the Puerto Rico Medicaid Program; and has a valid registration number from the Drug Enforcement Agency and the Certificate of Controlled
                  Substances of Puerto Rico, if required in his or her practice.

            
	 	
              HOSPITAL

            	 	
              An institution licensed as a general or special hospital by the Puerto Rico Health Department under Chapter 241 of the Health and Safety Code of
                  Private Psychiatric Hospitals under Chapter 577 of the Health and Safety Code (or who is a Provider which is a component part of the Puerto Rico or local governmental entity which does not require a license under the laws of Puerto Rico)
                  which is enrolled as a Provider in the Puerto Rico Medicaid Program.

            
	 	
              NON-MEDICAL PRACTICING PROVIDER

            	 	
              A person who possesses a license issued by the licensing agency of Puerto Rico enrolled in the Puerto Rico Medicaid Program or a properly trained
                  person who practices under the direct supervision of a licensed Provider offering support in health care services.

            
	 	
              CLINICAL LABORATORY

            	 	
              An entity that has a valid certificate issued by the Clinical Laboratory Improvement Act (“CLIA”) and which has a license issued by the licensing
                  agency of the Puerto Rico. The Contractor shall ensure that all of the clinical laboratories under contract have a CLIA registration certificate and the registration number or a waiver certificate.

            


      

      

      
        Page 139 of 324

        
          


      

      	 	
              RURAL HEALTH CLINIC (RHC)

            	 	
              A health facility that the Secretary of Health and Human Services has determined meets the requirements of Section 1861(a)(2) of the Social Security
                  Act; and that has entered into an agreement with the Secretary to provide services in Rural Health Clinics or Centers under Medicare and in accordance with 42 CFR 405.2402.

            
	 	
              LOCAL HEALTH DEPARTMENT

            	 	
              Local Health Department established under Act 81 from March 14, 1912.

            
	 	
              NON-HOSPITAL PROVIDING FACILITY

               

            	 	
              A Provider which is duly licensed and credentialed to provide services and is enrolled in the Puerto Rico Medicaid Program.

            
	 	
              SCHOOLS OF MEDICINE

               

            	 	
              Clinics located on the medical campus that provides Primary Care and Preventive Services to children and adolescents.

            
	 	
              MEDICAL PSYCHIATRIST

            	 	
              A person who possesses a license to practice medicine and a psychiatrist specialty license issued by the licensing agency of Puerto Rico and is
                  enrolled in the Puerto Rico Medicaid Program or a properly trained person who practices psychiatry under the direct supervision of a licensed Provider.

            
	 	
              PSYCHOLOGIST

            	 	
              A person who possesses a Doctoral or Master’s Degree in clinical or counseling psychology and a license issued by the licensing agency of Puerto
                  Rico and is enrolled in the Puerto Rico Medicaid Program or a properly trained person who practices psychology under the direct supervision of a licensed Provider.

            
	 	
              SOCIAL WORKER

            	 	
              A person who possesses a Master’s Degree in social work and a current license issued by the licensing agency of Puerto Rico and is enrolled in the
                  Puerto Rico Medicaid Program or a properly trained person who practices social work under the direct supervision of a licensed Provider.

            
	 	
              DETOXIFICATION FACILITY

            	 	
              An entity or health facility that has a valid certificate and license to provide detoxification treatments issued by the licensing agency of Puerto
                  Rico.

            
	 	
              SHORT TERM INTERVENTION CENTER (Stabilization Unit)

            	 	
              An entity or health facility that has a valid certificate and license to provide Behavioral Health Services issued by the licensing agency of Puerto
                  Rico.

            


       

      
        Page 140 of 324

        
          


      

      
        
          	

                	9.2.2	
                  The Contractor shall also ensure that Network Providers meet any other qualifications as prescribed by ASES.

                


        

      

       

      
        
          	

                	9.2.3	
                  Provider Credentialing

                


        

      

       

      
        
          	

                	9.2.3.1	
                  The Contractor shall be responsible for Credentialing and Re-Credentialing its Network Providers.

                


        

      

       

      
        
          	

                	9.2.3.2	
                  The Contractor shall ensure that all Network Providers are appropriately credentialed and qualified to provide services under the terms of this Contract, all applicable
                      Federal and Puerto Rico law, and comply with CMS Credentialing requirements included in CMS Chapter VI of the Medicare Managed Care Manual.

                


        

      

       

      
        
          	

                	9.2.3.3	
                  ASES strongly encourages Contractors to implement a Credentialing Electronic Record System. ASES reserves the right to request access to the Contractor’s Credentialing
                      Electronic Record Systems for monitoring purposes.

                


        

      

       

      
        
          	

                	9.2.3.4	
                  In the event ASES contracts with or requires Contractors to contract with a single credentialing verification organization to standardize Provider credentialing and
                      re-credentialing processes across the GHP program, the Contractor shall work with ASES on implementing any new processes related to centralized credentialing.

                


        

      

       

      
        
          	

                	9.2.3.5	
                  Credentialing is required for:

                


        

      

       

      
        
          	

                	9.2.3.5.1	
                  All physicians who provide services to the Contractor’s Enrollees,

                


        

      

       

      
        
          	

                	9.2.3.5.2	
                  All other types of Providers who provide services to the Contractor’s Enrollees, and who are permitted to practice independently under Puerto Rico law including but not
                      limited to: hospitals, X-ray facilities, clinical laboratories, and ambulatory service Providers.

                


        

      

       

      
        
          	

                	9.2.3.6	
                  Credentialing is not required for:

                


        

      

       

      
        
          	

                	9.2.3.6.1	
                  Providers who are permitted to furnish services only under the direct supervision of another practitioner;

                


        

      

       

      
        
          	

                	9.2.3.6.2	
                  Hospital-based Providers who provide services to Enrollees Incident to hospital services, unless those Providers are separately identified in Enrollee literature as
                      available to Enrollees; or

                


        

      

       

      
        
          	

                	9.2.3.6.3	
                  Students, residents, or fellows.

                


        

      

       

      
        Page 141 of 324

        
          


      

      
        
          	

                	9.2.3.7	
                  Standards for Credentialing and Re-Credentialing

                


        

      

       

      
        
          	

                	9.2.3.7.1	
                  The Contractor shall document the mechanism for Credentialing and Re-Credentialing of Network Providers or Providers it employs to treat Enrollees outside of the
                      inpatient setting and who fall under its scope of authority and action. This documentation shall include, but not be limited to, defining the scope of Providers covered, the criteria and the primary source verification of Information
                      used to meet the criteria, the process used to make decisions that shall not be discriminatory and the extent of delegated Credentialing and Re-Credentialing arrangements. The Contractor shall:

                


        

      

       

      
        
          	

                	9.2.3.7.1.1	
                  Have written policies and procedures for the Credentialing and Re-Credentialing process. Such process must permit providers to apply for Credentialing and
                      Re-Credentialing online;

                


        

      

       

      
        
          	

                	9.2.3.7.1.2	
                  Meet Puerto Rico and Federal regulations for Credentialing and Re-Credentialing, including 42 CFR 455.104, 455.105, 455.106 and 1002.3(b);

                


        

      

       

      
        
          	

                	9.2.3.7.1.3	
                  Use one (1) standard Credentialing form prescribed by ASES;

                


        

      

       

      
        
          	

                	9.2.3.7.1.4	
                  Designate a Credentialing committee or other peer review body to make recommendations regarding Credentialing/Re-Credentialing issues;

                


        

      

       

      
        
          	

                	9.2.3.7.1.5	
                  Complete the Credentialing process within forty-five (45) Calendar Days from receipt of completed application with all required primary source documentation;

                


        

      

       

      
        
          	

                	9.2.3.7.1.6	
                  Ensure Credentialing/Re-Credentialing forms require ownership and control disclosures, disclosure of business transactions, and criminal conviction information in
                      accordance with Section 9.2.3.7.1.2;

                


        

      

       

      
        
          	

                	9.2.3.7.1.7	
                  Verify that Network Providers maintain a current and valid license to practice. Verification must show that the license was in effect at the time of the Credentialing
                      decision with a copy of a good standing; or with the Junta de Licenciamiento Médico/Junta de Profesionales de la Salud CD;

                


        

      

       

      
        Page 142 of 324

        
          


      

      
        
          	

                	9.2.3.7.1.8	
                  Ensure education and training records, including, but not limited to, Internship, Residency, Fellowships, Specialty Boards etc., are validated and current. As per CMS
                      chapter VI, section 60, education verification is required only for the highest level of education or training attained;

                


        

      

       

      
        
          	

                	9.2.3.7.1.9	
                  Ensure board certification, when applicable, in each clinical specialty area for which the Provider is being credentialed;

                


        

      

       

      
        
          	

                	9.2.3.7.1.10	
                  Ensure clinical privileges are in good standing at the hospital designated by the Provider, when applicable, as the primary admitting facility. This information may be
                      obtained by contacting the facility, obtaining a copy of the participating facility directory or attestation by the Provider;

                


        

      

       

      
        
          	

                	9.2.3.7.1.11	
                  Ensure Network Providers maintain current and adequate malpractice insurance. This information may be obtained via the malpractice carrier, a copy of the insurance face
                      sheet or attestation by the Provider;

                


        

      

       

      
        
          	

                	9.2.3.7.1.12	
                  Obtain Information about sanctions or limitations on licensure from the applicable Puerto Rico licensing agency or board, or from a group such as the Federation of State
                      Medical Boards;

                


        

      

       

      
        
          	

                	9.2.3.7.1.13	
                  Ensure a valid Drug Enforcement Agency (“DEA") or Controlled Dangerous Substances (“CDS”) certificate in effect at the time of the Credentialing. This information can be
                      obtained through confirmation with CDS, entry into the National Technical Information Service (“NTIS”) database, or by obtaining a copy of the certificate;

                


        

      

       

      
        
          	

                	9.2.3.7.1.14	
                  Review Network Provider’s history of professional liability claims that resulted in settlements or judgments paid by or on behalf of the Provider: This information can be
                      obtained from the malpractice carrier or from the National Practitioner Data Bank;

                


        

      

       

      
        
          	

                	9.2.3.7.1.15	
                  Ensure that Behavioral Health Network Providers (as applicable) are trained and certified by the Substance Abuse and Mental Health Services Administration (“SAMHSA”) to
                      provide the opiate addiction treatment certifications stated in Section 7.5.11.3;

                


        

      

       

      
        Page 143 of 324

        
          


      

      
        
          	

                	9.2.3.7.1.16	
                  Ensure Credentialing of health care facilities shall be governed by, but not limited to, Law 101 of June 26, 1965, as amended, known as "Law of Facilities of Puerto
                      Rico;"

                


        

      

       

      
        
          	

                	9.2.3.7.1.17	
                  Screen all Providers against the Federal databases specified in 42 CFR 455.436 on a monthly basis to ensure Providers are not employing or contracting with excluded
                      individuals;

                


        

      

       

      
        
          	

                	9.2.3.7.1.18	
                  Have written policies and procedures, that have been prior approved in writing by ASES, to ensure and verify that providers have appropriate licenses and certifications
                      to perform services outlined in their respective Provider Contracts; and

                


        

      

       

      
        
          	

                	9.2.3.7.1.19	
                  Maintain records that verify its Credentialing and Re-Credentialing activities, including primary source verification and compliance with Credentialing/Re-Credentialing
                      requirements.

                


        

      

       

      
        
          	

                	9.2.3.7.2	
                  The Contractor shall perform the following functions:

                


        

      

       

      
        
          	

                	9.2.3.7.2.1	
                  Credential any Provider who contracts with the Contractor and maintaining complete Credentialing information for these Providers;

                


        

      

       

      
        
          	

                	9.2.3.7.2.2	
                  Identify potential and actual Network Providers who are enrolled with ASES as Medicaid Providers;

                


        

      

       

      
        
          	

                	9.2.3.7.2.3	
                  Require any Network Provider to be enrolled with the GHP as a managed care Provider;

                


        

      

       

      
        
          	

                	9.2.3.7.2.4	
                  Perform Site Visits. The Contractor’s site visit policy will be reviewed pursuant to CMS’ monitoring protocol. At a minimum, the Contractor should consider requiring
                      initial Credentialing site visits of the offices of Primary Care practitioners, obstetrician- gynecologists, or other high-volume Providers, as defined by the organization;

                


        

      

       

      
        Page 144 of 324

        
          


      

      
        
          	

                	9.2.3.7.2.5	
                  Re-Credential Network Providers every three (3) years;

                


        

      

       

      
        
          	

                	9.2.3.7.2.6	
                  Ensure all required documents and licenses are current at the time of initial Credentialing or Re-Credentialing;

                


        

      

       

      
        
          	

                	9.2.3.7.2.7	
                  Maintain a Provider file for all Network Providers. The Provider file shall be updated annually and consist of, at a minimum, the following documents: annual Puerto Rico
                      review, DEA license, malpractice insurance and ASSMCA license.

                


        

      

       

      
        
          	

                	9.2.3.7.2.8	
                  The Contractor shall ensure, and be able to demonstrate at the request of ASES, that: (i) Out-of-Network Providers have been credentialed by an authoritative entity and
                      that (ii) the Contractor’s internal Credentialing and Re-Credentialing processes are in accordance with 42 CFR 438.214 (Provider Selection).

                


        

      

       

      
        
          	

                	9.2.3.7.2.9	
                  If the Contractor determines, through the Credentialing or Re-Credentialing process, or otherwise, that a Provider could be excluded pursuant to 42 CFR 1001.1001, or if
                      the Contractor determines that the Provider has failed to make full and accurate disclosures as required in Sections 13.5.13, the Contractor shall deny the Provider’s request to participate in the Provider Network, or, for a current
                      Network Provider, as provided in Section 10.4.1.2, terminate the Provider Contract. The Contractor shall notify ASES of such a decision, and shall provide documentation of the bar on the Provider’s Network participation, within twenty
                      (20) Business Days of communicating the decision to the Provider. The Contractor shall screen its employees, Network Providers, and Subcontractors initially and on an ongoing monthly basis to determine whether any of them have been
                      excluded from participation in Medicare, Medicaid, CHIP, or any other Federal health care program (as defined in Section 1128B(f) of the Social Security Act). ASES or the Puerto Rico Medicaid Program shall, upon receiving notification
                      from a Contractor that the Contractor has denied Credentialing, notify the HHS Office of the Inspector General of the denial with twenty (20) Business Days of the date it receives the Information, in conformance with 42 CFR 1002.4.

                


        

      

       

      
        Page 145 of 324

        
          


      

      
        
          	

                	9.2.3.7.2.10	
                  The Contractor shall report to ASES on a monthly basis the Credentialing and Re-Credentialing status of Providers. The details of this report are described in Section
                      18.2.5.3 of this Contract.

                


        

      

       

      
        
          	

                	9.2.4	
                  Network Provider Enrollment as Medicaid Providers

                


        

      

       

      
        
          	

                	9.2.4.1	
                  Contractors shall ensure that all Network Providers are Medicaid-enrolled Providers consistent with the Provider disclosure, screening and enrollment requirement of 42
                      CFR part 455, subparts B and E as incorporated in 42 CFR 438.608(b).

                


        

      

       

      
        
          	

                	9.2.4.2	
                  Contractors may execute temporary Provider Contracts pending the outcome of the Medicaid provider enrollment process of up to one hundred twenty (120) Calendar Days but
                      must terminate a Network Provider Immediately upon notification from ASES that the Network Provider cannot be enrolled, or the expiration of the one hundred twenty (120) Calendar Day period without enrollment of the Provider, and
                      notify affected Enrollees.

                


        

      

       

      
        
          	

                	9.2.4.3	
                  Contractors shall assist ASES in facilitating the Medicaid Provider enrollment process, in the manner requested by ASES, including but not limited to the production or
                      certification of Provider Credentialing records, distribution of ASES Provider agreements and all other verbal and/or written communications related to the Medicaid Provider enrollment process.

                


        

      

       

      
        
          	

                	9.3	
                  Network Description

                


        

      

       

      
        
          	

                	9.3.1	
                  General Network

                


        

      

       

      
        
          	

                	9.3.1.1	
                  The General Network shall be comprised of all Providers available to Enrollees including those Providers who are designated as preferred providers and those Providers who
                      are not associated with a PMG.

                


        

      

       

      
        
          	

                	9.3.1.2	
                  The Contractor shall ensure that its General Network of Providers is adequate to assure Access to all Covered Services, and that all Providers are appropriately
                      credentialed, maintain current licenses, and have appropriate locations to provide the Covered Services.

                


        

      

       

      
        Page 146 of 324

        
          


      

      
        
          	

                	9.3.1.3	
                  The Contractor shall include and make a part of its General Network any Behavioral Health Provider who is qualified for the GHP (including meeting all Credentialing
                      standards in this Contract) and willing to participate in the Network.

                


        

      

       

      
        
          	

                	9.3.1.4	
                  If the Contractor’s General Network is unable to provide Medically Necessary Covered Services to an Enrollee within the requirements set forth in Section 9.5, the
                      Contractor shall adequately and timely (as defined in Section 9.5) cover these services using Providers outside of its Network without penalty or additional Co-Payments imposed on the Enrollee.

                


        

      

       

      
        
          	

                	9.3.1.5	
                  Primary Care Providers (PCPs)

                


        

      

       

      
        
          	

                	9.3.1.5.1	
                  PCPs will be responsible for providing, managing and coordinating all the services of the Enrollee, including the coordination with Behavioral Health personnel, in a
                      timely manner, and in accordance with the guidelines, protocols, and practices generally accepted in medicine.

                


        

      

       

      
        
          	

                	9.3.1.5.2	
                  The Contractor shall offer its Enrollees freedom of choice in selecting a PCP. The Contractor shall have policies and procedures describing how Enrollees select their
                      PCPs. The Contractor shall submit these policies and procedures to ASES for review and prior written approval according to the timeframes specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	9.3.1.5.3	
                  The PCP is responsible for maintaining each Enrollee’s Medical Record, which includes documentation of all services provided by the PCP as well as any specialty services.

                


        

      

       

      
        
          	

                	9.3.1.5.4	
                  The following shall be considered PCPs for purposes of contracting with a PMG:

                


        

      

       

      
        
          	

                	9.3.1.5.4.1	
                  General practitioners;

                


        

      

       

      
        
          	

                	9.3.1.5.4.2	
                  Internists;

                


        

      

       

      
        
          	

                	9.3.1.5.4.3	
                  Family practice;

                


        

      

       

      
        
          	

                	9.3.1.5.4.4	
                  Pediatricians (optional for minors under the age of twenty-one (21)); and

                


        

      

       

      
        Page 147 of 324

        
          


      

      
        
          	

                	9.3.1.5.4.5	
                  Gynecologists-Obstetricians (obligatory when the woman is pregnant or age twelve (12) or older; this Provider will also be selected for usual gynecological visits).

                


        

      

       

      
        
          	

                	9.3.1.5.5	
                  No PCP may own any financial control or have a direct or indirect economic interest (as defined in Act 101 of July 26, 1965) in any Ancillary Services facility or any
                      other Provider (including clinical laboratories, pharmacies, etc.) under contract with the PMG.

                


        

      

       

      
        
          	

                	9.3.1.5.6	
                  Nurse practitioners and physician assistants may not be PCPs.

                


        

      

       

      
        
          	

                	9.3.1.5.7	
                  The Contractor shall guarantee that women who are pregnant select a gynecologist-obstetrician as their PCP. Additionally, the Contractor will permit female Enrollees to
                      select a gynecologist-obstetrician for their routine gynecological visits at initial Enrollment.

                


        

      

       

      
        
          	

                	9.3.1.6	
                  Behavioral Health Providers

                


        

      

       

      
        
          	

                	9.3.1.6.1	
                  The Contractor shall have a sufficient number of Behavioral Health Providers to attend to the Behavioral Health needs of the Enrollees. The Contractor shall make
                      available all specialties specified in this Section 9.3.1.6.

                


        

      

       

      
        
          	

                	9.3.1.6.2	
                  The Contractor shall have available and under contract a sufficient number of the following types of Network Providers to render services to all Enrollees:

                


        

      

       

      
        
          	

                	9.3.1.6.2.1	
                  Psychiatrist;

                


        

      

       

      
        
          	

                	9.3.1.6.2.2	
                  Clinical or Counseling Psychologist;

                


        

      

       

      
        
          	

                	9.3.1.6.2.3	
                  Social Workers (“MSW”);

                


        

      

       

      
        
          	

                	9.3.1.6.2.4	
                  Care Managers;

                


        

      

       

      
        
          	

                	9.3.1.6.2.5	
                  Certified Addiction Counselors; and

                


        

      

       

      
        
          	

                	9.3.1.6.2.6	
                  Behavioral Health Facilities, as specified in Article 2.

                


        

      

       

      
        
          	

                	9.3.1.7	
                  Network Provider Types

                


        

      

       

      
        Page 148 of 324

        
          


      

      
        
          	

                	9.3.1.7.1	
                  For both the General Network and the PPN, the Contractor shall have available the following types of Network Providers:

                


        

      

       

      
        
          	

                	9.3.1.7.2	
                  Specialists:

                


        

      

       

      
        
          	

                	9.3.1.7.2.1	
                  Podiatrists, Optometrists, Ophthalmologists, Radiologists, Endocrinologists, Nephrologists, Pneumologists, Otolaryngologists (ENTs), Cardiologists, Urologists,
                      Gastroenterologists, Rheumatologists, Dermatologists, Oncologists, Neurologists, Infectious Disease Specialists, Orthopedists, Physical & Rehabilitative Specialists (Physiatrist), General Surgeons, and Chiropractors.

                


        

      

       

      
        
          	

                	9.3.1.7.2.2	
                  The Contractor shall offer its Enrollees freedom of choice in selecting a dentist.

                


        

      

       

      
        
          	

                	9.3.1.7.2.3	
                  The Contractor shall offer its Enrollees freedom of choice in selecting Behavioral Health Providers.

                


        

      

       

      
        
          	

                	9.3.1.7.3	
                  Facilities

                


        

      

       

      
        
          	

                	9.3.1.7.3.1	
                  Clinical Laboratories;

                


        

      

       

      
        
          	

                	9.3.1.7.3.2	
                  X-Ray Facilities;

                


        

      

       

      
        
          	

                	9.3.1.7.3.3	
                  Hospitals;

                


        

      

       

      
        
          	

                	9.3.1.7.3.4	
                  Providers and facilities for Behavioral Health (Mental Health and Substance Use Disorder) Services;

                


        

      

       

      
        
          	

                	9.3.1.7.3.5	
                  Specialized service Providers;

                


        

      

       

      
        
          	

                	9.3.1.7.3.6	
                  Urgent care centers and emergency rooms; and

                


        

      

       

      
        
          	

                	9.3.1.7.3.7	
                  Any other Providers or facilities needed to offer Covered Services, except pharmacies, considering the specific health needs of Enrollees.

                


        

      

       

      
        
          	

                	9.3.1.8	
                  Out-Of-Network Providers

                


        

      

       

      
        
          	

                	9.3.1.8.1	
                  If the Contractor’s General Network is unable to provide Medically Necessary Covered Services to an Enrollee, the Contractor shall adequately and timely (within the
                      standards in Section 9.5) cover these services using Providers outside of its General Network.

                


        

      

       

      
        Page 149 of 324

        
          


      

      
        
          	

                	9.3.1.8.2	
                  Except as provided with respect to Emergency Services (see Section 7.5.9), if the Contractor offers the service through a Provider in the General Network but the Enrollee
                      chooses to access the service from an Out-of-Network Provider, the Contractor is not responsible for payment.

                


        

      

       

      
        
          	

                	9.3.1.8.3	
                  The Contractor must ensure that Out-of-Network Providers are duly credentialed and shall pay them, at a minimum, the same rates the Contractor pays its Network Providers
                      dependent on Provider type. To be considered Duly Credentialed, the Contractor shall demonstrate and evidence that the Out-of-Network Provider is properly licensed for the practice of medicine in Puerto Rico, properly certified for
                      the specialty needed, participating provider of the Medicare Program or have privileges in good standing at a hospital from the Contractor's provider's network and complies with section 13.4 and 13.5.13.5 of this Contract.

                


        

      

       

      
        
          	

                	9.3.1.9	
                  The Contractor shall not restrict the choice of the Provider from whom an Enrollee may receive family planning services and supplies.

                


        

      

       

      
        
          	

                	9.3.1.10	
                  The Contractor shall provide female Enrollees with direct access to a women’s health specialist within the General Network for Covered Services necessary to provide
                      women's routine and preventive health care services in addition to the Enrollee's designated source of primary care if that source is not a woman's health specialist.

                


        

      

       

      
        
          	

                	9.3.2	
                  The Contractor shall ensure, in collecting Co-Payments, that in the event that a Co-Payment is imposed on Enrollees for an Out-of-Network service, the Co-Payment shall
                      not exceed the Co-Payment that would apply if services were provided by a Provider in the General Network.

                


        

      

       

      
        
          	

                	9.3.3	
                  The Contractor shall also develop, as a subset of its General Network of Providers, a Preferred Provider Network (“PPN”). The objectives of the PPN model are to increase
                      access to Providers and needed services, improve timely receipt of services, improve the quality of Enrollee care, enhance continuity of care, and facilitate effective exchange of Protected Health Information between Providers and the
                      Contractor. The PPN must satisfy the requirements for the General Network described in this section.

                


        

      

       

      
        
          	

                	9.3.3.1	
                  The PPN is established utilizing a PMG to deliver services to the Enrollees who select a PCP that is a member of an individual PMG.

                


        

      

       

      
        Page 150 of 324

        
          


      

      
        
          	

                	9.3.3.2	
                  The Contractor shall offer a PPN to all Enrollees. Each provider in the PPN shall be associated with an individual PMG whose group includes PCPs, psychologists or
                      Behavioral Health Providers in compliance with Section 8.2 and Attachment 10 to this Contract, clinical laboratories, x-ray facilities, specialists and other providers that meet network requirements described in this section.

                


        

      

       

      
        
          	

                	9.3.3.3	
                  Enrollees shall be allowed to receive services from all Providers within their PMG’s PPN without Referral or restriction.

                


        

      

       

      
        
          	

                	9.3.3.4	
                  Enrollees who receive a prescription from a Network Provider within the PPN/PMG shall be allowed to fill the prescription without the requirement of a Countersignature
                      from their PCP.

                


        

      

       

      
        
          	

                	9.3.3.5	
                  Additional Preferred Provider Network (“PPN”) Standards

                


        

      

       

      
        
          	

                	9.3.3.5.1	
                  The Contractor shall establish policies and procedures that, at a minimum, include:

                


        

      

       

      
        
          	

                	9.3.3.5.1.1	
                  Criteria for participating in the PPN versus the General Network;

                


        

      

       

      
        
          	

                	9.3.3.5.1.2	
                  Standards for monitoring Provider performance;

                


        

      

       

      
        
          	

                	9.3.3.5.1.3	
                   Methodologies for monitoring Access to care,

                


        

      

       

      
        
          	

                	9.3.3.5.1.4	
                  Methodologies for identifying compliance issues; and

                


        

      

       

      
        
          	

                	9.3.3.5.1.5	
                  Measures to address identified compliance issues.

                


        

      

       

      
        
          	

                	9.3.3.5.2	
                  The Contractor shall submit its policies and procedures to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this
                      Contract.

                


        

      

       

      
        
          	

                	9.4	
                  Network Adequacy Standards

                


        

      

       

      
        
          	

                	9.4.1	
                  The Contractor must maintain an Island-wide provider network that complies with the Network Adequacy Standards specified in Section 9.4. The Contractor must use
                      Geographical-access and thermomapping to demonstrate that the contracted network is distributed across Puerto Rico such that it meets the needs of Enrollees. The Contractor shall provide adequate Access to Enrollees at all times.

                


        

      

       

      
        
          	

                	9.4.2	
                  In the event the Contractor cannot meet a Network Adequacy Standard in Section 9.4, an exception must be requested and approved in writing by ASES. The request must
                      provide detailed information justifying the need for an exception and actions underway to meet compliance. The exception does not relieve the Contractor from remedying non-compliance with defined Network Adequacy Standards within a
                      reasonable timeframe, or complying with a Corrective Act Plan established in collaboration with ASES. All approved exceptions must be reported in the annual Provider Network and Evaluation plan described in Section 18.3

                


        

      

       

      
        Page 151 of 324

        
          


      

      
        
          	

                	9.4.2.1	
                  The standard by which ASES will evaluate the exception request will be based, at a minimum, on the number of Providers in that specialty practicing in Puerto Rico.

                


        

      

       

      
        
          	

                	9.4.3	
                  The Contractor shall comply with the following Provider-to-Enrollee Ratios, Provider Per Municipality requirements, and Required Network Providers standards for the
                      General Network:

                


        

      

       

      
        
          	

                	9.4.3.1	
                  PCP Provider-to-Enrollee Ratios

                


        

      

       

      
        
          	

                	9.4.3.1.1	
                  The following specialties are considered PCPs: Family Practice, Internal Medicine (for Adults), General Medicine, and Pediatrics.

                


        

      

       

      
        
          	

                	9.4.3.1.2	
                  The Contractor’s provider network must have one (1) PCP per one thousand seven hundred (1,700) Enrollees (excluding Gynecologists);

                


        

      

       

      
        
          	

                	9.4.3.1.3	
                  The Contractor’s provider network must have one (1) Gynecologist (selected as the Enrollee’s PCP, if the Enrollee is female and twelve (12) years of age or older) per two
                      thousand eight hundred (2,800) Enrollees (1:2,800);

                


        

      

       

      
        
          	

                	9.4.3.1.4	
                  In the event the Contractor assigns Enrollees to a PCP that exceeds the stated Provider-to-Enrollee Ratio requirement, the Contractor must obtain prior written approval
                      for an exception from ASES to continue to assign Enrollees to the PCP. All approved exceptions must be reported in the annual Provider Network and Evaluation plan described in Section 18.3.

                


        

      

       

      
        
          	

                	9.4.3.2	
                  Hospital Provider-to-Enrollee Ratios

                


        

      

       

      
        
          	

                	9.4.3.2.1	
                  The Contractor’s provider network must have one (1) Hospital per fifty thousand (50,000) Enrollees (1:50,000).

                


        

      

       

      
        
          	

                	9.4.3.3	
                  Provider Per Municipality Requirements

                


        

      

       

      
        
          	

                	9.4.3.3.1	
                  The Contractor’s provider network must have two (2) Adult PCPs and one (1) Pediatric PCPs, as defined in Sections 9.4.4.1.1 and 9.4.4.2.1, respectively, in each
                      municipality.

                


        

      

       

      
        Page 152 of 324

        
          


      

      
        
          	

                	9.4.3.3.2	
                  The Contractor’s provider network must have one (1) Psychologist in each municipality.

                


        

      

       

      
        
          	

                	9.4.3.4	
                  Required Network Providers

                


        

      

       

      
        
          	

                	9.4.3.4.1	
                  The Contractor’s provider network must have one (1) FQHC.

                


        

      

       

      
        
          	

                	9.4.3.4.2	
                  The Contractor’s provider network must include all Government Health Care Facilities identified in Section 9.6.

                


        

      

       

      
        
          	

                	9.4.3.4.3	
                  The Contractor’s provider network must include all available emergency stabilization units, psychiatric hospitals, psychiatric partial hospitals, and certified
                      Buprenorphine providers.

                


        

      

       

      
        
          	

                	9.4.4	
                  The Contractor shall comply with the minimum Time and Distance Standards for the General Network specified herein. Time and Distance Standards are developed for Urban and
                      Non-Urban Areas as defined in Article 2 of this Contract.

                


        

      

       

      
        
          	

                	9.4.4.1	
                  Adult Primary Care Providers (PCP)

                


        

      

       

      
        
          	

                	9.4.4.1.1	
                  Providers classified as Adult PCPs for purposes of Time and Distance Standards are Internal Medicine, Family Practice, and General Practice.

                


        

      

       

      
        
          	

                	9.4.4.1.2	
                  Enrollees living in Urban Areas and Non-Urban Areas must have a choice of at least two (2) PCPs within fifteen (15) miles/thirty (30) minutes.

                


        

      

       

      
        
          	

                	9.4.4.2	
                  Pediatric PCPs

                


        

      

       

      
        
          	

                	9.4.4.2.1	
                  Providers classified as Pediatric PCPs for purposes of Time and Distance Standards are the following: Family Practice, General Practice, and Pediatrics.

                


        

      

       

      
        
          	

                	9.4.4.2.2	
                  Enrollees living in Urban Areas and Non-Urban Areas must have a choice of at least two (2) PCPs within fifteen (15) miles/thirty (30) minutes.

                


        

      

       

      
        
          	

                	9.4.4.3	
                  Obstetrics and Gynecology (OB/GYN) Providers

                


        

      

       

      
        
          	

                	9.4.4.3.1	
                  For female Enrollees age twelve (12) and older, the Contractor must ensure the provider network for OB/GYN Providers meet the following Time and Distance standards:

                


        

      

       

      
        Page 153 of 324

        
          


      

      
        
          	

                	9.4.4.3.2	
                  Enrollees living in Urban Areas and Non-Urban Areas must have a choice of at least two (2) OB/GYN Providers within fifteen (15) miles/thirty (30) minutes.

                


        

      

       

      
        
          	

                	9.4.4.4	
                  High Volume Specialty Care Providers

                


        

      

       

      
        
          	

                	9.4.4.4.1	
                  High Volume Specialty Care Providers are Providers that comprise one (1) percent of utilization for the enrolled population, as identified by ASES. The Contractor must
                      meet the following Time and Distance standards as specified in this section.

                


        

      

       

      
        
          	

                	9.4.4.4.1.1	
                  Adult High Volume Specialty Care Providers

                


        

      

       

      
        
          	

                	9.4.4.4.1.1.1	
                  Providers classified as Adult High Volume Specialty Care Providers for purposes of Time and Distances standards are the following: Cardiology, Dermatology, Endocrinology,
                      Gastroenterology, Hematology, Oncology, Nephrology, Neurology, Orthopedic Surgery, Otoloaryngology, Podiatry, Psychiatry, Pulmonology, Rheumatology, Surgery, and Urology.

                


        

      

       

      
        
          	

                	9.4.4.4.1.1.2	
                  Enrollees living in Urban Areas must have one (1) of each type of Adult High Volume Specialty Care Provider within thirty (30) miles/sixty (60) minutes.

                


        

      

       

      
        
          	

                	9.4.4.4.1.1.3	
                  Enrollees living in Non-Urban Areas must have one (1) of each type Adult High Volume Specialist within forty-five (45) miles/ninety (90) minutes.

                


        

      

       

      
        
          	

                	9.4.4.4.1.2	
                  Pediatric High Volume Specialty Care Providers

                


        

      

       

      
        
          	

                	9.4.4.4.1.2.1	
                  Providers classified as Pediatric High Volume Specialty Care Providers for purposes of Time and Distance standards are the following: Allergy & Immunology,
                      Cardiology, Dermatology, Endocrinology, Gastroenterology, Orthopedic Surgery, Otoloaryngology, Pulmonology, Speech, Language and Hearing, and Surgery.

                


        

      

       

      
        Page 154 of 324

        
          


      

      
        
          	

                	9.4.4.4.1.2.2	
                  Enrollees living in Urban Areas must have one (1) of each type Pediatric High Volume Specialty Care Provider within thirty (30) miles/sixty (60) minutes.

                


        

      

       

      
        
          	

                	9.4.4.4.1.2.3	
                  Enrollees living in Non-Urban Areas must have one (1) of each type Pediatric High Volume Specialty Provider within forty-five (45) miles/ninety (90) minutes.

                


        

      

       

      
        
          	

                	9.4.4.5	
                  Adult and Pediatric Dental Providers

                


        

      

       

      
        
          	

                	9.4.4.5.1	
                  Enrollees living in Urban Areas must have one (1) Dental Provider within thirty (30) miles/sixty (60) minutes.

                


        

      

       

      
        
          	

                	9.4.4.5.2	
                  Enrollees living in Non-Urban Areas must have one (1) Dental Provider within forty-five (45) miles/ninety (90) minutes.

                


        

      

       

      
        
          	

                	9.4.4.6	
                  Adult and Pediatric Mental Health Providers

                


        

      

       

      
        
          	

                	9.4.4.6.1	
                  Providers classified as Adult and Pediatric Mental Health Providers for purposes of Time and Distance standards are the following: Psychiatrists, Psychologists, Licensed
                      Clinical Social Worker, and Licensed Marriage Counselor.

                


        

      

       

      
        
          	

                	9.4.4.6.2	
                  Enrollees living in Urban Areas and Non-Urban Areas must have one (1) Psychologist within fifteen (15) miles/thirty (30) minutes.

                


        

      

       

      
        
          	

                	9.4.4.6.3	
                  Enrollees living in Urban Areas and Non-Urban Areas must have one (1) Psychiatrist within fifteen (15) miles/thirty (30) minutes.

                


        

      

       

      
        
          	

                	9.4.4.6.4	
                  Enrollees living in Urban Areas and Non-Urban Areas must have one (1) Social Worker or Licensed Marriage Counselor within fifteen (15) miles/thirty (30) minutes.

                


        

      

       

      
        
          	

                	9.4.4.7	
                  Adult and Pediatric Substance Use Disorder (SUD) Providers

                


        

      

       

      
        
          	

                	9.4.4.7.1	
                  Providers classified as Adult and Pediatric SUD Providers for purposes of Time and Distance standards are the following: Addiction Medicine, Inpatient Facility, SUD
                      Treatment Programs (including intensive outpatient, inpatient, partial hospitalization, residential and withdrawal management).

                


        

      

       

      
        Page 155 of 324

        
          


      

      
        
          	

                	9.4.4.7.2	
                  Enrollees living in Urban Areas must have one (1) SUD Provider within thirty (30) miles/sixty (60) minutes.

                


        

      

       

      
        
          	

                	9.4.4.7.3	
                  Enrollees living in Non-Urban Areas must have one (1) SUD Provider within forty-five (45) miles/ninety (90) minutes.

                


        

      

       

      
        
          	

                	9.4.4.8	
                  Hospitals

                


        

      

       

      
        
          	

                	9.4.4.8.1	
                  The Contractor must ensure Enrollees have access to all necessary specialty hospitals as needed based on the needs of the enrolled population.

                


        

      

       

      
        
          	

                	9.4.4.8.2	
                  Enrollees living in Urban Areas must have one (1) Hospital within thirty (30) miles/sixty (60) minutes.

                


        

      

       

      
        
          	

                	9.4.4.8.3	
                  Enrollees living in Non-Urban Areas must have one (1) Hospital within forty-five (45) miles/ninety (90) minutes.

                


        

      

       

      
        
          	

                	9.4.4.9	
                  Emergency Room (Hospital and Freestanding)

                


        

      

       

      
        
          	

                	9.4.4.9.1	
                  Facilities subject to the Time and Distance standard in this section are emergency rooms, either in a Hospital or a freestanding facility.

                


        

      

       

      
        
          	

                	9.4.4.9.2	
                  Enrollees living in any area of Puerto Rico must have one (1) Emergency Room within twenty (20) miles/thirty (30) minutes.

                


        

      

       

      
        
          	

                	9.4.5	
                  Network Adequacy Standards for the Preferred Provider Network (PPN)

                


        

      

       

      
        
          	

                	9.4.5.1	
                  The Contractor must ensure the PPN complies with the Network Adequacy Standards in Sections 9.4.3 and 9.4.4 for applicable Providers.

                


        

      

       

      
        
          	

                	9.4.5.2	
                  Each PMG shall be considered a PPN based on the number of Enrollees who have selected a PCP associated with the individual PMG.

                


        

      

       

      
        
          	

                	9.4.6	
                  The Parties acknowledge that there are shortages of certain Providers. The Contractor will work with the Provider community to address Enrollee Access to Providers to the
                      extent possible. The Contractor will then develop policies and procedures to be prior approved in writing by ASES to ensure Enrollees have Access to services as necessary.

                


        

      

       

      
        Page 156 of 324

        
          


      

      
        
          	

                	9.4.7	
                  Subject to Section 9.4 of this Contract, the aforementioned Provider-to Enrollee Ratios, Provider Per Municipality, Required Network Provider, and Time and Distance
                      standards must be maintained for Enrollees, regardless of whether the Contractor offers treatment to other private patients.

                


        

      

       

      
        
          	

                	9.4.8	
                  ASES reserves the right to modify the Network Adequacy requirements herein based on a pattern of complaints from Enrollees or Providers regarding Access.

                


        

      

       

      
        
          	

                	9.4.9	
                  ASES reserves the right to modify Network Adequacy requirements herein based on a pattern of Access concerns in the Contractor’s Geographical Access and Appointment
                      Availability reports.

                


        

      

       

      
        
          	

                	9.5	
                  Access

                


        

      

       

      
        
          	

                	9.5.1	
                  Appointment Standards and Minimum Requirements for Access to Providers

                


        

      

       

      
        
          	

                	9.5.1.1	
                  The Contractor shall provide adequate Access to Enrollees at all times and are subject to the appointment requirements described in Section 9.5. The Contractor shall
                      provide Access to Covered Services in accordance with the following terms:

                


        

      

       

      
        
          	

                	9.5.1.1.1	
                  Non-Urgent Conditions

                


        

      

       

      
        
          	

                	9.5.1.1.1.1	
                  Routine physical exams shall be provided for all Enrollees within thirty (30) Calendar Days of the Enrollee’s request for the service, taking into account both the
                      medical and Behavioral Health need and condition. For Enrollees less than twenty-one (21) years of age, the Contractor shall meet the EPSDT timeframes specified in Section 7.9.3 of this Contract and in accordance with Act No. 408.

                


        

      

       

      
        
          	

                	9.5.1.1.1.2	
                  Routine evaluations for Primary Care shall be provided within thirty (30) Calendar Days, unless the Enrollee requests a later time;

                


        

      

       

      
        
          	

                	9.5.1.1.1.3	
                  Covered Services shall be provided within fourteen (14) Calendar Days following the request for service;

                


        

      

       

      
        
          	

                	9.5.1.1.1.4	
                  Specialist Services shall be provided within thirty (30) Calendar Days of the Enrollee’s original request for service;

                


        

      

       

      
        
          	

                	9.5.1.1.1.5	
                  Dental services shall be provided within sixty (60) Calendar Days following the request, unless the Enrollee requests a later date;

                


        

      

       

      
        Page 157 of 324

        
          


      

      
        
          	

                	9.5.1.1.1.6	
                  Behavioral Health Services shall be provided within fourteen (14) Calendar Day following the request, unless the Enrollee requests a later date;

                


        

      

       

      
        
          	

                	9.5.1.1.1.7	
                  Diagnostic laboratory, diagnostic imaging and other testing appointments shall be provided consistent with the clinical urgency, but no more than fourteen (14) Calendar
                      Days, unless the Enrollee requests a later time;

                


        

      

       

      
        
          	

                	9.5.1.1.1.8	
                  Diagnostic laboratory, diagnostic imaging and other testing, if a “walk-in” rather than an appointment system is used, the Enrollee wait time shall be consistent with
                      severity of the clinical need; and

                


        

      

       

      
        
          	

                	9.5.1.1.1.9	
                  ASES highly recommends that the Providers contracted by the Contractor implement an electronic prescribing system;

                


        

      

       

      
        
          	

                	9.5.1.1.2	
                  Urgent Conditions

                


        

      

       

      
        
          	

                	9.5.1.1.2.1	
                  Emergency Services shall be provided, including Access to an appropriate level of care as quickly as warranted based on the condition;

                


        

      

       

      
        
          	

                	9.5.1.1.2.2	
                  Primary medical, dental, and Behavioral Health Care outpatient appointments for urgent conditions shall be available within twenty-four (24) hours;

                


        

      

       

      
        
          	

                	9.5.1.1.2.3	
                  Urgent outpatient diagnostic laboratory, diagnostic imaging and other testing, appointment availability shall be consistent with the clinical urgency, but no longer than
                      forty-eight (48) hours;

                


        

      

       

      
        
          	

                	9.5.1.1.2.4	
                  Behavioral Health crisis services, face-to-face appointments shall be available within two (2) hours; and

                


        

      

       

      
        
          	

                	9.5.1.1.2.5	
                  Detoxification services shall be provided Immediately according to clinical necessity;

                


        

      

       

      
        
          	

                	9.5.1.1.3	
                  The timing of scheduled follow-up outpatient visits with practitioners shall be consistent with the clinical need; and

                


        

      

       

      
        Page 158 of 324

        
          


      

      
        
          	

                	9.5.1.1.4	
                  FQHC Services shall be provided in an FQHC setting. The Contractor shall adequately and timely cover these services out-of-network at no cost to Enrollees for as long as
                      the FQHC Services are unavailable in the Contractor’s General Network. All out-of-network services require a Referral from the Enrollee’s PCP.

                


        

      

       

      
        
          	

                	9.5.2	
                  Access to Services for Enrollees with Special Health Needs

                


        

      

       

      
        
          	

                	9.5.2.1	
                  The Contractor shall require that its Network Providers evaluate any progressive condition of an Enrollee with special health needs that requires a course of regular
                      monitored care or treatment. This evaluation will include the use of Providers for each identified case.

                


        

      

       

      
        
          	

                	9.5.2.2	
                  The Contractor shall establish a protocol to screen Enrollees for Special Coverage, Care Management, the High Cost High Needs Program, and the High Utilizer Program in
                      order to facilitate direct access to specialists. The Contractor shall submit its operational protocol to ASES for prior written approval according to the timeframe specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	9.5.3	
                  Hours of Service

                


        

      

       

      
        
          	

                	9.5.3.1	
                  The Contractor shall prohibit its Network Providers from having different hours and schedules for GHP Enrollees than what is offered to commercial Enrollees.

                


        

      

       

      
        
          	

                	9.5.3.2	
                  The Contractor shall prohibit its Providers from establishing specific days for the delivery of Referrals and requests for Prior Authorization for GHP Enrollees, and the
                      Contractor shall monitor compliance with this rule and take corrective action if there is failure to comply.

                


        

      

       

      
        
          	

                	9.5.3.3	
                  The Contractor shall require Psychiatric Hospitals (or a unit within a general hospital), Emergency or Stabilization Units to have open service hours covering twenty-four
                      (24) hours a day, seven (7) days a week. The Contractor shall require Partial Hospitalization Facilities to have open service hours covering ten (10) hours per day at least five (5) days per week and shall have available one (l)
                      nurse, one (1) social worker and one (1) psychologist/psychiatrist. The Contractor shall require all other Behavioral Health Facilities to have open service hours covering twelve (12) hours per day, at least (5) days per week and
                      shall have available one (1) nurse, one (1) social worker and one (1) psychologist/psychiatrist.

                


        

      

       

      
        
          	

                	9.5.4	
                  Preferential Turns

                


        

      

       

      
        Page 159 of 324

        
          


      

      
        
          	

                	9.5.4.1	
                  The Contractor shall agree to establish a system of Preferential Turns for residents of the island municipalities of Vieques and Culebra. Preferential Turns refers to a
                      policy of requiring Providers to give priority in treating Enrollees from these island municipalities, so that they may be seen by a physician within a reasonable time after arriving in the Provider’s office. This priority treatment
                      is necessary because of the remote locations of these municipalities, and the greater travel time required for the residents to seek medical attention. This requirement was established in Laws No. 86 enacted on August 16, 1997 (Arts.
                      1 through 4) and Law No. 200 enacted on August 5, 2004 (Arts. 1 through 5). The Contractor shall include this requirement in the Provider Guidelines (see Section 10.2.1.4).

                


        

      

       

      
        
          	

                	9.5.5	
                  Extended Schedule of PMGs

                


        

      

       

      
        
          	

                	9.5.5.1	
                  PMGs shall be available to provide primary care services or consultations Monday through Saturday of each Week, from 8:00 a.m. to 6:00 p.m. (Atlantic Time). The following
                      Holidays the PMG will not have to comply with this requirement: January 1st, January 6th, Good Friday, Thanksgiving Day and December 25th. The PMG has the sole discretion to decide whether or not to provide Primary Care
                      services during the previously listed holidays.

                


        

      

       

      
        
          	

                	9.5.5.2	
                  In addition, each Provider that offers urgent care services, as well as any other qualified Provider willing to provide urgent care services, shall have sufficient
                      personnel to offer urgent care services during extended periods Monday through Friday from 6:00 p.m. to 9:00 p.m. (Atlantic Time), in order to provide Enrollees greater Access to their PCPs and to urgent care services.

                


        

      

       

      
        
          	

                	9.5.5.3	
                  PMGs may collaborate with each other to establish extended office hours at one (1) or multiple facilities.

                


        

      

       

      
        
          	

                	9.5.5.4	
                  The Contractor shall submit to ASES its policies and procedures for how it will determine the adequacy and appropriateness of Providers’ available hours, approve such
                      arrangements, and monitor their operation and take corrective action if there is failure to comply. The policies and procedures shall be submitted for prior approval according to the timeframe specified in Attachment 12 to this
                      Contract.

                


        

      

       

      
        
          	

                	9.5.6	
                  Provider Services Call Center

                


        

      

       

      
        
          	

                	9.5.6.1	
                  The Contractor shall operate a Provider services call center with a separate toll-free telephone line to respond to Provider questions, comments, inquiries and requests
                      for prior authorizations.

                


        

      

       

      
        Page 160 of 324

        
          


      

      
        
          	

                	9.5.6.2	
                  The Contractor shall develop Provider service line policies and procedures that address staffing, training, hours of operation, access and response standards, monitoring
                      of calls via recording or other means, and compliance with standards. Such policies and procedures shall be prior approved in writing by ASES.

                


        

      

       

      
        
          	

                	9.5.6.3	
                  The Contractor shall ensure that the Provider service line is staffed adequately to respond to Providers’ questions at a minimum from 7 a.m. to 7 p.m. (Atlantic Time),
                      Monday through Friday, excluding Puerto Rico holidays.

                


        

      

       

      
        
          	

                	9.5.6.4	
                  The Contractor shall have an automated system available during non-business hours. This automated system shall include, at a minimum, information on how to obtain after
                      hours UM requests and a voice mailbox for callers to leave messages. The Contractor shall ensure that the automated system has adequate capacity to receive all messages. The Contractor shall return messages on the next Business Day.

                


        

      

       

      
        
          	

                	9.5.6.5	
                  The Provider service line shall also be adequately staffed to provide appropriate and timely responses regarding authorization requests as described in Article 11.4.2 of
                      this Contract. The Contractor may meet this requirement by having a separate Utilization Management line.

                


        

      

       

      
        
          	

                	9.5.6.6	
                  The call center staff shall have access to electronic documentation from previous calls made by a Provider.

                


        

      

       

      
        
          	

                	9.5.6.7	
                  The Contractor shall adequately staff the provider service line to ensure that the line, including the Utilization Management line/queue, meets the following minimum
                      performance standards on a monthly basis:

                


        

      

       

      
        
          	

                	9.5.6.7.1	
                  Less than five percent (5%) call abandonment rate;

                


        

      

       

      
        
          	

                	9.5.6.7.2	
                  Eighty percent (80%) of calls are answered by a live voice within thirty (30) seconds;

                


        

      

       

      
        
          	

                	9.5.6.7.3	
                  Blocked call rate does not exceed three percent (3%); and

                


        

      

       

      
        
          	

                	9.5.6.7.4	
                  One hundred percent (100%) of voicemails are returned within one (1) Business Day.

                


        

      

       

      
        
          	

                	9.5.6.8	
                  The Contractor shall submit a Call Center Report in a format prescribed by ASES.

                


        

      

       

      
        Page 161 of 324

        
          


      

      
        
          	

                	9.6	
                  Government Health Care Facilities

                


        

      

       

      
        
          	

                	9.6.1	
                  The Contractor shall include and make part of its General Network, health care facilities administered or operated by the Central Government and State Academic Medical
                      Centers providing services to the GHP, including at least the following:

                


        

      

       

      
        
          	

                	9.6.1.1	
                  Hospital Universitario Ramón Ruiz Arnau (HURRA);

                


        

      

       

      
        
          	

                	9.6.1.2	
                  Hospital Universitario de Adultos;

                


        

      

       

      
        
          	

                	9.6.1.3	
                  Hospital Federico Trilla;

                


        

      

       

      
        
          	

                	9.6.1.4	
                  Hospital Pediátrico Universitario;

                


        

      

       

      
        
          	

                	9.6.1.5	
                  Centro Cardiovascular de PR y del Caribe;

                


        

      

       

      
        
          	

                	9.6.1.6	
                  Administración de Servicios Médicos de PR (“ASEM”); and

                


        

      

       

      
        
          	

                	9.6.1.7	
                  Comprehensive Cancer Center of Puerto Rico (“Centro Comprensivo de Cancer”); and

                


        

      

       

      
        
          	

                	9.6.1.8	
                  Práctica Intramural del Recinto de Ciencias Médicas

                


        

      

      

      

      
        
          	ARTICLE 10	
                  PROVIDER CONTRACTING

                


        

      

       

      
        
          	

                	10.1	
                  General Provisions

                


        

      

       

      
        
          	

                	10.1.1	
                  The Contractor shall establish a care model in which the PCP, located within a PMG, manages and coordinates the Enrollee’s care in a timely manner.

                


        

      

       

      
        
          	

                	10.1.2	
                  The PCP shall provide, manage, and coordinate services to the Enrollee, including coordination with Behavioral Health personnel, in a timely manner, and in accordance
                      with the guidelines, protocols, and practices generally accepted in medicine.

                


        

      

       

      
        
          	

                	10.1.3	
                  The Contractor and each of its Network Providers shall work to ensure that physical and Behavioral Health Services are delivered in a coordinated manner and conform to
                      the standards as provided in Article 8.

                


        

      

       

      
        
          	

                	10.1.4	
                  The Contractor shall contract with enough PMGs to serve the Enrollees. As a precondition to executing any Provider Contract, the Contractor shall comply with the
                      requirements stated in Section 10.1.6.1 regarding submitting a model for each type of Provider Contract to ASES.

                


        

      

       

      
        
          	

                	10.1.5	
                  The Contractor shall not contract with any Provider without confirming and documenting that the Provider meets all of the Credentialing requirements specified in Section
                      9.2.3 of this Contract. Failure by the Contractor to adequately monitor the Credentialing of Providers may result in sanctions, liquidated damages, and/or fines in accordance with Articles 19 and 20 or termination of this Contract.

                


        

      

       

      
        Page 162 of 324

        
          


      

      
        
          	

                	10.1.6	
                  Model Provider Contracts

                


        

      

       

      
        
          	

                	10.1.6.1	
                  The Contractor shall submit a model for each type of Provider Contract to ASES for review and prior written approval, according to the timeframe specified in Attachment
                      12 to this Contract. The Contractor shall include in such submission, at a minimum, model contracts for PMGs, PCPs, Ancillary Service Providers, Hospitals, Emergency Rooms, and Ambulance Services. The Contractor shall provide ASES
                      with digitized copies of each finalized Provider Contract within thirty (30) Calendar Days of the effective date of the Provider Contract. At the time of submitting the finalized Provider Contract, the Contractor shall disclose to
                      ASES whether the Provider falls under the prohibition stated in Sections 29.1, 29.2, or 29.6 of this Contract.

                


        

      

       

      
        
          	

                	10.1.6.2	
                  ASES shall review each executed Provider Contract against the approved models of Provider Contracts. ASES reserves the right to cancel Provider Contracts or to impose
                      sanctions or fees against the Contractor for the omission of clauses required in the contracts with Providers.

                


        

      

       

      
        
          	

                	10.1.6.3	
                  On an ongoing basis, any modifications to models of Provider Contracts shall be submitted to ASES for review and prior written approval, before the amendment may be
                      executed. Similarly, any amendments to Provider Contracts shall be submitted to ASES for review and prior written approval.

                


        

      

       

      
        
          	

                	10.1.7	
                  The Contractor shall not discriminate against a Provider that is acting within the scope of its license or certification under applicable Puerto Rico law, in decisions
                      concerning contracting, solely on the basis of that license or certification. This Section shall not be construed as precluding the Contractor from using different payment amounts for different specialties, or for different Providers
                      in the same specialty.

                


        

      

       

      
        
          	

                	10.2	
                  Provider Training

                


        

      

       

      
        
          	

                	10.2.1	
                  Provider Guidelines

                


        

      

       

      
        
          	

                	10.2.1.1	
                  The Contractor shall prepare Provider Guidelines, to be distributed to all Network Providers (General Network and PPN), summarizing the GHP program. The Provider
                      Guidelines shall, in accordance with 42 CFR 438.236, (i) be based on valid and reliable clinical evidence or a consensus of Providers in the particular field; (ii) consider the needs of the Contractor’s Enrollees; (iii) be adopted in
                      consultation with Providers; and (iv) be reviewed and updated periodically, as appropriate.

                


        

      

       

      
        Page 163 of 324

        
          


      

      
        
          	

                	10.2.1.2	
                  The Provider Guidelines shall describe the procedures to be used to comply with the Provider’s duties and obligations pursuant to this Contract, and under the Provider
                      Contract.

                


        

      

       

      
        
          	

                	10.2.1.3	
                  The Contractor shall submit the Provider Guidelines to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	10.2.1.4	
                  The content of the Provider Guidelines will include, without being limited to, the following topics: the duty to verify eligibility; selection of Providers by the
                      Enrollee; Covered Services; procedures for Access to and provision of services; Preferential Turns, as applicable; coordination of Access to Behavioral Health Services; required service schedule; Medically Necessary Services available
                      twenty-four (24) hours ; report requirements; Utilization Management policies and procedures; Medical Record maintenance requirements; Complaint, Grievance, and Appeal procedures (see Article 14); Co-Payments; HIPAA requirements; the
                      prohibition on denial of Medically Necessary Services; Electronic Health Records and sanctions or fines applicable in cases of non-compliance; and Fraud, Waste and Abuse compliance.

                


        

      

       

      
        
          	

                	10.2.1.5	
                  The Provider Guidelines shall be delivered to each Network Provider as part of the Provider contracting process, and shall be made available to Enrollees and to Potential
                      Enrollees upon request. The selected Contractor shall maintain evidence of having delivered the Provider Guidelines to all of its Network Providers within fifteen (15) Calendar Days of award of the Provider Contract. The evidence of
                      receipt shall include the legible name of the Network Provider, NPI, date of delivery, and signature of the Network Provider and shall be made available to ASES Immediately upon request.

                


        

      

       

      
        
          	

                	10.2.1.6	
                  The Contractor shall have policies and procedures (that have been prior approved in writing by ASES in accordance with the timeframes in Attachment 12 to this Contract in
                      place, including both updates to the Provider Guidelines and other communications) to inform its Provider Network, in a timely manner, of programmatic changes such as changes to drug formularies, Covered Services, and protocols.

                


        

      

       

      
        
          	

                	10.2.2	
                  Provider Education

                


        

      

       

      
        
          	

                	10.2.2.1	
                  The Contractor shall develop a continuing education curriculum for Providers consisting of twenty (20) hours per year divided into five (5) hours per quarter. The
                      curriculum shall be submitted to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract. The curriculum shall include a description of how the Contractor will educate
                      Providers on Contract requirements and shall also include, at a minimum:

                


        

      

       

      
        Page 164 of 324

        
          


      

      
        
          	

                	10.2.2.1.1	
                  Initial and ongoing Provider training and education literacy in Public Health, management of Rheumatoid Arthritis, management of diabetes, and Medicaid with specific
                      emphasis on EPSDT and Behavioral Health Integration, the conditions of participation in the Contractor’s GHP Plan, billing processes, and the Provider’s responsibilities to the Contractor and its Enrollees; and

                


        

      

       

      
        
          	

                	10.2.2.1.2	
                  Initial and ongoing Provider education and training to address clinical issues and improve the service delivery system, including, but not limited to, assessments,
                      treatment plans, plans of care, discharge plans, evidence-based practices and models of care such as integrated care and trauma-informed care.

                


        

      

       

      
        
          	

                	10.2.2.2	
                  The Contractor shall coordinate topics with the PBM’s Academic Detailing Program
                      to develop educational activities addressing:

                


        

      

       

      
        
          	

                	10.2.2.2.1	
                  Management and implications of polypharmacy;

                


        

      

       

      
        
          	

                	10.2.2.2.2	
                  Condition management;

                


        

      

       

      
        
          	

                	10.2.2.2.3	
                  Management of prescriptions; and

                


        

      

       

      
        
          	

                	10.2.2.2.4	
                  Working with patients with conditions of special concern, including autism, ADHD, depression, and diabetes among others.

                


        

      

       

      
        
          	

                	10.2.2.3	
                  The Contractor shall use various forms of delivery when providing Providers’ training sessions, including web-based sessions, group workshops, face-to-face individualized
                      education, newsletters, communications, and office visits.

                


        

      

       

      
        
          	

                	10.2.2.4	
                  The Contractor shall make the dates and locations of sessions available to Providers, as soon as possible, but no later than five (5) Business Days prior to the event.

                


        

      

       

      
        
          	

                	10.2.2.5	
                  Training shall be offered throughout the different geographic regions of Puerto Rico and at different times of the day in order to accommodate participating Providers’
                      schedules.

                


        

      

       

      
        Page 165 of 324

        
          


      

      
        
          	

                	10.2.2.6	
                  The Contractor shall have a process to document Provider participation in continuing education, and shall provide ASES with, upon request, documentation that Provider
                      education and training requirements have been met.

                


        

      

       

      
        
          	

                	10.2.2.7	
                  The Contractor shall provide technical assistance to Providers as determined necessary by the Contractor or by ASES.

                


        

      

       

      
        
          	

                	10.2.2.8	
                  The Contractor shall maintain a record of its training and technical assistance activities, which it shall make available to ASES upon request.

                


        

      

       

      
        
          	

                	10.2.2.9	
                  The Contractor shall adopt practice guidelines in accordance with the criteria in 42 CFR 438.236. Practice guidelines shall be disseminated to all affected Providers, and
                      upon request to Enrollees and Potential Enrollees.

                


        

      

       

      
        
          	

                	10.2.2.9.1	
                  Decisions for utilization management, Enrollee education, coverage of services, and other areas to which the guidelines apply are consistent with the guidelines. This
                      includes consultation and application of USPSTF recommendations when the Contractor is making coverage and utilization management decisions.

                


        

      

       

      
        
          	

                	10.3	
                  Required Provisions in Provider Contracts

                


        

      

       

      
        
          	

                	10.3.1	
                  All Provider Contracts shall be labeled with the Provider’s NPI, if applicable. In general, the Contractor’s Provider Contracts shall:

                


        

      

       

      
        
          	

                	10.3.1.1	
                  Include a section summarizing the Contractor’s obligations under this Contract, as they affect the delivery of health care services under the GHP, and describing Covered
                      Services and populations (or, include the Provider Guidelines as an attachment);

                


        

      

       

      
        
          	

                	10.3.1.2	
                  Include a signature page that contains the Contractor and Provider names which are typed or legibly written, Provider company with titles, and dated signatures of all
                      appropriate parties;

                


        

      

       

      
        
          	

                	10.3.1.3	
                  Specify the effective dates of the Provider Contract;

                


        

      

       

      
        
          	

                	10.3.1.4	
                  Require that the Provider work to advance the integrated model of physical and Behavioral Health Services;

                


        

      

       

      
        
          	

                	10.3.1.5	
                  Require that the Provider comply with the applicable Federal and Puerto Rico laws listed in Attachment 1 to this Contract, and with all CMS requirements;

                


        

      

       

      
        Page 166 of 324

        
          


      

      
        
          	

                	10.3.1.6	
                  Require that the Provider verify the Enrollee’s Eligibility before providing services or making a Referral;

                


        

      

       

      
        
          	

                	10.3.1.7	
                  Prohibit any unreasonable denial, delay, or rationing of Covered Services to Enrollees; and violation of this prohibition shall be subject to the provisions of Article
                      VI, Section 6 of Act 72 and of 42 CFR Part 438, Subpart I (Sanctions);

                


        

      

       

      
        
          	

                	10.3.1.8	
                  Prohibit the Provider from making claims for any un-allowed administrative expenses, as listed in Section 22.1.15;

                


        

      

       

      
        
          	

                	10.3.1.9	
                  Prohibit the unauthorized sharing or transfer of ASES Data, as defined in Section 28.1;

                


        

      

       

      
        
          	

                	10.3.1.10	
                  Notify the Provider that the terms of the contract for services under the GHP program are subject to subsequent changes in legal requirements that are outside of the
                      control of ASES;

                


        

      

       

      
        
          	

                	10.3.1.11	
                  Require the Provider to comply with all reporting requirements contained in Article 18 of this Contract, as applicable, and particularly with the requirements to submit
                      Encounter Data for all services provided, and to report all instances of suspected Fraud, Waste, or Abuse;

                


        

      

       

      
        
          	

                	10.3.1.12	
                  Require the Provider to acknowledge that ASES Data (as defined in Section 28.1.1) belongs exclusively to ASES, and that the Provider may not give access to, assign, or
                      sell such Data to Third Parties, without Prior Authorization from ASES. The Contractor shall include penalty clauses in its Provider Contracts to prohibit this practice, and require that the fines be determined by and payable to ASES;

                


        

      

       

      
        
          	

                	10.3.1.13	
                  Prohibit the Provider from seeking payment from the Enrollee for any Covered Services provided to the Enrollee within the terms of the Contract, and require the Provider
                      to look solely to the Contractor for compensation for services rendered to Enrollees, with the exception of any nominal cost-sharing, as provided in Section 7.11;

                


        

      

       

      
        
          	

                	10.3.1.14	
                  Require the Provider to cooperate with the Contractor’s quality improvement and Utilization Management activities;

                


        

      

       

      
        
          	

                	10.3.1.15	
                  Not prohibit a Provider from acting within the lawful scope of practice, from advising or advocating on behalf of an Enrollee for the Enrollee’s health status, medical
                      care, or treatment or non-treatment options per 42 CFR 438.102(a)(1);

                


        

      

       

      
        Page 167 of 324

        
          


      

      
        
          	

                	10.3.1.16	
                  Not prohibit a Provider from advocating on behalf of the Enrollee in any Grievance and Appeal System or Utilization Management process, or individual authorization
                      process to obtain necessary health care services;

                


        

      

       

      
        
          	

                	10.3.1.17	
                  Require Providers to meet the timeframes for Access to services pursuant to Section 9.5 of this Contract;

                


        

      

       

      
        
          	

                	10.3.1.18	
                  Provide for continuity of treatment in the event that a Provider’s participation in the Contractor’s Network terminates during the course of an Enrollee’s treatment by
                      that Provider;

                


        

      

       

      
        
          	

                	10.3.1.19	
                  Require Providers to monitor and as necessary and appropriate register Enrollee patients to determine whether they have a medical condition that suggests Care Management
                      or inclusion in the High Cost High Needs Program services are warranted;

                


        

      

       

      
        
          	

                	10.3.1.20	
                  Prohibit Provider discrimination against high-risk populations or Enrollees requiring costly treatments;

                


        

      

       

      
        
          	

                	10.3.1.21	
                  Prohibit Providers who do not have a pharmacy license from directly dispensing medications, as required by the Puerto Rico Pharmacy Act (with the exception noted in
                      Section 7.5.12.3.2);

                


        

      

       

      
        
          	

                	10.3.1.22	
                  Specify that ASES, CMS, the Office of Inspector General, the Comptroller General, the Medicaid Fraud Control Unit, and their designees, shall have the right at any time
                      to inspect, evaluate, and audit any pertinent records or documents, including Enrollee records and financial records and transactions, and may inspect the premises, physical facilities, and equipment where activities or work related
                      to the GHP program is conducted. Upon request, the Provider shall assist in such reviews, including the provision of complete copies of medical records. The right to audit exists for ten (10) years from the final date of the contract
                      period or from the date of completion of any audit, whichever is later;

                


        

      

       

      
        
          	

                	10.3.1.23	
                  Include the definition and standards for Medical Necessity, pursuant to the definition in Section 7.2.1 of this Contract;

                


        

      

       

      
        
          	

                	10.3.1.24	
                  Require that the Provider attend promptly to requests for Prior Authorizations and Referrals, when Medically Necessary, in compliance with the timeframes set forth in
                      Section 9.5 and in 42 CFR 438.210 and the Puerto Rico Patient’s Bill of Rights;

                


        

      

       

      
        
          	

                	10.3.1.25	
                  Prohibit the Provider from establishing specific days for the delivery of Referrals or requests for Prior Authorization;

                


        

      

       

      
        Page 168 of 324

        
          


      

      
        
          	

                	10.3.1.26	
                  Notify the Provider that, in order to participate in the Medicare Platino Program, the Provider shall accept GHP Enrollees;

                


        

      

       

      
        
          	

                	10.3.1.27	
                  Specify rates of payment, as detailed in Section 10.5, and require that Providers accept such payment as payment in full for Covered Services provided to Enrollees, less
                      any applicable Enrollee Co-Payments pursuant to Section 7.11 of this Contract;

                


        

      

       

      
        
          	

                	10.3.1.28	
                  Specify acceptable billing and coding requirements including ICD-10;

                


        

      

       

      
        
          	

                	10.3.1.29	
                  Require that the Provider comply with the Contractor’s Cultural Competency plan;

                


        

      

       

      
        
          	

                	10.3.1.30	
                  Require that any Marketing Materials developed and distributed by the Provider be submitted to the Contractor for submission to ASES for prior written approval;

                


        

      

       

      
        
          	

                	10.3.1.31	
                  Specify that the Contractor shall be responsible for any payment owed to Providers for services rendered after the Effective Date of Enrollment, as provided in Section
                      5.2.2, including during the retroactive period described in Section 5.1.3.1;

                


        

      

       

      
        
          	

                	10.3.1.32	
                  Require Providers to collect Enrollee Co-Payments as specified in Attachment 8 to this Contract;

                


        

      

       

      
        
          	

                	10.3.1.33	
                  Require that Providers not employ or subcontract with individuals on the Puerto Rico or Federal LEIE, or with any entity that could be excluded from the Medicaid program
                      under 42 CFR 1001.1001 (ownership or control in sanctioned entities) and 1001.1051 (entities owned or controlled by a sanctioned person);

                


        

      

       

      
        
          	

                	10.3.1.34	
                  Require that Medically Necessary Services shall be available twenty-four (24) hours per day, seven (7) days per Week, to the extent feasible;

                


        

      

       

      
        
          	

                	10.3.1.35	
                  Prohibit the Provider from operating on a different schedule for GHP Enrollees than for other patients, and from in any other way discriminating in an adverse manner
                      between GHP Enrollees and other patients;

                


        

      

       

      
        
          	

                	10.3.1.36	
                  Not require that Providers sign exclusive Provider Contracts with the Contractor if the Provider is an FQHC or RHC;

                


        

      

       

      
        
          	

                	10.3.1.37	
                  Provide notice that the Contractor’s negotiated rates with Providers shall be adjusted in the event that the Executive Director of ASES directs the Contractor to make
                      such adjustments in order to reflect budgetary changes to the Medical Assistance program;

                


        

      

       

      
        Page 169 of 324

        
          


      

      
        
          	

                	10.3.1.38	
                  Impose fees or penalties if the Provider breaches the contract or violates Federal or Puerto Rico laws or regulations;

                


        

      

       

      
        
          	

                	10.3.1.39	
                  Require that the Provider make every effort to cost-avoid claims and identify and communicate to the Contractor available Third Party resources, as required in Section
                      23.4 of this Contract, and require that the Contractor cover no health care services that are the responsibility of the Medicare Program;

                


        

      

       

      
        
          	

                	10.3.1.40	
                  Provide that the Contractor shall not pay Claims for services covered under the Medicare Program, and that the Provider may not bill both the GHP and the Medicare Program
                      for a single service to a Dual Eligible Beneficiary;

                


        

      

       

      
        
          	

                	10.3.1.41	
                  Require the Provider to sign a release giving ASES access to the Provider’s Medicare billing Data for GHP Enrollees who are Dual Eligible Beneficiaries, provided that
                      such access is authorized by CMS and compliant with all HIPAA requirements;

                


        

      

       

      
        
          	

                	10.3.1.42	
                  Set forth the Provider’s obligations under the Physician Incentive Programs outlined in Section 10.7 of this Contract;

                


        

      

       

      
        
          	

                	10.3.1.43	
                  Require the Provider to notify the Contractor Immediately if or whether the Provider falls within the prohibitions stated in Sections 29.1, 29.2, or 29.6 of this Contract
                      or has been excluded from the Medicare, Medicaid, or Title XX Services Programs;

                


        

      

       

      
        
          	

                	10.3.1.44	
                  Include a penalty clause to require the return of public funds paid to a Provider that falls within the prohibitions stated in Section 29.1, 29.2 or 29.6 of this
                      Contract;

                


        

      

       

      
        
          	

                	10.3.1.45	
                  Require that all reports submitted by the Provider to the Contractor be labeled with the Provider’s NPI, if applicable;

                


        

      

       

      
        
          	

                	10.3.1.46	
                  Require the Provider to participate in the Provider education activities described in Section 10.2.2;

                


        

      

       

      
        
          	

                	10.3.1.47	
                  Include Provider dispute process as described in Section 14;

                


        

      

       

      
        
          	

                	10.3.1.48	
                  Require the Provider to disclose information on ownership and control as specified in Section 54.2;

                


        

      

       

      
        
          	

                	10.3.1.49	
                  Require the Provider to disclose information as listed in Section 23.7.4; and

                


        

      

       

      
        
          	

                	10.3.1.50	
                  Require the Provider to comply with any transition of care requirements set forth in 42 CFR 438.62 and as specified in Section 5.5.

                


        

      

       

      
        Page 170 of 324

        
          


      

      
        
          	

                	10.3.1.51	
                  Require Providers to submit timely, complete and accurate Encounter data. Failure to comply with Encounter data requirements may, at the Contractor’s discretion, subject
                      the Provider to financial penalties.

                


        

      

       

      
        
          	

                	10.3.1.52	
                  Notify the Provider that Overpayments may be recouped by ASES or the Contractor on behalf of ASES.

                


        

      

       

      
        
          	

                	10.3.1.53	
                  Include a statement that HIPAA does not bar disclosure of protected health information (PHI) to Federal and State health oversight agencies, including, but not limited
                      to, HHS-OIG, ASES, Medicaid Fraud Control Unit, and CMS, for oversight activities permitted under HIPAA, and provide that any such authorized agency or entity may use these records and information for administrative, civil, or
                      criminal investigations, or other uses as permitted under HIPAA.

                


        

      

       

      
        
          	

                	10.3.1.54	
                  Specify that in the event that ASES, MFCU, HHS-OIG, or CMS identify that an Overpayment occurred due to suspected or confirmed fraud, the Provider may not claim
                      recoupment by the Contractor or ASES as a defense to any criminal charges brought by a Federal or State entity of competent jurisdiction.

                


        

      

       

      
        
          	

                	10.3.1.55	
                  Require Providers to fully cooperate with any investigation performed by ASES, OIG, MFCU, or other State or Federal entities with competent jurisdiction, involving the
                      GHP, and in any subsequent actions that may result from such an investigation.

                


        

      

       

      
        
          	

                	10.3.1.56	
                  Require that PCPs administer the Ages and Stages Questionnaire (“ASQ”) to the parents of child Enrollees as required under Section 7.7.9.3 of this Contract, as
                      applicable.

                


        

      

       

      
        
          	

                	10.3.1.57	
                  Require that the PCP carry out the Modified Checklist for Autism in Toddlers
                      (“M-CHAT R/F”) pursuant to Section 7.7.9.2 of this Contract, as applicable.

                


        

      

       

      
        
          	

                	10.3.2	
                  In addition to the required provisions in Section 10.3.1, the following requirements apply to specific categories of Provider contracts.

                


        

      

       

      
        
          	

                	10.3.2.1	
                  The Contractor’s contracts with PMGs shall:

                


        

      

       

      
        
          	

                	10.3.2.1.1	
                  Require that the PMG provide services on a regular time schedule, Monday through Saturday, from 8:00 a.m. to 6:00 p.m. (Atlantic Time); PMG will not have to comply with
                      this requirement during the following holidays: January 1st, January 6th,
                      Good Friday, Thanksgiving and December 25th. The PMG has sole discretion to decide whether or not to provide services during the previously listed
                      holidays;

                


        

      

       

      
        Page 171 of 324

        
          


      

      
        
          	

                	10.3.2.1.2	
                  Require that the PMG employs enough personnel to offer urgent care services between 6:00 p.m. and 9:00 p.m. (Atlantic Time), Monday through Friday;

                


        

      

       

      
        
          	

                	10.3.2.1.3	
                  Require that the PMG coordinates with Behavioral Health personnel to ensure integrated physical and Behavioral Health Services, as provided in Article 8;

                


        

      

       

      
        
          	

                	10.3.2.1.4	
                  Require the PMG to work, to the extent possible, within the Contractor’s established PPN, in directing care for Enrollees and coordinating services;

                


        

      

       

      
        
          	

                	10.3.2.1.5	
                  Authorize the Contractor to adjudicate disputes between the PMG and its Network Providers about the validity of claims by any Network Provider; and

                


        

      

       

      
        
          	

                	10.3.2.1.6	
                  Require PMGs to provide assurances that the Encounter Data submitted by the PMG to the Contractor encompass all services provided to GHP Enrollees, including clinical
                      laboratories.

                


        

      

       

      
        
          	

                	10.3.2.2	
                  The Contractor’s Provider Contracts with PCPs shall require the PCP to inform and distribute Information to Enrollee patients about instructions on Advance Directives,
                      and shall require the PCP to notify Enrollees of any changes in Federal or Puerto Rico law relating to Advance Directives, no more than ninety (90) Calendar Days after the effective date of such change.

                


        

      

       

      
        
          	

                	10.3.2.3	
                  The Contractor’s Provider Contracts with a Network Provider who is a member of the PPN shall prohibit the Provider from collecting Co-Payments from GHP Enrollees, subject
                      only to the exceptions established in Article 9 of this Contract and the Attachment 8 to this Contract (Co-Payment Chart).

                


        

      

       

      
        
          	

                	10.3.2.4	
                  The Contractor’s Provider Contracts with Hospitals and Emergency Rooms shall prohibit the Hospital or Emergency Room from placing a lower priority on GHP Enrollees than
                      on other patients, and from referring GHP Enrollees to other facilities for reasons of economic convenience. Such contracts shall include sanctions penalizing this practice.

                


        

      

       

      
        
          	

                	10.4	
                  Termination of Provider Contracts

                


        

      

       

      
        
          	

                	10.4.1	
                  The Contractor shall comply with all Puerto Rico and Federal laws regarding Provider termination. The Provider Contracts shall:

                


        

      

       

      
        
          	

                	10.4.1.1	
                  Contain provisions allowing termination of the Provider Contract by the Contractor “for cause.” Termination of the Provider Contract will not be permitted without cause.
                      Cause for termination includes, but is not limited to, gross negligence in complying with contractual requirements or obligations; a pattern of noncompliance with contractual requirements or obligations that the Provider fails to
                      correct after being notified of such noncompliance by the Contractor; insufficiency of funds of ASES or the Contractor, which prevents them from continuing to pay for their obligations; changes in Federal or State law, among others.
                      The Contractor shall not terminate a Provider Contract in retaliation for the Provider exercising his or her Appeal rights, advocating on behalf of the Provider, or for advocating on behalf of an Enrollee.

                


        

      

       

      
        Page 172 of 324

        
          


      

      
        
          	

                	10.4.1.2	
                  Specify that in addition to any other right to terminate the Provider Contract, and notwithstanding any other provision of this Contract, ASES may demand Provider
                      termination Immediately, or the Contractor may Immediately terminate on its own, a Provider’s participation under the Provider Contract if:

                


        

      

       

      
        
          	

                	10.4.1.2.1	
                  The Provider fails to abide by the terms and conditions of the Provider Contract, as determined by ASES, or, in the sole discretion of ASES, if the Provider fails to come
                      into compliance within fifteen (15) Calendar Days after a receipt of notice from the Contractor specifying such failure and requesting such Provider to abide by the terms and conditions hereof; or

                


        

      

       

      
        
          	

                	10.4.1.2.2	
                  The Contractor or ASES learns that the Provider:

                


        

      

       

      
        
          	

                	10.4.1.2.2.1	
                  Falls within the prohibition stated in Section 29.1 or 29.2, or has a criminal conviction as provided in Section 29.6;

                


        

      

       

      
        
          	

                	10.4.1.2.2.2	
                  Has been or could be excluded from participation in the Medicare, Medicaid, or CHIP Programs;

                


        

      

       

      
        
          	

                	10.4.1.2.2.3	
                  Could be excluded from the Medicaid Program under 42 CFR 1001.1001 (ownership or control in sanctioned entities) and 1001.1051 (entities owned or controlled by a
                      sanctioned person); and/or

                


        

      

       

      
        
          	

                	10.4.1.2.2.4	
                  Fails to comply with the Provider Credentialing process and requirements or is not a Medicaid enrolled Provider.

                


        

      

       

      
        
          	

                	10.4.1.3	
                  Specify that any Provider whose participation is terminated under the Provider Contract for any reason shall utilize the applicable Appeals procedures outlined in the
                      Provider Contract. No additional or separate right of Appeal to ASES or the Contractor is created as a result of the Contractor’s act of terminating, or decision to terminate any Provider under this Contract. Notwithstanding the
                      termination of the Provider Contract with respect to any particular Provider, this Contract shall remain in full force and effect with respect to all other Providers.

                


        

      

       

      
        Page 173 of 324

        
          


      

      
        
          	

                	10.4.2	
                  The Contractor shall notify ASES at least forty-five (45) Calendar Days prior to the effective date of the suspension, termination, or withdrawal of a Provider from
                      participation in the Contractor’s General Network. If the cause for termination falls under Section 10.4.1.2, the Contractor shall provide to ASES an explanation of the reasons for termination Immediately.

                


        

      

       

      
        
          	

                	10.4.2.1	
                  Notices provided to ASES under Section 10.4.2 must be accompanied by an explanation regarding how Network Adequacy will be met regardless of the termination, and a plan
                      to transition Enrollees to a different Provider without interruptions to their care. Contractor shall amend or suspend the transition plan at ASES’s request.

                


        

      

       

      
        
          	

                	10.4.3	
                  Unless otherwise specified by ASES, the Contractor shall, within fifteen (15) Calendar Days of issuance of a notice of termination to a Provider, provide written notice
                      of the termination to Enrollees who received his or her Primary Care from, or was seen on a regular basis by, the terminated Provider, and shall assist the Enrollee as needed in finding a new Provider.

                


        

      

       

      
        
          	

                	10.5	
                  Provider Payment

                


        

      

       

      
        
          	

                	10.5.1	
                  General Provisions

                


        

      

       

      
        
          	

                	10.5.1.1	
                  The Contractor guarantees payment for all Medically Necessary Services rendered by Providers on a person’s Effective Date of Enrollment, including during the retroactive
                      period described in Section 5.1.3.1.

                


        

      

       

      
        
          	

                	10.5.1.2	
                  The Contractor shall require, as a condition of payment, that the Provider accept the amount paid by the Contractor or appropriate denial made by the Contractor (or, if
                      applicable, payment by the Contractor that is supplementary to the Enrollee’s Third Party payer) plus any applicable amount of Co-Payment responsibilities due from the Enrollee as payment in full for the service.

                


        

      

       

      
        
          	

                	10.5.1.3	
                  The Contractor shall ensure that Enrollees are held unaccountable by the Provider for the costs of Medically Necessary Services except for applicable Co-Payment amounts
                      (described in Section 9.3 of this Contract and Attachment 8 to this Contract).

                


        

      

       

      
        Page 174 of 324

        
          


      

      
        
          	

                	10.5.1.4	
                  The insolvency, liquidation, bankruptcy, or breach of contract of any Provider will not release the Contractor from its obligation to pay for all services rendered as
                      authorized under this Contract.

                


        

      

       

      
        
          	

                	10.5.1.5	
                  With the exceptions noted below, the Contractor shall negotiate rates with Providers, and such rates shall be specified in the Provider Contract. Payment arrangements may
                      take any form allowed under Federal law and the laws of Puerto Rico, including Capitation payments, Fee-for-Service payment, and salary, if any, subject to Section 10.6 concerning permitted risk arrangements. However, the Contractor
                      must consider the use of a benchmark for provider reimbursement rates equaling eighty percent (80%) of the 2018 Medicare fee schedule for the reimbursement of non-facility professional services related to cardiology and nuclear
                      medicine services, and seventy percent (70%) of the 2018 Medicare fee schedule for the reimbursement of non-facility professional services related to all other specialties except radiation oncology, hematology/oncology, urology,
                      interventional radiology and dialysis services.  Any use of the 2018 Medicare fee schedule as a guideline to set maximum provider reimbursement rates shall not obligate the Contractor to increase current provider reimbursement rates
                      that have been previously negotiated. The Contractor shall inform ASES in writing when it enters any Provider payment arrangement.

                


        

      

       

      
        
          	

                	10.5.1.6	
                  Any Capitation payment made by the Contractor to Providers shall be based on sound actuarial methods in accordance with 42 CFR 438.4. The Contractor shall submit data
                      supporting the actuarial soundness of Capitation Payments to ASES, including the base data generated by the Contractor. All Provider payments by the Contractor shall be reasonable, and the amount paid shall not jeopardize or infringe
                      upon the quality of the services provided.

                


        

      

       

      
        
          	

                	10.5.1.7	
                  Even if the Contractor does not enter into a capitated payment arrangement with a Provider, the Provider shall nonetheless be required to submit to the Contractor
                      detailed Encounter Data (see Section 16.8 of this Contract).

                


        

      

       

      
        
          	

                	10.5.1.8	
                  The Contractor shall be responsible for issuing to the forms required by the Department of the Treasury, in accordance with all Puerto Rico laws, regulations, and
                      guidelines.

                


        

      

       

      
        
          	

                	10.5.1.9	
                  The Contractor shall make timely payments to Providers in accordance with the timeliness standards outlined in Section 16.10 of this Contract.

                


        

      

       

      
        Page 175 of 324

        
          


      

      
        
          	

                	10.5.2	
                  Payments to FQHCs and RHCs. When the Contractor negotiates a contract with an FQHC and/or an RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social
                      Security Act, the Contractor shall pay to the FQHC or RHC rates that are comparable to rates paid to other similar Providers providing similar services. The Contractor shall cooperate with ASES and the Department of Health in ensuring
                      that payments to FQHCs and RHCs are consistent with Sections 1902(a)(15) and 1902(bb)(5) of the Social Security Act.

                


        

      

       

      
        
          	

                	10.5.3	
                  Requirement to Verify Eligibility. The Contractor warrants that all of its Network Providers shall verify the eligibility of Enrollees before the Provider provides
                      Covered Services. This verification of eligibility is a condition of receiving payment from the Contractor for Covered Services.

                


        

      

       

      
        
          	

                	10.5.4	
                  Payments to Providers Owing Funds to ASES. Upon receipt of notice from ASES that ASES is owed funds by a Provider due to an Overpayment or other reasons, the Contractor
                      shall reduce payment to the Provider for all Claims submitted by that Provider by one hundred percent (100%), or such other amount as ASES may elect, until the amount owed to ASES is recovered. The Contractor shall promptly remit any
                      such funds recovered to ASES in the manner specified by ASES. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the
                      Contract shall constitute agreement with the Contractor’s obligation to ASES.

                


        

      

       

      
        
          	

                	10.5.5	
                  Payment Rates Subject to Change. The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes, as directed by the Executive Director of
                      ASES, to the extent that such adjustments can be made within funds appropriated to ASES and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the
                      Provider, such that the Provider’s execution of the Provider Contract shall constitute agreement with the Contractor’s obligation to ASES.

                


        

      

       

      
        
          	

                	10.5.6	
                  Payments for Hospitalization Services or Services Extending for More than Thirty (30) Calendar Days. In the event of hospitalization or extended services that exceed
                      thirty (30) Calendar Days, the Provider may bill and collect payments for services rendered to the Enrollee at least once per month. These services shall be paid according to the procedures discussed in this Article 10.

                


        

      

       

      
        
          	

                	10.5.7	
                  Payments for Services to Dual Eligible Beneficiaries. The Contractor shall include in its Provider Contracts a notice that the Contractor shall not pay Claims for
                      services covered under the Medicare Program except as set forth in Section 23.5. No Provider may bill both the GHP and the Medicare Program for a single service rendered to a Dual Eligible Beneficiary. The Contractor shall include in
                      its Provider Contracts a requirement that the Provider shall comply with 42 CFR 447.15 to accept Medicaid payments as payment in full.

                


        

      

       

      
        Page 176 of 324

        
          


      

      
        
          	

                	10.5.8	
                  Payment for Pharmacy Services. The Contractor shall abide by and comply with the following payment process hereby established:

                


        

      

       

      
        
          	

                	10.5.8.1	
                  In covering pharmacy services, the Contractor shall adhere to the retail pharmacy reimbursement levels established in Attachment 6 to this Contract.

                


        

      

       

      
        
          	

                	10.5.8.2	
                  On a bi-monthly payment cycle to be set by the PBM, the PBM will provide the Contractor with the proposed Claims listing. The Contractor shall promptly review the payment
                      listing.

                


        

      

       

      
        
          	

                	10.5.8.3	
                  The PBM will submit to the Contractor the invoice and summary, which includes the amount of Claims cost to be paid to participating Pharmacies and the amount to switch
                      fees to be paid to the PBM. The Contractor shall electronically transfer funds to the PBM’s bank account within two (2) Business Days after receiving the invoice from the PBM. The Contractor shall certify the listing of medications
                      dispatched and paid bi-weekly to confirm the PBM’s and/or other Contractors’ administrative payment.

                


        

      

       

      
        
          	

                	10.5.8.4	
                  The Contractor, ASES, and the PBM shall cooperate to identify additional savings opportunities, including special purchasing opportunities, changes in network fees, etc.

                


        

      

       

      
        
          	

                	10.5.9	
                  Payments to Providers Outside the PPN. The Contractor shall provide for adequate payment in its contracts with Providers outside the PPN.

                


        

      

       

      
        
          	

                	10.5.10	
                  Payments for Emergency Services and Post-Stabilization Services

                


        

      

       

      
        
          	

                	10.5.10.1	
                  The Contractor shall not deny a Claim from a Provider for Emergency Services and shall make payment to a Provider for responding to an Enrollee’s Emergency Medical
                      Condition or Psychiatric Emergency by performing medical screening examinations and stabilizing treatment.

                


        

      

       

      
        
          	

                	10.5.10.2	
                  Pursuant to Section 1932(b)(2)(D) of the Social Security Act, the Contractor shall limit payments to Out-of-Network Providers of Emergency Services to the amount that
                      would have been paid if the service had been provided by a Network Provider.

                


        

      

       

      
        
          	

                	10.5.11	
                  Payments to State Health Facilities. The Contractor shall establish a payment system, upon request in writing by ASES, to improve cash flow to health care facilities administered or operated by the Central Government identified in
                      Section 9.6.1 that participate in the General Network. Such payment system shall not be structured as a pass-through payment.

                


        

      

       

      
        Page 177 of 324

        
          


      

      
        
          	

                	10.6	
                  Acceptable Risk Arrangements

                


        

      

       

      
        
          	

                	10.6.1	
                  The Contractor’s Provider Contracts with PMGs shall establish a financial risk arrangement agreed upon between the Contractor and the PMG which shall be clearly stated in
                      the PMG contract with the Contractor.

                


        

      

       

      
        
          	

                	10.7	
                  Physician Incentive Programs

                


        

      

       

      
        
          	

                	10.7.1	
                  General Provisions

                


        

      

       

      
        
          	

                	10.7.1.1	
                  The Contractor may, upon prior written approval from ASES, design and implement one (1) Physician Incentive Plan, and shall incorporate the requirements of this plan into
                      Provider Contracts. The Contractor shall submit a written request to ASES before implementing any such incentive program by providing a summary of the program for ASES review and approval at least sixty (60) Calendar Days before the
                      projected implementation date for the program. ASES has the absolute right to approve or disapprove the Physician Incentive program, and the program may be implemented only upon receipt of prior written approval from ASES.

                


        

      

       

      
        
          	

                	10.7.1.2	
                  ASES will approve a Physician Incentive Program only if it, in ASES’s discretion, meets the following requirements:

                


        

      

       

      
        
          	

                	10.7.1.2.1	
                  The program contains credible medical standards in support of the improvement of quality health services and reduces or eliminates any adverse effects on patients’ care;

                


        

      

       

      
        
          	

                	10.7.1.2.2	
                  All incentive payments to Providers are related to or made under quality initiatives supported or otherwise approved by CMS;

                


        

      

       

      
        
          	

                	10.7.1.2.3	
                  The implementation of the program in no way reduces or otherwise limits Enrollee Access to Medically Necessary Services (including a reduction in prescription drugs,
                      diagnostic tests or treatments, hospitalization, and other treatment available regardless of the incentives);

                


        

      

       

      
        
          	

                	10.7.1.2.4	
                  The Contractor shall employ continuous monitoring by an independent Third Party to confirm that Enrollee care is not adversely affected by the program;

                


        

      

       

      
        
          	

                	10.7.1.2.5	
                  The intent of the program is to improve the quality of the services to Enrollees. Enrollees shall be informed of the existence of the Physician Incentive program, and the
                      Provider shall be made fully responsible for the proper care to the Enrollee; and

                


        

      

       

      
        Page 178 of 324

        
          


      

      
        
          	

                	10.7.1.2.6	
                  Incentives are not used to penalize Providers who serve Enrollees whose treatment needs, according to the Provider’s medical judgment, do not fall within the Contractor’s
                      fixed clinical protocols.

                


        

      

       

      
        
          	

                	10.7.2	
                  Pay for Performance for Hospitals. ASES approves the use of incentive programs targeting hospitals, provided that the incentive programs:

                


        

      

       

      
        
          	

                	10.7.2.1	
                  Encourage the use of medical standards that support quality improvement and reduce adverse effects in Enrollee care;

                


        

      

       

      
        
          	

                	10.7.2.2	
                  Advance the quality initiatives supported by CMS;

                


        

      

       

      
        
          	

                	10.7.2.3	
                  Are not geared toward, and do not have the likely effect of, reducing or limiting services that the Enrollee needs or may need (for example, reduction of diagnostic
                      exams, hospitalization, or treatment);

                


        

      

       

      
        
          	

                	10.7.2.4	
                  Are not used solely as a mechanism for reducing payments to or recovering payments from Providers;

                


        

      

       

      
        
          	

                	10.7.2.5	
                  Contain clearly defined objectives, effectively communicated to both Providers and (upon request) Enrollees;

                


        

      

       

      
        
          	

                	10.7.2.6	
                  Aim to reduce “never events,” such as health care-associated infections and other hospital-acquired conditions (including reaction to foreign substances accidentally left
                      in during procedure, air embolism, blood incompatibility, pressure ulcers, and falls);

                


        

      

       

      
        
          	

                	10.7.2.7	
                  Address inappropriate admissions and readmissions; and

                


        

      

       

      
        
          	

                	10.7.2.8	
                  Address over-utilization of caesarian sections.

                


        

      

      

      

      
        
          	ARTICLE 11	
                  UTILIZATION MANAGEMENT

                


        

      

       

      
        
          	

                	11.1	
                  General

                


        

      

       

      
        
          	

                	11.1.1	
                  The Contractor shall comply with Puerto Rico and Federal requirements for Utilization Management (“UM”) including but not limited to 42 CFR Part 456.

                


        

      

       

      
        
          	

                	11.1.2	
                  The Contractor shall ensure the involvement of appropriate, knowledgeable, currently practicing Providers in the development of UM procedures.

                


        

      

       

      
        
          	

                	11.1.3	
                  The Contractor shall manage the use of a limited set of resources and maximize the effectiveness of care by evaluating clinical appropriateness, and authorizing the type
                      and volume of services through fair, consistent, and Culturally Competent decision-making processes while ensuring equitable Access to care and a successful link between care and outcomes.

                


        

      

       

      
        Page 179 of 324

        
          


      

      
        
          	

                	11.1.4	
                  The Contractor shall submit to ASES on an annual basis existing UM edits in the Contractor’s Claims processing system that control Utilization and prevent payment for
                      Claims that are duplicates, unbundled when they should be bundled, already covered under another charge, etc.

                


        

      

       

      
        
          	

                	11.1.5	
                  ASES reserves the right require the Contractor to submit any Utilization Management report.

                


        

      

       

      
        
          	

                	11.2	
                  Utilization Management Policies and Procedures

                


        

      

       

      
        
          	

                	11.2.1	
                  The Contractor shall provide assistance to Enrollees and Providers to ensure the appropriate Utilization of resources. The Contractor shall have written Utilization
                      Management policies and procedures included in the Provider Guidelines (see Section 10.2.1.4) that:

                


        

      

       

      
        
          	

                	11.2.1.1	
                  Include protocols and criteria for evaluating Medical Necessity, authorizing services, and detecting and addressing over, under, and inappropriate Utilization. Such
                      protocols and criteria shall comply with Federal and Puerto Rico laws and regulations.

                


        

      

       

      
        
          	

                	11.2.1.2	
                  Address which services require PCP Referral, which services require Prior Authorization, and how requests for initial and continuing services are processed, and which
                      services will be subject to concurrent, retrospective, or prospective review.

                


        

      

       

      
        
          	

                	11.2.1.3	
                  Describe mechanisms in place that ensure consistent application of review criteria for Prior Authorization decisions and consult with the requesting Provider when
                      appropriate.

                


        

      

       

      
        
          	

                	11.2.1.4	
                  Require that all Medical Necessity determinations be made in accordance with ASES’s Medical Necessity definition as stated in Section 7.2. Divergence from standards set
                      forth in clinical protocols and guidelines cannot be the sole reason for denying a Covered Service if the divergence is documented by the treating physician and supported by clinical evidence and generally accepted medical norms;
                      appropriate in type, frequency, grade, setting and duration; and not solely for the convenience of the Enrollee, treating or other Provider, or the Contractor.

                


        

      

       

      
        
          	

                	11.2.1.5	
                  Facilitate the delivery of high quality, low cost, efficient, and effective care.

                


        

      

       

      
        
          	

                	11.2.1.6	
                  Ensure that services are based on the history of the problem or illness, its context, and desired outcomes.

                


        

      

      

    

    
      Page 180 of 324

      
        


    

    
      
        
          	

                	11.2.1.7	
                  Emphasize relapse and crisis prevention, not just crisis intervention.

                


        

      

       

      
        
          	

                	11.2.1.8	
                  Detect over, under, and inappropriate Utilization of services to assess quality and appropriateness of services and to assess quality and appropriateness of care
                      furnished to Enrollees with special health care needs.

                


        

      

       

      
        
          	

                	11.2.1.9	
                  Ensure that any decision to deny a Service Authorization Request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a
                      Provider who has appropriate clinical expertise to understand the treatment of the Enrollee’s condition or disease, such as the Contractor’s medical director.

                


        

      

       

      
        
          	

                	11.2.2	
                  The Contractor shall submit its Utilization Management policies and procedures to ASES for review and prior written approval according to the timeframe specified in
                      Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	11.2.3	
                  The Contractor’s Utilization Management policies and procedures shall define when a conflict of interest for a Provider involved in Utilization Management activities may
                      exist and shall describe the remedy for such conflict.

                


        

      

       

      
        
          	

                	11.2.4	
                  The Contractor, and any delegated Utilization Management agent, shall not permit or provide compensation or anything of value to its employees, Agents, or contractors
                      based on:

                


        

      

       

      
        
          	

                	11.2.4.1	
                  Either a percentage of the amount by which a Claim is reduced for payment or the number of Claims or the cost of services for which the person has denied authorization or
                      payment; or

                


        

      

       

      
        
          	

                	11.2.4.2	
                  Any other method that encourages a decision to deny, limit, or discontinue a Medically Necessary Covered Service to any Enrollee, as set forth by 42 CFR 438.210(e).

                


        

      

       

      
        
          	

                	11.2.5	
                  If the Contractor delegates any of its utilization management responsibilities under this Section 11.2 or 11.4 to any delegated Utilization Management agent or
                      Subcontractor, such agent or Subcontractor shall also comply with written policies and procedures for processing requests for authorizations of services in accordance with 42 CFR 438.210(b)(1).

                


        

      

       

      
        
          	

                	11.3	
                  Utilization Management Guidance to Enrollees

                


        

      

       

      
        
          	

                	11.3.1	
                  As provided in Section 6.4.5.22, the Contractor shall provide clear guidance in its Enrollee Handbook on Utilization Management policies. Upon request, the Contractor
                      shall provide Utilization Management decision criteria to Providers, Enrollees, their families, and the public.

                


        

      

       

      
        Page 181 of 324

        
          


      

      
        
          	

                	11.4	
                  Prior Authorization and Referral Policies

                


        

      

       

      
        
          	

                	11.4.1	
                  Referrals

                


        

      

       

      
        
          	

                	11.4.1.1	
                  The Contractor shall not require a Referral from a PCP when an Enrollee seeks care from a Provider in the Contractor’s PPN.

                


        

      

       

      
        
          	

                	11.4.1.2	
                  A written Referral from the PCP shall be required:

                


        

      

       

      
        
          	

                	11.4.1.2.1	
                  For the Enrollee to access specialty care and services within the Contractor’s General Network but outside the PPN; and

                


        

      

       

      
        
          	

                	11.4.1.2.2	
                  For the Enrollee to access an Out-of-Network Provider (with the exception of Emergency Services).

                


        

      

       

      
        
          	

                	11.4.1.3	
                  A Referral for either the General Network or out-of-network services will be provided during the same visit with the PCP but no later than twenty-four (24) hours of the
                      Enrollee’s request.

                


        

      

       

      
        
          	

                	11.4.1.4	
                  When a Provider does not make the Referral in the required timeframe specified, or refuses to make a Referral, the Contractor shall issue an Administrative Referral.

                


        

      

       

      
        
          	

                	11.4.1.5	
                  Neither the Contractor nor any Provider or Subcontractor may impose a requirement that Referrals be submitted for the approval of committees, boards, Medical Directors,
                      etc. The Contractor shall strictly enforce this directive and shall issue Administrative Referrals (see Section 11.4.1.4) whenever it deems medically necessary.

                


        

      

       

      
        
          	

                	11.4.1.6	
                  If the Provider Access requirements of Section 9.5 of this Contract cannot be met within the PPN within thirty (30) Calendar Days of the Enrollee’s request for the
                      Covered Service, the PMG shall refer the Enrollee to a specialist within the General Network, without the imposition of Co-Payments. However, the Enrollee shall return to the PPN specialist once the PPN specialist is available to
                      treat the Enrollee.

                


        

      

       

      
        
          	

                	11.4.1.7	
                  The Contractor shall ensure that PMGs comply with the rules stated in this Section concerning Referrals, so that Enrollees are not forced to change PMGs in order to
                      obtain needed Referrals.

                


        

      

       

      
        
          	

                	11.4.1.8	
                  If the Referral system that is developed by the Contractor requires the use of electronic media, such equipment shall be installed in Network Providers’ offices at the
                      Contractor’s expense.

                


        

      

       

      
        
          	

                	11.4.2	
                  Timeliness of Prior Authorization

                


        

      

       

      
        Page 182 of 324

        
          


      

      
        
          	

                	11.4.2.1	
                  The Contractor shall ensure that Prior Authorization is provided for the Enrollee in the following timeframes, including on holidays and outside of normal business hours.

                


        

      

       

      
        
          	

                	11.4.2.1.1	
                  With the exception of Prior Authorization of covered prescription drugs as described in Section 7.5.12.4.2, the decision to grant or deny a Prior Authorization shall not
                      exceed seventy-two (72) hours from the time of the Enrollee’s Service Authorization Request for all Covered Services; except that, where the Contractor or the Enrollee’s Provider determines that the Enrollee’s life or health could be
                      endangered by a delay in accessing services, the Prior Authorization shall be provided as expeditiously as the Enrollee’s health requires, and no later than twenty-four (24) hours from the Service Authorization Request.

                


        

      

       

      
        
          	

                	11.4.2.1.2	
                  The Contractor may extend the time allowed for Prior Authorization decisions for up to fourteen (14) Calendar Days, where:

                


        

      

       

      
        
          	

                	11.4.2.1.2.1	
                  The Enrollee, or the Provider, requests the extension; or

                


        

      

       

      
        
          	

                	11.4.2.1.2.2	
                  The Contractor justifies to ASES a need for the extension in order to collect additional Information, such that the extension is in the Enrollee’s best interest.

                


        

      

       

      
        
          	

                	11.4.2.1.3	
                  If the timeframe is extended in accordance with 11.4.2.1.2.2, the Contractor shall give the Enrollee written notice of the reason behind granting the extension and inform
                      the Enrollee of the right to file a Grievance if he or she disagrees with that decision. The notice of the determination shall be sent as expeditiously as the Enrollee’s health condition requires and no later than the expiration date
                      of the extension.

                


        

      

       

      
        
          	

                	11.4.2.2	
                  For services that require Prior Authorization by the Contractor, the Service Authorization Request shall be submitted promptly by the Provider for the Contractor’s
                      approval, so that Prior Authorization may be provided within the timeframe set forth in this Section 11.4.2.

                


        

      

       

      
        
          	

                	11.4.2.3	
                  The Contractor shall notify the Enrollee and Provider, verbally or in writing, of the approval of a Service Authorization Request Immediately after such determination is
                      made. Notices of Adverse Benefit Determinations must comply with the requirements set forth in Section 14.4.

                


        

      

       

      
        Page 183 of 324

        
          


      

      
        
          	

                	11.4.3	
                  The Contractor shall submit to ASES Utilization Management clinical criteria to be used for services requiring Prior Authorization. ASES shall prior approve in writing
                      such Utilization Management clinical criteria.

                


        

      

       

      
        
          	

                	11.4.4	
                  Prohibited Actions

                


        

      

       

      
        
          	

                	11.4.4.1	
                  Any denial, unreasonable delay, or rationing of Medically Necessary Services to Enrollees is expressly prohibited. The Contractor shall ensure compliance with this
                      prohibition from Network Providers or any other entity related to the provision of Behavioral Health services to GHP Enrollees. Should the Contractor violate this prohibition, the Contractor shall be subject to the provisions of
                      Article VI, Section 6 of Act 72 and 42 CFR 438, Subpart I (Sanctions).

                


        

      

       

      
        
          	

                	11.4.5	
                  The Contractor shall employ appropriately licensed professionals to supervise all Prior Authorization decisions and shall specify the type of personnel responsible for
                      each type of Prior Authorization in its policies and procedures. Any decision to deny a Service Authorization Request or to authorize a service in an amount, duration, or scope that is less than requested shall be made by a Provider
                      who possesses the appropriate clinical expertise for treating the Enrollee’s condition. For Service Authorization Requests for dental services, only licensed dentists are authorized to make such decisions.

                


        

      

       

      
        
          	

                	11.4.6	
                  Emergency Services

                


        

      

       

      
        
          	

                	11.4.6.1	
                  Neither a Referral nor Prior Authorization shall be required for any Emergency Service, no matter whether the Provider is within the PPN, and notwithstanding whether
                      there is ultimately a determination that the condition for which the Enrollee sought treatment from an Emergency Services Provider was not an Emergency Medical Condition or Psychiatric Emergency.

                


        

      

       

      
        
          	

                	11.4.7	
                  Dental Services

                


        

      

       

      
        
          	

                	11.4.7.1	
                  The Contractor shall not require a Prior Authorization or a Referral for dental services except for maxillofacial surgery which requires Prior Authorization from a PCP.

                


        

      

       

      
        
          	

                	11.4.8	
                  Pharmacy Services

                


        

      

       

      
        
          	

                	11.4.8.1	
                  The Contractor shall require Prior Authorization for filling a drug prescription for certain drugs specified on the FMC, as provided in Section 7.5.12.10.

                


        

      

       

      
        
          	

                	11.4.8.2	
                  The Contractor shall require a Countersignature from the Enrollee’s PCP in order to fill a prescription written by a Provider who is not in the PPN.

                


        

      

       

      
        Page 184 of 324

        
          


      

      
        
          	

                	11.4.8.3	
                  Any required Prior Authorization or Countersignature for pharmacy services shall be conducted within the timeframes provided in Sections 7.5.12.4.

                


        

      

       

      
        
          	

                	11.4.8.4	
                  The Contractor shall comply with the Utilization Management policies and procedures in Section 7.5.12 of this Contract for pharmacy services.

                


        

      

       

      
        
          	

                	11.4.9	
                  Special Coverage

                


        

      

       

      
        
          	

                	11.4.9.1	
                  In order to obtain services under Special Coverage, an Enrollee shall be registered in the program, as provided in Section 7.7. Registration is a form of Utilization
                      control, to determine whether the Enrollee’s health condition warrants Access to the expanded services included in Special Coverage.

                


        

      

       

      In addition, as noted in Section 7.7.12, some individual Special Coverage services require Prior Authorization even for Enrollees who
          have registered under Special Coverage.

       

      
        
          	

                	11.4.10	
                  Behavioral Health Services. The Contractor shall not require a Prior Authorization or a Referral for Behavioral Health services except for Partial Hospitalizations,
                      Electroconvulsive Therapy and some medications as indicated in the FMC.

                


        

      

       

      
        
          	

                	11.5	
                  Use of Technology to Promote Utilization Management

                


        

      

       

      
        
          	

                	11.5.1	
                  ASES strongly encourages the Contractor to develop electronic, web-based Referral processes and systems. In the event that a Referral is made via the telephone, the
                      Contractor shall ensure that Referral Data are maintained in a Data file that can be accessed electronically by the Contractor, the Provider, and ASES.

                


        

      

       

      
        
          	

                	11.5.2	
                  In conjunction with its other Utilization Management policies, the Contractor shall submit the Referral processes to ASES for review and prior written approval in
                      accordance with Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	11.6	
                  Court-Ordered Evaluations and Services

                


        

      

       

      
        
          	

                	11.6.1	
                  In the event that an Enrollee requires Medicaid-covered services ordered by a court, the Contractor shall fully comply with all court orders while maintaining appropriate
                      Utilization Management practices.

                


        

      

       

      
        
          	

                	11.7	
                  Second Opinions

                


        

      

       

      
        
          	

                	11.7.1	
                  The Contractor shall provide a second opinion in any situation when there is a question concerning a diagnosis, the options for surgery, or alternative treatments of a
                      health condition when requested by any Enrollee, or by a parent, guardian, or other person exercising a custodial responsibility over the Enrollee.

                


        

      

       

      
        Page 185 of 324

        
          


      

      
        
          	

                	11.7.2	
                  The second opinion shall be provided by a qualified Network Provider, or, if a Network Provider is unavailable, the Contractor shall arrange for the Enrollee to obtain a
                      second opinion from an Out-of-Network Provider.

                


        

      

       

      
        
          	

                	11.7.3	
                  The second opinion shall be provided at no cost to the Enrollee.

                


           

          

        

      

      
        
          	ARTICLE 12	
                  QUALITY IMPROVEMENT AND PERFORMANCE PROGRAM

                


        

      

       

      
        
          	

                	12.1	
                  General Provisions

                


        

      

       

      
        
          	

                	12.1.1	
                  The Contractor shall provide for the delivery of quality care to all Enrollees with the primary goal of improving health status or, in instances where the Enrollee’s
                      health is not amenable to improvement, maintaining the Enrollee’s current health status by implementing measures to prevent any further deterioration of his or her health status.

                


        

      

       

      
        
          	

                	12.1.2	
                  The Contractor shall seek input from, and work with, Enrollees, Providers, community resources, and agencies to actively improve the quality of care provided to
                      Enrollees.

                


        

      

       

      
        
          	

                	12.1.3	
                  The Contractor shall ensure that its Quality Assessment and Performance Improvement Program effectively monitors the program elements listed in 42 CFR 438.66.

                


        

      

       

      
        
          	

                	12.1.4	
                  ASES, in strict compliance with 42 CFR 438.340 and other Federal and Puerto Rico regulations, shall evaluate the delivery of health care by the Contractor. Such quality
                      monitoring shall include monitoring of all the Contractor’s Quality Management/Quality Improvement (“QM/QI”) programs described in this Article 12 of this Contract.

                


        

      

       

      
        
          	

                	12.1.5	
                  The Contractor shall cooperate with any Puerto Rico or Federal monitoring of its performance under this Contract, which may include but is not limited to external quality
                      reviews, operational reviews, performance audits and evaluations.

                


        

      

       

      
        
          	

                	12.1.6	
                  The Contractor shall identify, collect and provide any Data, Medical Records or other Information requested by ASES or its authorized representative or the Federal agency
                      or its authorized representative in the format specified by ASES/Federal agency or its authorized representative. The Contractor shall ensure that the requested Data, Medical Records, and other Information is provided at no charge to
                      ASES, all Federal agencies, or their authorized representative.

                


        

      

       

      
        Page 186 of 324

        
          


      

      
        
          	

                	12.1.7	
                  If requested, the Contractor shall provide workspace at the Contractor’s local offices for ASES, any Federal agencies, or their authorized representative to review
                      requested Data, Medical Records, or other Information.

                


        

      

       

      
        
          	

                	12.1.8	
                  Advisory Board

                


        

      

       

      
        
          	

                	12.1.8.1	
                  The Contractor shall convene and facilitate an advisory board. Advisory board members shall serve to advise the Contractor on issues concerning service delivery and
                      quality of all Covered Services (e.g., Behavioral Health, physical health), Enrollee rights and responsibilities, resolution of Enrollee Grievances and Appeals and the needs of groups represented by advisory board members as they
                      pertain to Medicaid.

                


        

      

       

      
        
          	

                	12.1.8.2	
                  The advisory board shall consist of representatives from all GHP populations, family members, and Providers. The Contractor shall have an equitable representation of its
                      representatives in terms of race, gender, special populations, and Puerto Rico’s geographic areas.

                


        

      

       

      
        
          	

                	12.1.8.3	
                  The Contractor’s advisory board shall keep a written record of all attempts to invite and include its representatives in its meetings. The Advisory Board roster and
                      minutes shall be made available to ASES ten (10) Calendar Days following the meeting date. See Article 18 of this Contract for additional reporting requirements.

                


        

      

       

      
        
          	

                	12.1.8.4	
                  The Contractor shall hold quarterly, centrally located advisory board meetings throughout the Contract Term. The Contractor shall advise ASES ten (10) Calendar Days in
                      advance of meetings to be held. At least two (2) of the quarterly meetings shall focus on Enrollee issues to help ensure that Enrollee issues and concerns are heard and addressed. Attendance rosters and minutes for these two (2)
                      meetings shall be made available to ASES within ten (10) Calendar Days following the meeting date.

                


        

      

       

      
        
          	

                	12.1.8.5	
                  The Contractor shall ensure that all advisory board representatives actively participate in deliberations and that no one board representative dominates proceedings in
                      order to foster an inclusive meeting environment.

                


        

      

       

      
        
          	

                	12.2	
                  Quality Assessment Performance Improvement (“QAPI”) Program

                


        

      

       

      
        
          	

                	12.2.1	
                  The Contractor shall comply with Puerto Rico and Federal standards for Quality Management/Quality Improvement (“QM/QI”).

                


        

      

       

      
        
          	

                	12.2.1.1	
                  The Contractor shall establish QAPI that specifies the Contractor’s quality measurement and performance improvement activities using clinically sound, nationally
                      developed and accepted criteria.

                


        

      

       

      
        Page 187 of 324

        
          


      

      
        
          	

                	12.2.2	
                  For Medicaid and CHIP Eligibles, the QAPI program shall be in compliance with Federal requirements specified at 42 CFR 438.330.

                


        

      

       

      
        
          	

                	12.2.3	
                  The Contractor’s QAPI program shall be based on the latest available research in the area of quality assurance and at a minimum shall include:

                


        

      

       

      
        
          	

                	12.2.3.1	
                  A method of monitoring, analyzing, evaluating, and improving the delivery, quality and appropriateness of health care furnished to all Enrollees (including over, under,
                      and inappropriate Utilization of services) and including those with special health care needs, as defined by ASES in the quality strategy;

                


        

      

       

      
        
          	

                	12.2.3.2	
                  Written policies and procedures for quality assessment, Utilization Management, and continuous quality improvement that are periodically assessed for efficacy and reflect
                      Enrollee and Network Provider input;

                


        

      

       

      
        
          	

                	12.2.3.3	
                  Include an Information System sufficient to support the collection, integration, tracking, analysis, and reporting of Data, in compliance with 42 CFR 438.242;

                


        

      

       

      
        
          	

                	12.2.3.4	
                  Designated staff with expertise in quality assessment, Utilization Management, and continuous quality improvement;

                


        

      

       

      
        
          	

                	12.2.3.5	
                  A review of outcome Data at least quarterly for performance improvement recommendations and interventions;

                


        

      

       

      
        
          	

                	12.2.3.6	
                  A mechanism to detect over, under, and inappropriate Utilization of services;

                


        

      

       

      
        
          	

                	12.2.3.7	
                  Reports that have been evaluated, indicated recommendations that are implemented, and provided feedback to Providers and Enrollees;

                


        

      

       

      
        
          	

                	12.2.3.8	
                  A methodology and process for conducting Provider Credentialing and Re-Credentialing;

                


        

      

       

      
        
          	

                	12.2.3.9	
                  Procedures for validating completeness and quality of Encounter Data;

                


        

      

       

      
        
          	

                	12.2.3.10	
                  Annual PIPs as specified by ASES;

                


        

      

       

      
        
          	

                	12.2.3.11	
                  Development of an emergency room (ER) quality initiative program (see Section 12.4);

                


        

      

       

      
        
          	

                	12.2.3.12	
                  Development of a Health Care Improvement Program (see Section 12.5);

                


        

      

       

      
        Page 188 of 324

        
          


      

      
        
          	

                	12.2.3.13	
                  Reporting on specified performance measures, including specified performance measures (see Section 12.5.4.1);

                


        

      

       

      
        
          	

                	12.2.3.14	
                  Conducting Provider and Enrollee satisfaction surveys (see Section 12.6);

                


        

      

       

      
        
          	

                	12.2.3.15	
                  Quarterly reports on program results, conclusions, recommendations, and implemented system changes, as specified by ASES; and

                


        

      

       

      
        
          	

                	12.2.3.16	
                  Process for evaluating the impact and effectiveness of the Contractor’s QAPI program at least annually.

                


        

      

       

      
        
          	

                	12.2.4	
                  The Contractor’s annual QAPI program shall be submitted to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this
                      Contract and the annual reporting requirements outlined in Article 18.

                


        

      

       

      
        
          	

                	12.2.5	
                  The Contractor shall submit any changes to its QAPI program to ASES for review and prior written approval sixty (60) Calendar Days prior to implementation of the change.

                


        

      

       

      
        
          	

                	12.2.6	
                  Upon the request of ASES, the Contractor shall provide any Information and documents related to the implementation of the QAPI program.

                


        

      

       

      
        
          	

                	12.2.7	
                  As per 42 CFR 438.332(a) and (b), the Contractor shall inform ASES as to whether it has been accredited by a private, independent accrediting entity, and if so, shall
                      provide or authorize the accrediting entity to provide ASES, as applicable, a copy of its most recent accreditation review (including its accreditation status, expiration date of the accreditation, and survey type and level)
                      recommended actions or improvements, corrective action plans, and summaries of findings.

                


        

      

       

      
        
          	

                	12.3	
                  Performance Improvement Projects (PIPs)

                


        

      

       

      
        
          	

                	12.3.1	
                  At a minimum, the Contractor shall have a PIPs work plan and activities that are consistent with Federal and Puerto Rico statutes, regulations, and Quality Assessment and
                      Performance Improvement Program requirements for pursuant to 42 C.F.R. 438.330.For more detailed information refer to the “EQR Managed Care Organization Protocol” available at http://www.medicaid.gov/Medicaid-CHIP-
                      Program-Information/By-Topics/Quality-of-Care/Quality-of-Care-External- Quality-Review.html.

                


        

      

       

      
        
          	

                	12.3.2	
                  PIPs shall be designed to achieve, through ongoing measurements and intervention, significant improvement, sustained over time, in clinical care and administrative areas
                      that are expected to have a favorable effect on health outcomes and Enrollee satisfaction.

                


        

      

       

      
        
          	

                	12.3.3	
                  The Contractor shall implement PIPs in the following areas:

                


        

      

       

      
        Page 189 of 324

        
          


      

      
        
          	

                	12.3.3.1	
                  One (1) clinical care project in the area of increasing fistula use for Enrollees at-risk for dialysis;

                


        

      

       

      
        
          	

                	12.3.3.2	
                  One (1) clinical care project in the area of Behavioral Health;

                


        

      

       

      
        
          	

                	12.3.3.3	
                  One (1) administrative project in the area of EPSDT screening;

                


        

      

       

      
        
          	

                	12.3.3.4	
                  One (1) administrative project in the area of reverse co-location and co-location of physical and Behavioral Health and their integration; and

                


        

      

       

      
        
          	

                	12.3.3.5	
                  The Contractor shall conduct additional PIPs as specified by ASES during the Contract Term.

                


        

      

       

      
        
          	

                	12.3.4	
                  In designing its PIPs, the Contractor shall:

                


        

      

       

      
        
          	

                	12.3.4.1	
                  Show that the selected area of study is based on a demonstration of need and is expected to achieve measurable benefit to Enrollee (rationale);

                


        

      

       

      
        
          	

                	12.3.4.2	
                  Establish clear, defined and measurable goals and objectives that the Contractor shall achieve in each year of the project;

                


        

      

       

      
        
          	

                	12.3.4.3	
                  Measure performance using quality indicators that are objective, measurable, clearly defined and that allow tracking of performance and improvement over time;

                


        

      

       

      
        
          	

                	12.3.4.4	
                  Implement interventions designed to achieve quality improvements;

                


        

      

       

      
        
          	

                	12.3.4.5	
                  Evaluate the effectiveness of the interventions;

                


        

      

       

      
        
          	

                	12.3.4.6	
                  Establish standardized performance measures (such as HEDIS or another similarly standardized product);

                


        

      

       

      
        
          	

                	12.3.4.7	
                  Plan and initiate activities for increasing or sustaining improvement; and

                


        

      

       

      
        
          	

                	12.3.4.8	
                  Document the Data collection methodology used (including sources) and steps taken to assure Data is valid and reliable.

                


        

      

       

      
        
          	

                	12.3.5	
                  The Contractor shall submit all descriptions of PIPs and program details to ASES annually as part of the QAPI program.

                


        

      

       

      
        
          	

                	12.3.6	
                  Each PIP shall be evaluated by the EQRO. The Contractor shall provide information to the EQRO on the status and outcomes of the PIP upon request.

                


        

      

       

      
        
          	

                	12.3.7	
                  When requested, the Contractor shall submit Data to ASES or the EQRO for standardized PIPs. The Contractor shall collect valid and reliable Data, using qualified staff
                      and personnel to collect the Data. Failure of the Contractor to follow Data collection and submission requirements may result in sanctions.

                


        

      

       

      
        Page 190 of 324

        
          


      

      
        
          	

                	12.4	
                  ER Quality Initiative Program

                


        

      

       

      
        
          	

                	12.4.1	
                  The Contractor shall develop an emergency room (ER) quality initiative program, implementing efficient and timely monitoring of Enrollees’ use of the emergency room,
                      including whether such use was justified by a legitimate Emergency Medical Condition or Psychiatric Emergency.

                


        

      

       

      
        
          	

                	12.4.2	
                  The ER quality initiative program shall be designed to identify high users of Emergency Services for non-emergency situations and to allow for early interventions in
                      order to ensure appropriate Utilization of services and resources.

                


        

      

       

      
        
          	

                	12.4.3	
                  The ER quality initiative program shall specify all strategies to be used by the Contractor to address high users of inappropriate Emergency Services and include, at a
                      minimum, the following components:

                


        

      

       

      
        
          	

                	12.4.3.1	
                  Description of system(s) for tracking, monitoring, and reporting high users of ER services for non-emergency situations;

                


        

      

       

      
        
          	

                	12.4.3.2	
                  Criteria for defining non-emergency situations;

                


        

      

       

      
        
          	

                	12.4.3.3	
                  Educational component to inform (i) Enrollees about the proper use of ER services and how to access ER services and (ii) PCPs about identifying high users or potential
                      high users of ER services and reporting to the Contractor;

                


        

      

       

      
        
          	

                	12.4.3.4	
                  Protocols for identifying high users of inappropriate ER services and referring them to Care Management for needs assessment and identification of other more appropriate
                      services and resources;

                


        

      

       

      
        
          	

                	12.4.3.5	
                  Process for ensuring the provision of physical and Behavioral Health Services in an appropriate setting upon identification of the need.

                


        

      

       

      
        
          	

                	12.4.3.6	
                  Quarterly reporting on ER services Utilization; and

                


        

      

       

      
        
          	

                	12.4.3.7	
                  Process for monitoring and evaluating program effectiveness, identifying issues, and modifying the ER quality initiative program as necessary to improve service
                      Utilization.

                


        

      

       

      
        
          	

                	12.4.4	
                  The Contractor shall submit its ER quality initiative program to ASES as part of its QAPI program.

                


        

      

       

      
        Page 191 of 324

        
          


      

      
        
          	

                	12.5	
                  Health Care Improvement Program (HCIP)

                


        

      

       

      
        
          	

                	12.5.1	
                  The HCIP consists of four (4) initiatives subject to performance indicators specified in the Health Care Improvement Program Manual (“HCIP Manual”), Attachment 19 to this
                      Contract). The initiatives are further defined in the HCIP Manual and the HCIP Manual will be the authoritative document for specifying the performance indicators and measurement periods for the Contract Term.

                


        

      

       

      
        
          	

                	12.5.1.1	
                  High Cost Conditions Initiative;

                


        

      

       

      
        
          	

                	12.5.1.2	
                  Chronic Conditions Initiative;

                


        

      

       

      
        
          	

                	12.5.1.3	
                  Healthy People Initiative; and

                


        

      

       

      
        
          	

                	12.5.1.4	
                  Emergency Room High Utilizers Initiative

                


        

      

       

      
        
          	

                	12.5.2	
                  ASES shall establish a Retention Fund, whereby, per Section 22.4, ASES shall withhold two percent (2%) of PMPM Payments on a monthly basis otherwise payable to the
                      Contractor in order to incent the Contractor to meet performance indicators and targets under Health Care Improvement Program specified in the HCIP Manual. The HCIP Manual will be the authoritative document for specifying the
                      allocation of the overall withhold amount of the PMPM Payments across the initiatives in Section 12.5.1. The Retention Fund shall be reimbursed on a quarterly basis to the Contractor when a determination is made by ASES that the
                      Contractor has complied with the quality standards and criteria established by ASES in accordance with Section 22.4 of this Contract.

                


        

      

       

      
        
          	

                	12.5.2.1	
                  The Contractor shall submit its quality incentive program as part of its QAPI program. The program description shall include, at a minimum:

                


        

      

       

      
        
          	

                	12.5.2.1.1	
                  How the Contractor will educate Providers regarding the program requirements; and

                


        

      

       

      
        
          	

                	12.5.2.1.2	
                  Strategies for ensuring and monitoring program compliance.

                


        

      

       

      
        
          	

                	12.5.3	
                  When requested, the Contractor shall submit Data to ASES for standardized performance measures, within specified timelines and according to the established procedures
                      Data collection and reporting. The Contractor shall collect valid and reliable Data, using qualified staff and personnel to collect the Data. Failure of the Contractor to follow Data collection and reporting requirements may result in
                      sanctions.

                


        

      

       

      
        
          	

                	12.6	
                  Wellness Plan

                


        

      

       

      
        
          	

                	12.6.1	
                  In order to advance the goals of strengthening Preventive Services, providing integrated physical, Behavioral Health, and dental services to all Eligible Persons, and
                      educating Enrollees on health and wellness, the Contractor shall develop a Wellness Plan.

                


        

      

       

      
        Page 192 of 324

        
          


      

      
        
          	

                	12.6.1.1	
                  The Wellness Plan shall include a strategy for coordination with government agencies of Puerto Rico integral to disease prevention efforts and education efforts,
                      including the Health Department, the Department of the Family, and the Department of Education. The Wellness Plan shall incorporate strategies to reach all Enrollees including those living in remote areas.

                


        

      

       

      
        
          	

                	12.6.1.2	
                  The Wellness Plan shall present strategies for encouraging Enrollees to:

                


        

      

       

      
        
          	

                	12.6.1.2.1	
                  Seek an annual health checkup;

                


        

      

       

      
        
          	

                	12.6.1.2.2	
                  Appropriately use the services of the GHP, including GHP Service Line;

                


        

      

       

      
        
          	

                	12.6.1.2.3	
                  Seek women’s health screenings including mammograms, pap smears, cervical screenings, and tests for sexually transmitted infections;

                


        

      

       

      
        
          	

                	12.6.1.2.4	
                  Maintain a healthy body weight, through good nutrition and exercise;

                


        

      

       

      
        
          	

                	12.6.1.2.5	
                  Seek an annual dental exam;

                


        

      

       

      
        
          	

                	12.6.1.2.6	
                  Seek Behavioral Health screening;

                


        

      

       

      
        
          	

                	12.6.1.2.7	
                  Attend to the medical and developmental needs of children and adolescents, including vaccinations; and

                


        

      

       

      
        
          	

                	12.6.1.2.8	
                  Receive education regarding the diagnosis and treatment of high-risk diagnoses including:

                


        

      

       

      
        
          	

                	12.6.1.2.8.1	
                  Depression;

                


        

      

       

      
        
          	

                	12.6.1.2.8.2	
                  Schizophrenia;

                


        

      

       

      
        
          	

                	12.6.1.2.8.3	
                  Bipolar disorders;

                


        

      

       

      
        
          	

                	12.6.1.2.8.4	
                  Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder;

                


        

      

       

      
        
          	

                	12.6.1.2.8.5	
                  Substance abuse; and

                


        

      

       

      
        
          	

                	12.6.1.2.8.6	
                  Anxiety disorders.

                


        

      

       

      
        Page 193 of 324

        
          


      

      
        
          	

                	12.6.1.2.9	
                  The Contractor shall ensure that its Wellness Plan reaches, at a minimum, eighty-five percent (85%) of GHP Enrollees. To achieve the eighty-five (85%) goal, the
                      Contractor shall, in compliance with the requirements of HIPAA and the rules and regulations thereunder, utilize wellness advertisements, campaigns and/or seminars, including without limitation, health fairs, educational activities,
                      visits to enrollees, and others. The Contractor shall also ensure that educational activities are offered by duly licensed professionals, within the scope of their clinical career, who are knowledgeable enough in the specific areas to
                      be addressed in the educational activity. These professionals include, but are not limited to: Health Educators, Nutritionists, Nurses, Psychologists and Physicians.

                


        

      

       

      
        
          	

                	12.6.1.3	
                  The Contractor shall, according to the timeframe specified in Attachment 12 to this Contract, present its Wellness Plan to ASES for review and prior written approval.

                


        

      

       

      
        
          	

                	12.7	
                  Provider and Enrollee Satisfaction Surveys

                


        

      

       

      
        
          	

                	12.7.1	
                  The Contractor shall perform an annual satisfaction survey for Providers and Enrollees. The survey for Enrollees shall be the Consumer Assessment of Health Care Providers
                      and Systems (“CAHPS”) and the Experience of Care and Health Outcomes (“ECHO”) survey instruments.

                


        

      

       

      
        
          	

                	12.7.2	
                  The sample size for both surveys shall equal the number of respondents needed for a statistical confidence level of ninety-five percent (95%) with a margin of error not
                      more than five percent (5%) and shall not have a response rate less than fifty percent (50%).

                


        

      

       

      
        
          	

                	12.7.3	
                  The results of the surveys shall be submitted to ASES and to the Puerto Rico Medicaid Program.

                


        

      

       

      
        
          	

                	12.7.4	
                  The Contractor shall have a process for notifying Providers and Enrollees about the availability of survey findings and making survey findings available upon request.

                


        

      

       

      
        
          	

                	12.7.5	
                  The Contractor shall have a process for utilizing the results of the Provider and Enrollee surveys for monitoring service delivery and quality of services and for making
                      program enhancements.

                


        

      

       

      
        
          	

                	12.8	
                  External Quality Review

                


        

      

       

      
        
          	

                	12.8.1	
                  In compliance with Federal requirements at 42 CFR 438.358, ASES will contract with an External Quality Review Organization (“EQRO”) to conduct annual, external,
                      independent reviews of the quality outcomes, timeliness of, and Access to, the services covered in this Contract. The Contractor shall collaborate with ASES’s EQRO to develop studies, surveys, and other analytic activities to assess
                      the quality of care and services provided to Enrollees and to identify opportunities for program improvement. To facilitate this process the Contractor shall supply Data, including but not limited to Claims Data and Medical Records,
                      to the EQRO. Upon the request of ASES, the Contractor shall provide its protocols for providing Information, participating in review activities, and using the results of the reviews to improve the quality of the services and programs
                      provided to Enrollees.

                


        

      

       

      
        Page 194 of 324

        
          


      

      
        
          	

                	12.8.2	
                  The EQRO shall also audit the Contractor’s Performance Improvement Projects (“PIPs”), performance measure program, and the Contractor’s performance against quality
                      standards based on CMS criteria. The Contractor shall cooperate fully with the EQRO.

                


        

      

       

      
        
          	

                	12.8.3	
                  The Contractor shall participate with the EQRO in various other tasks and projects identified by ASES to gauge performance in a variety of areas, including the
                      integration of physical and Behavioral Health, care coordination, and treatment of special populations.

                


        

      

       

      
        
          	

                	12.8.4	
                  The EQRO retained by ASES shall not be a competitor of the Contractor and shall comply with 42 CFR 438.354.

                


        

      

      

      

      
        
          	ARTICLE 13	
                  FRAUD, WASTE, AND ABUSE

                


        

      

       

      
        
          	

                	13.1	
                  General Provisions

                


        

      

       

      
        
          	

                	13.1.1	
                  The Contractor shall have and implement a comprehensive internal administrative and management controls, policies, and procedures in place designed to prevent, detect,
                      report, investigate, correct, and resolve potential or confirmed cases of Fraud, Waste, and Abuse in the administration and delivery of services detailed in this Contract.

                


        

      

       

      
        
          	

                	13.1.2	
                  For Medicaid and CHIP Eligibles, the Contractor’s internal controls, policies, and procedures shall comply with all Federal requirements regarding Fraud, Waste, and Abuse
                      and program integrity, including but not limited to Sections 1128, 1128A, 1156, 1842(j)(2), 1902(a)(68), and 1903(i)(2)(C) of the Social Security Act, 42 CFR 438.608, the CMS Medicaid Integrity program, and the Deficit Reduction Act
                      of 2005. The Contractor shall exercise diligent efforts to ensure that no payments are made to any person or entity that has been excluded from participation in Federal health care programs. (See State Medicaid Director Letter
                      #09-001, January 16, 2009.)

                


        

      

       

      
        
          	

                	13.1.3	
                  The Contractor shall have surveillance and Utilization control programs and procedures (see 42 CFR 456.3, 42 CFR 456.4, 42 CFR 456.23) to safeguard against
                      under-utilization, unnecessary or inappropriate use of Covered Services and against excess payments for Covered Services.

                


        

      

       

      
        Page 195 of 324

        
          


      

      
        
          	

                	13.1.4	
                  The Contractor shall have adequate staffing and resources to identify and investigate unusual incidents and develop and implement Corrective Action plans to assist the
                      Contractor in preventing and detecting potential Fraud, Waste, and Abuse.

                


        

      

       

      
        
          	

                	13.1.5	
                  The Contractor shall establish effective lines of communication between the Contractor’s compliance officer and the Contractor’s employees to facilitate the oversight of
                      systems that monitor service Utilization and Encounters for Fraud, Waste, and Abuse.

                


        

      

       

      
        
          	

                	13.1.6	
                  The Contractor shall submit its Fraud, Waste, and Abuse policies and procedures, its proposed compliance plan, and its program integrity plan to ASES for prior written
                      approval according to the timeframe specified in Attachment 12 to this Contract.

                


        

      

       

      
        
          	

                	13.1.7	
                  Any changes to the Contractor’s Fraud, Waste, and Abuse policies and procedures shall be submitted to ASES for approval within fifteen (15) Calendar Days of the date the
                      Contractor plans to implement the changes and the changes shall not go into effect until ASES provides prior written approval.

                


        

      

       

      
        
          	

                	13.1.8	
                  The Contractor shall comply with all program integrity provisions of the PPACA including:

                


        

      

       

      
        
          	

                	13.1.8.1	
                  Enhanced Provider screening and enrollment, Section 6401;

                


        

      

       

      
        
          	

                	13.1.8.2	
                  Termination of Provider participation, Section 6501;

                


        

      

       

      
        
          	

                	13.1.8.3	
                  Provider disclosure of current or previous affiliation with excluded Provider(s), Section 6401; and

                


        

      

       

      
        
          	

                	13.1.8.4	
                  Provider screening and enrollment, 42 CFR Part 455, Subpart E.

                


        

      

       

      
        
          	

                	13.1.9	
                  The Contractor shall inform ASES in writing Immediately upon becoming aware of a compliance breach related to the Contractor and/or Network Provider.

                


        

      

       

      
        
          	

                	13.1.10	
                  The Contractor shall inform the Medicaid Fraud Control Unit and ASES of any meetings it holds with any other GHP MCOs related to compliance and program integrity issues
                      at least forty-eight (48) hours prior to the meeting. The Contractor shall provide a copy of the meeting minutes as well as the results of any follow-up investigations to ASES in writing Immediately.

                


        

      

       

      
        
          	

                	13.1.11	
                  The Contractor shall have policies and procedures prior approved in writing by ASES to address (i) Immediately notifying ASES of pending Network Provider investigations,
                      suspensions and debarment and (ii) transitioning Enrollees from suspended and debarred Network Providers.

                


        

      

       

      
        Page 196 of 324

        
          


      

      
        
          	

                	13.2	
                  Compliance Plan

                


        

      

       

      
        
          	

                	13.2.1	
                  The Contractor shall have a written Fraud, Waste, and Abuse compliance plan with stated program goals and objectives, program scope, and methodology to evaluate program
                      performance. A paper and electronic copy of the compliance plan shall be provided to ASES annually for prior written approval. ASES shall provide notice of approval, denial, or modification to the Contractor within thirty (30)
                      Calendar Days of receipt. The Contractor shall make any necessary changes required by ASES within an additional thirty (30) Calendar Days of the request.

                


        

      

       

      
        
          	

                	13.2.2	
                  At a minimum, the Contractor’s Fraud, Waste, and Abuse compliance plan shall, in accordance with 42 CFR 438.608:

                


        

      

       

      
        
          	

                	13.2.2.1	
                  Ensure that all of its officers, directors, managers and employees know and understand the provisions of the Contractor’s Fraud, Waste, and Abuse compliance plan;

                


        

      

       

      
        
          	

                	13.2.2.2	
                  Require the designation of a compliance officer and a compliance committee that are accountable to the Contractor’s senior management. The compliance officer shall have
                      express authority to provide unfiltered reports directly to the Contractor’s most senior leader and governing body;

                


        

      

       

      
        
          	

                	13.2.2.3	
                  Ensure and describe effective training and education for the compliance officer and the Contractor’s employees;

                


        

      

       

      
        
          	

                	13.2.2.4	
                  Ensure that Providers and Enrollees are educated about Fraud, Waste, and Abuse identification and reporting in the materials provided to them;

                


        

      

       

      
        
          	

                	13.2.2.5	
                  Ensure effective lines of communication between the Contractor’s compliance officer and the Contractor’s employees to ensure that employees understand and comply with the
                      Contractor’s Fraud, Waste, and Abuse program;

                


        

      

       

      
        
          	

                	13.2.2.6	
                  Ensure enforcement of standards of conduct through well-publicized disciplinary guidelines;

                


        

      

       

      
        
          	

                	13.2.2.7	
                  Ensure internal monitoring and auditing with provisions for prompt response to potential offenses, and for the development of corrective action initiatives relating to
                      the Contractor’s Fraud, Waste, and Abuse efforts;

                


        

      

       

      
        
          	

                	13.2.2.8	
                  Describe standards of conduct that articulate the Contractor’s commitment to comply with all applicable Puerto Rico and Federal requirements and standards;

                


        

      

       

      
        Page 197 of 324

        
          


      

      
        
          	

                	13.2.2.9	
                  Ensure that no individual who reports Provider violations or suspected cases of Fraud, Waste, and Abuse is retaliated against; and

                


        

      

       

      
        
          	

                	13.2.2.10	
                  Include a monitoring program that is designed to prevent and detect potential or suspected Fraud, Waste, and Abuse. This monitoring program shall include but not be
                      limited to:

                


        

      

       

      
        
          	

                	13.2.2.10.1	
                  Monitoring the billings of its Providers to ensure Enrollees receive services for which the Contractor is billed;

                


        

      

       

      
        
          	

                	13.2.2.10.2	
                  Requiring the investigation of all reports of suspected cases of Fraud and over-billings;

                


        

      

       

      
        
          	

                	13.2.2.10.3	
                  Reviewing Providers for over, under and inappropriate Utilization;

                


        

      

       

      
        
          	

                	13.2.2.10.4	
                  Verifying with Enrollees the delivery of services as claimed; and

                


        

      

       

      
        
          	

                	13.2.2.10.5	
                  Reviewing and trending Enrollee Complaints regarding Providers.

                


        

      

       

      
        
          	

                	13.2.3	
                  The Contractor, and any Subcontractors delegated the responsibility by the Contractor for coverage of services and payment of claims under this Contract, shall include in
                      all employee handbooks a specific discussion of the False Claims Act and its Fraud, Waste, and Abuse policies and procedures, the rights of employees to be protected as whistleblowers, and the Contractor and Subcontractor’s procedures
                      for detecting and preventing Fraud, Waste, and Abuse.

                


        

      

       

      
        
          	

                	13.2.4	
                  The Contractor shall include in the Enrollee Handbook instructions on how to report Fraud, Waste, and Abuse and the protections for whistleblowers.

                


        

      

       

      
        
          	

                	13.3	
                  Program Integrity Plan

                


        

      

       

      
        
          	

                	13.3.1	
                  The Contractor shall develop a program integrity plan that at a minimum:

                


        

      

       

      
        
          	

                	13.3.1.1	
                  Defines Fraud, Waste, and Abuse;

                


        

      

       

      
        
          	

                	13.3.1.2	
                  Specifies methods to detect Fraud, Waste, and Abuse;

                


        

      

       

      
        
          	

                	13.3.1.3	
                  Describes a process to perform investigations on each suspected case of Fraud, Waste, and Abuse;

                


        

      

       

      
        
          	

                	13.3.1.4	
                  Describes the Contractor’s staff responsible for conducting the investigations and reporting of potential Fraud, Waste, or Abuse, including an organizational chart
                      documenting roles and responsibilities;

                


        

      

       

      
        Page 198 of 324

        
          


      

      
        
          	

                	13.3.1.5	
                  Includes a variety of methods for identifying, investigating, and referring suspected cases to appropriate entities;

                


        

      

       

      
        
          	

                	13.3.1.6	
                  Includes a systematic approach to Data analysis;

                


        

      

       

      
        
          	

                	13.3.1.7	
                  Defines mechanisms to monitor frequency of Encounters and services rendered to Enrollees billed by Providers;

                


        

      

       

      
        
          	

                	13.3.1.8	
                  Identifies requirements to complete the preliminary investigation of Providers and Enrollees;

                


        

      

       

      
        
          	

                	13.3.1.9	
                  Include provisions regarding prompt terminations of inactive Providers due to inactivity in the past twelve (12) months;

                


        

      

       

      
        
          	

                	13.3.1.10	
                  Include a risk assessment of the Contractor’s various Fraud, Waste, and Abuse processes. The risk assessment shall include a listing of the Contractor’s top three (3)
                      vulnerable areas and outline action plans to mitigate risks;

                


        

      

       

      
        
          	

                	13.3.1.11	
                  Include procedures for the confidential reporting of potential Fraud, Waste, and Abuse, including potential Contractor violations; and

                


        

      

       

      
        
          	

                	13.3.1.12	
                  Include procedures to ensure that there is no retaliation against an individual who reports Contractor violations or other potential Fraud, Waste, or Abuse to the
                      Contractor or an external entity.

                


        

      

       

      
        
          	

                	13.3.2	
                  The Contractor’s program integrity plan shall comply in all respects with the ASES Guidelines for the development of a program integrity plan, included as Attachment 14
                      to this Contract. Upon review of the Contractor’s Program Integrity Plan (see Section 13.3), ASES will promptly (within twenty (20) Business Days) notify the Contractor of any needed revisions in order for the program integrity plan
                      to comply with the guidelines and with Federal law. The Contractor, in turn, shall promptly (within twenty (20) Business Days of receipt of the ASES comments) re-submit its Plan for ASES review and prior written approval.

                


        

      

       

      
        
          	

                	13.4	
                  Prohibited Affiliations with Individuals Debarred by Federal Agencies

                


        

      

       

      
        
          	

                	13.4.1	
                  The Contractor shall not knowingly have a relationship with the following:

                


        

      

       

      
        
          	

                	13.4.1.1	
                  An individual who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from
                      participating in non-procurement activities under Executive Order No. 12549 or under any guidelines implementing the Executive Order.

                


        

      

       

      
        Page 199 of 324

        
          


      

      
        
          	

                	13.4.1.2	
                  An individual who is an Affiliate, as defined in the Federal Acquisition Regulation, of a person described in Section 13.4.1.1. The relationship is defined as follows:

                


        

      

       

      
        
          	

                	13.4.1.2.1	
                  A director, officer, or partner of the Contractor;

                


        

      

       

      
        
          	

                	13.4.1.2.2	
                  A person with beneficial ownership of five percent (5%) or more of the Contractor’s equity; or

                


        

      

       

      
        
          	

                	13.4.1.2.3	
                  Any Subcontractor or other person with an employment, consulting, or other arrangement with the Contractor for the provision of items or services that are significant and
                      material the Contractor’s obligations under this Contract.

                


        

      

       

      
        
          	

                	13.4.1.2.4	
                  A Network Provider or person with an employment, consulting or other arrangement with the Contractor for the provision of items and services that are significant and
                      material to the Contractor’s obligations under the Contract.

                


        

      

       

      
        
          	

                	13.4.2	
                  The Contractor shall not have a relationship with an individual or entity that is excluded from participation in any Federal health care program under section 1129 or
                      1128A of the Social Security Act.

                


        

      

       

      
        
          	

                	13.5	
                  Reporting and Investigations

                


        

      

       

      
        
          	

                	13.5.1	
                  The Contractor shall cooperate with all duly authorized Federal and Puerto Rico agencies and representatives in reporting, investigating and prosecuting Fraud, Waste, and
                      Abuse.

                


        

      

       

      
        
          	

                	13.5.2	
                  The Contractor shall have methods for identifying, investigating, and referring suspected Fraud, Waste, and Abuse pursuant to 42 CFR 455.1, 42 CFR 455.13, 42 CFR 455.14
                      and 42 CFR 455.21 and Immediately notifying ASES. All suspected or confirmed instances of Provider Fraud and Enrollee abuse and neglect shall be referred Immediately by the Contractor to ASES, whom will also notify the Medicaid Fraud
                      Control Unit.

                


        

      

       

      
        
          	

                	13.5.3	
                  The Contractor shall Immediately report to ASES the identity of any Provider or other person who is debarred, suspended, or otherwise prohibited from participating in
                      procurement activities. ASES shall promptly notify the Secretary of Health and Human Services of the noncompliance, as required by 42 CFR 438.610(d).

                


        

      

       

      
        
          	

                	13.5.4	
                  The Contractor shall notify ASES within two (2) Business Days of any initiated investigation of a suspected case of Fraud, Waste, or Abuse. The Contractor shall conclude
                      its preliminary investigation within ten (10) Business Days of identifying the potential Fraud, Waste, or Abuse and shall provide the findings of its preliminary investigation in writing to ASES within two (2) Business Days of
                      completing the preliminary investigation.

                


        

      

       

      
        Page 200 of 324

        
          


      

      
        
        
          
            
              
                	

                      	13.5.5	
                        The Contractor shall subsequently report preliminary results of such investigation activities to ASES and other appropriate State and Federal entities. ASES will
                            provide the Contractor with guidance during the pendency of the investigation and will refer the matter to the US Department of Justice and the Medicaid Fraud Control Unit as appropriate. If directed by ASES and/or the Medicaid
                            Fraud Control Unit, the Contractor shall conduct a full investigation.

                      


              

            

             

            
              
                	

                      	13.5.6	
                        The Contractor shall provide the results of its full investigations in writing to ASES within two (2) Business Days of completing the investigation. The Contractor
                            shall consult with ASES, whom shall notify the Medicaid Fraud Control Unit, prior to taking any proposed action regarding an instance of suspected or confirmed fraud or Enrollee abuse.

                      


              

            

             

            
              
                	

                      	13.5.7	
                        The Contractor and all Subcontractors shall cooperate fully with Federal and State agencies, including the Medicaid Fraud Control Unit, in Fraud, Waste, and Abuse
                            investigations and subsequent legal actions, whether administrative, civil, or criminal. Such cooperation shall include actively participating in meetings, providing requested Information, access to records, and access to
                            interviews with employees and consultants, including but not limited to those with expertise in the administration of the program and/or medical or pharmaceutical matters or in any matter related to an investigation or
                            prosecution. Such cooperation shall also include providing personnel to testify at any hearings, trials, or other legal proceedings on an as-needed basis.

                      


              

            

             

            
              
                	

                      	13.5.8	
                        In accordance with Section 1903(i)(2)(C) of the Social Security Act and 42 CFR 455.23, the Contractor shall have a mechanism in place to suspend payments to any
                            Provider or other Subcontractor when there is a pending investigation of a Credible Allegation of Fraud under the Medicaid program. Suspension of payment shall be approved by ASES following instructions in Attachment 14 to this
                            Contract. In addition, for any cases related to Provider Fraud, which ASES must refer to the Medicaid Fraud Control Unit, the Contractor shall refrain from, or suspend any attempt to, recoup amounts related to the reported
                            instance of Provider Fraud from the referred Provider for a period of thirty (30) Calendar Days while the Medicaid Fraud Control Unit conducts its preliminary evaluation. The Contractor may resume recoupment efforts subsequent
                            to the thirty (30) Calendar Days unless otherwise instructed by the Medicaid Fraud Control Unit or ASES. A determination by the Medicaid Fraud Control Unit not to pursue further action on a referred case of Provider Fraud shall
                            in no way be interpreted to restrict attempts by the Contractor to continue to recoup outstanding amount from the Provider, or to pursue further correction action or penalty otherwise permitted by law or under the Provider
                            Contract.

                      


              

            

             

            
              
                	

                      	13.5.9	
                        If a Provider is suspended or terminated from participation in the Puerto Rico Medicaid Program by ASES, the Contractor shall also suspend or terminate the
                            Provider.

                      


              

            

             

            
              Page 201 of 324

              
                


            

            
              
                	

                      	13.5.10	
                        If a Provider is terminated from Medicare or another state’s Medicaid or State Children’s Health Insurance Program, the Contractor shall terminate its Provider
                            participation agreement with that Provider (see Section 1902(a)(39) of the Social Security Act and 42 CFR 455.416) and notify ASES Immediately.

                      


              

            

             

            
              
                	

                      	13.5.11	
                        The Contractor shall notify ASES at least two (2) Business Days prior to taking any action against a Provider for program integrity reasons, including, but not
                            limited to, denial of a Provider Credentialing/Re-Credentialing application, corrective action or limiting the ability of a Provider to participate in the program (e.g., suspending or terminating a Provider). The notification
                            shall include but not be limited to identification of the Provider and a description of the action, the reason for the action, and documentation to support the reason. The Contractor shall provide additional Information upon
                            ASES’s request.

                      


              

            

             

            
              
                	

                      	13.5.12	
                        The Contractor shall submit a risk assessment on an “as needed” basis and Immediately after a program integrity-related action against a Provider. The Contractor
                            shall inform ASES of such action and provide details of such financial action.

                      


              

            

             

            
              
                	

                      	13.5.12.1	
                        The Contractor shall Immediately disclose to ASES any and all criminal convictions of its managing employees (see 42 CFR 455.106).

                      


              

            

             

            
              
                	

                      	13.5.13	
                        Regarding Provider disclosures, the Contractor shall:

                      


              

            

             

            
              
                	

                      	13.5.13.1	
                        Not make payment to a Provider unless the Provider has submitted completed disclosures required by Federal law either to ASES or the Contractor. This includes but
                            is not limited to disclosure regarding ownership and control, business transactions, and criminal convictions (see 42 CFR Part 455, Subpart B).

                      


              

            

             

            
              
                	

                      	13.5.13.2	
                        Track information received from ASES identifying Providers from whom ASES has received completed disclosures.

                      


              

            

             

            
              
                	

                      	13.5.13.3	
                        For participating Providers for whom ASES has not received completed disclosures, as reported to the Contractor, collect and retain completed Provider disclosures
                            as part of initial Credentialing and then annually, using a disclosure form prior approved by ASES in writing.

                      


              

            

             

            
              
                	

                      	13.5.13.4	
                        In accordance with 42 CFR 455.106, Immediately report any criminal conviction disclosures to ASES and explain what action it will take (e.g., terminate the
                            Provider).

                      


              

            

             

            
              
                	

                      	13.5.13.5	
                        In accordance with Section 1866(j)(5) of the Social Security Act and implementing regulations, as part of Credentialing and Re-Credentialing, collect disclosures
                            from Out-of-Network Providers regarding any current or previous affiliations with a Provider or supplier that has uncollected debt, has been or is subject to a payment suspension under a Federal health care program (as defined
                            in Section 1128B(f)), has been excluded from participation under Medicare, Medicaid, CHIP, or has had its billing privileges denied or revoked. The Contractor shall notify ASES if the Contractor determines that such affiliation
                            poses an undue risk of Fraud, Waste, or Abuse and denies the application.

                      


              

            

             

            
              Page 202 of 324

              
                


            

            
              
                	

                      	13.6	
                        Service Verification with Enrollees

                      


              

            

             

            
              
                	

                      	13.6.1	
                        In accordance with 42 CFR 438.608(a)(5), the Contractor shall implement a process for verifying with Enrollees whether services billed by Providers were received.

                      


              

            

             

            
              
                	

                      	13.6.2	
                        The Contractor shall employ a methodology and sampling process prior approved by ASES to verify with its Enrollees on a monthly whether services billed to the
                            Contractor by Providers were actually received. The methodology and sampling process shall include criteria for identifying “high-risk” services and Provider types.

                      


              

            

             

            
              
                	

                      	13.7	
                        Stark Law Compliance

                      


              

            

             

            
              
                	

                      	13.7.1	
                        The Contractor shall have mechanisms in place to ensure that payments are not made in violation of Section 1903(s) of the Social Security Act with respect to
                            certain physician Referrals as defined in Section 1877 of the Social Security Act. The Contractor shall ensure that disclosing Parties provide a financial analysis that includes the total amount actually or potentially due and
                            owed as a result of the disclosed violation, a description of the methodology used to determine the amount due and owing, the total amount of remuneration involved physicians (or an immediate family member of such physicians)
                            received as a result of an actual or potential violation, and a summary of audit activity and documents used in the audit. In accordance with Section 6409 of the PPACA, the Contractor will encourage provider use of the
                            self-referral disclosure protocols, under which providers of services and suppliers may self-disclose actual or potential violations of the physicians’ self-referral statute (Section 1877 of the Social Security Act).

                      


              

            

             

            
              
                	ARTICLE 14	
                        GRIEVANCE AND APPEAL SYSTEM

                      


              

            

             

            
              
                	

                      	14.1	
                        General Requirements

                      


              

            

             

            
              
                	

                      	14.1.1	
                        In accordance with 42 CFR Part 438, Subpart F, the Contractor shall establish an internal Grievance and Appeal System under which Enrollees, or Providers acting on
                            their behalf, may express dissatisfaction with the Contractor or challenge the denial of coverage of, or payment for, Covered Services.

                      


              

            

             

            
              Page 203 of 324

              
                


            

            
              
                	

                      	14.1.2	
                        The Contractor’s Grievance and Appeal System shall include (i) a Complaint process, (ii) Grievance process, (iii) Appeal process, and (iv) access to the
                            Administrative Law Hearing process.

                      


              

            

             

            
              
                	

                      	14.1.3	
                        The Contractor shall designate, in writing, an officer who shall have primary responsibility for ensuring that Complaints, Grievances, and Appeals are resolved pursuant to this Contract and for signing all Notices of Adverse Benefit Determination. For such purposes, an officer shall mean a
                            president, vice president, secretary, treasurer, chairperson of the board of directors of the Contractor’s organization, the sole proprietor, the managing general partner of a partnership, or a person having similar executive
                            authority in the organization.

                      


              

            

             

            
              
                	

                      	14.1.4	
                        The Contractor shall develop a written Grievance and Appeal System and the policies and procedures that detail the operation of the Grievance System. The Grievance
                            and Appeal System policies and procedures shall be submitted to ASES for review and prior written approval according to the timeframe specified in Attachment 12 to this Contract.

                      


              

            

             

            
              
                	

                      	14.1.5	
                        At a minimum, the Contractor’s Grievance and Appeal System policies and procedures shall include the following:

                      


              

            

             

            
              
                	

                      	14.1.5.1	
                        Process for filing a Complaint, Grievance, or Appeal, or seeking an Administrative Law Hearing;

                      


              

            

             

            
              
                	

                      	14.1.5.2	
                        Process for receiving, recording, tracking, reviewing, reporting, and resolving Grievances filed verbally, in writing, or in-person;

                      


              

            

             

            
              
                	

                      	14.1.5.3	
                        Process for receiving, recording, tracking, reviewing, reporting, and resolving Appeals filed verbally or in writing;

                      


              

            

             

            
              
                	

                      	14.1.5.4	
                        Process for requesting an expedited review of an Appeal;

                      


              

            

             

            
              
                	

                      	14.1.5.5	
                        Process and timeframe for a Provider to file a Complaint, Grievance or Appeal on behalf of an Enrollee;

                      


              

            

             

            
              
                	

                      	14.1.5.6	
                        Process for notifying Enrollees of their right to file a Complaint, Grievance, or Appeal with the Patient Advocate Office and how to contact the Patient Advocate
                            Office;

                      


              

            

             

            
              
                	

                      	14.1.5.7	
                        Procedures for the exchange of Information with Providers, ASES, and the Enrollees regarding Complaints, Grievances, and Appeals;

                      


              

            

             

            
              
                	

                      	14.1.5.8	
                        Process and timeframes for notifying Enrollees in writing regarding receipt of Complaints, Grievances, Appeals, resolution, action, delay of review, and denial of
                            request for expedited review.

                      


              

            

             

            
              Page 204 of 324

              
                


            

            
              
                	

                      	14.1.6	
                        The Contractor’s Grievance and Appeal System shall fully comply with the Puerto Rico Patient’s Bill of Rights Act, to the extent that such provisions do not
                            conflict with, or pose an obstacle to Federal regulations.

                      


              

            

             

            
              
                	

                      	14.1.7	
                        The Contractor shall process each Complaint, Grievance, or Appeal in accordance with applicable Puerto Rico and Federal statutory and regulatory requirements, this
                            Contract, and the Contractor’s written policies and procedures. Pertinent facts from all Parties shall be collected during the process.

                      


              

            

             

            
              
                	

                      	14.1.8	
                        The Contractor shall include educational information in the Enrollee Handbook regarding the Contractor’s Grievance and Appeal System which at a minimum includes:

                      


              

            

             

            
              
                	

                      	14.1.8.1	
                        A description of the Contractor’s Grievance and Appeal System;

                      


              

            

             

            
              
                	

                      	14.1.8.2	
                        Instructions on how to file Complaints, Grievances and Appeals including the timeframes for filing;

                      


              

            

             

            
              
                	

                      	14.1.8.3	
                        The Contractor’s toll-free telephone number and office hours;

                      


              

            

             

            
              
                	

                      	14.1.8.4	
                        Information regarding an Enrollee’s right to file a Complaint, Grievance, or Appeal with the Patient Advocate Office and how to file a Complaint, Grievance, or
                            Appeal with the Patient Advocate Office;

                      


              

            

             

            
              
                	

                      	14.1.8.5	
                        Information describing the Administrative Law Hearing process and governing rules, including that the Enrollee must first exhaust the Contractor’s Grievance and
                            Appeal System before accessing the Administrative Law Hearing process; and

                      


              

            

             

            
              
                	

                      	14.1.8.6	
                        Timelines and limitations associated with filing Grievances or Appeals.

                      


              

            

             

            
              
                	

                      	14.1.9	
                        The Contractor shall give Enrollees reasonable assistance in completing forms and taking other procedural steps for Complaints, Grievances and Appeals. This
                            includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TDD and interpreter capability.

                      


              

            

             

            
              
                	

                      	14.1.10	
                        The Contractor shall include information regarding the Grievance and Appeal System in the Provider Guidelines and upon joining the Contractor’s Network, all
                            Providers and Subcontractors, as applicable shall receive training and education regarding the Contractor’s Grievance and Appeal System, which includes but is not limited to:

                      


              

            

             

            
              
                	

                      	14.1.10.1	
                        The Enrollee’s right to file Complaints, Grievances and, Appeals and the requirements and timeframes for filing;

                      


              

            

             

            
              Page 205 of 324

              
                


            

            
              
                	

                      	14.1.10.2	
                        The Enrollee’s right to file a Complaint, Grievance, or Appeal with the Patient Advocate Office;

                      


              

            

             

            
              
                	

                      	14.1.10.3	
                        The Enrollee’s right to an Administrative Law Hearing, how to obtain an Administrative Law Hearing, and representation rules at an Administrative Law Hearing;

                      


              

            

             

            
              
                	

                      	14.1.10.4	
                        The availability of assistance in filing a Complaint, Grievance, or Appeal;

                      


              

            

             

            
              
                	

                      	14.1.10.5	
                        The toll-free numbers to file oral Complaints, Grievances, and Appeals;

                      


              

            

             

            
              
                	

                      	14.1.10.6	
                        The Enrollee’s right to request continuation of Benefits during an Appeal, or an Administrative Law Hearing filing, and that if the Contractor’s Adverse Benefit
                            Determination is upheld in an Administrative Law Hearing, the Enrollee may be liable for the cost of any continued Benefits; and

                      


              

            

             

            
              
                	

                      	14.1.10.7	
                        Any Puerto Rico-determined Provider Appeal rights to challenge the failure of the Contractor to cover a service.

                      


              

            

             

            
              
                	

                      	14.1.11	
                        The Contractor shall have procedures in place to notify all Enrollees in their primary language of Complaint, Grievance, and Appeal dispositions.

                      


              

            

             

            
              
                	

                      	14.1.12	
                        The Contractor shall develop Grievance and Appeal System forms to be submitted for prior written approval by ASES according to the timeframe specified in Attachment
                            12 to this Contract. The approved forms shall be made available to all Enrollees, shall meet all requirements listed in Sections 6.2 and 6.3 for written materials, and shall, at a minimum:

                      


              

            

             

            
              
                	

                      	14.1.12.1	
                        Instruct the Enrollee or Enrollee’s Authorized Representative that documentary evidence should be included, if available; and

                      


              

            

             

            
              
                	

                      	14.1.12.2	
                        Include instructions for completion and submission.

                      


              

            

             

            
              
                	

                      	14.1.13	
                        All ASES prior approved Complaints, Grievances, and Appeals files and forms shall be made available to ASES for auditing. All Complaint, Grievance, and Appeal
                            documents and related information shall be considered as containing protected health information and shall be treated in accordance with HIPAA regulations and other applicable laws of Puerto Rico.

                      


              

            

             

            
              
                	

                      	14.1.14	
                        The Contractor shall ensure that the individuals who make decisions on Grievances and Appeals are individuals:

                      


              

            

             

            
              
                	

                      	14.1.14.1	
                        Who were not involved in any previous level of review or decision-making, or who were subordinates of any individual involved in a previous review or
                            decision-making;

                      


              

            

             

            
              Page 206 of 324

              
                


            

            
              
                	

                      	14.1.14.2	
                        Who, if deciding any of the following, are Providers who have the appropriate clinical expertise, as determined by ASES, in treating the Enrollee’s condition or
                            disease if deciding any of the following:

                      


              

            

             

            
              
                	

                      	14.1.14.2.1	
                        An Appeal of a denial that is based on lack of Medical Necessity;

                      


              

            

             

            
              
                	

                      	14.1.14.2.2	
                        A Grievance regarding denial of expedited resolutions of Appeal; and

                      


              

            

             

            
              
                	

                      	14.1.14.2.3	
                        Any Grievance or Appeal that involves clinical issues; and

                      


              

            

             

            
              
                	

                      	14.1.14.3	
                        Who take into account all comments, documents, records and other information submitted by Enrollee without regard to whether such information was submitted or
                            considered in the initial Adverse Benefit Determination.

                      


              

            

             

            
              
                	

                      	14.1.15	
                        The Contractor shall ensure that punitive action is not taken against a Provider who requests a Grievance, Appeal or an Administrative Law Hearing or supports an
                            Enrollee’s Grievance, Appeal or Administrative Law Hearing.

                      


              

            

             

            
              
                	

                      	14.1.16	
                        The Contractor and Subcontractors, as applicable, shall have a system in place to collect, analyze, and integrate Data regarding Complaints, Grievances, and
                            Appeals. At a minimum, the record shall be accessible to ASES and available upon request to CMS and include the following information:

                      


              

            

             

            
              
                	

                      	14.1.16.1	
                        Date Complaint, Grievance, or Appeal was received;

                      


              

            

             

            
              
                	

                      	14.1.16.2	
                        Enrollee’s name;

                      


              

            

             

            
              
                	

                      	14.1.16.3	
                        Enrollee’s Medicaid ID number, if applicable;

                      


              

            

             

            
              
                	

                      	14.1.16.4	
                        Name of the individual filing the Complaint, Grievance, or Appeal on behalf of the Enrollee;

                      


              

            

             

            
              
                	

                      	14.1.16.5	
                        Date of acknowledgement that receipt of Grievance or Appeal was mailed to the Enrollee;

                      


              

            

             

            
              
                	

                      	14.1.16.6	
                        Summary of Complaint, Grievance, or Appeal;

                      


              

            

             

            
              
                	

                      	14.1.16.7	
                        Date of each review or review meeting and resolution at each level, if applicable;

                      


              

            

             

            
              
                	

                      	14.1.16.8	
                        Date Notice of Disposition or Notice of Adverse Benefit Determination was mailed to the Enrollee;

                      


              

            

             

            
              
                	

                      	14.1.16.9	
                        Corrective Action required; and

                      


              

            

             

            
              
                	

                      	14.1.16.10	
                        Date of resolution.

                      


              

            

             

            
              Page 207 of 324

              
                


            

            
              
                	

                      	14.1.17	
                        Contractor shall have sufficient staffing to timely address Grievances, Complaints, Appeals, Provider disputes and to provide attorney representation or the
                            attendance of other required personnel at administrative hearings, when applicable.

                      


              

            

             

            
              
                	

                      	14.2	
                        Complaint

                      


              

            

             

            
              
                	

                      	14.2.1	
                        The Complaint process is the procedure for addressing Enrollee Complaints, defined as expressions of dissatisfaction about any matter other than an Adverse Benefit
                            Determination that are resolved at the point of contact rather than through filing a formal Grievance.

                      


              

            

             

            
              
                	

                      	14.2.2	
                        An Enrollee or Enrollee’s Authorized Representative may file a Complaint either orally or in writing. The Enrollee or Enrollee’s Authorized Representative may
                            follow-up an oral request with a written request. However, the timeframe for resolution begins with the date the Contractor receives the oral request.

                      


              

            

             

            
              
                	

                      	14.2.3	
                        An Enrollee or Enrollee’s Authorized Representative shall file a Complaint within fifteen (15) Calendar Days after the date of occurrence that initiated the
                            Complaint. If the Enrollee or Enrollee’s Authorized Representative attempts to file a Complaint beyond the fifteen (15) Calendar Days, the Contractor shall instruct the Enrollee or Enrollee’s Authorized Representative to file a
                            Grievance.

                      


              

            

             

            
              
                	

                      	14.2.4	
                        The Contractor shall have procedures in place to provide Notice of Dispositions of Complaints to all Enrollees in their primary language.

                      


              

            

             

            
              
                	

                      	14.2.5	
                        The Contractor shall resolve each Complaint within seventy-two (72) hours of the time the Contractor received the initial Complaint, whether orally or in writing.
                            If the Complaint is not resolved within this timeframe, the Complaint shall be treated as a Grievance. The Contractor cannot require the Enrollee to file a separate Grievance before proceeding to Appeal.

                      


              

            

             

            
              
                	

                      	14.2.6	
                        The Notice of Disposition shall include the results and date of the resolution of the Complaint and shall include notice of the right to file a Grievance or Appeal
                            and information necessary to allow the Enrollee to request an Administrative Law Hearing, if appropriate, including contact information necessary to pursue an Administrative Law Hearing.

                      


              

            

             

            
              
                	

                      	14.3	
                        Grievance Process

                      


              

            

             

            
              
                	

                      	14.3.1	
                        An Enrollee or Enrollee’s Authorized Representative may file a Grievance with the Contractor or with the Office of the Patient’s Advocate of Puerto Rico either
                            orally or in writing. A Provider cannot file a Grievance on behalf of an Enrollee unless written consent is granted by the Enrollee.

                      


              

            

             

            
              
                	

                      	14.3.2	
                        An Enrollee may file a Grievance at any time.

                      


              

            

             

            
              Page 208 of 324

              
                


            

            
              
                	

                      	14.3.3	
                        The Contractor shall acknowledge receipt of each Grievance in writing to the Enrollee (and the Provider, if the Provider filed the Grievance on the Enrollee’s
                            behalf) within ten (10) Business Days of receipt.

                      


              

            

             

            
              
                	

                      	14.3.4	
                        The Contractor shall provide written notice of the disposition of the Grievance as expeditiously as the Enrollee’s health condition requires, but in any event,
                            within ninety (90) Calendar Days from the day the Contractor receives the Grievance. If the Grievance originated from a Complaint that was not resolved within the seventy-two (72) hour timeframe set forth in Section 14.2.5, the
                            time already spent by the Contractor to resolve the original Complaint must be deducted from this ninety (90) Calendar Day timeframe.

                      


              

            

             

            
              
                	

                      	14.3.5	
                        The Notice of Disposition shall include the following:

                      


              

            

             

            
              
                	

                      	14.3.5.1	
                        The resolution of the Grievance,

                      


              

            

             

            
              
                	

                      	14.3.5.2	
                        The basis for the resolution, and

                      


              

            

             

            
              
                	

                      	14.3.5.3	
                        The date of the resolution.

                      


              

            

             

            
              
                	

                      	14.3.6	
                        The Contractor may extend the timeframe to provide a written notice of disposition of a Grievance for up to fourteen (14) Calendar Days if the Enrollee requests the
                            extension or the Contractor demonstrates (to the satisfaction of ASES, upon its request) that there is a need for additional Information and how the delay is in the Enrollee’s interest. If the Contractor extends the timeframe,
                            it shall, for any extension not requested by the Enrollee:

                      


              

            

             

            
              
                	

                      	14.3.6.1	
                        Make reasonable efforts to provide Enrollee prompt oral notice of the delay;

                      


              

            

             

            
              
                	

                      	14.3.6.2	
                        Give the Enrollee written notice of the reason for the delay within two (2) Calendar Days; and

                      


              

            

             

            
              
                	

                      	14.3.6.3	
                        Inform the Enrollee of the right to file a Grievance if the Enrollee disagrees with the decision to extend the timeframe.

                      


              

            

             

            
              
                	

                      	14.4	
                        Notice of Adverse Benefit Determination

                      


              

            

             

            
              
                	

                      	14.4.1	
                        Pusuant to 42 CFR 438.210(c), the Contractor shall provide written notice to the requesting Provider and the Enrollee of any decision by the Contractor to deny a
                            Service Authorization Request, or to authorize a service in an amount, duration, or scope that is less than requested. The Contractor’s notices shall meet the requirements of 42 CFR 438.404.

                      


              

            

             

            
              
                	

                      	14.4.2	
                        The Contractor’s written Notice of Adverse Benefit Determination to Enrollees must meet the language and format requirements in Section 6.2 and 6.3 and be set in
                            accordance with the timeframes described in Section 14.4.4.

                      


              

            

             

            
              Page 209 of 324

              
                


            

            
              
                	

                      	14.4.3	
                        The Notice of Adverse Benefit Determination shall contain the following:

                      


              

            

             

            
              
                	

                      	14.4.3.1	
                        The Adverse Benefit Determination the Contractor has taken or intends to take;

                      


              

            

             

            
              
                	

                      	14.4.3.2	
                        The reasons for the Adverse Benefit Determination;

                      


              

            

             

            
              
                	

                      	14.4.3.3	
                        The right of Enrollee to be provided, upon request and at no expense to Enrollee, reasonable access to and copies of all documents, records and other information
                            relevant to the Adverse Benefit Determination.

                      


              

            

             

            
              
                	

                      	14.4.3.4	
                        The Enrollee’s right to file an Appeal through the Contractor’s internal Grievance and Appeal System and the procedure for filing an Appeal;

                      


              

            

             

            
              
                	

                      	14.4.3.5	
                        The Enrollee’s right to request an Administrative Law Hearing after exhaustion of the Contractor’s Grievance and Appeal System;

                      


              

            

             

            
              
                	

                      	14.4.3.6	
                        The Enrollee’s right to allow a Provider to file an Appeal or an Administrative Law Hearing on behalf of the Enrollee, upon written consent;

                      


              

            

             

            
              
                	

                      	14.4.3.7	
                        The circumstances under which expedited review is available and how to request it; and

                      


              

            

             

            
              
                	

                      	14.4.3.8	
                        The Enrollee’s right to have Benefits continue pending resolution of the Appeal with the Contractor or during the Administrative Law Hearing in accordance with 42
                            CFR 438.420, how to request that Benefits be continued, and the circumstances under which the Enrollee may be required to pay for the costs of these services.

                      


              

            

             

            
              
                	

                      	14.4.4	
                        The Contractor shall mail the Notice of Adverse Benefit Determination within the following timeframes:

                      


              

            

             

            
              
                	

                      	14.4.4.1	
                        For termination, suspension, or reduction of previously authorized Covered Services, at least ten (10) Calendar Days before the date of Adverse Benefit
                            Determination. However, notice may be mailed no later than the date of Adverse Benefit Determination, unless otherwise specified, if one of the following exceptions applies:

                      


              

            

             

            
              
                	

                      	14.4.4.1.1	
                        The Contractor has factual Information confirming the death of an Enrollee.

                      


              

            

             

            
              
                	

                      	14.4.4.1.2	
                        The Contractor receives a clear written statement signed by the Enrollee that he or she no longer wishes to receive services or gives Information that requires
                            termination or reduction of services and indicates that he or she understands that this must be the result of supplying that Information.

                      


              

            

             

            
              Page 210 of 324

              
                


            

            
              
                	

                      	14.4.4.1.3	
                        The Enrollee’s whereabouts are unknown and the post office returns the Contractor’s mail directed to the Enrollee indicating no forwarding address (refer to 42 CFR
                            431.231(d) for procedures if the Enrollee’s whereabouts become known).

                      


              

            

             

            
              
                	

                      	14.4.4.1.4	
                        The Enrollee’s Provider prescribes a change in the level of medical care.

                      


              

            

             

            
              
                	

                      	14.4.4.1.5	
                        The Contractor may shorten the period of advance notice to five (5) Calendar Days before the date of Adverse Benefit Determination if the Contractor has facts
                            indicating that Adverse Benefit Determination should be taken because of probable Enrollee Fraud and the facts have been verified, if possible, through secondary sources.

                      


              

            

             

            
              
                	

                      	14.4.4.2	
                        For denial of payment, at the time of any Adverse Benefit Determination affecting the Claim.

                      


              

            

             

            
              
                	

                      	14.4.4.3	
                        For standard authorization decisions that deny or limit Covered Services within the timeframes required in Section 11.4.

                      


              

            

             

            
              
                	

                      	14.4.4.4	
                        If the Contractor extends the timeframe for the authorization decision and issuance of Notice of Adverse Benefit Determination according to Section 14.4.3, the
                            Contractor shall give the Enrollee written notice of the reasons for the decision to extend if he or she did not request the extension and the Enrollee’s right to file a Grievance if he or she disagrees with that decision. The
                            Contractor shall issue and carry out its determination as expeditiously as the Enrollee’s health requires and no later than the date the extension expires.

                      


              

            

             

            
              
                	

                      	14.4.4.5	
                        For authorization decisions not reached within the timeframes required in Section 11.4 for either standard or expedited authorizations, the Notice of Adverse
                            Benefit Determination shall be mailed on the date the timeframe expires, as this constitutes a denial and is thus an Adverse Benefit Determination.

                      


              

            

             

            
              
                	

                      	14.5	
                        Appeal Process

                      


              

            

             

            
              
                	

                      	14.5.1	
                        The Enrollee, the Enrollee’s Authorized Representative, or the Provider may file an Appeal either orally or in writing.

                      


              

            

             

            
              
                	

                      	14.5.2	
                        Oral inquiries seeking to appeal an Adverse Benefit Determination are treated as Appeals (to establish the earliest possible filing date for the Appeal), but
                            Enrollees must confirm oral requests for Appeals in writing within ten (10) Calendar Days of the oral filing, unless the Enrollee requests expedited resolution, then no additional follow-up is required.

                      


              

            

             

            
              Page 211 of 324

              
                


            

            
              
                	

                      	14.5.3	
                        The requirements of the Appeal process shall be binding for all types of Appeals, including expedited Appeals, unless otherwise established for expedited Appeals.
                            Only one (1) level of Appeal is permitted before proceeding to an Administrative Law Hearing.

                      


              

            

             

            
              
                	

                      	14.5.4	
                        The Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, may file an Appeal to
                            the Contractor within sixty (60) Calendar Days from the date on the Contractor’s Notice of Adverse Benefit Determination.

                      


              

            

             

            
              
                	

                      	14.5.5	
                        Appeals shall be filed directly with the Contractor, or its delegated representatives. The Contractor may delegate this authority to an Appeal committee, but the
                            delegation shall be in writing.

                      


              

            

             

            
              
                	

                      	14.5.6	
                        The Appeals process shall provide the Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s
                            written consent, a reasonable opportunity to present evidence and allegations of fact or law, in person, as well as in writing. The Contractor shall inform the Enrollee of the limited time available to provide this in case of
                            expedited review.

                      


              

            

             

            
              
                	

                      	14.5.7	
                        The Appeals process shall provide the Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s
                            written consent, opportunity, before and during the Appeals process, to examine the Enrollee’s case file, including Medical Records, and any other documents and records considered during the Appeals process and provide copies of
                            documents contained therein without charge and sufficiently in advance of the resolution timeframe for the Appeal.

                      


              

            

             

            
              
                	

                      	14.5.8	
                        The Appeals process shall include as Parties to the Appeal the Enrollee, the Enrollee’s Authorized Representative, the Provider acting on behalf of the Enrollee
                            with the Enrollee’s written consent, or the legal representative of a deceased Enrollee’s estate.

                      


              

            

             

            
              
                	

                      	14.5.9	
                        The Contractor shall resolve each standard Appeal and provide written notice of the disposition, as expeditiously as the Enrollee’s health condition requires but no
                            more than thirty (30) Calendar Days from the date the Contractor receives the Appeal.

                      


              

            

             

            
              
                	

                      	14.5.10	
                        The Contractor shall establish and maintain an expedited review process for Appeals, subject to prior written approval by ASES, when the Contractor determines
                            (based on a request from the Enrollee) or the Provider indicates (in making the request on the Enrollee’s behalf) that taking the time for a standard resolution could seriously jeopardize the Enrollee’s life or health or ability
                            to attain, maintain, or regain maximum function. The Enrollee, the Enrollee’s Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, may file an expedited Appeal either
                            orally or in writing.

                      


              

            

             

            
              Page 212 of 324

              
                


            

            
              
                	

                      	14.5.11	
                        The Contractor shall resolve each expedited Appeal and provide a written Notice of Disposition, as expeditiously as the Enrollee’s health condition requires, but no
                            longer than seventy-two (72) hours after the Contractor receives the Appeal and make reasonable efforts to provide oral notice.

                      


              

            

             

            
              
                	

                      	14.5.12	
                        If the Contractor denies an Enrollee’s request for expedited review, it shall utilize the timeframe for standard Appeals specified herein and shall make reasonable
                            efforts to give the Enrollee prompt oral notice of the denial, and follow-up within two (2) Calendar Days with a written notice. If the Enrollee disagrees with the decision to extend the prescribed timeframe, he or she shall be
                            informed of the right to file a Grievance and the Grievance shall be resolved within twenty-four (24) hours. The Contractor shall also make reasonable efforts to provide oral notice for resolution of an expedited review of an
                            Appeal.

                      


              

            

             

            
              
                	

                      	14.5.13	
                        The Contractor may extend the timeframe for standard or expedited resolution of the Appeal by up to fourteen (14) Calendar Days if the Enrollee, Enrollee’s
                            Authorized Representative, or the Provider acting on behalf of the Enrollee with the Enrollee’s written consent, requests the extension or the Contractor demonstrates (to the satisfaction of ASES, upon its request) that there is
                            need for additional information and how the delay is in the Enrollee’s interest. If the Contractor extends the timeframe, it shall, for any extension not requested by the Enrollee:

                      


              

            

             

            
              
                	

                      	14.5.13.1	
                        Make reasonable efforts to provide Enrollee prompt oral notice of the delay;

                      


              

            

             

            
              
                	

                      	14.5.13.2	
                        Give the Enrollee written notice of the reason for the delay within two (2) Calendar Days;

                      


              

            

             

            
              
                	

                      	14.5.13.3	
                        Inform the Enrollee of the right to file a Grievance if the Enrollee disagrees with the decision to extend the timeframe; and

                      


              

            

             

            
              
                	

                      	14.5.13.4	
                        Resolve the Appeal as expeditiously as the Enrollee’s health condition requires, and no later than the date the extension expires.

                      


              

            

             

            
              
                	

                      	14.5.14	
                        The Contractor shall provide written Notice of Disposition of an Appeal to the Enrollee (and the Provider, if the Provider filed the Appeal on the Enrollee’s
                            behalf) as well as a copy to ASES within two (2) Business Days of the resolution.

                      


              

            

             

            
              
                	

                      	14.5.15	
                        The written notice of Disposition shall be in a format and language that, at a minimum, meets applicable notification standards and shall include:

                      


              

            

             

            
              Page 213 of 324

              
                


            

            
              
                	

                      	14.5.15.1	
                        The results and date of the Appeal resolution; and

                      


              

            

             

            
              
                	

                      	14.5.15.2	
                        For decisions not wholly in the Enrollee’s favor:

                      


              

            

             

            
              
                	

                      	14.5.15.3	
                        The right to request an Administrative Law Hearing;

                      


              

            

             

            
              
                	

                      	14.5.15.4	
                        How to request an Administrative Law Hearing;

                      


              

            

             

            
              
                	

                      	14.5.15.5	
                        The right to continue to receive Benefits pending an Administrative Law Hearing;

                      


              

            

             

            
              
                	

                      	14.5.15.6	
                        How to request the continuation of Benefits; and

                      


              

            

             

            
              
                	

                      	14.5.15.7	
                        Notification that if the Contractor’s Adverse Benefit Determination is upheld in a hearing, the Enrollee may liable for the cost of any continued Benefits.

                      


              

            

             

            
              
                	

                      	14.6	
                        Administrative Law Hearing

                      


              

            

             

            
              
                	

                      	14.6.1	
                        The Contractor is responsible for explaining the Enrollee’s right to and the procedures for an Administrative Law Hearing, including that the Enrollee must exhaust
                            the Contractor’s Grievance, Complaints, and Appeals process before requesting an Administrative Law Hearing. However, if the Contractor fails to adhere to all notice and timing requirements set forth in 42 CFR 438.408, the
                            Enrollee is deemed to have exhausted the Contractor’s Appeals process and may proceed with initiating an Administrative Law Hearing.

                      


              

            

             

            
              
                	

                      	14.6.2	
                        The parties to the Administrative Law Hearing include the Contractor as well as the Enrollee or his or her Authorized Representative, or the representative of a
                            deceased Enrollee’s estate.

                      


              

            

             

            
              
                	

                      	14.6.3	
                        If the Contractor takes an Adverse Benefit Determination, the Enrollee appeals the Adverse Benefit Determination and the resolution of the Appeal is not in the
                            Enrollee’s favor, and the Enrollee requests an Administrative Law Hearing, ASES shall grant the Enrollee such hearing. The right to such Administrative Law Hearing, how to obtain it, and the rules concerning who may represent
                            the Enrollee at such hearing shall be explained to the Enrollee and by the Contractor.

                      


              

            

             

            
              
                	

                      	14.6.4	
                        ASES shall permit the Enrollee to request an Administrative Law Hearing within one hundred and twenty (120) Calendar Days of the Notice of Resolution of the Appeal.

                      


              

            

             

            
              
                	

                      	14.6.5	
                        Before the Administrative Law Hearing, the Enrollee and the Enrollee’s Authorized Representative, if applicable, can ask to look at and copy the documents and
                            records the Contractor will use at the Administrative Law Hearing or that the Enrollee may otherwise need to prepare his/her case for the hearing. The Contractor shall provide such documents and records at no charge to the
                            Enrollee.

                      


              

            

             

            
              Page 214 of 324

              
                


            

            
              
                	

                      	14.6.6	
                        The Administrative Law Hearing resolution shall be:

                      


              

            

             

            
              
                	

                      	14.6.6.1	
                        For standard resolution: within ninety (90) Calendar Days of the date the Enrollee filed the appeal with the Contractor (excluding the days the Enrollee took to
                            subsequently file for an Administrative Law Hearing).

                      


              

            

             

            
              
                	

                      	14.6.6.2	
                        For an expedited resolution: within three (3) Business Days from agency receipt of an Administrative Law Hearing request for a denial of a service.

                      


              

            

             

            
              
                	

                      	14.6.7	
                        The Contractor shall comply with all determinations rendered as a result of Administrative Law Hearings. Nothing in this Section 14.6 shall limit the remedies
                            available to ASES or the Federal government relating to any non-compliance by the Contractor with an Administrative Law Hearing determination or by the Contractor’s refusal to provide disputed services.

                      


              

            

             

            
              
                	

                      	14.6.8	
                        The decision issued as a result of the Administrative Law Hearing is subject to review before the Court of Appeals of Puerto Rico.

                      


              

            

             

            
              
                	

                      	14.6.9	
                        The Contractor shall comply with all determinations rendered as a result of Administrative Law Hearings. Nothing in this Section 14.6 shall limit the remedies
                            available to Puerto Rico or the Federal government relating to any non-compliance by the Contractor with an Administrative Law Hearing determination or by the Contractor’s refusal to provide disputed services.

                      


              

            

             

            
              
                	

                      	14.7	
                        Continuation of Benefits while the Appeal and Administrative Law Hearing are
                              Pending

                      


              

            

             

            
              
                	

                      	14.7.1	
                        As used in this Section, “timely” filing means filing on or before the later of the following:

                      


              

            

             

            
              
                	

                      	14.7.1.1	
                        Within ten (10) Calendar Days of the Contractor mailing the Notice of Adverse Benefit Determination; or

                      


              

            

             

            
              
                	

                      	14.7.1.2	
                        The intended effective date of the Contractor’s proposed Adverse Benefit Determination.

                      


              

            

             

            
              
                	

                      	14.7.2	
                        The Contractor shall continue the Enrollee’s Benefits if the Enrollee or the Enrollee’s Authorized Representative files the Appeal within sixty (60) Calendar Days
                            following the date on the Adverse Benefit Determination notice; the Appeal involves the termination, suspension, or reduction of a previously authorized course of treatment; the services were ordered by an authorized Provider;
                            the period covered by the original authorization has not expired; and the Enrollee timely files for continuation of the Benefits.

                      


              

            

             

            
              Page 215 of 324

              
                


            

            
              
                	

                      	14.7.3	
                        If, at the Enrollee’s request, the Contractor continues or reinstates the Enrollee’s Benefits while the Appeal or Administrative Law Hearing is pending, the
                            Benefits shall be continued until one of the following occurs:

                      


              

            

             

            
              
                	

                      	14.7.3.1	
                        The Enrollee withdraws the Appeal or request for the Administrative Law Hearing.

                      


              

            

             

            
              
                	

                      	14.7.3.2	
                        Ten (10) Calendar Day pass after the Contractor mails the Notice of Adverse Benefit Determination, unless the Enrollee, within the ten (10) Calendar Day timeframe,
                            has requested an Administrative Law Hearing with continuation of Benefits until an Administrative Law Hearing decision is reached.

                      


              

            

             

            
              
                	

                      	14.7.3.3	
                        An administrative law judge issues an Administrative Law Hearing decision adverse to the Enrollee.

                      


              

            

             

            
              
                	

                      	14.7.3.4	
                        The time period or service limits of a previously authorized service has been met.

                      


              

            

             

            
              
                	

                      	14.7.4	
                        If the final resolution of Appeal or Administrative Law Hearing is adverse to the Enrollee, that is, upholds the Contractor’s Adverse Benefit Determination, the
                            Contractor may recover from the Enrollee the cost of the services furnished to the Enrollee while the Appeal/Administrative Law Hearing was pending, to the extent that they were furnished solely because of the requirements of
                            this Section.

                      


              

            

             

            
              
                	

                      	14.7.5	
                        If the Contractor or ASES reverses a decision to deny, limit, or delay services that were not furnished while the Appeal/Administrative Law Hearing was pending, the
                            Contractor shall authorize or provide the disputed services promptly and as expeditiously as the Enrollee’s health condition requires but no later than seventy-two (72) hours from the date the Contractor receives notice
                            reversing the determination.

                      


              

            

             

            
              
                	

                      	14.7.6	
                        If the Contractor or ASES reverses a decision to deny authorization of services, and the Enrollee received the disputed services while the Appeal/Administrative Law
                            Hearing was pending, the Contractor shall pay for those services. The Contractor shall submit evidence of compliance.

                      


              

            

             

            
              
                	

                      	14.8	
                        Reporting Requirements

                      


              

            

             

            
              
                	

                      	14.8.1	
                        The Contractor shall log and track all Complaints, Grievances, Notices of Adverse Benefit Determination, Appeals, including extensions of time granted by the
                            Contractor for these items, as well as Administrative Law Hearing requests (see Section 14.1.16 for details regarding Information collected).

                      


              

            

             

            
              
                	

                      	14.8.2	
                        ASES may publicly disclose summary Information regarding the nature of Complaints, Grievances, and Appeals and related dispositions or resolutions in consumer
                            Information materials.

                      


              

            

             

            
              Page 216 of 324

              
                


            

            
              
                	

                      	14.8.3	
                        The Contractor shall submit quarterly Grievance and Appeal System reports to ASES using a format prescribed by ASES and incorporate the findings of these reports
                            into its Quality Strategy.

                      


              

            

             

            
              
                	

                      	14.9	
                        Remedy for Contractor Non-Compliance with Advance Directive Requirements.

                      


              

            

             

            In addition to the Complaint, Grievance, and Appeal rights described in this Article, an Enrollee may lodge with ASES a
                Complaint concerning the Contractor’s non-compliance with the Advance Directive requirements stated in Section 7.10 of this Contract.

             

              

            
              
                	ARTICLE 15	
                        ADMINISTRATION AND MANAGEMENT

                      


              

            

             

            
              
                	

                      	15.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	15.1.1	
                        The Contractor shall be responsible for the administration and management of all requirements of this Contract, and consistent with the Medicaid Managed Care
                            regulations of 42 CFR Part 438.

                      


              

            

             

            
              
                	

                      	15.1.2	
                        All costs and expenses related to the administration and management of this Contract shall be the responsibility of the Contractor.

                      


              

            

             

            
              
                	

                      	15.2	
                        Place of Business and Hours of Operation

                      


              

            

             

            
              
                	

                      	15.2.1	
                        Given that Enrollment occurs chiefly on site in the Contractor’s administrative offices, the Contractor shall ensure that its administrative offices are physically
                            accessible to all Enrollees and fully equipped to perform all functions related to carrying out this Contract.

                      


              

            

             

            
              
                	

                      	15.2.2	
                        The Contractor shall maintain a number and geographic distribution of administrative offices to provide reasonable physical accessibility for Enrollees. The plan
                            for administrative offices must be approved in writing by ASES.

                      


              

            

             

            
              
                	

                      	15.2.3	
                        The Contractor shall accommodate any request by ASES to visit the Contractor’s administrative offices to ensure that the offices are compliant with the Americans
                            with Disabilities Act’s (“ADA”) requirements for public buildings, and with all other applicable Federal and Puerto Rico rules and regulations.

                      


              

            

             

            
              
                	

                      	15.2.4	
                        The Contractor must maintain one (1) central administrative office and additional administrative offices as described in section 15.2.2 of this Contract.

                      


              

            

             

            
              
                	

                      	15.2.5	
                        The Contractor’s office shall be centrally located and in a location accessible by foot and by vehicle traffic.

                      


              

            

             

            
              
                	

                      	15.2.6	
                        Contractor’s written communications to Enrollees must contain the address of the location identified as the legal, duly-licensed, central administrative office.
                            This administrative office must be open at least between the hours of 9:00 a.m. and 5:00 p.m. (Atlantic Time) during Business Days; In addition, pursuant to the Contractor’s Enrollment Outreach plan (see Section 6.12), the
                            Contractor’s administrative office must have extended open hours (until 7:00 p.m. (Atlantic Time) at least one (1) Business Day per Week; and must be open (to the extent necessary to permit Enrollment activities) one Saturday
                            per month, from 9:00 a.m. to 5:00 p.m. (Atlantic Time)).

                      


              

            

             

            
              Page 217 of 324

              
                


            

            
              
                	

                      	15.2.7	
                        The Contractor shall ensure that the office(s) are adequately staffed, throughout the Contract Term, to ensure that Potential Enrollees may visit the office to
                            enroll at any time during Contractor’s hours of operation. This provision will ensure that Enrollees and Providers receive prompt and accurate responses to inquiries.

                      


              

            

             

            
              
                	

                      	15.2.8	
                        The Contractor shall provide access to Information to Enrollees through GHP Service Line, during the hours provided in Section 6.8.3 of this Contract.

                      


              

            

             

            
              
                	

                      	15.2.9	
                        The Contractor shall provide access twenty-four (24) hours a day, seven (7) days per Week to its website.

                      


              

            

             

            
              
                	

                      	15.3	
                        Training and Staffing

                      


              

            

             

            
              
                	

                      	15.3.1	
                        The Contractor shall conduct ongoing training for all of its staff, in all departments, to ensure appropriate functioning in all areas and to ensure that staff:

                      


              

            

             

            
              
                	

                      	15.3.1.1	
                        Understand the GHP program and the Medicaid Managed Care requirements;

                      


              

            

             

            
              
                	

                      	15.3.1.2	
                        Are aware of all programmatic changes; and

                      


              

            

             

            
              
                	

                      	15.3.1.3	
                        Are trained in the Contractor’s Cultural Competency plan.

                      


              

            

             

            
              
                	

                      	15.3.2	
                        The Contractor shall submit a staff training plan and a current organizational chart to ASES for review and prior written approval according to the timeframe
                            specified in Attachment 12 to this Contract.

                      


              

            

             

            
              
                	

                      	15.4	
                        Data Certification

                      


              

            

             

            
              
                	

                      	15.4.1	
                        The Contractor shall certify all Data pursuant to 42 CFR 438.606. The Data that must be certified include, but are not limited to, Enrollment Information, Encounter
                            Data, and other Information required by ASES and contained in Contracts, the Contractor’s Proposal, and related documents. The Data must be certified by one of the following: the Contractor’s Chief Executive Officer (“CEO”), the
                            Contractor’s Chief Financial Officer (“CFO”), or an individual who has delegated authority to sign for, and who reports directly to the Contractor’s CEO or CFO. The certification must attest, based on best knowledge,
                            Information, and belief, as follows:

                      


              

            

             

            
              Page 218 of 324

              
                


            

            
              
                	

                      	15.4.1.1	
                        To the accuracy, completeness and truthfulness of the Data; and

                      


              

            

             

            
              
                	

                      	15.4.1.2	
                        To the accuracy, completeness, and truthfulness of the documents specified by ASES.

                      


              

            

             

            
              
                	

                      	15.4.2	
                        The Contractor shall submit the certification concurrently with the certified Data.

                      


              

            

             

            
              
                	

                      	15.4.3	
                        Contractor shall sign the Trading Partner Agreement included as Attachment 30 to this Contract.

                      


              

            

             

            
              
                	

                      	15.5	
                        Implementation Plan and Submission of Initial Deliverables

                      


              

            

             

            
              
                	

                      	15.5.1	
                        The Contractor shall develop an Implementation Plan that verifies that the Contractor will submit the Deliverables listed in the chart in Attachment 12 to this
                            Contract, and that details any additional procedures and activities that will be accomplished during the period between the Effective Date of this Contract and November 1, 2018, which is the Implementation Date of this Contract.
                            The Implementation Plan shall include coordination and cooperation with ASES and its representatives during all phases.

                      


              

            

             

            
              
                	

                      	15.5.2	
                        The Contractor shall submit its implementation plan to ASES for ASES’s review and written approval according to the timeframe specified in Attachment 12 to this
                            Contract. Implementation of the Contract shall not commence prior to ASES written approval.

                      


              

            

             

            
              
                	

                      	15.5.3	
                        The Contractor will not receive any additional payment to cover start up or implementation costs.

                      


              

            

             

            
              
                	ARTICLE 16	
                        PROVIDER PAYMENT MANAGEMENT

                      


              

            

             

            
              
                	

                      	16.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	16.1.1	
                        The The Contractor shall administer an effective, accurate and efficient Provider payment management function that (i) under this Contract’s risk arrangement
                            adjudicates and settles Provider Claims for Covered Services that are filed within the timeframes specified by this Article 16 and in compliance with all applicable Puerto Rico and Federal laws, rules, and regulations; (ii)
                            processes PMPM Payments to applicable Providers within the timeframes specified by this Article; and (iii) performs Claims payment administrative functions for all Providers as specified by this Article 16.

                      


              

            

             

            
              
                	

                      	16.1.2	
                        The Contractor shall maintain a Claims management system that can accurately identify the date of receipt (the date the Contractor receives the Claim as indicated
                            by the date-stamp), real-time-accurate history of actions taken on each Provider Claim (i.e. paid, denied, suspended, appealed, etc.), and the date of payment (the date of the check or other form of payment).

                      


              

            

             

            
              Page 219 of 324

              
                


            

            
              
                	

                      	16.1.3	
                        To the extent feasible, the Contractor shall implement an Automated Clearinghouse (“ACH”) mechanism that allows Providers to request and receive Electronic Funds
                            Transfer (“EFT”) of Claims payments. The Contractor shall encourage its Providers, as an alternative to the filing of paper-based Claims, to submit and receive Claims Information through Electronic Data Interchange (“EDI”),
                            i.e., electronic Claims. Electronic Claims must be processed in adherence to Information exchange and Data management requirements specified in Article 17. As part of this electronic Claims management (“ECM”) function, the
                            Contractor shall also provide on-line and phone-based capabilities to obtain Claims processing status Information.

                      


              

            

             

            
              
                	

                      	16.1.4	
                        If the Contractor does not receive Claims through an EDI system, the Contractor shall either provide a central address to which Providers must submit Claims; or
                            provide to each Network Provider a complete list, including names, addresses, electronic mail and phone number, of entities to which the Providers must submit Claims.

                      


              

            

             

            
              
                	

                      	16.1.5	
                        The Contractor shall notify Network Providers in writing of any changes in the policies and procedures, subject to prior written approval of ASES, for filing Claims
                            at least thirty (30) Calendar Days before the effective date of the change. If the Contractor is unable to provide thirty (30) Calendar Days of notice, it must give Providers a thirty (30) Calendar Day extension on their Claims
                            filing deadline to ensure Claims are routed to the correct processing center.

                      


              

            

             

            
              
                	

                      	16.1.6	
                        To be processed, all Claims submitted for payment shall comply with the Clean Claim standards as established by Federal regulation (42 CFR 447.46), and with the
                            standards described in Section 16.10.2 of this Contract.

                      


              

            

             

            
              
                	

                      	16.1.7	
                        The Contractor shall generate explanations of benefits and remittance advices in accordance with ASES standards for formatting, content, and timeliness.

                      


              

            

             

            
              
                	

                      	16.1.8	
                        The Contractor shall not pay any Claim submitted by a Provider during the period of time when such Provider is excluded or suspended from the Medicare, Medicaid,
                            CHIP or Title V Maternal and Child Health Services Block Grant programs for Fraud, Waste, or Abuse or otherwise included on the Department of Health and Human Services Office of the Inspector General exclusions list, or employs
                            someone on this list, and when the Contractor knew, or had reason to know, of that exclusion, after a reasonable time period after reasonable notice has been furnished to the Contractor. The Contractor shall not pay any Claim
                            submitted by a Provider that is on Payment Hold.

                      


              

            

             

            
              
                	

                      	16.1.9	
                        The Contractor is prohibited from paying for an item or service with respect to any amount expended for which funds may not be used under the Assisted Suicide
                            Funding Restriction Act of 1997.

                      


              

            

             

            
              
                	

                      	16.1.10	
                        Network Providers may not receive payment other than by the Contractor for services covered under this Agreement, except when such payments are specifically
                            required to be made by ASES under Title XIX of the Social Security Act, or its implementing regulations, or when ASES makes direct payments to Network Providers for graduate medical education costs approved under the Medicaid
                            State Plan. The Contractor is prohibited from making payment on any amount expended for any item or service not covered under the Medicaid State Plan.

                      


              

            

             

            
              Page 220 of 324

              
                


            

            
              
                	

                      	16.1.11	
                        Pursuant to Section 1903(i) of the Social Security Act the Contractor is prohibited from paying for organ transplants unless the State Plan provides, and the
                            Contractor follows, written standards that provide for similarly situated individuals to be treated alike and for any restriction on facilities or practitioners to be consistent with the accessibility of high quality of care to
                            Enrollees.

                      


              

            

             

            
              
                	

                      	16.2	
                        Payment Schedule

                      


              

            

             

            
              
                	

                      	16.2.1	
                        At a minimum, the Contractor shall run one (1) Provider payment cycle per Week, on the same day each Week, as determined by the Contractor. The Contractor shall
                            develop a payment schedule to be submitted to ASES for review and its prior written approval according to the timeframe specified in Attachment 12 to this Contract.

                      


              

            

             

            
              
                	

                      	16.2.2	
                        Other than for cause explicitly stated in the Provider Contract, payment to Providers made in the form of a Capitation payment shall be issued not later than the
                            fifteenth (15th) Calendar Day of the month. Any Provider Capitation payment retained by the Contractor past the 15th Calendar Day of each month shall accrue interest at the prevailing highest legal interest rate for personal loans as such rate is determined by the Board of the Office of
                            the Commissioner of Financial Institutions, and interest shall be paid along with the Capitation payment to the Provider for that month. The Contractor shall make such payment regardless of receiving the PMPM Payment under
                            Section 22.1.1 of the Contract.

                      


              

            

             

            
              
                	

                      	16.3	
                        Required Claims Processing Reports

                      


              

            

             

            
              
                	

                      	16.3.1	
                        The Contractor shall submit to ASES a monthly report not later than the fifth (5th)
                            Calendar Day after the last day of the month listing all paid, pending, and denied Claims during that month. The report shall be made available in an electronic format and shall detail all paid, pending, and denied Claims for
                            all Providers.

                      


              

            

             

            
              
                	

                      	16.3.2	
                        The report shall list, by Provider, Claims paid from the preceding month, and those that are pending payment and the reason for the payment delay or the reason for
                            the Contractor’s decision to deny the Claim.

                      


              

            

             

            
              
                	

                      	16.3.3	
                        In the event that Providers associated with a PMG consent to the disbursement of payment directly to the PMG, the Contractor shall so specify in its report.

                      


              

            

             

            
              Page 221 of 324

              
                


            

            
              
                	

                      	16.4	
                        Submission of Encounter Data

                      


              

            

             

            
              
                	

                      	16.4.1	
                        Providers shall furnish Encounter Data to the Contractor per Section 17.3.3 and Attachment 26 to this Contract on a monthly basis. The Data shall be submitted
                            regardless of the payment arrangement, capitated or otherwise, agreed upon between the Contractor and the Provider. Encounter Data for all items and services provided by Network Providers, even if the Network Provider is
                            reimbursed on a Capitated basis, must be submitted with the paid field indicating the allowed amount, even if the amount is zero (0) dollars.

                      


              

            

             

            
              
                	

                      	16.4.2	
                        Encounter Data must comply with HIPAA security and privacy standards and be submitted in the format and timeframe required by the Medicaid Statistical Information
                            System (MMIS) or format required by any successor system in accordance with 42 CFR 438.818.

                      


              

            

             

            
              
                	

                      	16.4.3	
                        ASES will perform quarterly Encounter Data validation to evaluate level of accuracy, which will be used to determine if liquidated damages should be assessed on the
                            Contractor.

                      


              

            

             

            
              
                	

                      	16.5	
                        Relationship with Pharmacy Benefit Manager (PBM)

                      


              

            

             

            
              
                	

                      	16.5.1	
                        The Contractor shall work with the PBM engaged by ASES to facilitate the processing of pharmacy services Claims submitted by the PBM, as provided in Section
                            7.5.12.11.

                      


              

            

             

            
              
                	

                      	16.5.2	
                        To facilitate Claims processing, the Contractor shall send to the PBM, on a Daily Basis, the Enrollee Data described in Section 5.3.8.

                      


              

            

             

            
              
                	

                      	16.6	
                        Timely Payment of Claims

                      


              

            

             

            
              
                	

                      	16.6.1	
                        The Contractor shall comply with the timely processing of Claims standards contained in Section 1902(a)(37) of the Social Security Act and Federal regulations at 42
                            CFR 447.46.

                      


              

            

             

            
              
                	

                      	16.6.2	
                        Provider Contracts shall include the following provisions for timely payment of Clean Claims.

                      


              

            

             

            
              
                	

                      	16.6.2.1	
                        A Clean Claim under 42 CFR 447.46(b), as defined in 42 CFR 447.45(b), is a Claim received by the Contractor for adjudication, which can be processed without
                            obtaining additional Information from the Provider of the service or from a Third Party. It includes a Claim with errors originating in the Contractor’s Claims system. It does not include a Claim from a Provider who is under
                            investigation for Fraud, Waste, or Abuse, or a Claim under review for Medical Necessity.

                      


              

            

             

            
              
                	

                      	16.6.2.2	
                        Provider Contracts shall provide that ninety-five percent (95%) of all Clean Claims must be paid by the Contractor not later than thirty (30) Calendar Days from the
                            date of receipt of the Claim (including Claims billed by paper and electronically), and one hundred percent (100%) of all Clean Claims must be paid by the Contractor not later than fifty (50) Calendar Days from the date of
                            receipt of the Claim.

                      


              

            

             

            
              Page 222 of 324

              
                


            

            
              
                	

                      	16.6.2.3	
                        Any Clean Claims not paid within thirty (30) Calendar Days shall bear interest in favor of the Provider on the total unpaid amount of such Claim, according to the
                            prevailing highest legal interest rate fixed by the Puerto Rico Commissioner of Financial Institutions. Such interest shall be considered payable on the day following the terms of this Section, and interest shall be paid
                            together with the claim.

                      


              

            

             

            
              
                	

                      	16.6.3	
                        An Unclean Claim is any Claim that falls outside the definition of Clean Claim in Section 16.10.2.1. The Contractor shall include the following provisions in its
                            Provider Contracts for timely resolution of Unclean Claims.

                      


              

            

             

            
              
                	

                      	16.6.3.1	
                        Ninety percent (90%) of Unclean Claims must be resolved and processed with payment by the Contractor, if applicable, not later than ninety (90) Calendar Days from
                            the date of initial receipt of the Claim. This includes Claims billed on paper or electronically.

                      


              

            

             

            
              
                	

                      	16.6.3.2	
                        Of the remaining ten percent (10%) of total Unclean Claims that may remain outstanding after ninety (90) Calendar Days,

                      


              

            

             

            
              
                	

                      	16.6.3.2.1	
                        Nine percent (9%) of the Unclean Claims must be resolved and processed with payment by the Contractor, if applicable, not later than six (6) calendar months from
                            the date of initial receipt (including Claims billed on paper and those billed electronically); and

                      


              

            

             

            
              
                	

                      	16.6.3.2.2	
                        One percent (1%) of the Unclean Claims must be resolved and processed with payment by the Contractor, if applicable, not later than one year (twelve (12) months)
                            from the date of initial receipt of the Claim (including Claims billed on paper and those billed electronically).

                      


              

            

             

            
              
                	

                      	16.6.4	
                        The Contractor shall not establish any administrative procedures, such as administrative audits, authorization number, or other formalities under the control of the
                            Contractor, which could prevent the Provider from submitting a Clean Claim.

                      


              

            

             

            
              
                	

                      	16.6.5	
                        The foregoing timely payment standards are more stringent than those required in the Federal regulations, at 42 CFR 447.46. The Contractor shall include the
                            foregoing standards in each Provider Contract and, per 42 CFR 447.46(c).

                      


              

            

             

            
              
                	

                      	16.6.6	
                        The Contractor shall deliver to Providers, within fifteen (15) Calendar Days of award of the Provider Contract (along with the Provider Guidelines described in
                            Section 10.2.1), Claims coding and processing guidelines for the applicable Provider type, and the definition of a Clean Claim, as requested in this Article 16, to be applied.

                      


              

            

             

            
              Page 223 of 324

              
                


            

            
              
                	

                      	16.6.7	
                        The Contractor shall give Providers ninety (90) Calendar Days’ notice in advance of the effective date of any change in Claims coding and processing deadlines.

                      


              

            

             

            
              
                	

                      	16.7	
                        Contractor Denial of Claims and Resolution of Contractual and Claims Disputes

                      


              

            

             

            
              
                	

                      	16.7.1	
                        Not later than the fifth (5th) Business Day after the receipt of a Provider Claim that the Contractor has deemed not to meet the Clean Claim requirements, the
                            Contractor shall suspend the Claim and request in writing (notification via e-mail, the Contractor’s website, or an interim remittance advice satisfies this requirement) all outstanding Information such that the Claim can be
                            deemed clean. Upon receipt of all the requested Information from the Provider, the Contractor shall complete processing of the Claim in accordance with the standards outlined in this Section..

                      


              

            

             

            
              
                	

                      	16.7.2	
                        Claims suspended for additional Information must be closed (paid or denied) such that compliance with the timely payment rules outlined in Section 16.10 is
                            achieved.

                      


              

            

             

            
              
                	

                      	16.7.3	
                        The Contractor must process, and finalize, all appealed Claims to a paid or denied status within thirty (30) Calendar Days of receipt of the appealed Claim; for
                            Claims for which the Contractor has requested further information, per Section 16.7.1, the Contractor shall pay or deny the Claim within thirty (30) Calendar Days of receipt of the requested Information.

                      


              

            

             

            
              
                	

                      	16.7.4	
                        The Contractor shall send Providers written notice (notification via e-mail, surface mail, the Contractor’s website, or a remittance advice satisfies this
                            requirement) for each Claim that is denied, including an explanation of the reason(s) for the denial, the date the Contractor received the Claim, and a reiteration of the outstanding Information required from the Provider to
                            adjudicate the Claim.

                      


              

            

             

            
              
                	

                      	16.7.5	
                        Provider Dispute Resolution System

                      


              

            

             

            
              
                	

                      	16.7.5.1	
                        The Contractor shall establish and use a procedure to resolve billing, payment, and other administrative disputes between Providers and the Contractor arising under
                            Provider Contracts including a Provider Complaint resolution process implemented by the Contractor to address, among others, lost or incomplete Claims forms or electronic submissions; Contractor requests for additional
                            explanation as to services or treatment rendered by a Provider; and inappropriate or unapproved Referrals issued by Providers. This dispute resolution system shall exclude Grievances filed by Providers on behalf of Enrollees
                            pursuant to Section 14.3 of this Contract.

                      


              

            

             

            
              Page 224 of 324

              
                


            

            
              
                	

                      	16.7.5.2	
                        For any dispute between the Provider and Contractor arising under the Provider Contract, the Contractor shall implement an internal dispute resolution system, which
                            shall include the opportunity for an aggrieved Provider to submit a timely written complaint to the Contractor. The Contractor shall issue a written decision on the Provider’s complaint within fifteen (15) Calendar Days of
                            receipt of the Provider’s written complaint. A Contractor’s written decision that is in any way adverse to the Provider shall include an explanation of the grounds for the decision and a notice of the Provider’s right to and
                            procedures for an Administrative Law Hearing within ASES.

                      


              

            

             

            
              
                	

                      	16.7.5.2.1	
                        Providers disputing the denial of payment for a submitted Claim, or the payment of an amount that is less than the amount for which the Claim was submitted, shall
                            be afforded a term of one hundred twenty (120) Calendar Days to submit a written Complaint. Contractor shall issue a determination regarding such Claims within one hundred twenty (120) Calendar Days.

                      


              

            

             

            
              
                	

                      	16.7.5.3	
                        If the Provider is not satisfied with the decision on its complaint within the Contractor’s dispute resolution system, the Provider may pursue an Administrative Law
                            Hearing. The parties to the Administrative Law Hearing shall be the Contractor and the Provider. ASES shall grant a Provider request for an Administrative Law Hearing, provided that the Provider submits a written appeal,
                            accompanied by supporting documentation, not more than thirty (30) Calendar Days following the Provider’s receipt of the Contractor’s written decision.

                      


              

            

             

            
              
                	

                      	16.7.5.4	
                        Judicial Review. A decision issued as a result of the Administrative Law Hearing
                            provided for in Section 16.11.6.3 shall be subject to review before the Court of Appeals of Puerto Rico.

                      


              

            

             

            
              
                	

                      	16.8	
                        Contractor Recovery from Providers

                      


              

            

             

            
              
                	

                      	16.8.1	
                        When the Contractor determines after the fact that it has paid a Claim incorrectly the Contractor may request applicable reimbursement from the Provider through
                            written notice, stating the basis for the request. The notice shall list the Claims and the amounts to be recovered.

                      


              

            

             

            
              
                	

                      	16.8.2	
                        The Provider will have a period of sixty (60) Calendar Days to make the requested payment, to agree to Contractor retention of said payment, or to dispute the
                            recovery action.

                      


              

            

             

            
              Page 225 of 324

              
                


            

            
              
                	

                      	16.9	
                        ASES Review of Contractor, Subcontractor, and Provider Use of Puerto Rico and
                              Federal Funds

                      


              

            

             

            
              
                	

                      	16.9.1	
                        The Contractor shall cooperate fully and diligently with ASES and/or its auditors in their review of the use of Puerto Rico and Federal funds provided to the
                            Contractor under the GHP Program. The Contractor, its Subcontractors, and Network Providers shall, upon request, make available to ASES and/or its auditors any and all administrative, financial, and Medical Records relating to
                            the administration of and the delivery of items or services for which Puerto Rico and Federal monies are expended. In addition, the Contractor and its Subcontractors including Network Providers shall provide ASES and/or its
                            auditors with access during normal business hours to its respective place of business and records.

                      


              

            

             

            
              
                	

                      	16.10	
                        ASES Recovery from Contractor

                      


              

            

             

            
              
                	

                      	16.10.1	
                        ASES and the Contractor shall diligently work in good faith together to resolve any audit findings identified through audits by ASES. All audit findings shall be
                            resolved or a Corrective Action Plan shall be implemented within ninety (90) Calendar Days of issuance of a final audit report. Any Overpayment remittance due to ASES from the Contractor will be offset from future payments to
                            the Contractor, or invoiced by ASES to the Contractor.

                      


              

            

             

            
              
                	ARTICLE 17	
                        INFORMATION MANAGEMENT AND SYSTEMS

                      


              

            

             

            
              
                	

                      	17.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	17.1.1	
                        The Contractor shall have Information management processes and Information Systems (hereafter referred to as Systems) that enable it to meet GHP requirements, ASES
                            and Federal reporting requirements, all other Contract requirements, and any other applicable Puerto Rico and Federal laws, rules and regulations including but not limited to the standards and operating rules in Section 1104 of
                            the PPACA and associated regulations, the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), Health Information Technology for Economic and
                              Clinical Health Act (HITECH) and associated regulations and 42 CFR 438.242.

                      


              

            

             

            
              
                	

                      	17.1.2	
                        The Contractor’s Data and Systems shall comply with the standards and operating rules for EFT, eligibility, Claim status and health care payment/remittance advice
                            transactions, in accordance with 45 C.F.R. parts 160 and 162..

                      


              

            

             

            
              
                	

                      	17.1.3	
                        The Contractor’s Systems shall possess capacity sufficient to handle the workload projected for the start of the program and will be scalable and flexible so they
                            can be adapted as needed, within negotiated timeframes, in response to program or Enrollment changes.

                      


              

            

             

            
              Page 226 of 324

              
                


            

            
              
                	

                      	17.1.4	
                        The Contractor’s Systems shall have the capability of adapting to any future changes necessary as a result of modifications to the service delivery system and its
                            requirements, including Data collection, records and reporting based upon unique Enrollee and Provider identifiers to track services and expenditures across funding streams. The Systems shall be scalable and flexible so they can
                            be adapted as needed, within negotiated timeframes, in response to changes in Contract requirements, increases in Enrollment estimates, etc. The System architecture shall facilitate rapid application of the more common changes
                            that can occur in the Contractor’s operation, including but not limited to:

                      


              

            

             

            
              
                	

                      	17.1.4.1	
                        Changes in pricing methodology;

                      


              

            

             

            
              
                	

                      	17.1.4.2	
                        Rate changes;

                      


              

            

             

            
              
                	

                      	17.1.4.3	
                        Eligibility criteria changes;

                      


              

            

             

            
              
                	

                      	17.1.4.4	
                        Changes in Utilization Management criteria;

                      


              

            

             

            
              
                	

                      	17.1.4.5	
                        Additions and deletions of Provider types; and

                      


              

            

             

            
              
                	

                      	17.1.4.6	
                        Additions and deletions of procedure, diagnosis and other service codes.

                      


              

            

             

            
              
                	

                      	17.1.4.7	
                        Changes in the Enrollment methodology.

                      


              

            

             

            
              
                	

                      	17.1.5	
                        The Contractor shall provide secure, online access to select system functionality to at least three (3) ASES personnel to facilitate resolution of Enrollee
                            inquiries and to research Enrollee-related issues as needed.

                      


              

            

             

            
              
                	

                      	17.1.6	
                        The Contractor shall participate in systems work groups organized by ASES. The Systems work groups will meet on a designated schedule as agreed to by ASES and the
                            Contractors.

                      


              

            

             

            
              
                	

                      	17.1.7	
                        The Contractor shall provide a continuously available electronic mail communication link (E-mail system) with ASES. This system shall be:

                      


              

            

             

            
              
                	

                      	17.1.7.1	
                        Available from the workstations of the designated Contractor contacts; and

                      


              

            

             

            
              
                	

                      	17.1.7.2	
                        Capable of attaching and sending documents created using software products other than Contractor systems, including Puerto Rico’s currently installed version of
                            Microsoft Office and any subsequent upgrades as adopted.

                      


              

            

             

            
              
                	

                      	17.2	
                        Global System Architecture and Design Requirements

                      


              

            

             

            
              
                	

                      	17.2.1	
                        The Contractor shall comply with Federal and Puerto Rico policies, standards and regulations in the design, development and/or modification of the Systems it will
                            employ to meet the aforementioned requirements and in the management of information contained in those Systems. Additionally, the Contractor shall adhere to ASES and Puerto Rico-specific system and Data architecture standards
                            and/or guidelines.

                      


              

            

             

            
              Page 227 of 324

              
                


            

            
              
                	

                      	17.2.2	
                        The Contractor’s Systems shall meet Federal and industry standards of architecture, including but not limited to the following requirements:

                      


              

            

             

            
              
                	

                      	17.2.2.1	
                        Conform to HIPAA standards for Data and document management;

                      


              

            

             

            
              
                	

                      	17.2.2.2	
                        Contain controls to maintain information integrity. These controls shall be in place at all appropriate points of processing. The controls shall be tested in
                            periodic and spot audits following a methodology to be developed jointly by and mutually agreed upon by the Contractor and ASES; and

                      


              

            

             

            
              
                	

                      	17.2.2.3	
                        Partner with ASES in the development of transaction/event code set, Data exchange and reporting standards not specific to HIPAA or other Federal efforts and will
                            conform to such standards as stipulated in the plan to implement the standards.

                      


              

            

             

            
              
                	

                      	17.2.3	
                        Where web services are used in the engineering of applications, the Contractor’s Systems shall conform to World Wide Web Consortium (W3C) standards such as XML,
                            UDDI, WSDL and SOAP so as to facilitate integration of these Systems with ASES and other Puerto Rico systems that adhere to a service-oriented architecture.

                      


              

            

             

            
              
                	

                      	17.2.4	
                        Audit trails shall be incorporated into all Systems to allow information on source Data files and documents to be traced through the processing stages to the point
                            where the information is finally recorded. The audit trails shall:

                      


              

            

             

            
              
                	

                      	17.2.4.1	
                        Contain a unique log-on or terminal ID, the date, and time of any create/modify/delete action and, if applicable, the ID of the system job that effected the action;

                      


              

            

             

            
              
                	

                      	17.2.4.2	
                        Have the date and identification “stamp” displayed on any on-line inquiry;

                      


              

            

             

            
              
                	

                      	17.2.4.3	
                        Have the ability to trace Data from the final place of recording back to its source Data file and/or document shall also exist;

                      


              

            

             

            
              
                	

                      	17.2.4.4	
                        Be supported by listings, transaction reports, update reports, transaction logs, or error logs;

                      


              

            

             

            
              
                	

                      	17.2.4.5	
                        Facilitate auditing of individual Claim records as well as batch audits; and

                      


              

            

             

            
              Page 228 of 324

              
                


            

            
              
                	

                      	17.2.4.6	
                        Be maintained for ten (10) years in either live and/or archival systems. The duration of the retention period may be extended at the discretion of and as indicated
                            to the Contractor by ASES as needed for ongoing audits or other purposes.

                      


              

            

             

            
              
                	

                      	17.2.5	
                        The Contractor shall house indexed images of documents used by Enrollees and Providers to transact with the Contractor in the appropriate database(s) and document
                            management systems so as to maintain the logical relationships between certain documents and certain Data. The Contractor shall follow all applicable requirements for the management of Data in the management of documents.

                      


              

            

             

            
              
                	

                      	17.2.6	
                        The Contractor shall institute processes to insure the validity and completeness of the Data it submits to ASES. At its discretion, ASES will conduct general Data
                            validity and completeness audits using industry-accepted statistical sampling methods. Data elements that will be audited include but are not limited to: Enrollee ID, date of service, Provider ID, category and sub category (if
                            applicable) of service, diagnosis codes, procedure codes, revenue codes, date of Claim processing, and date of Claim payment.

                      


              

            

             

            
              
                	

                      	17.2.6.1	
                        Where a System is herein required to, or otherwise supports, the applicable batch or on-line transaction type, the system shall comply with HIPAA-standard
                            transaction code sets.

                      


              

            

             

            
              
                	

                      	17.2.6.2	
                        The Contractor shall assure that all Contractor staff is trained in all HIPAA requirements, as applicable.

                      


              

            

             

            
              
                	

                      	17.2.7	
                        The layout and other applicable characteristics of the pages of Contractor websites shall be compliant with Federal “Section 508 standards” and Web Content
                            Accessibility Guidelines developed and published by the Web Accessibility Initiative.

                      


              

            

             

            
              
                	

                      	17.3	
                        System and Data Integration Requirements

                      


              

            

             

            
              
                	

                      	17.3.1	
                        The Contractor’s systems shall be able to transmit, receive and process Data in HIPAA-compliant formats that are in use as of the Contract Implementation Date.

                      


              

            

             

            
              
                	

                      	17.3.2	
                        Data and Report Validity and Completeness. The Contractor shall institute processes to ensure the validity and completeness of the data, including reports, it
                            submits to ASES. At its discretion, ASES will conduct general data validity and completeness audits using industry-accepted statistical sampling methods. Data elements that will be audited include, but are not limited to:
                            enrollee ID, date of service, assigned Medicaid provider ID, category and subcategory (if applicable) of service, diagnosis codes, procedure codes, revenue codes, date of claim processing, and (if and when applicable) date of
                            claim payment. Control totals shall also be reviewed and verified

                      


              

            

             

            
              Page 229 of 324

              
                


            

            
              
                	

                      	17.3.3	
                        The Contractor’s applications shall be able to interface with ASES’s systems for purposes of Data exchange and will conform to standards and specifications set by
                            ASES. These standards and specifications are subject to change. Current standards and specifications are detailed in Attachment 26 to this Contract.

                      


              

            

             

            
              
                	

                      	17.3.4	
                        The Contractor’s System(s) shall be able to transmit and receive transaction Data to and from ASES’s systems as required for the appropriate processing of Claims.

                      


              

            

             

            
              
                	

                      	17.3.4.1	
                        The Contractor will be required to perform any necessary changes to update interfaces to ASES’s systems, including those required by the Medicaid Management
                            Information System (MMIS) as well as new Eligibility and Enrollment processes. These interface changes may require changes in the Contractors core systems.

                      


              

            

             

            
              
                	

                      	17.3.5	
                        Each month the Contractor shall generate Encounter Data files from its Claims management system(s) and/or other sources. Such files must be submitted in
                            standardized Accredited Standards Committee (ASC) X12N 837 and National Council for Prescription Drug Programs (NCPDP) formats, and the ASC X12N 835 format as appropriate. The files will contain settled Claims and Claim
                            adjustments and Encounter Data from Providers for the most recent month for which all such transactions were completed. The Contractor shall provide these files electronically to ASES and/or its Agent at a frequency and level of
                            detail to be specified by CMS and ASES based on program administration, oversight, and program integrity needs, and in adherence to the procedure, content standards and format indicated in Attachment 26 to this Contract. The
                            Contractor shall make changes or corrections to any systems, processes or Data transmission formats as needed to comply with Encounter Data quality standards as originally defined or subsequently amended.

                      


              

            

             

            
              
                	

                      	17.3.6	
                        The Contractor’s System(s) shall be capable of generating files in the prescribed formats for upload into ASES Systems used specifically for program integrity and
                            compliance purposes.

                      


              

            

             

            
              
                	

                      	17.3.7	
                        The Contractor’s System(s) shall possess mailing address standardization functionality in accordance with US Postal Service conventions.

                      


              

            

             

            
              
                	

                      	17.3.8	
                        To comply with MAGI requirements, the Contractor must update its Information Systems in accordance with the procedures and timelines set forth in Attachment 26 to
                            this Contract and any other subsequent guidance issued by ASES.

                      


              

            

             

            
              
                	

                      	17.4	
                        System Access Management and Information Accessibility Requirements

                      


              

            

             

            
              
                	

                      	17.4.1	
                        The Contractor’s System shall employ an access management function that restricts access to varying hierarchical levels of system functionality and Information. The
                            access management function shall:

                      


              

            

             

            
              Page 230 of 324

              
                


            

            
              
                	

                      	17.4.1.1	
                        Restrict access to information on a "need-to-know" basis, e.g. users permitted inquiry privileges only will not be permitted to modify information;

                      


              

            

             

            
              
                	

                      	17.4.1.2	
                        Restrict access to specific System functions and Information based on an individual user profile, including inquiry only capabilities; global access to all
                            functions will be restricted to specified staff jointly agreed to by ASES and the Contractor; and

                      


              

            

             

            
              
                	

                      	17.4.1.3	
                        Restrict attempts to access system functions to three (3), with a system function that automatically prevents further access attempts and records these occurrences.

                      


              

            

             

            
              
                	

                      	17.4.2	
                        The Contractor shall make System information available to duly Authorized Representatives of ASES and other Puerto Rico and Federal agencies to evaluate, through
                            inspections or other means, the quality, appropriateness and timeliness of services performed.

                      


              

            

             

            
              
                	

                      	17.4.3	
                        The Contractor shall have procedures to provide for prompt transfer of System Information upon request to other Network or Out-of-Network Providers for the medical
                            management of the Enrollee in adherence to HIPAA and other applicable requirements.

                      


              

            

             

            
              
                	

                      	17.4.4	
                        All Information, whether Data or documents, and reports that contain or make references to said Information, involving or arising out of this Contract, are owned by
                            ASES. The Contractor is expressly prohibited from sharing or publishing ASES Information and reports without the prior written consent of ASES. In the event of a dispute regarding the sharing or publishing of Information and
                            reports, ASES’s decision on this matter shall be final and not subject to appeal.

                      


              

            

             

            
              
                	

                      	17.5	
                        Systems Availability and Performance Requirements

                      


              

            

             

            
              
                	

                      	17.5.1	
                        The Contractor shall ensure that critical systems, including but not limited to the Enrollee and Provider portal and/or phone-based functions and information, such
                            as confirmation of Contractor Enrollment (“CCE”) and electronic Claims management (ECM), Enrollee services and Provider services, are available to the applicable System users twenty-four (24) hours a day, seven (7) Calendar Days
                            a Week, except during periods of scheduled System Unavailability agreed upon by ASES and the Contractor. Unavailability caused by events outside of a Contractor’s Span of Control is outside of the scope of this requirement.

                      


              

            

             

            
              
                	

                      	17.5.2	
                        The Contractor shall ensure that at a minimum all non-critical system functions and information is available to the applicable system users between the hours of
                            7:00 a.m. and 7:00 p.m. Monday through Friday (Atlantic Time).

                      


              

            

             

            
              Page 231 of 324

              
                


            

            
              
                	

                      	17.5.3	
                        The Contractor shall develop an automated method of monitoring critical systems on at least a thirty (30) minute basis twenty-four (24) hours a day, seven (7) days
                            per Week.

                      


              

            

             

            
              
                	

                      	17.5.4	
                        Upon discovery of any problem within its Span of Control that may jeopardize System availability and performance as defined in this Section of the Contract, the
                            Contractor shall notify the applicable ASES staff in person, via phone, and/or electronic mail. The Contractor shall deliver notification as soon as possible but no later than 7:00 pm (Atlantic Time) if the problem occurs during
                            the Business Day and no later than 9:00 am (Atlantic Time) the following Business Day if the problem occurs after 7:00 pm (Atlantic Time).

                      


              

            

             

            
              
                	

                      	17.5.5	
                        Where the operational problem results in delays in report distribution or problems in on-line access during the Business Day, the Contractor shall notify the
                            applicable ASES staff within fifteen (15) minutes of discovery of the problem, in order for the applicable work activities to be rescheduled or be handled based on System Unavailability protocols.

                      


              

            

             

            
              
                	

                      	17.5.6	
                        The Contractor shall provide to appropriate ASES staff information on System Unavailability events, as well as status updates on problem resolution. These up-dates
                            shall be provided on an hourly basis and made available via electronic mail, telephone and, if applicable, the Contractor’s website.

                      


              

            

             

            
              
                	

                      	17.5.7	
                        The following rules govern unscheduled System Unavailability.

                      


              

            

             

            
              
                	

                      	17.5.7.1	
                        CCE Functions

                      


              

            

             

            
              
                	

                      	17.5.7.1.1	
                        Unscheduled System Unavailability of CCE functions caused by the failure of systems and telecommunications technologies within the Contractor’s Span of Control will
                            be resolved, and the restoration of services implemented, within thirty (30) minutes of the official declaration of System Unavailability.

                      


              

            

             

            
              
                	

                      	17.5.7.1.2	
                        Throughout the Contract Term, the Contractor shall have in place a method to validate eligibility manually twenty-four (24) hours per day, seven (7) days a Week as
                            a contingency to any unscheduled Systems Unavailability for CCE functions.

                      


              

            

             

            
              
                	

                      	17.5.7.2	
                        ECM Functions. Unscheduled System Unavailability of ECM functions caused by the failure
                            of systems and technologies within the Contractor’s Span of Control will be resolved, and the restoration of services implemented, within sixty (60) minutes of the official declaration of System Unavailability, if unavailability
                            occurs during normal business hours; or within sixty (60) minutes of the start of the next Business Day, if unavailability occurs outside business hours.

                      


              

            

             

            
              Page 232 of 324

              
                


            

            
              
                	

                      	17.5.7.3	
                        All Other Contractor System Functions. Unscheduled System Unavailability of all other
                            Contractor System functions caused by systems and telecommunications technologies within the Contractor’s Span of Control shall be resolved, and the restoration of services implemented:

                      


              

            

             

            
              
                	

                      	17.5.7.3.1	
                        Within four (4) hours of the official declaration of Unscheduled System Unavailability, when unavailability occurs during business hours, and

                      


              

            

             

            
              
                	

                      	17.5.7.3.2	
                        Within two (2) hours of the start of the next Business Day, when unavailability occurs during non-business hours.

                      


              

            

             

            
              
                	

                      	17.5.8	
                        Cumulative System Unavailability caused by systems and telecommunications technologies within the Contractor’s Span of Control shall not exceed one (1) hour during
                            any continuous five (5) Calendar Day period for functions that affect GHP Enrollees and services. For functions that do not affect GHP Enrollees, cumulative System Unavailability caused by systems and telecommunications
                            technologies within the Contractor’s Span of Control shall not exceed four (4) hours during any continuous five (5) Business Day periods.

                      


              

            

             

            
              
                	

                      	17.5.9	
                        The Contractor shall not be responsible for the availability and performance of systems and telecommunications technologies outside of the Contractor’s Span of
                            Control.

                      


              

            

             

            
              
                	

                      	17.5.10	
                        For any System outage that is not corrected within the required time limits, the Contractor shall provide full written documentation that includes a Corrective
                            Action Plan, describing how the problem will be prevented from occurring again, within five (5) Business Days of the problem’s occurrence.

                      


              

            

             

            
              
                	

                      	17.5.11	
                        Regardless of the architecture of its Systems, the Contractor shall develop and be continually ready to invoke a Business Continuity and Disaster Recovery (“BC-DR”)
                            plan that at a minimum addresses the following scenarios: (i) the central computer installation and resident software are destroyed or damaged; (ii) System interruption or failure resulting from network, operating hardware,
                            software, or operational errors that compromises the integrity of transactions that are active in a live system at the time of the outage; (iii) System interruption or failure resulting from network, operating hardware, software
                            or operational errors that compromises the integrity of Data maintained in a live or archival system; and (iv) System interruption or failure resulting from network, operating hardware, software or operational errors that does
                            not compromise the integrity of transactions or Data maintained in a live or archival system but does prevent access to the System, i.e. causes unscheduled System Unavailability. This BC-DR plan must be prior approved by ASES.

                      


              

            

             

            
              
                	

                      	17.5.12	
                        The Contractor shall on an annual basis test its BC-DR plan through simulated disasters and lower level failures in order to demonstrate to ASES that it can restore
                            System functions per the standards outlined elsewhere in this Section 17.5 of the Contract. The results of these tests shall be reported to ASES within thirty (30) Calendar Days of completion of said tests.

                      


              

            

             

            
              Page 233 of 324

              
                


            

            
              
                	

                      	17.5.13	
                        In the event that the Contractor fails to demonstrate in the tests of its BC-DR plan that it can restore system functions per the standards outlined in this
                            Contract, the Contractor shall be required to submit to ASES a Corrective Action Plan that describes how the failure will be resolved. The Corrective Action Plan will be delivered within five (5) Business Days of the conclusion
                            of the test.

                      


              

            

             

            
              
                	

                      	17.5.14	
                        The Contractor shall submit a monthly Systems Availability and Performance Report to ASES as further described in Section18.2.8 of this Contract.

                      


              

            

             

            
              
                	

                      	17.6	
                        System Testing and Change Management Requirements

                      


              

            

             

            
              
                	

                      	17.6.1	
                        The Contractor shall absorb the cost of routine maintenance, inclusive of defect correction, System changes required to effect changes in Puerto Rico and Federal
                            statute and regulations, and production control activities, of all Systems within its Span of Control.

                      


              

            

             

            
              
                	

                      	17.6.2	
                        The Contractor shall respond to ASES reports of System problems not resulting in System Unavailability according to the following timeframes:

                      


              

            

             

            
              
                	

                      	17.6.2.1	
                        Within five (5) Calendar Days of receipt, the Contractor shall respond in writing to notices of System problems.

                      


              

            

             

            
              
                	

                      	17.6.2.2	
                        Within fifteen (15) Calendar Days, the correction will be made or a requirements analysis and specifications document will be due.

                      


              

            

             

            
              
                	

                      	17.6.3	
                        The Contractor shall correct the deficiency by an effective date to be determined by ASES.

                      


              

            

             

            
              
                	

                      	17.6.4	
                        The Contractor’s Systems will have a system-inherent mechanism for recording any change to a software module or subsystem.

                      


              

            

             

            
              
                	

                      	17.6.5	
                        The Contractor shall put in place procedures and measures for safeguarding ASES from unauthorized modifications to the Contractor’s Systems.

                      


              

            

             

            
              
                	

                      	17.6.6	
                        Unless otherwise agreed to in advance by ASES, scheduled System Unavailability to perform System maintenance, repair and/or upgrade activities to Contractor’s CCE
                            systems shall take place between 11 p.m. on a Saturday and 6 a.m. on the following Sunday (Atlantic Time).

                      


              

            

             

            
              
                	

                      	17.6.7	
                        The Contractor shall work with ASES pertaining to any testing initiative as required by ASES.

                      


              

            

             

            
              Page 234 of 324

              
                


            

            
              
                	

                      	17.6.8	
                        The Contractor shall provide sufficient System access to allow verification of System functionality, availability and performance by ASES during the times required
                            by ASES prior to April 1, 2015 which is the Implementation Date of the Contract, and as subsequently required during the Contract Term.

                      


              

            

             

            
              
                	

                      	17.7	
                        System Security and Information Confidentiality and Privacy Requirements

                      


              

            

             

            
              
                	

                      	17.7.1	
                        The Contractor shall provide for the physical safeguarding of its Data processing facilities and the Systems and Information housed therein. The Contractor shall
                            provide ASES with access to Data facilities upon ASES’s request. The physical security provisions shall be in effect for the life of this Contract.

                      


              

            

             

            
              
                	

                      	17.7.2	
                        The Contractor shall restrict perimeter access to equipment sites, processing areas, and storage areas through a card key or other comparable system, as well as
                            provide accountability control to record access attempts, including attempts of unauthorized access.

                      


              

            

             

            
              
                	

                      	17.7.3	
                        The Contractor shall include physical security features designed to safeguard processor site(s) through required provision of fire retardant capabilities, as well
                            as smoke and electrical alarms, monitored by security personnel.

                      


              

            

             

            
              
                	

                      	17.7.4	
                        The Contractor shall ensure that the operation of all of its Systems is performed in accordance with Puerto Rico and Federal regulations and guidelines related to
                            security and confidentiality of the protected information managed by the Contractor, and shall strictly comply with HIPAA Privacy and Security Rules, as amended, and with the Breach Notification Rules under the HITECH Act.

                      


              

            

             

            
              
                	

                      	17.7.5	
                        The Contractor will put in place procedures, measures and technical security to prohibit unauthorized access to the regions of the Data communications network
                            inside of a Contractor’s Span of Control.

                      


              

            

             

            
              
                	

                      	17.7.6	
                        The Contractor shall ensure compliance with:

                      


              

            

             

            
              
                	

                      	17.7.6.1	
                        42 CFR Part 431 Subpart F (confidentiality of information concerning applicants and enrollees of public medical assistance programs);

                      


              

            

             

            
              
                	

                      	17.7.6.2	
                        42 CFR Part 2 (confidentiality of alcohol and drug abuse records); and

                      


              

            

             

            
              
                	

                      	17.7.6.3	
                        Special confidentiality provisions in Puerto Rico or Federal law related to people with HIV/AIDS and mental illness.

                      


              

            

             

            
              
                	

                      	17.7.7	
                        The Contractor shall provide its Enrollees with its HIPAA Notice of Privacy Practices that conforms to all applicable Federal and State laws. The Contractor shall
                            provide ASES with a copy of this Notice.

                      


              

            

             

            
              Page 235 of 324

              
                


            

            
              
                	

                      	17.8	
                        Information Management Process and Information Systems Documentation Requirements

                      


              

            

             

            
              
                	

                      	17.8.1	
                        The Contractor shall ensure that written System Process and Procedure Manuals document and describe all manual and automated system procedures for its information
                            management processes and Information Systems. These manuals shall be provided to ASES Immediately upon request.

                      


              

            

             

            
              
                	

                      	17.8.2	
                        The System User Manuals shall contain information about, and instructions for, using applicable System functions and accessing applicable system Data.

                      


              

            

             

            
              
                	

                      	17.8.3	
                        When a System change that would alter the conditions and services agreed upon in this Contract is subject to ASES sign off, the Contractor shall draft revisions to
                            the appropriate manuals prior to ASES sign off of the change.

                      


              

            

             

            
              
                	

                      	17.8.4	
                        Updates to the electronic version of these manuals shall occur in real time; updates to the printed version of these manuals shall occur within ten (10) Business
                            Days of the update taking effect.

                      


              

            

             

            
              
                	

                      	17.8.5	
                        ASES reserves the right to audit the Contractor’s policies and procedures manuals and protocols compliance related to its Information Systems.

                      


              

            

             

            
              
                	

                      	17.9	
                        Reporting Functionality Requirements

                      


              

            

             

            
              
                	

                      	17.9.1	
                        The Contractor’s Systems shall have the capability of producing a wide variety of reports that support program management, policymaking, quality improvement,
                            program evaluation, analysis of fund sources and uses, funding decisions and assessment of compliance with Federal and Puerto Rico requirements.

                      


              

            

             

            
              
                	

                      	17.9.2	
                        The Contractor shall support a mechanism for obtaining service and expenditure reports by funding source, Provider, Provider type or other characteristic; and
                            Enrollee, Enrollee group/category or other characteristic.

                      


              

            

             

            
              
                	

                      	17.9.3	
                        The Contractor shall extend access to this mechanism to select ASES personnel in a secure manner to access Data, including program and fiscal information regarding
                            Enrollees served, services rendered, etc. and the ability for said personnel to develop and/or retrieve reports. This requirement could be met by the provision of access to a decision support system/Data warehouse. The
                            Contractor shall provide training in and documentation on the use of this mechanism.

                      


              

            

             

            
              
                	

                      	17.9.4	
                        Within five (5) Calendar Days upon ASES’s request, the Contractor will deliver a copy of the then current ASES’s System information to ASES in a mutually acceptable
                            form and format.

                      


              

            

             

            
              Page 236 of 324

              
                


            

            
              
                	

                      	17.10	
                        Disaster Recovery, Disaster Declaration, Data Content Delivery to ASES

                      


              

            

             

            
              
                	

                      	17.10.1	
                        The Contractor shall maintain a disaster recovery and business recovery plan in effect throughout the term of the Contract. The disaster recovery plan shall be
                            subject to ASES review upon reasonable notice to the Contractor. The Contractor shall maintain reasonable safeguards against the destruction, loss, intrusion and unauthorized alteration of printed materials and data in its
                            possession. At a minimum, the Contractor shall perform (i) incremental daily back-ups, (ii) weekly full backups, and (iii) such additional back-ups as the Contractor may determine to be necessary to maintain such reasonable
                            safeguards.

                      


              

            

             

            
              
                	

                      	17.10.2	
                        Both Parties recognize that a failure by the Contractor’s Network may adversely impact ASES business and operations, as the responsible party for the GHP.
                            Therefore, in the event that the Contractor’s Network designed to deliver the services herein contemplated becomes unable, or is anticipated to become unable, to deliver such services on a timely basis, Contractor shall
                            Immediately notify ASES by telephone, and shall work closely with ASES to fix the problem. In the event that Contractor fails to provide such required notice to ASES and such delay in the notification has a material and adverse
                            effect upon ASES and/or Enrollees, ASES may terminate this Contract for cause as provided in Article 35 of this Contract.

                      


              

            

             

            
              
                	

                      	17.10.3	
                        Within five (5) Calendar Days upon ASES’s request, the Contractor will deliver a copy of the then current ASES’s Data Content to ASES in a mutually acceptable form
                            and format which is useable and readable and understandable by ASES.

                      


              

            

             

            
              
                	

                      	17.11	
                        Health Information Organization (HIO) and Health Information Exchange (HIE)
                              Requirements

                      


              

            

             

            
              
                	

                      	17.11.1	
                        The Contractor shall initiate the active participation in any Health Information Organization (HIO) that offers Health Information Exchange (HIE) services, in order
                            to integrate the Enrollees’ Protected Health Information, facilitate access to and retrieval of their clinical Data to provide safer and more timely, efficient, effective, and equitable patient-centered care. The HIO
                            participation is also required to support the analysis of the health of the population. As required by ASES, the Contractor shall be active in a HIO and cooperate with this effort.

                      


              

            

             

            
              
                	

                      	17.11.2	
                        ASES shall retain the right to request from the Contractor the active participation in the Puerto Rico Health Information Exchange Corporation (PRHIEC), the Puerto
                            Rico HIO State Designated Entity, in order to achieve the effective alignment of activities across Medicaid and Puerto Rico public health programs, to avoid duplicate efforts and to ensure integration and support of a unified
                            approach to information exchange for the GHP Program.

                      


              

            

             

            
              Page 237 of 324

              
                


            

            
              
                	

                      	17.11.3	
                        The Contractor shall verify that the HIO complies with all Information System standards and requirements for interoperability and security capabilities dictated by
                            ONCHIT, and other Federal and Puerto Rico regulations.

                      


              

            

             

            
              
                	

                      	17.11.4	
                        The Contractor shall work with Network Providers and staff to encourage active participation in an HIO, as specified in the strategic plan found in Attachment 17 to
                            this Contract.

                      


              

            

             

            
              
                	ARTICLE 18	
                        REPORTING

                      


              

            

             

            
              
                	

                      	18.1	
                        General Requirements

                      


              

            

             

            
              
                	

                      	18.1.1	
                        ASES may, at its discretion, require the Contractor to submit additional reports or any other data, documentation or information relating to the performance of the
                            Contractor’s obligations both on an ad hoc and recurring basis as required by ASES or CMS. If ASES requests any revisions to the reports already submitted, the Contractor shall make the changes and re-submit the reports,
                            according to the time period and format specified by ASES.

                      


              

            

             

            
              
                	

                      	18.1.2	
                        The Contractor shall submit all reports to ASES in the manner and format prescribed by ASES and as prescribed in the reporting guide.

                      


              

            

             

            
              
                	

                      	18.1.3	
                        The Contractor shall submit all reports, including but not limited to those required by Law 72, Article 7, Section 2, in a manner and format prescribed by ASES.

                      


              

            

             

            
              
                	

                      	18.1.4	
                        All reports submitted to ASES containing information about a Provider must include the Provider’s National Provider Identifier (NPI), if applicable.

                      


              

            

             

            
              
                	

                      	18.1.5	
                        All quantitative reports shall include a summary table that presents Data over time including monthly, quarterly and/or year-to-date summaries as directed by ASES.

                      


              

            

             

            
              
                	

                      	18.1.6	
                        ASES’s requirements regarding reports, report content, and frequency of submission are subject to change at any time during the term of the Contract. A list of
                            required reports is provided in Attachment 16 to this Contract. ASES shall notify the Contractor, in writing, of changes to existing required report content, format or schedule at least fourteen (14) Calendar Days prior to
                            implementing the reporting change. ASES shall notify the Contractor, in writing, of new reports at least forty-five (45) Calendar Days prior to implementing the new report. The Contractor shall be held harmless if ASES fails to
                            meet this requirement for any changes for existing reports. However, the Contractor is not otherwise relieved of any responsibility for the submission of late, inaccurate or otherwise incomplete reports. The first submission of
                            a report revised by ASES to include a change in Data requirements or definition will not be subject to penalty for accuracy.

                      


              

            

             

            
              Page 238 of 324

              
                


            

            
              
                	

                      	18.1.7	
                        The Contractor shall submit reports timely and in proper format. The submission of late, inaccurate, or otherwise incomplete reports constitutes failure to report.
                            “Timely submission” shall mean that the report was submitted on or before the date it was due. “Accuracy” shall mean the report was prepared according to the specific written guidance, including report template, provided by ASES
                            to the Contractor. All elements must be met for each required report submission. Therefore, the report must be timely, accurate and contain an analysis. If any portion of the report element is not met, the report is deemed in
                            “error” and the Contractor will be considered to not be in compliance with the Contract and will be subject to intermediate sanctions and or liquidated damages and/or fines in accordance with Articles 19 and 20 of this Contract.
                            The Contractor shall not be penalized if an error in a previously submitted report is identified by the Contractor and reported to ASES prior to ASES’s identification of the error. Corrected reports in this type of situation
                            will be submitted to ASES in a timeframe determined by ASES after consulting with the Contractor. Failure to comply with the agreed upon timeframes for correction and resubmission shall be subject to intermediate sanctions and
                            or liquidated damages and/or fines in accordance with Articles 19 and 20 of this Contract.

                      


              

            

             

            
              
                	

                      	18.1.8	
                        Each report must include an analysis, which shall include, at a minimum: (i) identification of any changes compared to previous reporting periods as well as
                            trending over time; (ii) an explanation of said changes (positive or negative); (iii) an action plan or performance improvement activities addressing any negative changes; and (iv) any other additional information pertinent to
                            the reporting period. ASES may assess intermediate sanctions, liquidated damages and/or fines in accordance with Articles 19 and 20 of this Contract for failure to address any of these requirements. The above Data requirements
                            may be represented in charts, graphs, tables and any other Data illustrations to demonstrate findings.

                      


              

            

             

            
              
                	

                      	18.1.9	
                        The Contractor shall review, as part of its continuous improvement activities, timeliness and accuracy of reports submitted to ASES to identify instances and
                            patterns of non-compliance. The Contractor shall perform an analysis identifying any patterns or issues of non-compliance and shall implement quality improvement activities to improve overall performance and compliance.

                      


              

            

             

            
              
                	

                      	18.1.10	
                        The Contractor shall submit all reports to ASES, unless indicated otherwise in this Contract, according to the schedule below. Failure to report timely may result
                            in intermediate sanctions, liquidated damages and/or fines in accordance with Articles 19 and 20. Reports or other required Data shall be received on or before scheduled due dates.

                      


              

            

             

            
              
                	

                      	18.1.11	
                        The Contractor shall submit all reports to ASES, unless indicated otherwise in this Contract, according to the schedule below:

                      


              

            

             

            
              Page 239 of 324

              
                


            

            	 	 	
                    DELIVERABLES

                  	 	 	
                    DUE DATE

                  
	 	 	
                    Weekly Reports

                  	 	 	
                    Friday of the following Week

                  
	 	 	
                    Monthly Reports

                  	 	 	
                    Fifteenth (15th) Calendar Day of the following month

                  
	 	 	
                    Quarterly Reports

                  	 	 	
                    Thirtieth (30th) Calendar Day of the following month

                  
	 	 	
                    Semi-Annual Reports

                  	 	 	
                    March 31 and September 30 of the Contract year

                  
	 	 	
                    Annual Reports

                  	 	 	
                    Ninety (90) Calendar Days after the end of the Contract Year

                  


             

            
              
                	

                      	18.1.12	
                        If a report due date falls on a weekend or a Puerto Rico holiday, receipt of the report the next Business Day is acceptable.

                      


              

            

             

            
              
                	

                      	18.1.13	
                        Extensions to report submission dates will be considered by ASES after the Contractor has contacted the ASES designated point of contact via email at least
                            twenty-four (24) hours in advance of the report due date. Extension for submission of reports should be under rare and unusual circumstances. If ASES grants an extension, and the report is submitted before the extended deadline,
                            the report(s) will be considered timely and not subject to penalty for timeliness. Not requesting an extension within at least twenty-four (24) hours of the report due date is considered failure to report timely.

                      


              

            

             

            
              
                	

                      	18.1.14	
                        Anytime a report is rejected for any reason, the Contractor shall resubmit the report within ten (10) Business Days from notification of the rejection or as
                            directed by ASES.

                      


              

            

             

            
              
                	

                      	18.1.15	
                        The Contractor shall submit all reports electronically to ASES’s FTP site unless directed otherwise by ASES. ASES shall provide the Contractor with access to the
                            FTP site. The email generated by the FTP upload will be used as the time stamp for the submission of the report(s).

                      


              

            

             

            
              
                	

                      	18.1.16	
                        ASES shall provide feedback, as necessary, to the Contractor regarding format and timeliness of reports within forty-five (45) Calendar Days from the due date of
                            the report.

                      


              

            

             

            
              
                	

                      	18.1.17	
                        All reports in the reporting templates provided to the Contract require Contractor certification. The Authorized Certifier or an equivalent position as delegated by
                            the Contractor and approved by ASES, shall review the accuracy of language, analysis, and Data in each report prior to submitting the report to ASES. The Authorized Certifier shall include a signed attestation each time the
                            report is submitted. The attestation must include a certification, based on best knowledge, information, and belief, as to the accuracy, completeness and truthfulness of the Data in the report. Reports will be deemed incomplete
                            if an attestation is not included.

                      


              

            

             

            
              Page 240 of 324

              
                


            

            
              
                	

                      	18.1.18	
                        The Contractor Data transfers shall occur in standard format as prescribed by ASES and will be compliant with HIPAA and Federal regulations. The Contractor shall
                            submit in formats as prescribed by ASES so long as ASES’s direction does not conflict with any Federal law.

                      


              

            

             

            
              
                	

                      	18.2	
                        Specific Report Requirements

                      


              

            

             

            
              
                	

                      	18.2.1	
                        The following section provides an overview and description of all reports required by this Contract. The details and requirements of the reports are subject to
                            change at the discretion of ASES.

                      


              

            

             

            
              
                	

                      	18.2.2	
                        Administrative Reports

                      


              

            

             

            
              
                	

                      	18.2.2.1	
                        The Contractor shall submit a monthly Call Center Report that provides
                            information about the Enrollee services, Provider services, and nurse advice lines. The report shall, at a minimum, include by language queue: (i) number of calls received; (ii) number of calls answered; (iii) abandonment rate;
                            (iv) number of calls answered within thirty (30) seconds; and (v) call topics.

                      


              

            

             

            
              
                	

                      	18.2.2.2	
                        The Contractor shall submit a quarterly Enrollee Enrollment Materials Report
                            regarding the mailing of initial and replacement Enrollee Enrollment materials including Enrollee ID cards, Enrollee handbooks, and Provider directories. The Data in the report shall be reported separately for initial mailings
                            to new Enrollees and requests for replacement materials for current Enrollees. The report shall include, at a minimum, the following: (i) number of ID cards, handbooks and Provider directories mailed during the month regardless
                            of whether the request was made by phone, online or in person; (ii) number of ID cards, handbooks and Provider directories mailed within Contract standards; and (iii) number of ID cards, handbooks and Provider directories not
                            mailed within Contract standards.

                      


              

            

             

            
              
                	

                      	18.2.2.3	
                        The Contractor shall submit a quarterly Fraud, Waste, and Abuse Report.
                            The report contains three subsections:

                      


              

            

             

            
              
                	

                      	18.2.2.3.1	
                        Information regarding suspicious activity, Fraud, Waste, and Abuse cases, recoupments, Cost Avoidance, Referrals, and other information as directed by ASES. At a
                            minimum, the report shall include: (i) Enrollee name and ID number; (ii) Provider name, Provider type and NPI; (iii) source and date of Complaint; (iv) nature of Complaint (including alleged persons or entities involved,
                            category of services, factual explanation of the allegation and dates of contact); (v) all communications between the Contractor and the Provider about the Complaint; (vi) approximate dollars involved or amount paid to the
                            Provider during the past three (3) years (whichever is greater); (vii) amount recouped; (viii) disciplinary measures imposed, if any; and (ix) legal disposition of the case.

                      


              

            

             

            
              Page 241 of 324

              
                


            

            
              
                	

                      	18.2.2.3.2	
                        List by name all Network Provider suspensions or terminations, at a minimum, (i) each Network Provider’s name; (ii) the Network Provider’s specialty; (iii) the
                            Network Provider’s NPI; (iv) the Network Provider’s primary city; (v) reason(s) for the action taken; and (vi) the effective date of the suspension or termination. If the Contractor has taken no action against Providers during
                            the quarter this should be documented in the report.

                      


              

            

             

            
              
                	

                      	18.2.2.3.3	
                        Include information pertaining to employees and Contractors that have been suspended or debarred from participating in the program.

                      


              

            

             

            
              
                	

                      	18.2.2.4	
                        The Contractor shall submit a monthly Privacy and Confidentiality Report. The





                            report shall provide information on any Incidents that involve the loss, theft or unauthorized use or access of Enrollee PHI. The report shall include at a minimum: (i) the date of the Incident; (ii) the date of notification to
                            ASES; (iii) the nature and scope of the Incident; (iv) the Contractor’s response to the Incident; (v) the number of Enrolles actually or potentially impacted; (vi) any mitigating measures taken by the Contractor to prevent
                            similar incidents.

                      


              

            

             

            
              
                	

                      	18.2.2.5	
                        The Contractor shall submit a monthly Systems Incident Report. The report shall provide information on any Incidents that involve unauthorized access to the Contractor’s systems, databases or servers.
                            This report shall be provided at least annually, but the Contractor shall provide the report ten (10) Business Days following an Incident. The report shall include, at a minimum, the date of the Incident, the date of
                            notification to ASES, the nature and scope of the Incident, the Contractor’s response to the Incident, and the mitigating measures taken by the Contractor to prevent similar Incidents in the future. “Port scans” or other
                            unsuccessful queries to the Contractor’s Information System shall not be considered a privacy/security Incident for purposes of this report.

                      


              

            

             

            
              
                	

                      	18.2.2.6	
                        The Contractor shall submit a quarterly Federally Qualified Health Center (FQHC) Report as required by ASES and the Puerto Rico Medicaid Program. The report
                            contains the following subsections:

                      


              

            

             

            
              
                	

                      	18.2.2.6.1	
                        Fee for Services Payment Report and Attestation includes all FFS payments by PMG.

                      


              

            

             

            
              Page 242 of 324

              
                


            

            
              
                	

                      	18.2.2.6.2	
                        Visits Data Support and Attestation includes information on face-to-face visits by type of Provider, population category, and other criteria.

                      


              

            

             

            
              
                	

                      	18.2.2.6.3	
                        PMG Population Detail and Attestation includes Enrollees by category (Federal, State, CHIP and Other) by PMG.

                      


              

            

             

            
              
                	

                      	18.2.2.6.4	
                        Capitation Settlement and Attestation includes a reconciliation of payments per capita.

                      


              

            

             

            
              
                	

                      	18.2.2.7	
                        The Contractor shall submit a monthly Special Coverage Registry Report. The





                            report shall provide information on all registered Enrollees, PMG, PCP NPI, type of registry, Special Coverage category, diagnosis code, start and end dates, identify new cases, case status, reason(s) for closing the case. For
                            the Obstetric category, the expected date of delivery, last menstrual period and Obstetric Specialist NPI.

                      


              

            

             

            
              
                	

                      	18.2.2.8	
                        The Contractor shall submit a monthly HCHN Registry Report for ASES to
                            process monthly PMPM Payments. The report shall provide information on all HCHN Enrollees that are identified by the Contractor following the procedures established in Attachment 28 to this Contract. ASES will perform a
                            retroactive review of the conditions identified by Enrollee utilizing the monthly claims data submitted by the Contractor to ASES. If the data does not support the identified condition(s), ASES may retroactively recoup the
                            difference in PMPM Payment.

                      


              

            

             

            
              
                	

                      	18.2.2.9	
                        The Contractor shall submit an annual Disclosure of Information on Annual
                              Business Transactions as described in Section 23.7.4 of the Contract.

                      


              

            

             

            
              
                	

                      	18.2.2.10	
                        Within forty-five (45) days of the end of the Puerto Rico Government’s fiscal year, Contractor shall submit the statistical report required under Section 2, Article
                            VII of Law 72-1993 in the layout specified by ASES.

                      


              

            

             

            
              
                	

                      	18.2.3	
                        Claims

                      


              

            

             

            
              
                	

                      	18.2.3.1	
                        The Contractor shall submit a monthly Claims Activity Report. At a
                            minimum, this report shall identify: (i) the number of Claims received; (ii) number of Claims denied (by reason); (iii) number of Claims paid; (iv) number of Claims pending (by reason); (v) and the total amount paid for all
                            Providers (by Provider category) specified by ASES in accordance with Section 16.2 of this Contract.

                      


              

            

             

            
              
                	

                      	18.2.3.2	
                        The Contractor shall submit Encounter Data in a standardized format as
                            specified by ASES (see Section 16.3 of this Contract and Attachment 26) transmitted electronically to ASES on a monthly basis. The Contractor shall provide any information and/or Data requested in a format to be specified by
                            ASES as required to support the validation, testing or auditing of the completeness and accuracy of Encounter Data submitted by the Contractor.

                      


              

            

             

            
              Page 243 of 324

              
                


            

            
              
                	

                      	18.2.4	
                        Covered Services

                      


              

            

             

            
              
                	

                      	18.2.4.1	
                        The Contractor shall submit an annual CMS 416 Report that measures and
                            documents EPSDT screening and participation rates. In addition to the requirements in the CMS 416 Report, the Contractor shall report on
                            any additional Data that ASES determines is necessary for monitoring and compliance purposes.

                      


              

            

             

            
              
                	

                      	18.2.4.2	
                        The Contractor shall submit a quarterly Executive Director and Utilization Data
                              Report that provides information on selected GHP populations and Providers. The report shall include, at a minimum:

                      


              

            

             

            
              
                	

                      	18.2.4.2.1	
                        Enrollee, Special Conditions and Child: Information regarding (i) GHP Enrollees; (ii) Enrollees in special programs (including Enrollees with Special Coverage);
                            (iii) PPN and Network Providers; (iv) services for children; (v) dental services; (vi) hospitalizations, and statistical data on the top ten (10) most prevalent diagnosis as specified by ASES.

                      


              

            

             

            
              
                	

                      	18.2.4.2.2	
                        Preventable Conditions. Information as defined in Sections 7.1.1.1.1 and 7.1.1.1.2 of
                            this Contract. The report shall include but not be limited to, a description of each identified instance of a Provider Preventable Condition, the name of the applicable Provider, and a summary of corrective actions taken by the
                            Contractor or Provider to address any underlying causes of the Provider Preventable Condition.

                      


              

            

             

            
              
                	

                      	18.2.4.2.3	
                        Dental, Hospital, Emergency Room

                      


              

            

             

            
              
                	

                      	18.2.4.2.3.1	
                        Dental. The total number of dental services and the cost on a quarterly basis.

                      


              

            

             

            
              
                	

                      	18.2.4.2.3.2	
                        Hospital Services. Total number of bed days and cost quarterly for Physical Health and
                            Behavioral health, separately.

                      


              

            

             

            
              
                	

                      	18.2.4.2.3.3	
                        Emergency Room. On a quarterly basis, the total number of ER visits and costs; the top
                            conditions for Physical Health admissions; and the top conditions for Behavioral Health admissions.

                      


              

            

             

            
              Page 244 of 324

              
                


            

            
              
                	

                      	18.2.4.2.4	
                        Outpatient/Ambulatory Services. The total number of Outpatient services by type on a
                            quarterly basis. Types of services include: Office visits, PCP encounters, imaging Laboratory, Pathology, OP Surgery, Other Medical Procedures and Services and Other Ancillary Services. Behavioral Health OP services by type on a
                            quarterly basis. Types of BH services include: Psychiatrist, Psychologist, BH treatment by a General Practitioner, Other, Partial Hospitalization, Clinical Labs and all Other Ancillary BH Services. Behavioral Ambulatory Clinics:
                            the number of Enrollees (including walk-ins) receiving Behavioral Health Services therein and the number of Providers rendering these services during such period.

                      


              

            

             

            
              
                	

                      	18.2.4.2.5	
                        Admissions and Re-admissions. The number of discharges and re-admissions within thirty
                            (30) Calendar Days of a previous discharge, distributed by Physical Health and Behavioral Health; the top three (3) diagnosis codes for Physical Health and Behavioral Health; and the top five (5) re-admission facilities by
                            Physical Health and Behavioral Health.

                      


              

            

             

            
              
                	

                      	18.2.4.2.6	
                        Prior Authorization (PA). PA information by service, specifying (i) total PA requests
                            received; (ii) total process by type of determination; (iii) denials by reason and type of service; and (iv) HCHN PA processed and denied by condition.

                      


              

            

             

            
              
                	

                      	18.2.5	
                        Provider Reports

                      


              

            

             

            
              
                	

                      	18.2.5.1	
                        The Contractor shall submit a monthly Network Provider List Report that
                            provides information on the number of Providers with and without assigned lives in the Contractor’s General and PPN network. At a minimum, the report shall include information on the Network Provider’s: (i) name; (ii) specialty;
                            (iii) NPI; (iv) specialty code; (v) license number; (vi) primary office location; (vii) office hours; (viii) Credentialing status; (ix) PMG affiliation; (x) ratio to Enrollees (including PCPs, Behavioral Health Providers); and
                            (xi) the number of assigned lives (if applicable); and (xii) credentialing and re-credentialing information. For facilities, the report shall include: (i) EIN; (ii) name of the entity; (iii) municipality code; (iv) Provider type
                            code; and (v) the NPI.

                      


              

            

             

            
              
                	

                      	18.2.5.2	
                        The Contractor shall submit quarterly Geographical Access reports using
                            geographic Information Systems software that allows ASES to analyze, at a minimum, the following: (i) description of geographic systems software utilized to generate geographic access reports; (ii) description of monitoring
                            activities to ensure Access standards are met and that Enrollees have Access to services; (iii) description of gaps in geographic Access and methodologies used to identify them; (iv) Data on all service locations for PCP and all
                            specialty Providers; and (v) number of Enrollees that are currently assigned to the Network Provider (PCPs only).

                      


              

            

             

            
              Page 245 of 324

              
                


            

            
              
                	

                      	18.2.5.3	
                        The Contractor shall submit a quarterly Appointment Availability Report that





                            provides network assurance reviews and outreach to individual Providers. The report should include a 25% review of the Contractor’s provider network. The report shall (i) verify appointment availability and timeliness; (ii)
                            verify contact information, address, phone, email and fax numbers; (iii) verify open/closed panel status and identify Providers accepting new patients; (iv) verify disability access, equipment or limitations; (v) verify
                            languages spoken and cultural specific training; and (vi) verification of co-location hours based on assigned Enrollees.

                      


              

            

             

            
              
                	

                      	18.2.5.4	
                        The Contractor shall submit an annual Provider Satisfaction Report that
                            encompasses Physical and Behavioral Health Network Providers. The report shall include but not be limited to, a summary of the Provider survey methods and findings for Physical and Behavioral Health Network Providers separately
                            and an analysis of opportunities for improvement. See Section 12.6 for additional information regarding Provider Satisfaction Surveys.

                      


              

            

             

            
              
                	

                      	18.2.5.5	
                        The Contractor shall submit a quarterly Provider Training and Outreach
                              Evaluation Report to evaluate the initiatives in the plan and present findings and lessons learned. The report shall specify the training topic(s), the targeted Providers, the content of the training, the training
                            schedule (including dates/times and locations), training methods, funds expended, and number and types of attendees.

                      


              

            

             

            
              
                	

                      	18.2.5.6	
                        The Contractor shall submit an annual Physician Incentive Program Report in




                            a narrative format including the information specified by regulation in order for ASES to adequately monitor the Contractor’s program under the criteria in 42 CFR 422.208 and 422.210.

                      


              

            

             

            
              
                	

                      	18.2.6	
                        Quality

                      


              

            

             

            
              
                	

                      	18.2.6.1	
                        The Contractor shall submit a quarterly Grievances and Appeals Report. The





                            Contractor shall submit reports of all Provider and Enrollee Grievances (informal and formal), Appeals, Notices of Adverse Benefit Determinations and Administrative Law Hearings utilizing the ASES-provided reporting templates
                            and codes. The report will also capture Enrollee comments and inquiries made through the Contractor’s website.

                      


              

            

             

            
              Page 246 of 324

              
                


            

            
              
                	

                      	18.2.6.2	
                        The Contractor shall submit a quarterly Health Care Improvement Program (HCIP)
                              Report. The Contractor shall use measurements and performance guidelines outlined in the HCIP Manual, Attachment 19 to this Contract.

                      


              

            

             

            
              
                	

                      	18.2.6.3	
                        The Contractor shall submit an annual Enrollee Satisfaction Survey Report
                            that includes, but is not limited to, a summary of the Enrollee survey methods, findings, analysis and evaluation. The report shall present information separately for CAHPS and ECHO. The survey and findings shall be presented by
                            populations as determined by ASES (e.g., Adults, children, Behavioral Health and Chronic Conditions). The report must provide an action plan addressing areas for improvement of the Contractor as identified in the survey results.
                            Refer to Section 12.6 of this Contract for additional information regarding the survey.

                      


              

            

             

            
              
                	

                      	18.2.6.4	
                        The Contractor shall submit an annual Audited HEDIS Results Report. The
                            Contractor shall use only NCQA published HEDIS standardized measures that specify how MCOs collect, audit, calculate and report performance information.

                      


              

            

             

            
              
                	

                      	18.2.6.4.1	
                        Each HEDIS submission must require the following information:

                      


              

            

             

            
              
                	

                      	18.2.6.4.1.1	
                        A signed attestation that will provided by ASES;

                      


              

            

             

            
              
                	

                      	18.2.6.4.1.2	
                        Quantitative Data and Qualitative Data collected according to HEDIS technical specifications. This Data shall be reported to ASES in an excel workbook and as a
                            searchable .PDF document; and

                      


              

            

             

            
              
                	

                      	18.2.6.4.1.3	
                        A final HEDIS Compliance Audit Report and supporting documentation according to HEDIS Compliance Audit standards, policies and procedures. The Contractor shall
                            contract with a certified HEDIS auditor to validate the processes of the Contractor. For Medicaid and CHIP Eligibles, the validation procedures shall be consistent with Federal requirements specified at 42 CFR 438.358(b)(2).

                      


              

            

             

            
              
                	

                      	18.2.6.4.2	
                        As specified in Section 12.3.4.6 of this Contract, the Contractor shall submit the standardized HEDIS measures in the format required by ASES. On January each year,
                            ASES will notify Contractors on the HEDIS measures to be reported.

                      


              

            

             

            
              Page 247 of 324

              
                


            

            
              
                	

                      	18.2.6.4.3	
                        ASES may add, change, or remove HEDIS reporting requirements with notice sixty (60) Calendar Days in advance of the effective date of the addition, change, or
                            removal.

                      


              

            

             

            
              
                	

                      	18.2.6.4.4	
                        When requested, the Contractor shall submit Data to ASES for standardized performance measures, within specified timelines and according to the established
                            procedures Data collection and reporting. The Contractor shall collect valid and reliable Data, using qualified staff and personnel to collect the Data. Failure of the Contractor to follow Data collection and reporting
                            requirements may result in sanctions, liquidated damages and/or other fines in accordance with Articles 19 and 20 of this Contract.

                      


              

            

             

            
              
                	

                      	18.2.7	
                        Utilization Management

                      


              

            

             

            
              
                	

                      	18.2.7.1	
                        The Contractor shall submit a quarterly Integration Model Report that
                            includes information on Physical and Behavioral Health Services.

                      


              

            

             

            The report shall, at a minimum, include the following data as specified by ASES:

             

            
              
                	

                      	18.2.7.1.1	
                        Co-location Services. By Provider, the total membership, BHP quarterly required hours
                            and actual quarterly hours, the number of unique Enrollees, the total number of hours served by col-location, the number of initial assessments, the number of Enrollees receiving short intervention and the number of Enrollees
                            where case discussion took place with any Provider.

                      


              

            

             

            
              
                	

                      	18.2.7.1.2	
                        Reverse Co-location Services. By facility or clinic; the number of BHP quarterly
                            required hours and actual quarterly hours; the total number of patients seen for Physical Health issues (by number of visits, not by unique Enrollees); number of services; number of Enrollees in the Serious Mental Illness (SMI)
                            registry, and of those Enrollees seen for Physical Health, how many were in the SMI registry.

                      


              

            

             

            
              
                	

                      	18.2.7.1.3	
                        Beneficiary Educational Activities. By facility, the Enrollment number, the total
                            number of Enrollees seen, the program name, date, duration, and number of attendees.

                      


              

            

             

            
              Page 248 of 324

              
                


            

            
              
                	

                      	18.2.7.1.4	
                        Provider Educational Activities. By date, the total number of education hours, the
                            clinic name, the total number of staff members, and total number that attended the activity.

                      


              

            

             

            
              
                	

                      	18.2.7.1.5	
                        Care Management. Care management data by program category, HCHN and Chronic Conditions
                            data by diagnosis category, screenings by category, and referrals.

                      


              

            

             

            
              
                	

                      	18.2.7.1.6	
                        Pregnancy data on the pregnant population and Prenatal and Maternal Program.

                      


              

            

             

            
              
                	

                      	18.2.7.1.7	
                        Number of Enrollees in each category as registered in the quarter: Smoking cessation, autism, ADD, and Buprenorphine.

                      


              

            

             

            
              
                	

                      	18.2.8	
                        Systems

                      


              

            

             

            
              
                	

                      	18.2.8.1	
                        The Contractor shall submit a monthly Systems Availability and Performance
                              Report that provides information on availability and unavailability by major system as well as response times for the Contractor’s confirmation of Contractor’s Enrollment and electronic Claims management functions, as
                            measured within the Contractor’s Span of Control. The report shall meet the requirements of Section 17.5.

                      


              

            

             

            
              
                	

                      	18.2.8.2	
                        The Contractor shall submit an annual Business Continuity and Disaster Recovery
                              (“BC-DR”) Test Report for review and written approval as specified by ASES in accordance with Section 17.5. The Contractor shall conduct annual tests of the BC-DR system and report the findings of the test results with
                            the system generated log report within thirty (30) Calendar Days of the date of the test.

                      


              

            

             

            
              
                	

                      	18.2.9	
                        Financial Management

                      


              

            

             

            
              
                	

                      	18.2.9.1	
                        The Contractor shall submit a quarterly Unaudited Financial Statement Report in






                            a format and level of detail as specified by ASES.

                      


              

            

             

            
              
                	

                      	18.2.9.2	
                        The Contractor shall submit an annual Report on Controls Placed in Operation and
                              Tests of Operating Effectiveness. The report must meet all standards and requirements of the AICPA’s SSAE 18 for the Contractor’s operations performed for ASES under this Contract.

                      


              

            

             

            
              
                	

                      	18.2.9.3	
                        The Contractor shall submit an annual Audited Financial Statements. The
                            Contractor shall provide ASES with copies of its audited financial statements following general accepted accounting principles and generally accepted auditing standards in the US, at its own cost and charge, for the duration of
                            the Contract, and as of the end of each Contract Year during the Contract Term, regarding the financial operations related to the GHP Program. These reports shall be submitted to ASES no later the ninety (90) Calendar Days after
                            the close of the Contract Year.

                      


              

            

             

            
              Page 249 of 324

              
                


            

            
              
                	

                      	18.2.9.4	
                        The Contractor shall submit a quarterly Cost Avoidance Report. The
                            report shall describe, as specified by ASES, the Contractor’s findings regarding routine audits of Network Providers to evaluate cost-avoidance performance.

                      


              

            

             

            
              
                	

                      	18.2.9.5	
                        The Contractor shall submit an annual Report to Puerto Rico Insurance
                              Commissioner’s Office in the format agreed upon by the National Association of Insurance Commissioners (NAIC).

                      


              

            

             

            
              
                	

                      	18.2.9.6	
                        The Contractor shall submit an Annual Corporate Report at the close of
                            the Contractor’s fiscal/calendar year.

                      


              

            

             

            
              
                	

                      	18.2.9.7	
                        The Contractor shall, in the format specified by ASES, submit a duly signed Pharmacy





                              Certification every two weeks, including the amount of pharmacy claims paid, rejected, denied, reversed and adjusted.

                      


              

            

             

            
              
                	

                      	18.2.9.8	
                        The Contractor shall submit a quarterly Incurred But Not Paid Report (IBNR) in





                            the format required by ASES.

                      


              

            

             

            
              
                	

                      	18.2.9.9	
                        The Contractor shall, in the format specified by ASES, submit a Medical Loss
                              Ratio Report in accordance with Section 22.2 by July 31 following the end of the Contract Year.

                      


              

            

             

            
              
                	

                      	18.3	
                        Annual Plans

                      


              

            

             

            
              
                	

                      	18.3.1	
                        Departmental annual plans are required as follows:

                      


              

            

             

            
              
                	

                      	18.3.1.1	
                        The Contractor shall submit an annual Maternal and Prenatal Plan in
                            accordance with Section 7.5.8.

                      


              

            

             

            
              
                	

                      	18.3.1.2	
                        The Contractor shall submit an annual EPSDT Plan as described in Section
                            7.9.

                      


              

            

             

            
              
                	

                      	18.3.1.3	
                        The Contractor shall submit an annual Wellness Plan in accordance with
                            Section 12.6.

                      


              

            

             

            
              
                	

                      	18.3.1.4	
                        The Contractor shall submit an annual Compliance Plan that meets the
                            requirements outlined in Section 13.2.

                      


              

            

             

            
              
                	

                      	18.3.1.5	
                        The Contractor shall submit an annual Program Integrity Plan that meets
                            the requirements outlined in Section 13.3.

                      


              

            

             

            
              Page 250 of 324

              
                


            

            
              
                	

                      	18.3.1.6	
                        The Contractor shall submit an annual Provider Training and Outreach Plan
                            describing Provider training initiatives including, but not limited to, the following: (i) Prior Authorizations; (ii) Claims/Encounter Data submissions; (iii) how to access Ancillary Service Providers; (iv) Enrollee rights and
                            responsibilities; (v) quality improvement program/initiatives; (vi) Provider and Enrollee Appeals and Grievances; (vii) recoupment of funds processes and procedures; (viii) EPSDT benefit requirements, including Preventive
                            Services guidelines; and (ix) Fraud, Waste and Abuse.

                      


              

            

             

            
              
                	

                      	18.3.1.7	
                        The Contractor shall submit an annual Provider Network Development and
                              Management Plan that at a minimum, shall include: (i) summary of Network Providers, by type and geographic location in Puerto Rico; (ii) demonstration of monitoring activities to ensure that access standards are met and
                            Enrollees have timely access to services, per the requirements of this Contract; (iii) a summary of Network Provider capacity issues by service and municipality, the Contractor’s remediation and quality management/quality
                            improvement activities and the targeted and actual completion dates for those activities; (iv) network deficiencies by service and by geographical area and interventions to address the deficiencies; and (v) ongoing activities
                            for Provider network development and expansion taking into consideration identified participating provider capacity, network deficiencies, service delivery issues and future needs, and (vi) if an exception has been granted, an
                            update on recruiting initiatives.

                      


              

            

             

            
              
                	

                      	18.3.1.8	
                        The Contractor shall submit an annual UM Program Description/Work Plan.
                            The program description shall include a description of the structure and accountability mechanisms. At a minimum, the description shall include: (i) scope of the UM program, (ii) goals and objective of the UM program, (iii)
                            program structure including organizational structure, authority and accountability and committee structure; (iv) description of UM networking and support; and (v) a description of the following UM processes: pre-service review,
                            concurrent review, post service review, discharge planning and emergency department services. The UM Work Plan shall include: (i) planned
                            UM improvement activities that will address quality of service delivery; (ii) specific mechanism for periodic Data tracking and trending of UM performance indicators; and (iii) periodic evaluations of the effectiveness of UM
                            interventions.

                      


              

            

             

            
              
                	

                      	18.3.1.9	
                        The Contractor shall submit an annual BC-DR Plan in accordance with
                            Section 17.5.

                      


              

            

             

            
              Page 251 of 324

              
                


            

            
              
                	

                      	18.3.1.10	
                        The Contractor shall submit an annual Physician Incentive Plan in
                            accordance with Section 23.6.

                      


              

            

             

            
              
                	ARTICLE 19	
                        ENFORCEMENT – INTERMEDIATE SANCTIONS

                      


              

            

             

            
              
                	

                      	19.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	19.1.1	
                        In monitoring Contractor’s compliance with the terms of the Contract, ASES may impose intermediate sanctions, and/or liquidated damages, and/or fines pursuant to
                            Puerto Rico Act No. 72-1993 and ASES Regulation No. 8446, for Contractor’s failure to comply with the terms and conditions of this Contract (as further specified in Articles 19 and 20 of this Contract).

                      


              

            

             

            
              
                	

                      	19.1.2	
                        In the event the Contractor incurs any proscribed conduct or otherwise is in default as to any applicable term, condition, or requirement of this Contract, and in
                            accordance with any applicable provision of 42 CFR 438.700 and Section 4707 of the Balanced Budget Act of 1997, at any time following the Effective Date of the Contract, the Contractor agrees that, in addition to the terms of
                            Section 35.1.1 of this Contract, ASES may impose intermediate sanctions against the Contractor for any such default in accordance with this Article 19. ASES may impose both intermediate sanctions and fines pursuant to Puerto
                            Rico Act No. 72-1993 and ASES Regulation 8446. The assessment or non-assessment of intermediate sanctions under this Contract cannot and will not limit the power or authority of ASES to impose any other fines, civil money
                            penalties, sanctions, or other remedies recognized by Puerto Rico or Federal laws or regulations, including, but not limited to, Puerto Rico Act No. 72-1993 and ASES Regulation No. 8446.

                      


              

            

             

            
              
                	

                      	19.1.3	
                        Notwithstanding any intermediate sanctions imposed upon the Contractor under this Article 19, other than Contract termination, the Contractor shall continue to
                            provide all Covered Services and other Benefits under this Contract.

                      


              

            

             

            
              
                	

                      	19.1.4	
                        ASES shall have the right impose the following intermediate sanctions:

                      


              

            

             

            
              
                	

                      	19.1.4.1	
                        Civil Money Penalty. ASES may impose a civil money penalty for the following categories
                            of events.

                      


              

            

             

            
              
                	

                      	19.1.4.1.1	
                        Category 1. A civil money penalty in accordance with any applicable provision of 42 CFR
                            438.700 up to one-hundred thousand dollars ($100,000) per determination shall be imposed for this category. The following constitute Category 1 events:

                      


              

            

             

            
              
                	

                      	19.1.4.1.1.1	
                        Acts that discriminate among Enrollees on the basis of their health status or need for health care services. This includes termination of Enrollment or refusal to
                            reenroll a Potential Enrollee, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage Enrollment by beneficiaries whose medical or Behavioral Health condition or history
                            indicates probable need for substantial future medical or Behavioral Health Services. Notwithstanding the foregoing, ASES may impose a civil money penalty in the amount of fifteen thousand dollars ($15,000) per each (i)
                            Potential Enrollee that was not enrolled because of discriminatory practices as described above and/or (ii) discriminatory practices imposed on Enrollees, subject to the overall limit of one-hundred thousand dollars ($100,000)
                            per each determination.

                      


              

            

             

            
              Page 252 of 324

              
                


            

            
              
                	

                      	19.1.4.1.1.2	
                        The misrepresentation or falsification of information submitted to ASES and/or CMS.

                      


              

            

             

            
              
                	

                      	19.1.4.1.2	
                        Category 2. A civil money penalty in accordance with any applicable provision of 42 CFR 438.700 up to twenty-five thousand dollars ($25,000) per determination shall be imposed for this category. The following constitute
                            Category 2 events:

                      


              

            

             

            
              
                	

                      	19.1.4.1.2.1	
                        Failure by the Contractor to substantially provide Medically Necessary Services that the Contractor is required to provide, under applicable law or under this
                            Contract, to an Enrollee under this Contract.

                      


              

            

             

            
              
                	

                      	19.1.4.1.2.2	
                        Misrepresentation or falsification by the Contractor of information that it furnishes to an Enrollee, Potential Enrollee, or Provider.

                      


              

            

             

            
              
                	

                      	19.1.4.1.2.3	
                        Failure by the Contractor to comply with the requirements for Physician Incentive Plans, as set forth in 42 CFR 422.208 and 422.210.

                      


              

            

             

            
              
                	

                      	19.1.4.1.2.4	
                        The distribution by the Contractor, directly or indirectly through any Agent or independent contractor, of Marketing Materials that have not been prior approved by
                            ASES or that contain false or materially misleading information.

                      


              

            

             

            
              
                	

                      	19.1.4.1.3	
                        Category 3. Pursuant to 42 CFR 438.704(c), ASES may impose a civil money penalty for the Contractor’s imposition of premiums or charges in excess of the amounts permitted under the Medicaid program. The maximum amount of
                            the penalty is the greater of twenty-five thousand dollars ($25,000) or double the amount of the excess charges. ASES will deduct from the penalty the amount of overcharge and return it to the affected Enrollees.

                      


              

            

             

            
              Page 253 of 324

              
                


            

            
              
                	

                      	19.1.4.2	
                        Temporary Management. ASES may appoint temporary management for the Contractor’s GHP
                            operations, as provided in 42 C.F.R. 438.702 and 42 C.F.R. 438.706 as a result of Contractor’s:

                      


              

            

             

            
              
                	

                      	19.1.4.2.1	
                        Continued egregious behavior, including but not limited to behavior described in Categories 1 through 3 of this Article 19;

                      


              

            

             

            
              
                	

                      	19.1.4.2.2	
                        Behavior that is contrary to, or is non-compliant with, Sections 1903(m) or 1932 of the Social Security Act, as amended, found at 42 U.S.C. §§ 1396b (m) and
                            1396u-2;

                      


              

            

             

            
              
                	

                      	19.1.4.2.3	
                        Actions which have caused substantial risk to an Enrollee’s health; and/or

                      


              

            

             

            
              
                	

                      	19.1.4.2.4	
                        Behavior which has led ASES to determine that temporary management is necessary to ensure the health of Contractor’s Enrollees while improvements to remedy Category
                            1 through 3 violations are being made, or until the Contractor’s orderly termination or reorganization.

                      


              

            

             

            
              
                	

                      	19.1.4.2.5	
                        If temporary management is appointed for any reason specified in Sections 19.1.4.2 above, such temporary management will cease once ASES has, in its discretion,
                            determined that the sanctioned behavior will not re-occur.

                      


              

            

             

            
              
                	

                      	19.1.4.3	
                        Enrollment Termination. ASES may grant Enrollees the right to terminate Enrollment
                            without cause, and notify the affected Enrollees of their right to disenroll when:

                      


              

            

             

            
              
                	

                      	19.1.4.3.1	
                        The Contractor has engaged in continued egregious behavior, including but not limited to behavior described in Categories 1 through 3 of this Article 19;

                      


              

            

             

            
              
                	

                      	19.1.4.3.2	
                        The Contractor has engaged in behavior that is contrary to, or is non-compliant with, Sections 1903(m) or 1932 of the Social Security Act, as amended, found at 42
                            U.S.C. §§ 1396b (m) and 1396u-2;

                      


              

            

             

            
              
                	

                      	19.1.4.3.3	
                        The Contractor has taken actions that have caused substantial risk to Enrollees’ health;

                      


              

            

             

            
              Page 254 of 324

              
                


            

            
              
                	

                      	19.1.4.3.4	
                        ASES determines that temporary management is necessary or convenient to ensure the health of the Contractor’s Enrollees; or

                      


              

            

             

            
              
                	

                      	19.1.4.3.5	
                        ASES determines that such Enrollment termination is necessary or appropriate to remedy Category 1 through 3 violations.

                      


              

            

             

            
              
                	

                      	19.1.4.4	
                        Enrollment Suspension. ASES may suspend all new Enrollments, including default Enrollment, after the effective date of the intermediate sanction and until the intermediate sanction is no longer in effect.

                      


              

            

             

            
              
                	

                      	19.1.4.5	
                        Payment Suspension. ASES may suspend payment of the PMPM Payment for Enrollees enrolled
                            after the effective date of the intermediate sanction and until CMS or ASES is satisfied that the reason for imposition of the intermediate sanction no longer exists and is not likely to re-occur or upon the Termination Date of
                            the Contract.

                      


              

            

             

            
              
                	

                      	19.1.4.6	
                        Mandatory Imposition of Certain Intermediate Sanctions. ASES shall impose the temporary
                            management and Enrollment suspension intermediate sanctions described in Sections 19.1.4.2 and 19.1.4.3 above, if ASES finds that the Contractor has repeatedly failed to meet substantive requirements in Sections 1903(m) or 1932
                            of the Social Security Act, as amended, found at 42 U.S.C. §§ 1396b (m) and 1396u-2.

                      


              

            

             

            
              
                	

                      	19.1.4.7	
                        Subject to Article 35 of this Contract, in lieu of imposing a sanction allowed under this Article 19, ASES may terminate this Contract, without any liability
                            whatsoever (but subject to making any payments due under this Contract through any such date of termination), if the terms of a Corrective Action Plan implemented pursuant to this Article 19 to address a failure specified in
                            Category 1 or Category 2 of this Article 19 are not implemented to ASES’s approval or if such failure continues or is not corrected, to ASES’s satisfaction.

                      


              

            

             

            
              
                	

                      	19.2	
                        Notice of Administrative Inquiry

                      


              

            

             

            
              
                	

                      	19.2.1	
                        ASES may issue the Contractor a notice of imposition of sanctions in lieu of a notice of administrative inquiry if ASES determines, in its sole discretion, that the
                            Contractor’s non-compliance will not be cured with a Corrective Action Plan. In all other cases, ASES shall issue a notice of administrative inquiry informing Contractor about ASES’s compliance, monitoring, and auditing
                            activities regarding potential non-compliance as described in this Article 19. This notice of administrative inquiry shall include the following:

                      


              

            

             

            
              Page 255 of 324

              
                


            

            
              
                	

                      	19.2.1.1	
                        A brief description of the facts;

                      


              

            

             

            
              
                	

                      	19.2.1.2	
                        Citations to Puerto Rico and Federal laws and regulations, or Contract provisions that the Contractor has breached;

                      


              

            

             

            
              
                	

                      	19.2.1.3	
                        The Contractor’s non-compliance with Puerto Rico and Federal laws and regulations or Contract provisions as referenced in the Contract;

                      


              

            

             

            
              
                	

                      	19.2.1.4	
                        The Contractor’s breach of applicable intermediate sanction Contract provisions;

                      


              

            

             

            
              
                	

                      	19.2.1.5	
                        ASES’s authority to determine and impose intermediate sanctions under this Article 19;

                      


              

            

             

            
              
                	

                      	19.2.1.6	
                        The amount of potential, or Contractor’s exposure to intermediate sanctions, when they will be imposed and how they were computed; and

                      


              

            

             

            
              
                	

                      	19.2.1.7	
                        If applicable, a statement requiring the Contractor to submit a Corrective Action Plan within fifteen (15) Calendar Days of receipt of the notice of administrative
                            inquiry under this Article 19.

                      


              

            

             

            
              
                	

                      	19.2.2	
                        The Contractor shall submit a Corrective Action Plan within fifteen (15) Calendar Days of receipt of the notice of administrative inquiry. However, the submission
                            of a Corrective Action Plan shall not limit ASES’s power and authority to impose intermediate sanctions, fines, liquidated damages, or any other remedy allowed under this Contract or under Federal or Puerto Rico laws and
                            regulations.

                      


              

            

             

            
              
                	

                      	19.2.3	
                        A notice of administrative inquiry shall not be deemed to constitute and is not ASES’s final or partial determination of intermediate sanctions. Thus, any
                            administrative inquiries issued by ASES are not subject to administrative review under Section 19.5, and would be considered premature rendering any administrative examiner without jurisdiction to review the matter.

                      


              

            

             

            
              
                	

                      	19.2.4	
                        If the Contractor fails to comply with any material provision under a Corrective Action Plan submitted to ASES pursuant to Section 19.2.2 above, ASES may impose:

                      


              

            

             

            
              
                	

                      	19.2.4.1	
                        A daily $5,000 civil money penalty, up to a maximum total of $100,000, for Contractor’s ongoing failure to comply with any material provision of the Corrective
                            Action Plan; or

                      


              

            

             

            
              
                	

                      	19.2.4.2	
                        The applicable intermediate sanction for any or all behavior that resulted in the Contractor’s submission of the Corrective Action Plan pursuant to Section 19.2
                            above.

                      


              

            

             

            
              Page 256 of 324

              
                


            

            
              
                	

                      	19.3	
                        Notice of Imposition of Intermediate Sanctions

                      


              

            

             

            
              
                	

                      	19.3.1	
                        Prior to the imposition of intermediate sanctions, ASES will issue a notification, delivered thorough US Postal Service Certified Mail, to the Contractor that
                            includes the following:

                      


              

            

             

            
              
                	

                      	19.3.1.1	
                        A brief description of the facts;

                      


              

            

             

            
              
                	

                      	19.3.1.2	
                        Citations to Puerto Rico and Federal laws and regulations, or Contract provision(s) that the Contractor has breached;

                      


              

            

             

            
              
                	

                      	19.3.1.3	
                        ASES’s determination to impose intermediate sanctions;

                      


              

            

             

            
              
                	

                      	19.3.1.4	
                        Intermediate sanctions imposed and their effective date;

                      


              

            

             

            
              
                	

                      	19.3.1.5	
                        Methodology for the civil money penalty calculation or determination of the intermediate sanctions; and

                      


              

            

             

            
              
                	

                      	19.3.1.6	
                        A statement that the Contractor has a right to object and request an administrative review of the imposition of intermediate sanctions pursuant to the procedures in
                            ASES Regulation 8446.

                      


              

            

             

            
              
                	

                      	19.3.2	
                        ASES shall notify CMS in writing of the imposition of intermediate sanctions within thirty (30) Calendar Days of imposing sanctions and concurrently provide the
                            Contractor with a copy of such notice

                      


              

            

             

            
              
                	

                      	19.4	
                        Administrative Review. Contractor has the right to object and seek
                            administrative review of the imposition of intermediate sanctions, including but not limited to civil money penalties, by ASES, pursuant to the procedures in ASES Regulation No. 8446.

                      


              

            

             

            
              
                	

                      	19.4.1	
                        The Contractor has the right within fifteen (15) Calendar Days following receipt of the notice of imposition of intermediate sanctions to seek administrative review
                            in writing of ASES’s determination and any such immediate sanctions, pursuant to Act 72 or under any other applicable law or regulation. This time period can be extended for an additional fifteen (15) Calendar Days if the
                            Contractor submits a written request that includes a credible explanation of why it needs additional time, the request is receipted by ASES before the end of the initial period, and ASES has determined that the Contractor’s
                            conduct does not pose a threat to an Enrollee’s health or safety.

                      


              

            

             

            
              
                	

                      	19.4.2	
                        As part of the administrative review, the Parties shall cooperate with the examining officer, and follow all applicable procedures for the administrative review.

                      


              

            

             

            
              
                	

                      	19.4.3	
                        Upon completion of the administrative review, the examining officer may recommend to:

                      


              

            

             

            
              
                	

                      	19.4.3.1	
                        Confirm the intermediate sanctions;

                      


              

            

             

            
              Page 257 of 324

              
                


            

            
              
                	

                      	19.4.3.2	
                        Modify or amend the intermediate sanctions pursuant to applicable law or regulation; or

                      


              

            

             

            
              
                	

                      	19.4.3.3	
                        Eliminate the imposed intermediate sanctions.

                      


              

            

             

            
              
                	

                      	19.4.4	
                        Once the sanction becomes final ASES shall deduct the amount of the sanction from the PMPM Payment or the Retention Fund.

                      


              

            

             

            
              
                	

                      	19.4.5	
                        In addition to the actions described under Section 19.4.3, the examining officer may recommend the delivery and implementation of a Corrective Action Plan with
                            respect to the Contractor’s failure to comply with the terms of this Contract as set forth in ASES’ notice of intermediate sanctions.

                      


              

            

             

            
              
                	

                      	19.4.6	
                        ASES shall notify CMS in writing of any modification in the imposition of intermediate sanctions through the administrative review process within thirty (30)
                            Calendar Days of receipt of the examining officer’s determination, and concurrently provide the Contractor with a copy of such notice.

                      


              

            

             

            
              
                	

                      	19.5	
                        Judicial Review. To the extent administrative review is sought by the
                            Contractor pursuant to Section 19.4, the Contractor has the right to seek judicial review of ASES’s actions by the Puerto Rico Court of Appeals, San Juan Panel, within thirty (30) Calendar Days of the notice of final
                            determination issued by ASES.

                      


              

            

             

            
              
                	

                      	19.6	
                        Federal Sanctions. Payments provided for under this Contract will be denied
                            for new Enrollees when, and for so long as, payment for those Enrollees is denied by CMS in accordance with the requirements in 42 C.F.R. 438.730.

                      


              

            

             

            
              
                	ARTICLE 20	
                        ENFORCEMENT – LIQUIDATED DAMAGES AND OTHER REMEDIES

                      


              

            

             

            
              
                	

                      	20.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	20.1.1	
                        ASES may impose intermediate sanctions, liquidated damages, and/or fines pursuant to Puerto Rico Act No. 72-1993 and ASES Regulation No. 8446 (as indicated in
                            Articles 19 and 20 of this Contract).

                      


              

            

             

            
              
                	

                      	20.1.2	
                        In the event the Contractor is in default as to any applicable term, condition, or requirement of this Contract, and in accordance with any applicable provision of
                            42 CFR 438.700 and Section 4707 of the Balanced Budget Act of 1997, at any time following the Effective Date of this Contract, the Contractor agrees that, in addition to the terms of Section 35.1.1 of this Contract, ASES may
                            assess liquidated damages against the Contractor for any such default, in accordance with this Article 20. The Parties further acknowledge and agree that the specified liquidated damages are reasonable and the result of a good
                            faith effort by the Parties to estimate the anticipated or actual harm caused by the Contractor’s breach and are in lieu of any other financial remedies to which ASES may otherwise have been entitled. The assessment or
                            non-assessment of liquidated damages under the Contract cannot and will not limit the power or authority of ASES to impose fines, civil money penalties, sanctions, or other remedies under Article 19 of this Contract or otherwise
                            under Puerto Rico or Federal laws or regulations, including but not limited to Puerto Rico Act No. 72-1993 and ASES Regulation No. 8446.

                      


              

            

             

            
              Page 258 of 324

              
                


            

            
              
                	

                      	20.1.3	
                        Notwithstanding any sanction, including liquidated damages, imposed upon the Contractor, other than Contract termination, the Contractor shall continue to provide
                            all Covered Services and other Benefits under this Contract.

                      


              

            

             

            
              
                	

                      	20.1.4	
                        The Contractor’s breach or failure to comply with the terms and conditions of this Contract for which liquidated damages may be assessed under this Article 20 shall
                            be divided into four (4) categories of events. ASES retains the discretion to impose liquidated damages or other sanctions for Contractor’s non-compliance with an obligation of the Contractor under this Contract or Puerto Rico
                            Law that is not specified under the categories in Sections 20.2, 20.3, 20.4 or 20.5.

                      


              

            

             

            
              
                	

                      	20.2	
                        Category 1

                      


              

            

             

            
              
                	

                      	20.2.1	
                        Liquidated damages in accordance with any applicable provision of this Contract of up to one-hundred thousand dollars ($100,000) per violation, Incident or
                            occurrence may be imposed for Category 1 events. The following constitute Category 1 events:

                      


              

            

             

            
              
                	

                      	20.2.1.1	
                        Material non-compliance with an ASES or CMS directive, determination or notice to cease and desist not otherwise described in Article 19 or other provision of this
                            Article 20, provided that the Contractor has received prior written notice with respect to such specific material non-compliance, and afforded an opportunity to cure within a reasonable period to be determined by ASES in its
                            sole discretion.

                      


              

            

             

            
              
                	

                      	20.3	
                        Category 2

                      


              

            

             

            
              
                	

                      	20.3.1	
                        Liquidated damages in accordance with any applicable provision of this Contract of up to twenty-five thousand dollars ($25,000) per violation, Incident, or
                            occurrence may be imposed for Category 2 events. The following constitute Category 2 events:

                      


              

            

             

            
              
                	

                      	20.3.1.1	
                        Subject to ASES compliance with its obligations under Article 22 of this Contract, repeated noncompliance by the Contractor with any material obligation that
                            adversely affects the services that the Contractor is required to provide under Article 7 of this Contract;

                      


              

            

             

            
              
                	

                      	20.3.1.2	
                        Failure of the Contractor to assume its duties and obligations under this Contract in accordance with the transition timeframes specified herein;

                      


              

            

             

            
              Page 259 of 324

              
                


            

            
              
                	

                      	20.3.1.3	
                        Failure of the Contractor to terminate a Provider that imposes Co-Payments or other cost-sharing on Enrollees that are in excess of the fees permitted by ASES, as
                            listed on Attachment 8 to this Contract (ASES will deduct the amount of the overcharge and return it to the affected Enrollees);

                      


              

            

             

            
              
                	

                      	20.3.1.4	
                        Failure of the Contractor to address Enrollees’ Complaints, Appeals, and Grievances, and Provider disputes, within the timeframes specified in this Contract;

                      


              

            

             

            
              
                	

                      	20.3.1.5	
                        Failure of the Contractor to comply with the confidentiality provisions in accordance with 45 CFR 160 and 164; and

                      


              

            

             

            
              
                	

                      	20.3.1.6	
                        Failure of the Contractor to comply with a subcontracting requirement in the Contract.

                      


              

            

             

            
              
                	

                      	20.4	
                        Category 3

                      


              

            

             

            
              
                	

                      	20.4.1	
                        Liquidated damages in accordance with any applicable provision this Contract of five-thousand dollars ($5,000) per day may be imposed for Category 3 events. The
                            following constitute Category 3 events:

                      


              

            

             

            
              
                	

                      	20.4.1.1	
                        Failure to submit required reports in the timeframes prescribed in Article 18;

                      


              

            

             

            
              
                	

                      	20.4.1.2	
                        Submission of incorrect or deficient Deliverables or reports in accordance with Article 18 of this Contract;

                      


              

            

             

            
              
                	

                      	20.4.1.3	
                        Failure to comply with the Claims processing standards as follows:

                      


              

            

             

            
              
                	

                      	20.4.1.3.1	
                        Failure to process and finalize to a paid or denied status ninety-five percent (95%) of all Clean Claims within thirty (30) Calendar Days of receipt;

                      


              

            

             

            
              
                	

                      	20.4.1.3.2	
                        Failure to process and finalize to a paid or denied status one hundred percent (100%) of all Clean Claims within fifty (50) Calendar Days of receipt; and

                      


              

            

             

            
              
                	

                      	20.4.1.3.3	
                        Failure to process Unclean Claims as specified in Section 16.6.3 of this Contract;

                      


              

            

             

            
              
                	

                      	20.4.1.4	
                        Failure to pay Providers interest at the rate identified in and otherwise in accordance with Section 16.6.2 of this Contract when a Clean Claim is not adjudicated
                            within the Claims processing deadlines;

                      


              

            

             

            
              Page 260 of 324

              
                


            

            
              
                	

                      	20.4.1.5	
                        Failure to comply with the quarterly submission of EPSDT reports to ASES according to the guidelines to be issued by ASES under Section 7.9.1;

                      


              

            

             

            
              
                	

                      	20.4.1.6	
                        Failure to notify PCPs of the gaps in care analysis in accordance with the EPSDT guidelines to be issued by ASES under Section 7.9.1;

                      


              

            

             

            
              
                	

                      	20.4.1.7	
                        Failure to provide the Claims Payment Disbursement Illustration and Actuarial Report Information required in Section 18 of this Contract;

                      


              

            

             

            
              
                	

                      	20.4.1.8	
                        Failure to seek, collect and/or report Third Party Liability information as provided in Section 23.4 of this Contract; and

                      


              

            

             

            
              
                	

                      	20.4.1.9	
                        Failure of Contractor to issue written notice to Enrollees upon Provider’s termination of a Provider as described in Section 10.4.3 of this Contract.

                      


              

            

             

            
              
                	

                      	20.5	
                        Category 4

                      


              

            

             

            
              
                	

                      	20.5.1	
                        Liquidated damages as specified below may be imposed for Category 4 events. The following constitute Category 4 events:

                      


              

            

             

            
              
                	

                      	20.5.1.1	
                        Failure to implement the BC-DR plan as follows:

                      


              

            

             

            
              
                	

                      	20.5.1.1.1	
                        Implementation of the (BC-DR) plan exceeds the proposed time by two (2) or less Calendar Days: five thousand dollars ($5,000) per day up to day 2;

                      


              

            

             

            
              
                	

                      	20.5.1.1.2	
                        Implementation of the (BC-DR) plan exceeds the proposed time by more than two (2) and up to five (5) Calendar Days: ten thousand dollars ($10,000) per each day
                            beginning with day 3 and up to day 5;

                      


              

            

             

            
              
                	

                      	20.5.1.1.3	
                        Implementation of the (BC-DR) plan exceeds the proposed time by more than five (5) and up to ten (10) Calendar Days, twenty-five thousand dollars ($25,000) per day
                            beginning with day 6 and up to day 10;

                      


              

            

             

            
              
                	

                      	20.5.1.1.4	
                        Implementation of the (BC-DR) plan exceeds the proposed time by more than ten (10) Calendar Days: fifty thousand dollars ($50,000) per each day beginning with day
                            11;

                      


              

            

             

            
              
                	

                      	20.5.1.2	
                        Unscheduled System Unavailability in violation of Article 17, in ASES’s discretion, two hundred fifty dollars ($250) for each thirty (30) minute period or portions
                            thereof;

                      


              

            

             

            
              Page 261 of 324

              
                


            

            
              
                	

                      	20.5.1.3	
                        Failure to make available to ASES or its Agent, valid extracts of Encounter Information for a specific month within fifteen (15) Calendar Days of the close of the
                            month: five hundred dollars ($500) per day. After thirty (30) Calendar Days of the close of the month: two thousand dollars ($2,000) per Calendar Day;

                      


              

            

             

            
              
                	

                      	20.5.1.4	
                        Failure to correct a system problem not resulting in System Unavailability within the allowed timeframe, where failure to complete was not due to the action or
                            inaction on the part of ASES as documented in writing by the Contractor:

                      


              

            

             

            
              
                	

                      	20.5.1.4.1	
                        One (1) to fifteen (15) Calendar Days late: two hundred and fifty dollars ($250) per Calendar Day for days 1 through 15;

                      


              

            

             

            
              
                	

                      	20.5.1.4.2	
                        Sixteen (16) to thirty (30) Calendar Days late: five hundred dollars ($500) per Calendar Day for days 16 through 30; and

                      


              

            

             

            
              
                	

                      	20.5.1.4.3	
                        More than thirty (30) Calendar Days late: one thousand dollars ($1,000) per Calendar Day for days 31 and beyond; and

                      


              

            

             

            
              
                	

                      	20.5.1.5	
                        Failure to meet the GHP Service Line performance standards:

                      


              

            

             

            
              
                	

                      	20.5.1.5.1	
                        One-thousand dollars ($1,000) for each percentage point that is below the target answer rate of eighty percent (80%) in thirty (30) seconds;

                      


              

            

             

            
              
                	

                      	20.5.1.5.2	
                        One-thousand dollars ($1,000) for each percentage point that is above the target of a three percent (3%) Blocked Call rate; and

                      


              

            

             

            
              
                	

                      	20.5.1.5.3	
                        One-thousand dollars ($1,000) for each percentage point that is above the target of a five percent (5%) Abandoned Call rate.

                      


              

            

             

            
              
                	

                      	20.6	
                        Other Remedies

                      


              

            

             

            
              
                	

                      	20.6.1	
                        Subject to Article 35 of this Contract, in lieu of imposing a Remedy allowed under this Article 20, ASES may elect to terminate this Contract, without any liability
                            whatsoever (but subject to making any payments due, if any, under this Contract through any such date of termination), if the terms of a Corrective Action Plan implemented pursuant to this Article 20 to address a failure
                            specified in Category 1 or Category 2 of this Article 20 are not implemented to ASES’s satisfaction or if such failure continues or is not corrected, to ASES’s sole satisfaction.

                      


              

            

             

            
              
                	

                      	20.6.2	
                        In the event of non-compliance by the Contractor with Article 18 of this Contract, ASES shall have the right to Withhold, with respect to Article 18, a sum not to
                            exceed ten percent (10%) of the Per Member Per Month Payment for the following month and for continuous consecutive months thereafter until such noncompliance is cured and corrected to ASES’ satisfaction in lieu of imposing any
                            liquidated damages, penalties or sanctions against the Contractor hereunder. ASES shall release the Withhold of the PMPM Payment to the Contractor within two (2) Business Days after the corresponding event of noncompliance is
                            cured to ASES’s sole satisfaction.

                      


              

            

             

            
              Page 262 of 324

              
                


            

            
              
                	

                      	20.7	
                        Notice of Administrative Inquiry regarding Liquidated Damages and/or Other Article
                              20 Remedies

                      


              

            

             

            
              
                	

                      	20.7.1	
                        Administrative Inquiry. ASES may issue the Contractor a notice of imposition of liquidated damages and/or other Article 20 remedies in lieu of a notice of
                            administrative inquiry regarding liquidated damages and/or other Article 20 remedies if ASES determines, in its sole discretion, that the Contractor’s non-compliance will not be cured with a Corrective Action Plan. In all other
                            cases, ASES shall issue a notice of administrative inquiry informing the Contractor about ASES’s compliance, monitoring, and auditing activities regarding potential non-compliance as described in this Article 20. This notice of
                            administrative inquiry shall include the following:

                      


              

            

             

            
              
                	

                      	20.7.1.1	
                        A brief description of the facts;

                      


              

            

             

            
              
                	

                      	20.7.1.2	
                        Citations to Puerto Rico and Federal laws and regulations, or Contract provision(s) the Contractor has breached;

                      


              

            

             

            
              
                	

                      	20.7.1.3	
                        The Contractor’s non-compliance with Puerto Rico and Federal laws and regulations or Contract provisions;

                      


              

            

             

            
              
                	

                      	20.7.1.4	
                        The Contractor’s breach of applicable Contract provisions and event categories that could result in remedies or liquidated damages pursuant to this Article 20;

                      


              

            

             

            
              
                	

                      	20.7.1.5	
                        ASES’s authority to determine and seek liquidated damages or other remedies against the Contractor under this Article 20;

                      


              

            

             

            
              
                	

                      	20.7.1.6	
                        The amount of potential, or Contractor’s exposure to liquidated damages, or other Article 20 remedies, when they will be imposed and how they were computed; and

                      


              

            

             

            
              
                	

                      	20.7.1.7	
                        If applicable, a statement requiring the Contractor to submit a Corrective Action Plan within fifteen (15) Calendar Days of receipt of the notice of administrative
                            inquiry under this Article 20.

                      


              

            

             

            
              
                	

                      	20.7.2	
                        The Contractor shall submit a Corrective Action Plan within fifteen (15) Calendar Days of receipt of the notice of administrative inquiry issued pursuant to this
                            Article 20.

                      


              

            

             

            
              Page 263 of 324

              
                


            

            
              
                	

                      	20.7.3	
                        A notice of administrative inquiry shall not constitute ASES’s final or partial determination of liquidated damages. Thus, any administrative inquiries made are not
                            subject to administrative review under Section 20.7.6 and would be construed to be premature rendering any administrative examiner without jurisdiction to review the matter.

                      


              

            

             

            
              
                	

                      	20.7.4	
                        If the Contractor fails to comply with any material provision under a Corrective Action Plan submitted to ASES pursuant to Section 20.7.2 above, ASES may impose:

                      


              

            

             

            
              
                	

                      	20.7.4.1	
                        A daily amount of $5,000 in liquidated damages, up to a maximum total amount of $100,000, for the Contractor’s failure to comply with any material provision part or
                            condition of the Corrective Action Plan; and/or

                      


              

            

             

            
              
                	

                      	20.7.4.2	
                        The applicable Article 20 Remedy for any or all behavior that resulted in the submission of Corrective Action Plan pursuant to Section 20.7.2 above.

                      


              

            

             

            
              
                	

                      	20.7.5	
                        Notice of Imposition of Liquidated Damages and/or Other Remedies

                      


              

            

             

            
              
                	

                      	20.7.5.1	
                        Prior to the imposition of liquidated damages and/or any other remedies under this Article 20, ASES will issue a notification, delivered thorough US Postal Service
                            Certified Mail, to the Contractor that includes the following:

                      


              

            

             

            
              
                	

                      	20.7.5.1.1	
                        A brief description of the facts;

                      


              

            

             

            
              
                	

                      	20.7.5.1.2	
                        Citations to Puerto Rico and Federal laws and regulations, or Contract provision(s) the Contractor has breached;

                      


              

            

             

            
              
                	

                      	20.7.5.1.3	
                        ASES’s determination to assess and impose liquidated damages and/or any other Article 20 Remedy;

                      


              

            

             

            
              
                	

                      	20.7.5.1.4	
                        Liquidated damages and/or any other Article 20 Remedy imposed and their effective date;

                      


              

            

             

            
              
                	

                      	20.7.5.1.5	
                        Methodology for the liquidated damages and/or any other Article 20 Remedy calculation; and

                      


              

            

             

            
              
                	

                      	20.7.5.1.6	
                        A statement that the Contractor has a right to object and request an administrative review of the imposition of liquidated damages and other Article 20 remedies
                            pursuant to the procedures in ASES Regulation 8446 and Puerto Rico Act No. 38-2017, as amended.

                      


              

            

             

            
              Page 264 of 324

              
                


            

            
              
                	

                      	20.7.5.2	
                        The Contractor shall submit a Corrective Action Plan to ASES within thirty (30) Calendar Days of receipt of a notice of liquidated damages or other remedies
                            pursuant to this Article 20.

                      


              

            

             

            
              
                	

                      	20.7.6	
                        Administrative Review. The Contractor has the right to object and seek administrative review of the imposition of liquidated damages and/or any other Remedy under
                            this Article 20.7, pursuant to the procedures in ASES Regulation No. 8446.

                      


              

            

             

            
              
                	

                      	20.7.6.1	
                        As part of the administrative review, the Parties shall cooperate with the examining officer, and follow all applicable procedures for the administrative review.

                      


              

            

             

            
              
                	

                      	20.7.6.2	
                        Once the sanction becomes final ASES shall deduct the amount of the sanction from the PMPM Payment or the Retention Fund.

                      


              

            

             

            
              
                	

                      	20.8	
                        Judicial Review. The Contractor has the right to seek reconsideration and
                            judicial review of ASES’s determination pursuant to the procedures in ASES Regulation No. 8446 and Puerto Rico Act No. 389-2017, as amended.

                      


              

            

             

            
              
                	ARTICLE 21	
                        CONTRACT TERM

                      


              

            

             

            
              
                	

                      	21.1	
                        Subject to and upon the terms and conditions herein, this Contract shall be in full force and effect on November 1, 2018 and shall terminate on September 30, 2021.
                            The Contractor shall begin providing Covered Services to Enrollees on November 1, 2018, which shall be deemed to be the Implementation Date of the Contract. The foregoing notwithstanding, ASES, subject to Article 35 reserves the
                            right, prior written notice of ninety (90) Calendar Days, to amend or partially terminate the Contract at any time to implement a demonstrative plan to incorporate the new public health policies and/or strategies of the
                            Government. Upon written notice of amendment or partial termination of this Contract pursuant to this Article 21, ASES will evaluate in good faith a renegotiation of PMPM Payments payable under this Contract.

                      


              

            

             

            
              
                	

                      	21.2	
                        The Contract Term shall begin at 12:01 a.m., Puerto Rico Time, Effective Date of the Contract and shall continue until 11:59 p.m., Puerto Rico time, on September
                            30, 2021.

                      


              

            

             

            
              
                	

                      	21.3	
                        The provision of Covered Services and Benefits to Enrollees by the Contractor under this Contract shall begin on November 1, 2018, which is the Implementation Date
                            of the Contract.

                      


              

            

             

            
              
                	

                      	21.4	
                        The PMPM Payments shall be negotiated for every rating period covered by the Contract (namely from November 1, 2018 to October 31, 2019, from November 1, 2019 to
                            October 31, 2020, and November 1, 2020 to September 30, 2021). Any increase in the PMPM Payment shall be subject to ASES’s determination that the proposed new amount is actuarially sound.

                      


              

            

             

            
              Page 265 of 324

              
                


            

            
              
                	

                      	21.5	
                        The Contract shall expire at the close of the Contract Term unless earlier terminated under Article 35.

                      


              

            

             

            
              
                	

                      	21.6	
                        ASES is hereby granted the option to renew this Contract for an additional term of up to one (1) fiscal year, which shall begin on October 1, 2021 and end at
                            midnight on September 30, 2022. The terms of the renewal shall be negotiated, but any increase in PMPM Payment shall be subject to ASES’s determination that the proposed new amount is actuarially sound. The option to renew the
                            Contract shall be exercisable solely and exclusively by ASES.

                      


              

            

             

            
              
                	ARTICLE 22	
                        PAYMENT FOR SERVICES

                      


              

            

             

            
              
                	

                      	22.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	22.1.1	
                        The actual PMPM Payment will be equal to the number of Enrollees as of the last day of the month proceeding the month in which payment is made, multiplied by the
                            negotiated PMPM Payment agreed to between the Contractor and ASES. The rates are specified in Attachment 11 to this Contract. The due date for the PMPM Payment to the Contractor shall be the fifth (5th) day of each month. However, ASES shall have the right to make partial payments throughout the month, provided that payment in full will be made on or before the last day
                            of each month. The PMPM Payment made based upon the number of Enrollees as of the last day of the preceding month will be reconciled to the actual number of Enrollees for that month when that information is available and
                            appropriate PMPM Payment adjustments will be made.

                      


              

            

             

            
              
                	

                      	22.1.2	
                        ASES shall provide PMPM Payments only for those Enrollees for whom ASES has received adequate notification of Enrollment from the Contractor as of the date
                            specified by ASES, per Section 5.2.2. ASES will work with the Contractor to establish the amount of any PMPM Payments that are due to the Contractor for any Enrollee that has retroactive coverage per Section 5.1.3.1.

                      


              

            

             

            
              
                	

                      	22.1.3	
                        Risk Adjustment. PMPM Payments for the rate cells specified in Section 22.1.7.1 shall be risk adjusted, using publicly available risk adjustment software, on a
                            semi-annual basis by rate cell against all other Contractors to the same population category.

                      


              

            

             

            
              
                	

                      	22.1.3.1	
                        The rate cells that will be risk adjusted are Federal Adult, Federal Children, State Adult, State Children, CHIP, and Federal HCHN (Pulmonary, Diabetes, High
                            Cardio, Renal and Cancer), State HCHN (Pulmonary, Diabetes, High Cardio, Renal, and Cancer), and CHIP HCHN (Pulmonary and Diabetes).

                      


              

            

             

            
              
                	

                      	22.1.3.2	
                        The risk scores shall be established for each Contractor across all rate cells. As necessary, the risk scores will be established using a credibility formula for
                            each Contractor. The credibility formula will be determined by ASES’ actuary.

                      


              

            

             

            
              Page 266 of 324

              
                


            

            
              
                	

                      	22.1.3.2.1	
                        For an Enrollee’s individual Claims data to be the basis for a risk adjustment score hereunder, such Enrollee must have been enrolled in the GHP for at least six
                            (6) full months during the time period from which Claims data are used to calculate the adjustment. In the event an Enrollee has not been enrolled in the GHP for at least six (6) full months, such Enrollee shall receive a risk
                            score equal to the Contractor’s average risk score.

                      


              

            

             

            
              
                	

                      	22.1.3.2.2	
                        All diagnosis codes submitted by the Contractor shall be included in calculations of risk scoring irrespective of placement of such diagnosis codes in the Encounter
                            Data records.

                      


              

            

             

            
              
                	

                      	22.1.3.2.3	
                        Diagnosis codes from Claims or Encounters that included a lab and radiology procedure or revenue code on any line, with the exception of those associated with an
                            inpatient hospital claim, will not be collected for the risk adjustment analysis. It is assumed that these diagnosis codes could be for testing purposes and may not definitively indicate an Enrollee’s disease condition.

                      


              

            

             

            
              
                	

                      	22.1.3.2.4	
                        Encounter records may not be supplemented by medical record data. Diagnosis codes may only be recorded by the Provider at the time of the creation of the medical
                            record and may not be retroactively adjusted except to correct errors.

                      


              

            

             

            
              
                	

                      	22.1.3.2.5	
                        A significant change in risk scores by a Contractor may warrant an audit of the diagnosis collection and submission methods. To the extent that ASES’ actuary
                            believes the Encounter Data limitations are resulting in risk score variances among Contractors, ASES reserves the right to request diagnosis codes and other information to perform risk adjustment.

                      


              

            

             

            
              
                	

                      	22.1.3.3	
                        Initial Risk Adjustment Period. The initial risk adjustment period shall be the first
                            six (6) month period during which the Contractor receives its initial enrollment under this Contract. The risk scores for the initial risk adjustment period will be calculated using the Contractor’s enrollment as of the first
                            month following the month in which Enrollment is completed and will be based on a weighted average of the number of months each Enrollee is enrolled with the specific Contractor.

                      


              

            

             

            
              
                	

                      	22.1.3.3.1	
                        The Claims data to be used for such calculations shall be the Claims data for Claims with dates of services from the most recent twelve (12) month period that ASES
                            determines to be reasonably complete. To the extent an Enrollee was enrolled with another Contractor during the most recent twelve (12) month period that ASES has determined to be reasonably complete, the Encounters accepted by
                            ASES during that period shall be used in addition to the aforementioned Claims data.

                      


              

            

             

            
              Page 267 of 324

              
                


            

            
              
                	

                      	22.1.3.3.1.1	
                        ASES shall provide written notification to the Contractor of the initial risk adjustment factor, along with sufficient detail supporting the calculations.
                            Contractors shall have thirty (30) Calendar Days after the date ASES sent such notice to review the calculations and detail provided and to submit questions, if any, to ASES regarding the same. No modification to the
                            Contractor’s PMPM Payment may be made during such thirty (30) Calendar Day review period.

                      


              

            

             

            
              
                	

                      	22.1.3.3.1.2	
                        If the Contractor disputes the risk adjustment factor during the review period, ASES shall meet with the Contractor within a reasonable timeframe to achieve a good
                            faith resolution of the disputed matter.

                      


              

            

             

            
              
                	

                      	22.1.3.3.2	
                        Modifications to the Contractor’s PMPM Payment resulting from the application of the risk adjustment factor, if any, shall be effective retroactively to the first
                            month of the initial enrollment and prospectively to the end of the initial risk adjustment period.

                      


              

            

             

            
              
                	

                      	22.1.3.3.3	
                        All risk scores shall be budget neutral to ASES or normalized to a 1.0000 value among the Contractors.

                      


              

            

             

            
              
                	

                      	22.1.3.4	
                        Ongoing Risk Adjustment Periods. For every six (6) month period thereafter, Enrollee
                            risk scores shall be recalculated using Enrollee Claims or Encounter Data, as applicable, from a prior twelve (12) month period.

                      


              

            

             

            
              
                	

                      	22.1.3.4.1	
                        ASES shall provide written notification to the Contractor of the risk adjustment factor, along with sufficient detail supporting the calculations. Contractors shall
                            have thirty (30) Calendar Days after the date ASES sent such notice to review the calculations and detail provided and to submit questions, if any, to ASES regarding the same. No modification to the Contractor’s PMPM Payment may
                            be made during such thirty (30) Calendar Day review period.

                      


              

            

             

            
              Page 268 of 324

              
                


            

            
              
                	

                      	22.1.3.4.2	
                        If the Contractor disputes the risk adjustment factor during the review period, ASES shall meet with the contractor within a reasonable timeframe to achieve a good
                            faith resolution of the disputed matter.

                      


              

            

             

            
              
                	

                      	22.1.3.4.3	
                        Modifications to the Contractor’s PMPM Payment resulting from the application of the applicable risk adjustment factor, if any, shall be effective for the duration
                            of the applicable adjustment period, effective as of the first day thereof.

                      


              

            

             

            
              
                	

                      	22.1.3.4.4	
                        All risk scores shall be budget neutral to ASES or normalized to a 1.0000 value among the Contractors.

                      


              

            

             

            
              
                	

                      	22.1.3.5	
                        In the event the application of the risk adjustment factor for a retroactive period results in a reduction or increase to a Contractor’s PMPM Payment, such
                            reduction or increase will be applied on a prospective basis to the PMPM Payments.

                      


              

            

             

            
              
                	

                      	22.1.4	
                        ASES will have the discretion to recoup payments made to the Contractor for ineligible Enrollees, including, but not limited to, the following:

                      


              

            

             

            
              
                	

                      	22.1.4.1	
                        Enrollees incorrectly enrolled with more than one Contractor;

                      


              

            

             

            
              
                	

                      	22.1.4.2	
                        Enrollees who die prior to the Enrollment month for which the payment was made;

                      


              

            

             

            
              
                	

                      	22.1.4.3	
                        Enrollees whom ASES later determines were not eligible for Medicaid during the Enrollment month for which payment was made.

                      


              

            

             

            
              
                	

                      	22.1.4.4	
                        Enrollees whom were not domiciled in Puerto Rico during the Enrollment month for which payment was made;

                      


              

            

             

            
              
                	

                      	22.1.4.5	
                        Enrollees whom were incarcerated during the Enrollment month for which payment was made.

                      


              

            

             

            
              
                	

                      	22.1.5	
                        Any payments due to ASES from the Contractor will be offset from future payments to the Contractor, or may be invoiced by ASES to the Contractor, at ASES’s
                            discretion.

                      


              

            

             

            
              
                	

                      	22.1.6	
                        The Contractor shall have the right to recoup from Providers or other persons to whom the Contractor has made payment for any payments made for which ASES has
                            recouped the PMPM Payment.

                      


              

            

             

            
              
                	

                      	22.1.7	
                        The PMPM Payment for Enrollees not enrolled for the full month shall be determined on a pro rata basis by dividing the monthly Capitation amount by the number of
                            days in the month and multiplying the result by the number of days including and following the Effective Date of Enrollment or the number of days prior to and including the Effective Date of Disenrollment, as applicable. The
                            Contractor is entitled to a PMPM Payment for each Enrollee as of the Effective Date of Enrollment, including the period referred to in Section 5.2.2. The Contractor is entitled to a PMPM Payment for each Enrollee up to the
                            Effective Date of Disenrollment, including the period referred to in Section 5.3.

                      


              

            

             

            
              Page 269 of 324

              
                


            

            
              
                	

                      	22.1.8	
                        Payment for services under this Contract will not commence before Implementation Date of the Contract.

                      


              

            

             

            
              
                	

                      	22.1.9	
                        Payments for the first month of program operations under this Contract will be made only upon a determination by ASES that the Contractor has complied with all of
                            its obligations for the implementation of this Contract, including a finding by ASES that the Contractor has satisfied the readiness review, and the Contractor’s submission of initial Deliverables as specified in Attachment 12
                            to this Contract.

                      


              

            

             

            
              
                	

                      	22.1.10	
                        In order to receive payments from ASES, the Contractor shall provide to ASES, and keep current, its tax identification number, billing address, and other contact
                            information, as required by ASES.

                      


              

            

             

            
              
                	

                      	22.1.11	
                        The Contractor acknowledges that the payments agreed to under the terms of this Contract in addition to any applicable cost-sharing as provided in Attachment 8 to
                            this Contract constitute full payment for Covered Services and Benefits under GHP. ASES will have no responsibility for payment for Covered Services and Benefits beyond that amount unless the Contractor has obtained prior
                            written approval, in the form of a Contract amendment, authorizing an increase in the total payment.

                      


              

            

             

            
              
                	

                      	22.1.12	
                        Fee-for-Service amounts paid by the Contractor for Claims, or Capitation payments made by the Contractor derived or otherwise based on Encounter Data submitted by
                            Providers, resulting from services determined not to be Medically Necessary by the Contractor, will not be considered in the Contract's experience for purposes of prospective rate adjustments.

                      


              

            

             

            
              
                	

                      	22.1.13	
                        Pursuant to the terms of this Contract, should ASES assess liquidated damages or other Remedies for the Contractor’s noncompliance or deficiency with the terms of
                            this Contract, such amount may be withheld from the PMPM Payment for the following month, and for continuous consecutive months thereafter until such noncompliance or deficiency is corrected at ASES’s satisfaction.

                      


              

            

             

            
              
                	

                      	22.1.14	
                        The Contractor shall maintain all the Utilization and financial Data related to this Contract duly segregated from its regular accounting system including, but not
                            limited to, the general ledger.

                      


              

            

             

            
              
                	

                      	22.1.15	
                        Administrative expenses to be included in determining the experience of the program are those directly related to this Contract. Separate allocations of expenses
                            from the Contractor’s insurance plans, other than GHP, from the Contractor’s related companies, from the Contractor’s parent company, or from other entities will be reflected or made a part of the financial Data described in the
                            preceding section. Any pooling of operating expenses with other of the Contractor's groups, cost-shifting, financial consolidation or the implementation of other combined financial measures is expressly forbidden.

                      


              

            

             

            
              Page 270 of 324

              
                


            

            
              
                	

                      	22.1.16	
                        The following administrative expenses are unallowable for purposes of reporting program expenditures and prospective rate setting:

                      


              

            

             

            
              
                	

                      	22.1.16.1	
                        Costs of entertainment, festivities and other activities for the recreation of the personnel of the insurer, including employees, managers, directors, officers or
                            Third Parties, such as: expenses for parties, dinners, food, alcoholic beverages, gifts, etc.;

                      


              

            

             

            
              
                	

                      	22.1.16.2	
                        Costs of advertising, public relations and marketing, except as provided in Section 6.15 of this Contract;

                      


              

            

             

            
              
                	

                      	22.1.16.3	
                        Costs of recruiting office, managerial and executive personnel;

                      


              

            

             

            
              
                	

                      	22.1.16.4	
                        Payroll costs related to corporate officers and employees exceeding the equivalent time dedicated to work related to the GHP program if these same officers and
                            employees also perform duties in support of other lines of business. Payroll expenses to be charged to GHP shall be reasonable according to industry standards and the only time that may be charged is when they perform work
                            specific to the GHP program;

                      


              

            

             

            
              
                	

                      	22.1.16.5	
                        Any payment related to the liquidation of payroll or marginal benefits due to termination (severance) and restructuring of the company (downsizing), including
                            “parachute” clauses, for board of directors, corporate officers or executives of the Contractor;

                      


              

            

             

            
              
                	

                      	22.1.16.6	
                        The Contractor’s employer contributions to savings plans for employees, directors, officers or executives of the Contractor;

                      


              

            

             

            
              
                	

                      	22.1.16.7	
                        Costs related to the awarding and exercise of stock options of employees, directors, officers or executives of the Contractor;

                      


              

            

             

            
              
                	

                      	22.1.16.8	
                        Payment of productivity bonuses, or bonuses of another nature, to directors, officers, executives and employees, excluding the Christmas bonus as required by the
                            law;

                      


              

            

             

            
              
                	

                      	22.1.16.9	
                        Costs of trips to the US or to foreign countries, whether for business, continued education or pleasure;

                      


              

            

             

            
              
                	

                      	22.1.16.10	
                        Expenses or payments related to vacations, including, but not limited to, stay expenses, hotel, air, land or sea transportation, food, gratuity, etc.;

                      


              

            

             

            
              Page 271 of 324

              
                


            

            
              
                	

                      	22.1.16.11	
                        First class fees for air tickets, and travel expenses including charter flights or in commercial lines, within or outside of Puerto Rico;

                      


              

            

             

            
              
                	

                      	22.1.16.12	
                        Payments related to attendance and stay at conventions, seminars, workshops, or continued education, for executives, directors, officers or employees of the
                            Contractor, whether within or outside of Puerto Rico;

                      


              

            

             

            
              
                	

                      	22.1.16.13	
                        Payments related to educational expenses such as: training, retraining, studies, scholarships, memberships, dues, employee licenses, etc., except for, and limited
                            to,  the cost of professional licenses required for personnel directly providing health-related services to Enrollees;

                      


              

            

             

            
              
                	

                      	22.1.16.14	
                        Payments related to automobile expenses, including rent, lease, purchase and depreciation, car allowance, maintenance expenses, gasoline, repairs, etc., except for,
                            and limited to, mileage costs incurred by nurses, doctors or care managers during the provision of Disease Management and/or Care Management services to Enrollees;

                      


              

            

             

            
              
                	

                      	22.1.16.15	
                        Costs of transportation, including taxi service, airplanes, charters, urban train, automobiles, and gasoline or diesel for motor vehicles;

                      


              

            

             

            
              
                	

                      	22.1.16.16	
                        Payment of cellular phone expenses, including Internet access;

                      


              

            

             

            
              
                	

                      	22.1.16.17	
                        Monies used for gifts, gratuity, contests, prizes, donations, charity, etc.;

                      


              

            

             

            
              
                	

                      	22.1.16.18	
                        Any commissions, management fees or similar charges from related parties without express approval from ASES;

                      


              

            

             

            
              
                	

                      	22.1.16.19	
                        Categorizing expenses under a general category such as overhead, other, miscellaneous, is expressly forbidden; and

                      


              

            

             

            
              
                	

                      	22.1.16.20	
                        Any other expense not allowed by ASES.

                      


              

            

             

            
              
                	

                      	22.1.17	
                        The Contractor shall provide ASES every month with a PMPM Payment Disbursement Report. This document shall present the distribution of the Capitation or other
                            service payments to Providers, Claim expenses by coverage, reserves, and administrative expenses. Failure to comply with the requirements contained herein may be cause for the imposition of liquidated damages as outlined in
                            Section 20 of this Contract.

                      


              

            

             

            
              
                	

                      	22.1.18	
                        The Contractor shall provide to ASES, on a monthly basis, actuarial Data in a format specified in the Actuarial Report provided by ASES. Failure to comply with the
                            requirements contained herein may be cause for the imposition of liquidated damages as outlined in Section 20 of this Contract.

                      


              

            

             

            
              Page 272 of 324

              
                


            

            
              
                	

                      	22.1.19	
                        The Contractor shall report all of the profit of its partially- or wholly-owned subsidiaries or Affiliates realized from services rendered in relation to this
                            Contract (the “Affiliated Profit”), unless the Contractor demonstrates and ASES agrees that the Affiliated Profit did not result from preferential contractual terms included in the Contractor’s contracts or arrangements with its
                            partially- or wholly-owned subsidiaries and Affiliates.

                      


              

            

             

            
              
                	

                      	22.1.19.1	
                        Preferential contract terms are those that result in a cost or expense that exceeds fair market value, or those that exceed other terms for the provisioning of same
                            or similar goods and services as would be agreed to by a reasonable person under the same or similar circumstances prevailing at the time the decision was made for the same or similar good or service. In determining whether
                            preferential contract terms exist, consideration must be given to factors including “sound business practices,” “arm’s length bargaining” and “market prices for comparable goods and services for the geographical area.”
                            Contractual terms shall also be deemed preferential if the Contractor’s partially- or wholly-owned subsidiaries of Affiliates charge the Contractor a higher price for the same or similar goods or services than the lowest price
                            charged by the Contractor’s partially- or wholly-owned subsidiaries or Affiliates to any and all other clients.

                      


              

            

             

            
              
                	

                      	22.1.19.2	
                        Notwithstanding the above, if a Contractor’s subsidiary or Affiliate charges the Contractor for goods or services provided under or associated with the GHP program
                            and such charges exceed sixty percent (60%) of the total revenue of the subsidiary or Affiliate, such charges must be at cost.

                      


              

            

             

            
              
                	

                      	22.1.19.3	
                        The Contractor shall report to ASES’s Office of Finance all related-party transactions within thirty (30) Calendar Days and provide a copy of the contract for each
                            transaction detailing the amounts paid or to be paid, charged or transferred and goods or services to be provided under the contract. A certification under penalty from criminal perjury from the Contractor’s President,
                            Vice-President, Chief Financial Officer, or Treasurer specifying what are the “at cost” and/or “fair market value” amounts of the contract, as applicable, shall be included with each submission.

                      


              

            

             

            
              
                	

                      	22.1.20	
                        To comply with 42 CFR 438.608(d) and 42 CFR 433.312, the Contractor shall, consistent with the procedures set forth in Attachment 23 to this Contract, refund (i)
                            the share of the Overpayment due to ASES within eleven (11) months of the discovery and (ii) the share of an Overpayment due to ASES within fifteen (15) Calendar Days from a final judgment on a Fraud, Waste, or Abuse Action. The
                            Contractor must also require and have a mechanism for a Provider to report to the Contractor when it has received an Overpayment, to return that Overpayment to the Contractor with a written reason for the Overpayment within
                            sixty (60) Calendar Days after the date on which the Overpayment was identified. The Contractor shall report annually to ASES on their recoveries of all Overpayments.

                      


              

            

             

            
              Page 273 of 324

              
                


            

            
              
                	

                      	22.2	
                        Medical Loss Ratio

                      


              

            

             

            
              
                	

                      	22.2.1	
                        The Contractor shall report a Medical Loss Ratio (MLR) and related data, including the data on the basis of which ASES will determine the compliance of the
                            Contractor with the Medical Loss Ratio Requirement, as required under 42 CFR 438.8(k) for each MLR reporting year, which aligns with the rating period. Such reporting shall be provided to ASES no later than July 31 of the
                            following year.

                      


              

            

             

            
              
                	

                      	22.2.2	
                        The Contractor shall calculate its MLR and related data based on the methodology set forth in 42 CFR 438.8 and any other instructions issued by CMS or ASES.
                            Effective November 1, 2018, the Contractor shall achieve a minimum MLR, as calculated per 42 CFR 438.8, of at least ninety-two percent (92%) for the MLR reporting year.

                      


              

            

             

            
              
                	

                      	22.2.3	
                        If the Contractor’s MLR is below ninety-two percent (92%), the Contractor must pay a remittance to ASES within thirty (30) Calendar Days of notification from ASES
                            that a remittance is owed. The amount of the remittance owed is the difference between the Contractor’s Medical Loss Ratio for the MLR reporting year and target Medical Loss Ratio of ninety-two percent (92%). The requirement to
                            pay the remittance survives the termination of this Contract.

                      


              

            

             

            
              
                	

                      	22.3	
                        Contractor Objections to Payment

                      


              

            

             

            
              
                	

                      	22.3.1	
                        If the Contractor wishes to contest the amount of payments made by ASES in accordance with the terms outlined in Section 22.1 for services provided under the terms
                            of this Contract, the Contractor shall submit to ASES all relevant documentation supporting the Contractor’s objection no later than thirty (30) Calendar Days after payment is made. Once this term has ended, the Contractor
                            forfeits its right to claim any additional amounts.

                      


              

            

             

            
              
                	

                      	22.3.2	
                        After the Contractor’s submission of all relevant information, the Contractor and ASES will meet to discuss the matter. If after discussing the matter and analyzing
                            all relevant Data it is subsequently determined that an error in payment was made, the Contractor and ASES will develop a plan to remedy the situation, which must include a timeframe for resolution agreed to by both Parties,
                            within a time period mutually agreed upon by both Parties.

                      


              

            

             

            
              
                	

                      	22.4	
                        Retention Fund for Health Care Improvement Program

                      


              

            

             

            
              
                	

                      	22.4.1	
                        ASES shall maintain a Retention Fund of the PMPM Payment each month as part of the Health Care Improvement Program (HCIP) described in Section 12.5 and Attachment
                            19 to this Contract. The overall Retention Fund Percentage is two percent (2%) of the PMPM Payment according Attachment 19 to this Contract.

                      


              

            

             

            
              Page 274 of 324

              
                


            

            
              
                	

                      	22.4.2	
                        With respect to each HCIP initiative, ASES, as indicated herein, shall upon expiration of each quarter during the Contract Term conduct a review to determine if the
                            Contractor has met the applicable performance targets for that period according to the following process:

                      


              

            

             

            
              
                	

                      	22.4.2.1	
                        The Contractor shall submit a quarterly report no later than ninety (90) Calendar Days after the end of each quarter regarding each of the performance indicators to
                            be evaluated, as determined by ASES (from those listed in Attachment 19 to this Contract);

                      


              

            

             

            
              
                	

                      	22.4.2.2	
                        No later than thirty (30) Calendar Days after receipt of the Contractor’s quarterly reports, ASES shall determine if the Contractor has met the applicable
                            performance objectives for each measure for that period;

                      


              

            

             

            
              
                	

                      	22.4.2.3	
                        If the Contractor is in full compliance with the applicable performance targets for said period, ASES shall disburse to the Contractor, no later than thirty (30)
                            Calendar Days after ASES determines compliance with the performance objectives, the portion of the PMPM Payment associated with each initiative for such period.

                      


              

            

             

            
              
                	

                      	22.4.3	
                        The Retention Fund for the HCIP and any other withhold arrangements between ASES and the Contractor must comply the requirements set forth in 42 CFR 438.6(b)(3).

                      


              

            

             

            
              
                	

                      	22.5	
                        Maternity Kick Payment

                      


              

            

             

            
              
                	

                      	22.5.1	
                        ASES will perform a review as described in Attachment 29 to this Contract to determine any applicable Maternity Kick Payments by utilizing claims and encounter data
                            submitted by the Contractor to ASES. The Contractor shall receive $4,641.59 for each delivery reported and validated by ASES. If the data or an audit process does not validate the reported delivery(ies), ASES may retroactively
                            recoup the Maternity Kick Payment.

                      


              

            

             

            
              
                	ARTICLE 23	
                        FINANCIAL MANAGEMENT

                      


              

            

             

            
              
                	

                      	23.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	23.1.1	
                        The Contractor shall be responsible for the sound financial management of Puerto Rico and Federal funds provided to the Contractor under the GHP Program.

                      


              

            

             

            
              Page 275 of 324

              
                


            

            
              
                	

                      	23.1.2	
                        The Contractor shall notify ASES in writing of any loans or other special financial arrangements made between the Contractor and any PMG or any other Provider. Any
                            such loans shall strictly conform to the legal requirements of Federal and Puerto Rico anti-Fraud and anti-kickback laws and regulations.

                      


              

            

             

            
              
                	

                      	23.1.3	
                        The Contractor shall provide ASES with copies of its audited financial statements following Generally Accepted Accounting Principles (“GAAP”), at its own cost and
                            expense, within ninety (90) Calendar Days following the end of each Contract Year during the Contract Term as specified in Section 18.2.9.3. The statements shall be provided in a format specified by ASES.

                      


              

            

             

            
              
                	

                      	23.1.4	
                        The Contractor shall provide to ASES a copy of its Annual Report required to be filed with the Puerto Rico Office of the Insurance Commissioner (OIC Report), as
                            applicable, in the format agreed upon by the National Association of Insurance Commissioners (NAIC), for the year ended on December 31, 2017, and subsequently thereafter, during the Contract Term and any renewals, not later than
                            March 31 of each year. The Contractor shall submit to ASES a reconciliation of the OIC Report with its annual audited financial statements filed pursuant to Section 23.1.3 and Section 18.2.9.8.

                      


              

            

             

            
              
                	

                      	23.1.5	
                        The Contractor shall provide to ASES unaudited financial statements for each quarter during the Contract Term, not later thirty (30) Calendar Days after the close
                            of each quarter in a format specified by ASES.

                      


              

            

             

            
              
                	

                      	23.1.6	
                        The Contractor shall provide to ASES a copy of the annual corporate report of its parent company at the close of the calendar year.

                      


              

            

             

            
              
                	

                      	23.1.7	
                        The Contractor shall maintain adequate procedures and controls to ensure that any payments pursuant to this Contract are properly made. In establishing and
                            maintaining such procedures, the Contractor shall provide for separation of the functions of certification and disbursement.

                      


              

            

             

            
              
                	

                      	23.1.8	
                        The Contractor acknowledges, and shall incorporate in contracts with Subcontractors, that the GHP is a government-funded program. As such, the administrative costs
                            that are deemed allowable shall be in accordance with cost principles permissible, and with Federal and Puerto Rico applicable guidelines, including Office of Management and Budget Circulars, primarily recognizing that: (1) a
                            cost shall be reasonable if it is of the type generally recognized as ordinary and necessary, and if in its nature and amount, and taking into consideration the purpose for which it was disbursed, it does not exceed that which
                            would be incurred by a prudent person in the ordinary course of business under the circumstances prevailing at the time the decision was made to incur the cost; and (2) a cost shall be reasonable if it is allocable to or related
                            to the cost objective that compels cost association. The Contractor will not allow administrative costs as specified in Section 22.1.15 above.

                      


              

            

             

            
              Page 276 of 324

              
                


            

            
              
                	

                      	23.1.9	
                        The Contractor shall maintain an accounting system for GHP separate from the rest of its commercial activities. This system will only include GHP Data.

                      


              

            

             

            
              
                	

                      	23.1.10	
                        The Contractor shall provide, throughout the Contract Term, any other necessary and related information that is deemed necessary by ASES in order to evaluate the
                            Contractor’s financial capacity and stability.

                      


              

            

             

            
              
                	

                      	23.2	
                        Solvency and Financial Requirements

                      


              

            

             

            
              
                	

                      	23.2.1	
                        The Contractor shall establish and maintain adequate net worth, working capital, and financial reserves to carry out its obligations under this Contract. An
                            indemnity agreement containing terms and conditions acceptable to ASES between the Contractor and its parent company may satisfy the requirements set forth in Sections 23.2.2 and 23.2.3.

                      


              

            

             

            
              
                	

                      	23.2.2	
                        The Contractor shall maintain at all times during the Contract Term a minimum two hundred percent (200%) of risk-based capital. ASES reserves the right to require
                            additional capital guarantees as ASES deems reasonably necessary. The Contractor shall comply, as applicable, with Article 3.151 and Article 19.140 of the Puerto Rico Insurance Code relating to insolvency protection.

                      


              

            

             

            
              
                	

                      	23.2.3	
                        The Contractor shall provide assurances to ASES that its provision against the risk of insolvency is adequate, in compliance with the Federal standards set forth in
                            42 CFR 438.116, and shall submit data on the basis of which ASES will determine that the Contractor has made adequate provision against the risk of insolvency. In particular, the Contractor shall, according to the timeframe
                            specified in Attachment 12 to this Contract, furnish documentation, certified by a Certified Public Accountant, of:

                      


              

            

             

            
              
                	

                      	23.2.3.1	
                        The relationship between PMPM Payments and capital, with the optimal relationship being 10:1, in order to prove capacity to assume risk;

                      


              

            

             

            
              
                	

                      	23.2.3.2	
                        A debt level of less than seventy-five percent (75%).and

                      


              

            

             

            
              
                	

                      	23.2.3.3	
                        Relationship of current assets to total liabilities shall be at least eighty percent (80%).

                      


              

            

             

            
              
                	

                      	23.2.4	
                        As part of its accounting and budgeting function, and in accordance with the Insurance Code of Puerto Rico, the Contractor shall establish an actuarially sound
                            process for estimating and tracking potential liability associated with IBNR Claims. As part of its reserving process the Contractor shall conduct annual reviews to assess its IBNR reserving methodology and make adjustments as
                            necessary.

                      


              

            

             

            
              
                	

                      	23.2.5	
                        The Contractor shall establish a reserve fund for IBNR Claims that under no circumstances may exceed ten percent (10%) of Capitation to PMGs. The reserve shall be
                            reconciled and adjusted every ninety (90) Calendar Days and, if necessary, any excess will be liquidated. Once the PMG has the reserve necessary as determined by the Contractor, the monthly retention may not exceed three percent
                            (3%) of Capitation. Any increase must be justified in information from the PMG file. One hundred and eighty (180) Calendar Days after the end of the Contract Term, the Contractor shall reconcile the IBNR reserve. Any remainder
                            of the IBNR funds shall be returned to the PMGs within sixty (60) Calendar Days from the date that the Contractor conducts the reconciliation. This period may not be extended.

                      


              

            

             

            
              Page 277 of 324

              
                


            

            
              
                	

                      	23.2.6	
                        The Contractor agrees to provide any additional guarantees that ASES may require as a result of the periodical evaluation performed by the Office of the
                            Commissioner of Insurance of the financial health of the Contractor.

                      


              

            

             

            
              
                	

                      	23.3	
                        Reinsurance and Stop Loss

                      


              

            

             

            
              
                	

                      	23.3.1	
                        ASES will not administer a Reinsurance program.

                      


              

            

             

            
              
                	

                      	23.3.2	
                        The Contractor shall have and maintain a minimum of one million dollars ($1,000,000.00) in Reinsurance protection against financial loss due to outlier
                            (catastrophic) cases or otherwise maintain self-insurance acceptable to ASES. The Contractor shall submit to ASES such documentation as is necessary to prove the existence of this protection, which may include policies and
                            procedures of Reinsurance. The Contractor may request that ASES waive this requirement by providing sufficient documentation to ASES that the Contractor has adequate protection against financial loss due to outlier
                            (catastrophic) cases. ASES shall review such documentation and, at its discretion, deem this requirement to be met.

                      


              

            

             

            
              
                	

                      	23.3.3	
                        The Contractor shall establish a stop-loss limit amount that is in compliance with the limits specified in 42 CFR 422.208(f). The limit shall be activated when the
                            expense of providing Covered Services to an Enrollee, including all outpatient and inpatient expenses, reaches this sum. The Contractor shall have mechanisms in place to identify the stop loss once it is reached for an Enrollee,
                            and shall establish monthly reports to inform PMGs of Enrollees who have reached the stop-loss limit. The Contractor shall assume all losses exceeding the limit.

                      


              

            

             

            
              
                	

                      	23.3.4	
                        The Contractor’s stop-loss responsibility shall not be transferred to a PMG unless the PMG and the Contractor expressly agree in writing to the PMG’s assuming this
                            risk and the associated risk distribution arrangement has been previously approved in writing by ASES.

                      


              

            

             

            
              
                	

                      	23.4	
                        Third Party Liability and Cost Avoidance

                      


              

            

             

            
              
                	

                      	23.4.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	23.4.1.1	
                        The GHP shall be the payer of last resort for all Covered Services rendered on behalf of Medicaid and CHIP Enrollees in accordance with Federal regulations at 42
                            CFR 433 Subpart D; ASES will enforce this rule with respect to all GHP Enrollees.

                      


              

            

             

            
              Page 278 of 324

              
                


            

            
              
                	

                      	23.4.1.2	
                        The Contractor shall exercise full assignment rights as applicable and shall be responsible for making every reasonable effort to determine the legal liability of
                            Third Parties to pay for services rendered to Enrollees under this Contract and to cost avoid or recover any such liability from the Third Party. “Third Party,” for purposes of this Section, shall mean any person or entity that
                            is or may be liable to pay for the care and services rendered to a GHP Enrollee. Examples of a Third Party include, but are not limited to, an Enrollee’s health insurer, casualty insurer, a managed care organization, and
                            Medicare.

                      


              

            

             

            
              
                	

                      	23.4.1.3	
                        The Contractor, and by extension its Providers and Subcontractors, hereby agree to utilize for Claims Cost Avoidance purposes, within thirty (30) Calendar Days of
                            learning of such sources, other available public or private sources of payment for services rendered to Enrollees in the Contractor’s Plan. If Third Party Liability (TPL) exists for part or all of the services provided directly
                            by the Contractor to an Enrollee, the Contractor shall make reasonable efforts to recover from TPL sources the value of services rendered. If TPL exists for part or all of the services provided to an Enrollee by a Subcontractor
                            or a Provider, and the Third Party will make payment within a reasonable time, the Contractor may pay the Subcontractor or Provider only the amount, if any, by which the Subcontractor’s or Provider’s allowable Claim exceeds the
                            amount of TPL.

                      


              

            

             

            
              
                	

                      	23.4.1.4	
                        The Contractor shall deny payment on a Claim that has been denied by a Third Party payer when the reason for denial is the Provider’s failure to follow prescribed
                            procedures, including, but not limited to, failure to obtain Prior Authorization, failure to file Claims timely, etc.

                      


              

            

             

            
              
                	

                      	23.4.1.5	
                        The Contractor shall, within five (5) Business Days of issuing a denial of any Claim based on TPL, provide TPL Data to the Provider.

                      


              

            

             

            
              
                	

                      	23.4.1.6	
                        The Contractor shall treat funds recovered from Third Parties as offsets to Claims payments. The Contractor shall report all Cost Avoidance values to ASES in
                            accordance with Federal guidelines and as provided for in this Section.

                      


              

            

             

            
              
                	

                      	23.4.1.7	
                        The Contractor shall post all Third Party payments or recoveries to Claim-level detail by Enrollee.

                      


              

            

             

            
              Page 279 of 324

              
                


            

            
              
                	

                      	23.4.1.8	
                        If the Contractor operates or administers a non-GHP program or other lines of business, the Contractor shall access the resources of those entities to assist ASES
                            with the identification of Enrollees with access to other insurance or sources of payment.

                      


              

            

             

            
              
                	

                      	23.4.1.9	
                        The Contractor shall audit and review its Providers’ Claims, using monthly the reports submitted pursuant to Section 16.7 of this Contract or other pertinent Data,
                            to ensure that Providers are not receiving duplicate payment for services billable to Third Parties. The Contractor shall report to ASES on a quarterly basis its findings regarding Claims, invoices, or duplicate or inappropriate
                            payments. According to the timeframe specified in Attachment 12 to this Contract, the Contractor shall submit to ASES for its review and prior written approval a plan for such routine audits.

                      


              

            

             

            
              
                	

                      	23.4.1.10	
                        The Contractor shall demonstrate, upon request, to ASES that reasonable effort has been made to seek, including through collaboration with Providers, to collect and
                            report Third Party recoveries. ASES shall have the sole responsibility for determining whether or not reasonable efforts have been demonstrated. Said determination shall take into account reasonable industry standards and
                            practices.

                      


              

            

             

            
              
                	

                      	23.4.1.11	
                        The Contractor shall comply with 42 CFR 433 Subpart D – Third Party Liability and 42 CFR 447.20 Provider Restrictions: State Plan Requirements, and work
                            cooperatively with ASES to assure compliance with the requirements therein, as it relates to the Medicaid and CHIP populations served by the Contractor’s plan and its Third Party Liability and Cost Avoidance responsibilities.

                      


              

            

             

            
              
                	

                      	23.4.2	
                        Legal Causes of Action for Damages. ASES or its designee will have the sole and exclusive right to pursue and collect payments made by the Contractor when a legal
                            cause of action for damages is instituted on behalf of a GHP Enrollee against a Third Party, or when ASES receives notices that legal counsel has been retained by or on behalf of any Enrollee. The Contractor shall cooperate with
                            ASES in all collection efforts, and shall also direct its Providers to cooperate with ASES in these efforts.

                      


              

            

             

            
              
                	

                      	23.4.3	
                        Estate Recoveries. ASES (or another agency of the Government) will have the sole and exclusive right to pursue and recover correctly paid benefits from the estate
                            of a deceased Enrollee who was Medicaid Eligible in accordance with Federal and Puerto Rico law. Such recoveries will be retained by ASES.

                      


              

            

             

            
              
                	

                      	23.4.4	
                        Subrogation

                      


              

            

             

            
              
                	

                      	23.4.4.1	
                        Third Party resources shall include subrogation recoveries. The Contractor shall be required to seek subrogation amounts regardless of the amount believed to be
                            available as required by Federal Medicaid guidelines and Puerto Rico law.

                      


              

            

             

            
              Page 280 of 324

              
                


            

            
              
                	

                      	23.4.4.2	
                        The amount of any subrogation recoveries collected by the Contractor outside of the Claims processing system shall be treated by the Contractor as offsets to
                            medical expenses for the purposes of reporting.

                      


              

            

             

            
              
                	

                      	23.4.4.3	
                        The Contractor shall conduct diagnosis and trauma code editing to identify potential subrogation Claims. This editing should, at minimum, identify Claims with a
                            diagnosis of 900.00 through 999.99 (excluding 994.6) or Claims submitted with an accident trauma indicator of ‘Y.’

                      


              

            

             

            
              
                	

                      	23.4.5	
                        Cost Avoidance

                      


              

            

             

            
              
                	

                      	23.4.5.1	
                        When the Contractor is aware of health or casualty insurance coverage before paying for a Covered Service, the Contractor shall avoid payment by promptly (within
                            fifteen (15) Business Days of receipt) rejecting the Provider’s Claim and directing that the Claim be submitted first to the appropriate Third Party.

                      


              

            

             

            
              
                	

                      	23.4.5.2	
                        Exceptions to the Cost Avoidance Rule. In the following situations, the Contractor
                            shall first pay its Providers and then coordinate with the liable Third Party, unless prior approval to take other action is obtained from ASES:

                      


              

            

             

            
              
                	

                      	23.4.5.2.1	
                        The coverage is derived from a parent whose obligation to pay support is being enforced by a government agency.

                      


              

            

             

            
              
                	

                      	23.4.5.2.2	
                        The Claim is for maternal and prenatal services to a pregnant woman or for EPSDT services that are covered by the Medicaid program.

                      


              

            

             

            
              
                	

                      	23.4.5.2.3	
                        The Claim is for labor, delivery, and post-partum care and does not involve hospital costs associated with an inpatient stay.

                      


              

            

             

            
              
                	

                      	23.4.5.2.4	
                        The Claim is for a child who is in the custody of ADFAN.

                      


              

            

             

            
              
                	

                      	23.4.5.2.5	
                        The Claim involves coverage or services mentioned in this Section in combination with another service.

                      


              

            

             

            
              
                	

                      	23.4.5.3	
                        If the Contractor knows that the Third Party will neither pay for nor provide the Covered Service, and the service is Medically Necessary, the Contractor shall
                            neither deny payment for the service nor require a written denial from the Third Party.

                      


              

            

             

            
              Page 281 of 324

              
                


            

            
              
                	

                      	23.4.5.4	
                        If the Contractor does not know whether a particular service is covered by the Third Party, and the service is Medically Necessary, the Contractor shall promptly
                            (within ten (10) Business Days of receipt of the Claim) contact the Third Party and determine whether or not such service is covered rather than requiring the Enrollee to do so. Further, the Contractor shall require the Provider
                            to bill the Third Party if coverage is available.

                      


              

            

             

            
              
                	

                      	23.4.6	
                        Sharing of TPL Information by ASES

                      


              

            

             

            
              
                	

                      	23.4.6.1	
                        By the fifth (5th) Calendar Day after the close of the month during which ASES
                            learns of such information, ASES will provide the Contractor with a list of all known health insurance information on Enrollees for the purpose of updating the Contractor’s files.

                      


              

            

             

            
              
                	

                      	23.4.6.2	
                        Additionally, by the fifteenth (15th) Calendar Day after the close of the calendar
                            quarter, ASES will provide to the Contractor a copy of a report containing all of the health insurers licensed by Puerto Rico as of the close of the previous quarter, and any other related information that is needed to file TPL
                            Claims.

                      


              

            

             

            
              
                	

                      	23.4.7	
                        Sharing of TPL Information by the Contractor

                      


              

            

             

            
              
                	

                      	23.4.7.1	
                        The Contractor shall submit a monthly report to ASES (following ASES file content, format and transmission specifications) by the fifth (5th) Calendar Day after the close of the month during which the Contractor learns that an Enrollee has new health insurance coverage, or casualty
                            insurance coverage, or of any change in an Enrollee’s health insurance coverage. The Contractor shall impose a corresponding requirement on its Providers to notify the Contractor of any newly discovered coverage.

                      


              

            

             

            
              
                	

                      	23.4.7.2	
                        When the Contractor becomes aware that an Enrollee has retained counsel, who either may institute or has instituted a legal cause of action for damages against a
                            Third Party, the Contractor shall notify ASES in writing, including the Enrollee’s name and GHP Enrollee identification number, the date of the accident/incident, the nature of the injury, the name and address of the Enrollee’s
                            legal representative, copies of the pleadings, and any other documents related to the action in the Contractor’s possession or control. This shall include, but not be limited to, the name of the Provider, the Enrollee’s
                            diagnosis, the Covered Service provided to the Enrollee, and the amount paid to the Provider for each service.

                      


              

            

             

            
              
                	

                      	23.4.7.3	
                        The Contractor shall notify ASES within thirty (30) Calendar Days of the date it becomes aware of the death of one of its Medicaid Eligible Enrollees age fifty-five
                            (55) or older, giving the Enrollee’s full name, Social Security number, and date of death. ASES will then determine whether it can recover correctly paid Medicaid benefits from the Enrollee’s estate.

                      


              

            

             

            
              Page 282 of 324

              
                


            

            
              
                	

                      	23.4.7.4	
                        The Contractor agrees to share with ASES instances of Enrollee non-cooperation with the Contractor’s and with Network Providers’ efforts to determine sources of
                            Third Party Liability.

                      


              

            

             

            
              
                	

                      	23.4.7.5	
                        The Contractor agrees to cooperate with ASES in its oversight and monitoring reviews of all Third Party Liability activities.

                      


              

            

             

            
              
                	

                      	23.4.8	
                        Historic Cost Avoidance due to the existence of liable Third Parties is embedded in the cost of health services delivery and is reflected in the rates upon which
                            ASES will base PMPM Payments to the Contractor. The PMPM Payment does not include any reductions due to tort recoveries.

                      


              

            

             

            
              
                	

                      	23.5	
                        GHP as Secondary Payer to Medicare

                      


              

            

             

            
              
                	

                      	23.5.1	
                        In general, as provided in Section 7.12, except for services offered by Medicare Platino plans which operate independently of this Contract, the GHP does not
                            duplicate coverage provided by Medicare to Dual Eligible Beneficiaries and the Contractor shall not be a secondary payer for services for which Medicare is liable.

                      


              

            

             

            
              
                	

                      	23.5.1.1	
                        However, in a situation in which a Covered Service is covered in whole or part by both Medicare and GHP (for example, hospitalization services for a Dual Eligible
                            Beneficiary who is enrolled in Medicare Part A only and whose hospitalization costs exceed the Medicare limit, per Section 7.12. of this Contract), the Contractor shall determine liability as a secondary payer as follows:

                      


              

            

             

            
              
                	

                      	23.5.1.1.1	
                        If the total amount of Medicare’s established liability for the services (Medicare paid amount) is equal to or greater than the negotiated contract rate between the
                            Contractor and the Provider for the services, minus any GHP cost-sharing requirements, then the Provider is not entitled to, and the Contractor shall not pay, any additional amounts for the services.

                      


              

            

             

            
              
                	

                      	23.5.1.1.2	
                        If the total amount of Medicare’s established liability (Medicare paid amount) is less than the negotiated contract rate between the Contractor and the Provider for
                            the services, minus any GHP cost-sharing requirements, the Provider is entitled to, and the Contractor shall pay, the lesser of:

                      


              

            

             

            
              
                	

                      	23.5.1.1.2.1	
                        The Medicaid cost-sharing (Deductibles and coinsurance) payment amount for which the Dual Eligible Beneficiary is responsible under Medicare, and

                      


              

            

             

            
              Page 283 of 324

              
                


            

            
              
                	

                      	23.5.1.1.2.2	
                        An amount which represents the difference between (1) the negotiated contract rate between the Contractor and the Provider for the service minus any GHP
                            cost-sharing requirements, and (2) the established Medicare liability for the services.

                      


              

            

             

            
              
                	

                      	23.5.2	
                        Enrollment Exclusions and Contractor Liability for the Cost of Care. Any Dual Eligible Beneficiary who is already enrolled in a Medicare Platino Plan may not be
                            enrolled by the Contractor. However, if the Contractor operates its own Medicare Platino plan, the Contractor may enroll a Dual Eligible Beneficiary in the Platino plan, which furnishes GHP Benefits, per separate contract with
                            ASES.

                      


              

            

             

            
              
                	

                      	23.5.3	
                        Protections for Medicaid Enrollees

                      


              

            

             

            
              
                	

                      	23.5.3.1	
                        The Contractor shall neither impose, nor allow Providers to impose, any cost-sharing charges of any kind upon Medicaid Eligibles enrolled in GHP, other than as
                            authorized in this Contract.

                      


              

            

             

            
              
                	

                      	23.5.3.2	
                        Unless otherwise permitted by Federal or Puerto Rico law, Covered Services may not be denied to a Medicaid Enrollee because of a Third Party’s potential liability
                            to pay for the services, and the Contractor shall ensure that its Cost Avoidance efforts do not prevent Enrollees from receiving Medically Necessary Services.

                      


              

            

             

            
              
                	

                      	23.6	
                        Physician Incentive Plans

                      


              

            

             

            
              
                	

                      	23.6.1	
                        Any Physician Incentive Plans established by the Contractor shall comply with Federal and Puerto Rico regulations, including 42 CFR 422.208 and 422.210, and 42 CFR
                            438.3(i), and with the requirements in Section 10.7 of this Contract.

                      


              

            

             

            
              
                	

                      	23.6.2	
                        The Contractor shall obtain prior written approval from ASES before implementing any Physician Incentive Plan arrangements, as provided in Section 10.7, and shall
                            provide information about such arrangements to Enrollees upon request, as required in Section 6.4.5 of the Contract. Such disclosure shall include:

                      


              

            

             

            
              
                	

                      	23.6.2.1	
                        Whether services not furnished by the Provider or PMG are covered by the incentive plan;

                      


              

            

             

            
              
                	

                      	23.6.2.2	
                        The type of incentive arrangement;

                      


              

            

             

            
              
                	

                      	23.6.2.3	
                        The percentage of Withhold or bonus;

                      


              

            

             

            
              Page 284 of 324

              
                


            

            
              
                	

                      	23.6.2.4	
                        The panel size and if patients are pooled, the method used; and

                      


              

            

             

            
              
                	

                      	23.6.2.5	
                        If the Provider or PMG is at substantial financial risk proof that the Provider or PMG has adequate stop loss coverage, including amount and type of stop loss.

                      


              

            

             

            
              
                	

                      	23.6.3	
                        Annually, the Contractor shall report the information specified by the regulations to ASES in order that ASES can adequately monitor the Contractor’s plan, under
                            the criteria set forth in 42 CFR 422.208 and 422.210.

                      


              

            

             

            
              
                	

                      	23.6.4	
                        Such Physician Incentive Plans may not provide for payment, either directly or indirectly, to a Provider or PMG as an inducement to reduce or limit Medically
                            Necessary Services furnished to an Enrollee.

                      


              

            

             

            
              
                	

                      	23.7	
                        Financial Reporting Requirements

                      


              

            

             

            
              
                	

                      	23.7.1	
                        The Contractor shall submit to ASES all of the reports as indicated in Section 18.1.

                      


              

            

             

            
              
                	

                      	23.7.2	
                        Failure to submit the reports within the established timeframes, or failure to submit complete, accurate reports, may result in the imposition of liquidated damages
                            and/or fines as outlined in Article 20 of this Contract.

                      


              

            

             

            
              
                	

                      	23.7.3	
                        The Contractor, at its sole expense, shall submit by May 15 (or a later date if approved by ASES) of each year a “Report on Controls Placed in Operation and Tests
                            of Operating Effectiveness,” meeting all standards and requirements of the SSAE 18 for the Contractor’s operations performed for ASES under the GHP Contract.

                      


              

            

             

            
              
                	

                      	23.7.3.1	
                        The audit shall be conducted by an independent auditing firm, with prior audit experience using AICPA “Statements on Auditing Standards”.  The auditor shall meet
                            all AICPA standards for independence. The selection of, and contract with the independent auditor shall be subject to the prior written approval of ASES. ASES reserves the right to, at the Contractor’s expense; designate other
                            auditors or reviewers to examine the Contractor’s operations and records for monitoring and/or stewardship purposes.

                      


              

            

             

            
              
                	

                      	23.7.3.2	
                        The Contractor will deliver to ASES, along with the Report on Controls Placed in Operation and Tests of Operating Effectiveness, the findings and recommendations of
                            the independent audit firm encountered in the preparation of such a report.  The audit shall be conducted and the report shall be prepared in accordance with generally accepted auditing standards for such audits as defined in
                            the publications of the AICPA, entitled “Statements on Auditing Standards” (SAS). In particular, SSAE 18 is to be used.

                      


              

            

             

            
              Page 285 of 324

              
                


            

            
              
                	

                      	23.7.3.3	
                        The Contractor shall respond to the audit findings and recommendations within thirty (30) Calendar Days of receipt of the final audit report. Also the Contractor
                            must submit a Corrective Action Plan to ASES which will be subject to ASES’ prior review and written approval within twenty (20) Calendars Days of the notification of the audit. The Contractor must implement the Corrective
                            Action Plan, as a maximum, within fifteen (15) Calendar Days of its approval by ASES. The entity should request an extension by formal written request addressed to the Office of Compliance of ASES who will evaluate the request
                            and provide the specific timeframe for the extension.

                      


              

            

             

            
              
                	

                      	23.7.4	
                        The Contractor shall submit to ASES a “Disclosure of Information on Annual Business Transactions.” This report shall include:

                      


              

            

             

            
              
                	

                      	23.7.4.1	
                        Definition of A Party in Interest. As defined in Section 1318(b) of the Public Health
                            Service Act, a party in interest is:

                      


              

            

             

            
              
                	

                      	23.7.4.1.1	
                        (i) Any director, officer, partner, or employee responsible for management or administration of the Contractor; (ii) any person or legal entity that is directly or
                            indirectly the beneficial owner of more than five percent (5%) of the equity of the Contractor; (iii) any person or legal entity that is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and
                            valuing more than five percent (5%) of the Contractor; or, (iv) in the case of a Contractor organized as a nonprofit corporation, an incorporator or enrollee of such corporation under applicable Puerto Rico corporation law;

                      


              

            

             

            
              
                	

                      	23.7.4.1.2	
                        Any organization in which a person or a legal entity described in Section 23.7.4.1.1 is director, officer or partner; has directly or indirectly a beneficial
                            interest of more than five percent (5%) of the equity of the Contractor; or has a mortgage, deed of trust, note, or other interest valuing more than five percent (5%) of the assets of the Contractor;

                      


              

            

             

            
              
                	

                      	23.7.4.1.3	
                        Any person directly or indirectly controlling, controlled by, or under common control with the Contractor; or

                      


              

            

             

            
              
                	

                      	23.7.4.1.4	
                        Any spouse, child, or parent of an individual described in Sections 23.7.4.1.1-23.7.4.1.3.

                      


              

            

             

            
              
                	

                      	23.7.4.2	
                        Types of Transactions Which Must Be Disclosed. Business transactions which must be
                            disclosed include:

                      


              

            

             

            
              
                	

                      	23.7.4.2.1	
                        Any sale, exchange or lease of any property between the Contractor and a party in interest;

                      


              

            

             

            
              Page 286 of 324

              
                


            

            
              
                	

                      	23.7.4.2.2	
                        Any lending of money or other extension of credit between the Contractor and a party in interest; and

                      


              

            

             

            
              
                	

                      	23.7.4.2.3	
                        Any furnishing for consideration of goods, services (including management services) or facilities between the Contractor and the party in interest. This does not
                            include salaries paid to employees for services provided in the normal course of their employment.

                      


              

            

             

            
              
                	

                      	23.7.4.3	
                        The information which must be disclosed in the transactions listed in this Section 23.7.4 between the Contractor and a party of interest includes:

                      


              

            

             

            
              
                	

                      	23.7.4.3.1	
                        The name of the party in interest for each transaction;

                      


              

            

             

            
              
                	

                      	23.7.4.3.2	
                        A description of each transaction and the quantity or units involved;

                      


              

            

             

            
              
                	

                      	23.7.4.3.3	
                        The accrued dollar value of each transaction during the fiscal year; and

                      


              

            

             

            
              
                	

                      	23.7.4.3.4	
                        Justification of the reasonableness of each transaction.

                      


              

            

             

            
              
                	

                      	23.7.4.4	
                        As per 42 CFR 455.105 the Contractor, within thirty-five (35) Calendar Days of the date of request by the HHS Secretary, ASES or the Puerto Rico Medicaid agency,
                            and on an annual basis to ASES and the Puerto Rico Medicaid agency, shall report full and complete information about:

                      


              

            

             

            
              
                	

                      	23.7.4.4.1	
                        The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the twelve (12) month period ending on the
                            day of the request; and

                      


              

            

             

            
              
                	

                      	23.7.4.4.2	
                        Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the five (5) year
                            period ending on the date of the request.

                      


              

            

             

            
              
                	

                      	23.7.4.5	
                        Disclosures of Information on Annual Business Transactions or other reports of transactions between the Contractor and parties in interest provided to ASES or other
                            agencies must be made available to Enrollees upon reasonable request.

                      


              

            

             

            
              Page 287 of 324

              
                


            

            
              
                	ARTICLE 24	
                        PAYMENT OF TAXES

                      


              

            

             

            
              
                	

                      	24.1	
                        The Contractor certifies and guarantees that at the time of execution of this Contract:

                      


              

            

             

            
              
                	

                      	24.1.1	
                        It is an entity duly authorized to conduct business in Puerto Rico and has filed income tax returns for the previous five (5) years;

                      


              

            

             

            
              
                	

                      	24.1.2	
                        It complied with and paid unemployment insurance tax, disability insurance tax (Law 139), social security for drivers (“seguro social choferil”), if applicable;

                      


              

            

             

            
              
                	

                      	24.1.3	
                        It filed State Department reports for the five (5) previous years; and

                      


              

            

             

            
              
                	

                      	24.1.4	
                        It does not owe any kind of taxes to Puerto Rico.

                      


              

            

             

            
              
                	

                      	24.2	
                        The Contractor will forthwith pay all taxes lawfully imposed upon it with respect to this Contract or any product delivered in accordance herewith. ASES makes no
                            representation whatsoever as to the liability or exemption from liability of Contractor to any tax imposed by any governmental entity.

                      


              

            

             

            
              
                	

                      	24.3	
                        Notwithstanding the above, if, as a result of the enactment of any Federal, state, local or municipal legal provision, administrative regulation, or government
                            directive, the Contractor is burdened with a requirement to pay a fee, tax, imposition, levy, or duty with regards to any of the proceeds of this Contract, including but not limited to the imposition of any fees pertaining to
                            the existence of any government contracts, or any sales and use tax (IVU, for its Spanish acronym), ASES will evaluate, in good faith, an adjustment to the PMPM Payment under this Contract, among other possible alternatives.

                      


              

            

             

            
              
                	ARTICLE 25	
                        RELATIONSHIP OF PARTIES

                      


              

            

             

            
              
                	

                      	25.1	
                        Neither Party is an Agent, employee, or servant of the other. It is expressly agreed that the Contractor and any Subcontractors and Agents, officers, and employees
                            of the Contractor or any Subcontractor in the performance of this Contract shall act as independent contractors and not as officers or employees of ASES. The Parties acknowledge, and agree, that the Contractor, its Agent,
                            employees, and servants shall in no way hold themselves out as Agent, employees, or servants of ASES. It is further expressly agreed that this Contract shall not be construed as a partnership or joint venture between the
                            Contractor or any Subcontractor and ASES.

                      


              

            

             

            
              
                	ARTICLE 26	
                        INSPECTION OF WORK

                      


              

            

             

            
              
                	

                      	26.1	
                        ASES, the Puerto Rico Medicaid Program, other agencies of the Government, the US Department of Health and Human Services, the General Accounting Office, the US
                            Comptroller General, the Comptroller General of Puerto Rico, if applicable, or their Authorized Representatives, shall have the right to enter into the premises of the Contractor or all Subcontractors, or such other places where
                            duties under this Contract are being performed for ASES, to inspect, monitor or otherwise evaluate the services or any work performed pursuant to this Contract. All inspections and evaluations of work being performed shall be
                            conducted with prior notice and during normal business hours. All inspections and evaluations shall be performed in such a manner that will not unduly delay work.

                      


              

            

             

            
              Page 288 of 324

              
                


            

            
              
                	ARTICLE 27	
                        GOVERNMENT PROPERTY

                      


              

            

             

            
              
                	

                      	27.1	
                        The Contractor agrees that any papers, materials and other documents that are produced or that result, directly or indirectly, from, under or in connection with the
                            Contractor’s provision of the services under this Contract shall be the property of ASES upon creation of such documents, for whatever use that ASES deems appropriate, and the Contractor further agrees to prepare any and all
                            documents, including the Deliverables listed in Attachment 12 to this Contract, or to take any additional actions that may be necessary in the future to effectuate this provision fully. In particular, if the work product or
                            services include the taking of photographs or videotapes of individuals, the Contractor shall obtain the consent from such individuals authorizing the use by ASES of such photographs, videotapes, and names in conjunction with
                            such use. The Contractor shall also obtain necessary releases from such individuals, releasing ASES from any and all claims or demands arising from such use.

                      


              

            

             

            
              
                	

                      	27.2	
                        The Contractor shall be responsible for the proper custody and care of any ASES-owned property furnished for the Contractor’s use in connection with the performance
                            of this Contract. The Contractor will reimburse ASES for its loss or damage, normal wear and tear excepted, while such property is in the Contractor’s custody or use.

                      


              

            

             

            
              
                	ARTICLE 28	
                        OWNERSHIP AND USE OF DATA AND SOFTWARE

                      


              

            

             

            
              
                	

                      	28.1	
                        Ownership and Use of Data

                      


              

            

             

            
              
                	

                      	28.1.1	
                        All Information created from Data, documents, messages (verbal or electronic), reports, or meetings involving or arising out of or in connection with this Contract
                            is owned by ASES (the information will be hereinafter referred to as “ASES Data and Information”). The Contractor shall make all Data and Information available to ASES, which will also provide the Data to CMS or other pertinent
                            government agencies and authorities upon request. The Contractor is expressly prohibited from sharing, distributing, disseminating, or publishing ASES Data and Information without the express prior written consent of ASES. In
                            the event of a dispute regarding what is or is not ASES Data and Information, ASES’s decision on this matter shall be final and not subject to appeal.

                      


              

            

             

            
              
                	

                      	28.1.2	
                        ASES acknowledges that before executing this Contract and in contemplation of the same, the Contractor has developed and designed certain programs and systems such
                            as standard operating procedures, programs, business plans, policies and procedures, which ASES acknowledges are the exclusive property of the Contractor. Nevertheless, in case of default by the Contractor, ASES is hereby
                            authorized to use to the extent allowable by any applicable commercial software and hardware licensing that exists at that moment or with which agreement can be reached at that moment with the vendor to modify such licensing to
                            permit its use by ASES, at no cost to ASES, such properties for a period of one hundred and twenty (120) Calendar Days to effect an orderly transition to any new Contractor or service provider. In any cases where the use of such
                            systems from an operational perspective would also impact other lines of the Contractor’s business or where licensing restrictions cannot be remedied, the Contractor shall operate such systems on behalf of ASES. Such operation
                            by the Contractor on behalf of ASES can occur at ASES’ discretion under the full supervision of their employees or appointed third party personnel. Under such a scenario, ASES’ access to Data will be restricted through the most
                            efficient means possible to the Contractor’s Data segment. If the Contractor fails to operate such systems on ASES’ behalf in a timely manner per normal previous operating schedule, ASES may claim ownership of such systems and
                            operate them for its own purposes.

                      


              

            

             

            
              Page 289 of 324

              
                


            

            
              
                	

                      	28.1.3	
                        The Contractor shall not deny access to ASES’s Data under any case or circumstances, nor retain ASES’s Data while controversies between ASES and the Contractor are
                            resolved and finally adjudicated

                      


              

            

             

            
              
                	

                      	28.2	
                        Responsibility for Information Technology Investments

                      


              

            

             

            
              
                	

                      	28.2.1	
                        The Parties understand and agree that the cost of any newly acquired or developed software programs or upgrades or enhancements to existing software programs,
                            hardware, or other related information technology equipment or infrastructure component, made in order to comply with the requirements of this Contract shall be borne in its entirety by the Contractor.

                      


              

            

             

            
              
                	ARTICLE 29	
                        CRIMINAL BACKGROUND CHECKS

                      


              

            

             

            
              
                	

                      	29.1	
                        ASES is prohibited by law from entering into contracts with any person or entity that has been, or whose affiliated subsidiary companies, or any of its
                            shareholders, partners, officers, principals, managing employees, subsidiaries, parent companies, officers, directors, board members, or ruling bodies have been, under investigation for, accused of, convicted of, or sentenced to
                            imprisonment, in Puerto Rico, the other USA jurisdictions, or any other jurisdiction, for any crime involving corruption, fraud, embezzlement, or unlawful appropriation of public funds, pursuant to Act 458, as amended, and Act
                            84 of 2002.

                      


              

            

             

            
              
                	

                      	29.2	
                        Before the Effective Date of this Contract, and in order for the Contract to take effect, the Contractor shall provide to ASES a certification that neither the
                            Contractor nor the affiliated persons/entities listed in Section 29.1 falls under the prohibition stated in Section 29.1. In addition, the Contractor shall provide to ASES a certification as to whether, to the best of its
                            knowledge after inquiry, any Network Provider, or any shareholder, partner, officer, principal, managing employee, subsidiary, parent company, officer, director, board member, or ruling body of a Network Provider, falls under
                            the prohibition stated in Section 29.1.

                      


              

            

             

            
              Page 290 of 324

              
                


            

            
              
                	

                      	29.3	
                        ASES may terminate this Contract if ASES determines that the Contractor, or any of the natural persons listed in Section 29.1, falls within the prohibition stated
                            in Section 29.1, or failed to provide an accurate certification as required in Section 29.2. In addition, the Contractor shall terminate a Provider Contract if it determines that a Provider, or any of the natural persons listed
                            in Section 29.1, falls within the prohibition stated in Section 29.1.

                      


              

            

             

            
              
                	

                      	29.4	
                        During the Contract Term, the Contractor shall promptly (within twenty (20) Business Days of the date it receives the information) report any significant fact or
                            event related to the rule stated in this Article.

                      


              

            

             

            
              
                	

                      	29.5	
                        In cases in which none of the events listed in Section 29.1 has occurred, but statements or admissions of crimes have been made by or against the Contractor or one
                            of its shareholders, partners, officers, principals, subsidiaries, or parent companies, ASES shall provide all pertinent information about the matter, within twenty (20) Business Days from the date it receives the information,
                            to the Secretary of Justice of Puerto Rico, who will make the pertinent findings and recommendations concerning the Contract.

                      


              

            

             

            
              
                	

                      	29.6	
                        In addition, as provided in 42 CFR 455.106(c), ASES may refuse to enter into or renew an agreement with any entity if any person who has an ownership or control
                            interest in the entity, or is an Agent or managing employee of the entity, has ever been convicted of a criminal offense related to the person’s involvement in any program established under Medicare, Medicaid, or the Title XX
                            services programs. Before the Effective Date of this Contract, pursuant to 42 CFR 455.106(a), the Contractor shall disclose to ASES the identity of any person who has ever been convicted of a criminal offense related to the
                            Medicare, Medicaid, or Title XX services programs. The Contractor shall collect the same information on criminal conviction for Providers during the Credentialing process, as provided in Section 9.2.3 and shall, immediately upon
                            receipt of such information relating to a Provider, disclose the information to ASES. ASES will notify the HHS Inspector General of any disclosures related to criminal convictions within twenty (20) Business Days from the date
                            that ASES receives the information, as required by 42 CFR 455.106.

                      


              

            

             

            
              
                	ARTICLE 30	
                        SUBCONTRACTS

                      


              

            

             

            
              
                	

                      	30.1	
                        Use of Subcontractors

                      


              

            

             

            
              
                	

                      	30.1.1	
                        In carrying out the terms of this Contract, the Contractor, with the prior written approval of ASES, may enter into written Subcontract(s) with other entities for
                            the provision of administrative services or a combination of Covered Services and administrative services, under terms and conditions acceptable to ASES in its sole discretion.

                      


              

            

             

            
              Page 291 of 324

              
                


            

            
              
                	

                      	30.1.2	
                        The Contractor shall assume sole responsibility for all functions performed by a Subcontractor(s), as well as any payments to a Subcontractor(s) for services
                            related to this Contract. In the event that a Subcontractor is incapable of performing the service contracted for by the Contractor, the Contractor shall (i) notify ASES within two (2) Business Days and (ii) assume
                            responsibility for providing the services that the Subcontractor is incapable of performing. The Contractor shall remain obligated to provide any services that the Subcontractor is incapable of performing.

                      


              

            

             

            
              
                	

                      	30.1.3	
                        If the Contractor becomes aware of a Subcontractor’s failure to comply with this Contract, the Contractor shall correct the failure within thirty (30) Calendar Days
                            of becoming aware of the failure.

                      


              

            

             

            
              
                	

                      	30.1.4	
                        All Subcontracts between the Contractor and Subcontractors must be in writing, must comply with all applicable Medicaid laws and regulations, including
                            subregulatory guidance and provisions set forth in this Contract, as applicable, and must specify the activities and responsibilities delegated to the Subcontractor containing terms and conditions consistent with this Contract
                            and 42 CFR 438.230(c). The Subcontracts must also include provisions for revoking delegation or imposing other sanctions if the Subcontractor’s performance is inadequate. The Contractor and the Subcontractors must also make
                            reference to a business associates agreement between the Parties.

                      


              

            

             

            
              
                	

                      	30.1.5	
                        All Subcontracts between the Contractor and Subcontractors must ensure that the Contractor evaluates the prospective Subcontractor’s ability to perform the
                            activities to be delegated; monitors the Subcontractor’s performance on an ongoing basis and subjects it to formal review according to a periodic schedule established by ASES and consistent with industry standards or Puerto Rico
                            laws and regulations; and identifies deficiencies or areas for improvement, ensuring that corrective action is taken as appropriate or required. The Contractor must provide to ASES, on behalf of the Subcontractor, any and all
                            materials required under Puerto Rico law to enter into a contract with the Government of Puerto Rico, in accordance with Puerto Rico Department of Treasury Circular Letter Number 1300-16-16.

                      


              

            

             

            
              
                	

                      	30.1.6	
                        The Contractor shall not Subcontract or permit anyone other than Contractor personnel to perform any of the work, services, or other performances required of the
                            Contractor under this Contract relating to functions associated with the provision of Benefits to Enrollees or assign any of its rights or obligations hereunder, without the prior written consent of ASES. Prior to hiring or
                            entering into a Subcontract with any Subcontractor, any and all Subcontractors shall be previously approved in writing by ASES. ASES reserves the right to review all Subcontract agreements at any time during the Contract Term.
                            Upon request from ASES, the Contractor shall provide in writing the names of all proposed or actual Subcontractors.

                      


              

            

             

            
              Page 292 of 324

              
                


            

            
              
                	

                      	30.1.7	
                        The Contractor shall not engage nor contract with a person or entity that is debarred or suspended or otherwise excluded from participating in procurement
                            activities under the Federal Acquisition Regulation (FAR) or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549,
                            or a person or entity that is an Affiliate, as defined in FAR, of a such a person or entity (see 42 CFR 438.610).

                      


              

            

             

            
              
                	

                      	30.1.8	
                        ASES shall have the right to review all financial or business transactions between the Contractor and a Subcontractor at any time upon request. ASES, CMS, or Office
                            of Inspector General may inspect, evaluate and audit the Subcontractor at any time if ASES, CMS or Office of Inspector General determines there is a reasonable possibility of fraud or similar risk. ASES shall also retain the
                            right to review all criminal background checks for all employees of the Subcontractor, as referenced in Article 29, as well as any past exclusion from Federal programs.

                      


              

            

             

            
              
                	

                      	30.1.9	
                        The Contractor shall provide ASES Immediate notice by certified mail, of any action or suit filed and of any claim made against the Contractor by the Subcontractor
                            or against a Subcontractor(s) that, in the opinion of the Contractor, may result in litigation related in any way to this Contract. The Contractor shall provide notification in writing as to how this action or suit may affect
                            the overall provision of services to Enrollees and the Contractor’s plan to mitigate such affect.

                      


              

            

             

            
              
                	

                      	30.1.10	
                        When a Subcontract related to the provision of Covered Services or that includes Claims processing services is being terminated other than for cause, the Contractor
                            shall give at least one hundred twenty (120) Calendar Days prior written notice of the termination to ASES. If the termination is for cause, the Contractor shall Immediately notify ASES.

                      


              

            

             

            
              
                	

                      	30.1.11	
                        The Contractor shall give ASES Immediate notice in writing by registered mail or certified mail of any action or suit filed by any Subcontractor and prompt notice
                            of any claim made against the Contractor by any Subcontractor or vendor that, in the opinion of Contractor, may result in litigation related in any way to this Contract.

                      


              

            

             

            
              
                	

                      	30.1.12	
                        Pursuant to the requirements of 42 CFR 438.230(c)(3)(i) and 42 CFR 438.3(k), ASES, CMS, the Office of Inspector General, the Comptroller General, and their
                            respective designees shall have the right at any time to inspect, evaluate, and audit any books, records, contractors, computer or other electronic systems of the Subcontractor, or of the Subcontractor’s contractor, that pertain
                            to any aspect of services and activities performed or determination of amounts payable under this Agreement.

                      


              

            

             

            
              Page 293 of 324

              
                


            

            
              
                	

                      	30.1.13	
                        All Subcontractors must fulfill the requirements of 42 CFR 438.3, 438.6 and 438.230 as appropriate. Subcontractors shall also retain, as applicable, Enrollee
                            grievance and appeal records as per 42 CFR 438.416, base data for setting actuarially sound capitation rates as per 42 CFR 438.5(c), Medical Loss Ratio reports as per 42 CFR 438.8(k), and the data, information and documentation
                            specified in 42 CFR 438.604, 438.606, 438.608, and 438.610 for a period of no less than ten (10) years, as set forth in Section 33.1.1.

                      


              

            

             

            
              
                	

                      	30.1.14	
                        All Subcontracts entered into by the Contractor must comply with the applicable 42 CFR part 438 requirements that pertain to the service or activity performed by
                            the Subcontractor.

                      


              

            

             

            
              
                	

                      	30.2	
                        Cost or Pricing by Subcontractors

                      


              

            

             

            
              
                	

                      	30.2.1	
                        The Contractor shall submit to ASES, and shall require any Subcontractors hereunder to submit to ASES, cost or pricing Data for any Subcontract to this Contract
                            prior to award. The Contractor shall also certify that the information submitted by the Subcontractor is, to the best of the Contractor’s knowledge and belief, accurate, complete and current as of the date of agreement, or the
                            date of the negotiated price of the Subcontract or amendment to the Contract. The Contractor shall insert the substance of this Section in each Subcontract hereunder.

                      


              

            

             

            
              
                	

                      	30.2.2	
                        If ASES determines that any price, including profit or fee negotiated in connection with this Contract, or any cost reimbursable under this Contract was increased
                            by any significant sum because of the inaccurate cost or pricing Data, then such price and cost shall be reduced accordingly and this Contract and the Subcontract shall be modified in writing to reflect such reduction.

                      


              

            

             

            
              
                	ARTICLE 31	
                        REQUIREMENT OF INSURANCE LICENSE

                      


              

            

             

            
              
                	

                      	31.1	
                        In order for this Contract to take effect, the Contractor must be licensed to underwrite health insurance by the Puerto Rico Insurance Commissioner. The Contractor
                            must submit a copy of its insurance license according to the timeframe specified in Attachment 12 to this Contract.

                      


              

            

             

            
              
                	

                      	31.2	
                        The Contractor shall renew the license as required, and shall submit evidence of the renewal to ASES within thirty (30) Calendar Days of the expiration date of the
                            license.

                      


              

            

             

            
              
                	ARTICLE 32	
                        CERTIFICATIONS

                      


              

            

             

            
              
                	

                      	32.1	
                        The Contractor shall provide to ASES within fifteen (15) Calendar Days of the Effective Date of this Contract, and thereafter by January 10 of each calendar year
                            during the Contract Term, the certifications and other documents set forth below, according to the timeframe specified below. If any certification, document, acknowledgment, or other representation or assurance on the
                            Contractor’s part under this Article, or elsewhere in this Contract, is determined to be false or misleading, ASES shall have cause for termination of this Contract or to withhold the amount of any existing debt owed to the
                            Government of Puerto Rico in order to make a payment on behalf of the Contractor. In the event that the Contract is terminated based upon this Article, the Contractor shall reimburse ASES all sums of monies received under the
                            Contract; provided, however, that the amount reimbursed shall not exceed the amount of outstanding debt, less any payments made by the Contractor in satisfaction of such debt.

                      


              

            

             

            
              Page 294 of 324

              
                


            

            
              
                	

                      	32.2	
                        The Contractor shall submit the following certifications:

                      


              

            

             

            
              
                	

                      	32.2.1	
                        Certification issued by the Treasury Department of Puerto Rico (Model SC-2888) with evidence that that the Contractor has filed income tax returns in the past five
                            (5) years or has non-profit status;

                      


              

            

             

            
              
                	

                      	32.2.2	
                        Certification from the Treasury Department of Puerto Rico that Contractor has no outstanding debt with the Department or, if such a debt exists, it is subject to a
                            payment plan or pending administrative review under applicable law or regulation (Model SC-3537);

                      


              

            

             

            
              
                	

                      	32.2.3	
                        Certification from the Center for the Collection of Municipal Revenues certifying that there is no outstanding debt or, if a debt exists, that such debt is subject
                            to payment plan or pending administrative review under applicable law or regulations;

                      


              

            

             

            
              
                	

                      	32.2.4	
                        Certification from the Department of Labor and Human Resources certifying compliance with unemployment insurance, temporary disability insurance and/or chauffeur’s
                            social security, if applicable;

                      


              

            

             

            
              
                	

                      	32.2.5	
                        Evidence of Incorporation and of Good Standing issued by the Department of State of Puerto Rico;

                      


              

            

             

            
              
                	

                      	32.2.6	
                        Certification of current municipal license tax (“Patentes Municipales”), if applicable;

                      


              

            

             

            
              
                	

                      	32.2.7	
                        Certification issued by the Minor Children Support Administration (“ASUME”, by its Spanish acronym) of no outstanding alimony or child support debts, if applicable;

                      


              

            

             

            
              
                	

                      	32.2.8	
                        A sworn statement certifying that it has no debt with the Government, or with any State agencies, corporations or instrumentalities that provide or are related to
                            the provision of health services; or that such debt is subject to a payment plan with which the Contractor is in compliance, a work plan to reconcile amounts in controversy with which the Contractor is in compliance, or pending
                            administrative review under applicable law or regulations; and

                      


              

            

             

            
              
                	

                      	32.2.9	
                        Certification from the Puerto Rico Administration of Medical Services (“ASEM”, its Spanish acronym) certifying that there is no outstanding debt or, if a debt
                            exists, that such debt is subject to a payment plan with which the Contractor is in compliance, a work plan to reconcile amounts in controversy with which the Contractor is in compliance, or pending administrative review under
                            applicable law or regulations.

                      


              

            

             

            
              Page 295 of 324

              
                


            

            
              
                	

                      	32.3	
                        The Contractor shall, in addition, provide the following documents:

                      


              

            

             

            
              
                	

                      	32.3.1	
                        A list of all contracts the Contractor has with government agencies, public corporations or municipalities, including those contracts in the process of being
                            executed;

                      


              

            

             

            
              
                	

                      	32.3.2	
                        A letter indicating if any of its directors serves as member of any governmental board of directors or commission;

                      


              

            

             

            
              
                	

                      	32.3.3	
                        A certificate of the Corporate Resolution, or appropriate resolution, authorizing the person signing this Contract to appear on behalf of the Contractor;

                      


              

            

             

            
              
                	

                      	32.3.4	
                        Evidence of compliance with the Compensation System for Work-Related Accidents Act (“Fondo del Seguro del Estado de Puerto Rico”); and

                      


              

            

             

            
              
                	

                      	32.3.5	
                        A copy of the Insurance Coverage Certificate as required in Article 37.

                      


              

            

             

            
              
                	

                      	32.4	
                        If the Contractor fails to meet the obligations of Sections 32.2 and 32.3 within the required timeframe, ASES shall cease payment to the Contractor until the
                            documents have been delivered to the ASES’s satisfaction, or adequate evidence is provided to ASES that reasonable efforts have been made to obtain the documents.

                      


              

            

             

            
              
                	ARTICLE 33	
                        RECORDS REQUIREMENTS

                      


              

            

             

            
              
                	

                      	33.1	
                        General Provisions

                      


              

            

             

            
              
                	

                      	33.1.1	
                        The Contractor and its Subcontractors, if any, shall preserve and make available all of its records pertaining to the performance under this Contract for inspection
                            or audit, as provided below, throughout the Contract Term, for a period of ten (10) years from the date of final payment under this Contract, and for such period, if any, as is required by applicable statute or by any other
                            section of this Contract. If the Contract is completely or partially terminated, the records relating to the work terminated shall be preserved and made available for period of ten (10) years from the Termination Date of the
                            Contract or of any resulting final settlement. The Contractor is responsible to preserve all records pertaining to its performance under this Contract, and to have them available and accessible in a timely manner, and in a
                            reasonable format that assures their integrity. Records that relate to Appeals, litigation, or the settlements of Claims arising out of the performance of this Contract, or costs and expenses of any such agreements as to which
                            exception has been taken by the Contractor or any of its duly Authorized Representatives, shall be retained by Contractor until such Appeals, litigation, Claims or exceptions have been disposed of.

                      


              

            

             

            
              Page 296 of 324

              
                


            

            
              
                	

                      	33.2	
                        Records Retention and Audit Requirements

                      


              

            

             

            
              
                	

                      	33.2.1	
                        Since funds from the Puerto Rico Plans under Title XIX and Title XXI of the Social Security Act Medical Assistance Programs (Medicaid and CHIP) are used to finance
                            this project in part, the Contractor shall agree to comply with the requirements and conditions of the Centers for Medicare and Medicaid Services (CMS), the US Comptroller General, the Comptroller of Puerto Rico and ASES, as to
                            the maintenance of records related to this Contract.

                      


              

            

             

            
              
                	

                      	33.2.2	
                        Puerto Rico and Federal standards for audits of ASES Agents, contractors, and programs are applicable to this section and are incorporated by reference into this
                            Contract as though fully set out herein.

                      


              

            

             

            
              
                	

                      	33.2.3	
                        Pursuant to the requirements of 42 CFR 434.6(a)(5) and 42 CFR 434.38, ASES, CMS, the Office of Inspector General, the Comptroller General, the Medicaid Fraud
                            Control Unit, and their respective designees shall have the right at any time to inspect, evaluate, and audit any pertinent records or documents of the Contractor and Subcontractors, and may inspect the premises, physical
                            facilities, equipment, computers or other electronic systems where activities or work related to the GHP program is conducted. The right to audit exists for ten (10) years from the final date of the contract period or from the
                            date of completion of any audit, whichever is later. Any records requested hereunder shall be produced Immediately for on-site review or sent to the requesting authority by mail within fourteen (14) Calendar Days following a
                            request. All records shall be provided at the sole cost and expense of the Contractor. ASES shall have unlimited rights to use, disclose, and duplicate all Information and Data in any way relating to this Contract in accordance
                            with applicable Puerto Rico and Federal laws and regulations.

                      


              

            

             

            
              
                	

                      	33.2.4	
                        In certain circumstances, as follows, the authorities listed in Section 33.2.3 shall have the right to inspect and audit records in a timeframe that exceeds the
                            timeframe set forth in Section 33.1.1.

                      


              

            

             

            
              
                	

                      	33.2.4.1	
                        ASES determines that there is a special need to retain a particular record or group of records for a longer period and notifies the Contractor at least thirty (30)
                            Calendar Days before the expiration of the timeframe set forth in Section 33.1.1.

                      


              

            

             

            
              
                	

                      	33.2.4.2	
                        There has been a Contract termination, dispute, fraud, or similar fault by the Contractor, resulting in a final judgment or settlement against the Contractor, in
                            which case the retention may be extended to three (3) years from the date of the final judgment or settlement.

                      


              

            

             

            
              
                	

                      	33.2.4.3	
                        ASES determines that there is a reasonable possibility of Fraud, and gives the Contractor notice, before the expiration of the timeframe set forth in Section
                            33.1.1, that it wishes to extend the time period for retention of records.

                      


              

            

             

            
              Page 297 of 324

              
                


            

            
              
                	

                      	33.2.4.4	
                        There has been, during the time period set forth in Section 33.1.1, an audit initiated by CMS, the Comptroller of Puerto Rico, the US Comptroller General, and/or
                            ASES, in which case the timeframe for retention of records shall extend until the conclusion of the audit and publication of the final report.

                      


              

            

             

            
              
                	

                      	33.2.5	
                        All records retention requirements set forth in this Article or in any other Article shall be subject at all times and to the extent mandated by law and regulation,
                            to the HIPAA regulations described elsewhere in this Contract.

                      


              

            

             

            
              
                	

                      	33.3	
                        Medical Record Requests

                      


              

            

             

            
              
                	

                      	33.3.1	
                        The Contractor shall ensure that a copy of each Enrollee’s Medical Record is made available, without charge, upon the written request of the Enrollee or Authorized
                            Representative within fourteen (14) Calendar Days of the receipt of the written request.

                      


              

            

             

            
              
                	

                      	33.3.2	
                        The Contractor shall ensure that Medical Records are furnished at no cost to a Provider, upon the Enrollee’s request, no later than fourteen (14) Calendar Days
                            following the written request.

                      


              

            

             

            
              
                	ARTICLE 34	
                        CONFIDENTIALITY

                      


              

            

             

            
              
                	

                      	34.1	
                        General Confidentiality Requirements

                      


              

            

             

            
              
                	

                      	34.1.1	
                        The Contractor shall protect all information, records, and Data collected in connection with the Contract from unauthorized disclosures. In addition, the Contractor
                            shall agree to guard the confidentiality of Enrollee information. Access to all individually identifiable information relating to Medicaid Enrollees that is obtained by the Contractor shall be limited by the Contractor to
                            Subcontractors, consultants, advisors or agencies that require the information in order to perform their duties in accordance with this Contract, and to such others as may be authorized by ASES in accordance with applicable law,
                            including individuals seeking access to their own Protected Health Information, as defined by HIPAA (PHI).

                      


              

            

             

            
              
                	

                      	34.1.2	
                        The Contractor is responsible for understanding the degree to which information obtained through the performance of this Contract is confidential under Puerto Rico
                            and Federal law, rules, and regulations.

                      


              

            

             

            
              
                	

                      	34.1.3	
                        Any other individual or entity shall be granted access to confidential Information only after complying with the requirements of Puerto Rico and Federal law
                            pertaining to such access and the terms of this Contract. ASES shall have absolute authority to determine if and when any other individual or entity has properly obtained the right to have access to this confidential
                            information. Contractor is permitted to de-identify PHI or create limited data sets, but such de-identification and use of de-identified data and limited data sets must be in full compliance with 45 CFR 164.514. Nothing herein
                            shall prohibit the disclosure of information in summary, statistical, or other form that does not identify particular individuals if the information is de-identified in accordance with applicable laws and regulations. The
                            Contractor shall retain the right to use information for its quality and Utilization Management and research purposes subject to the Data ownership and publicity requirements defined within the Contract. Notwithstanding the
                            foregoing, Contractor may not use or disclose PHI for research unless such use or disclosure is in full compliance with applicable law, including HIPAA.

                      


              

            

             

            
              Page 298 of 324

              
                


            

            
              
                	

                      	34.1.4	
                        The Contractor, its employees, Agents, Subcontractors, consultants or advisors must treat all information that is obtained through Providers’ performance of the
                            services under this Contract, including, but not limited to, information relating to Enrollees, Potential Enrollees, as confidential Information to the extent that confidential treatment is provided under Puerto Rico and Federal
                            law, rules, and regulations.

                      


              

            

             

            
              
                	

                      	34.1.5	
                        Any disclosure or transfer of confidential information by the Contractor, including information required by ASES, will be encrypted or otherwise secured in
                            accordance with applicable law. If the Contractor receives a request for information deemed confidential under this Contract, the Contractor will Immediately notify ASES of such request, and will make reasonable efforts to
                            protect the information from public disclosure.

                      


              

            

             

            
              
                	

                      	34.1.6	
                        In accordance with the timeframes outlined in Attachment 12 to this Contract, the Contractor shall develop and provide to ASES for review and approval written
                            policies and procedures for the protection of all records and all other documents deemed confidential under this Contract including Medical Records/Enrollee information and adolescent/sexually transmitted disease appointment
                            records. All Enrollee information, Medical Records, Data and Data elements collected, maintained, disclosed, transmitted, disposed or used in the administration of this Contract shall be protected by the Contractor from
                            unauthorized disclosure per the HIPAA Privacy and Security standards codified at 45 CFR Part 160 and 45 CFR Part 164, Subparts A, C and E, and in accordance with Law 111 of September 7, 2005. The Contractor must provide
                            safeguards that restrict the use, access, management, transmittal, disposal or disclosure of PHI concerning Enrollees to purposes directly connected with the administration of this Contract and as permitted by the HIPAA Business
                            Associate Agreement.

                      


              

            

             

            
              
                	

                      	34.1.7	
                        The Contractor must comply with HIPAA notification requirements, including those set forth in HITECH. The Contractor must notify ASES’s Privacy Officer and Director
                            of Compliance by secure email of all Breaches or suspected Breaches of unspecified PHI, as defined by HITECH and Law 111 of September 7, 2005, without unreasonable delay and in no event later than twenty-four (24) hours, if so
                            directed by ASES or required by law, must also notify individuals and the federal Department of Health and Human Services and provide any other notices required by law. If, in ASES’s determination, the Contractor has not
                            provided notice in the manner or format prescribed by HITECH, then ASES may require the Contractor to provide such notice or be subject to sanctions for non-compliance.

                      


              

            

             

            
              Page 299 of 324

              
                


            

            
              
                	

                      	34.1.8	
                        Assurance of Confidentiality

                      


              

            

             

            
              
                	

                      	34.1.8.1	
                        The Contractor shall take reasonable steps to ensure the physical security of Data under its control, including, but not limited to: fire protection; protection
                            against smoke and water damage; alarm systems; locked files, guards, or other devices reasonably expected to prevent loss or unauthorized removal of manually held Data; passwords, access logs, badges, or other methods reasonably
                            expected to prevent loss or unauthorized access to electronically or mechanically held Data; limited terminal access; limited access to input documents and output documents; and design provisions to limit use of Enrollee names.

                      


              

            

             

            
              
                	

                      	34.1.8.2	
                        The Contractor shall inform and provide quarterly trainings to each of its employees having any involvement with personal Data or other confidential information,
                            whether with regard to design, development, operation, or maintenance, of the Puerto Rico and Federal law relating to confidentiality. The Contractor shall also set forth training requirements for its Agents, Subcontractors,
                            consultants, advisors and Providers.

                      


              

            

             

            
              
                	

                      	34.1.9	
                        Return of Confidential Data

                      


              

            

             

            
              
                	

                      	34.1.9.1	
                        The Contractor shall return all Data, PHI, and other confidential information furnished pursuant to this Contract promptly at the request of ASES in whatever form
                            it is maintained by the Contractor. Upon the termination or completion of the Contract, the Contractor may not use any such Data or any material derived from the Data for any purpose not permitted by Puerto Rico or Federal law
                            or regulation and where so instructed by ASES shall destroy such Data or material if permitted and required by Puerto Rico or Federal law or regulation.

                      


              

            

             

            
              
                	

                      	34.1.10	
                        Publicizing Safeguarding Requirements

                      


              

            

             

            
              
                	

                      	34.1.10.1	
                        The Contractor shall comply with 42 CFR 431.304. The Contractor agrees to publicize provisions governing the confidential nature of information about Enrollees,
                            including the legal sanctions imposed for improper disclosure and use. The Contractor must include these provisions in the Enrollee handbook and provide copies of these provisions to Enrollees and to other persons and agencies
                            to which information is disclosed.

                      


              

            

             

            
              Page 300 of 324

              
                


            

            
              
                	

                      	34.1.10.2	
                        In addition to the requirements expressly stated in this Article, the Contractor must comply with any policy, rule, or reasonable requirement of ASES that relates
                            to the safeguarding or disclosure of information relating to Enrollees, the Contractor’s operations, or the Contractor’s performance of this Contract.

                      


              

            

             

            
              
                	

                      	34.1.10.3	
                        In the event of the expiration of this Contract or termination thereof for any reason, all confidential information disclosed to and all copies thereof made by the
                            Contractor and its Agents, Subcontractors, consultants, and advisors must be returned promptly to ASES at its request or, at ASES’s option, erased or destroyed in the presence of ASES employees or representatives in compliance
                            with applicable laws and regulations. The Contractor must provide ASES certificates evidencing such destruction.

                      


              

            

             

            
              
                	

                      	34.1.10.4	
                        The Contractor’s contracts with practitioners and other Providers shall explicitly state expectations about the confidentiality of ASES’s confidential information
                            and Enrollee records.

                      


              

            

             

            
              
                	

                      	34.1.10.5	
                        The Contractor shall afford Enrollees and/or their Authorized Representatives the opportunity to approve or deny the release of identifiable personal information by
                            the Contractor to a person or entity outside of the Contractor, except to duly authorized Subcontractors, Providers or review organizations, or when such release is required by law, regulation, or quality standards or as
                            otherwise permitted in the HIPAA Business Associate Agreement.

                      


              

            

             

            
              
                	

                      	34.1.10.6	
                        This Article 34 does not restrict the Contractor from making any disclosure pursuant to any applicable law, or under any court or government agency, provided that
                            the Contractor, prior to the disclosure, Immediately provides notice to ASES of such order.

                      


              

            

             

            
              
                	

                      	34.1.11	
                        Disclosure of ASES’s Confidential Information

                      


              

            

             

            
              
                	

                      	34.1.11.1	
                        The Contractor shall Immediately report to ASES any and all suspected and actual unauthorized disclosures (breaches) or uses of confidential information of which it
                            or its Subcontractors, consultants, or Agents are aware or have knowledge of. The Contractor acknowledges that any publication or disclosure of confidential information to unauthorized persons may cause immediate and irreparable
                            harm to ASES and may constitute a violation of Puerto Rico or Federal statutes. If the Contractor, its Subcontractors, consultants, or Agents should publish or disclose Confidential Information to others without authorization,
                            ASES will immediately be entitled to injunctive relief or any other remedies to which it is entitled under law or equity. ASES will have the right to recover from the Contractor all damages and liabilities caused by or arising
                            from the Contractor’s, its Subcontractors’, Network Providers’, representatives’, consultants’, or Agents’ failure to protect confidential Information. The Contractor will defend with counsel approved by ASES, indemnify and hold
                            harmless ASES from all damages, costs, liabilities, and expenses caused by or arising from the Contractor’s, or its Subcontractors’, Providers’, representatives’, consultants’ or Agents’ failure to protect confidential
                            Information. ASES will not unreasonably withhold approval of counsel selected by the Contractor.

                      


              

            

             

            
              Page 301 of 324

              
                


            

            
              
                	

                      	34.1.12	
                        The Contractor shall remove any person from performance of services hereunder upon notice that ASES reasonably believes that such person has failed to comply with
                            the confidentiality obligations of this Contract. The Contractor shall replace such removed personnel in accordance with the staffing requirements of this Contract.

                      


              

            

             

            
              
                	

                      	34.1.13	
                        ASES, the Government, Federal officials as authorized by Federal law or regulations, or the Authorized Representatives of these Parties shall have access to all
                            confidential information in accordance with the requirements of Puerto Rico and Federal laws and regulations.

                      


              

            

             

            
              
                	

                      	34.1.14	
                        The confidentiality provisions contained in this Contract survive the termination of this contract and shall bind the Contractor, and its PMGs and Network
                            Providers, so long as they maintain any PHI relating to Enrollees.

                      


              

            

             

            
              
                	

                      	34.2	
                        HIPAA Compliance

                      


              

            

             

            
              
                	

                      	34.2.1	
                        The Contractor shall assist ASES in its efforts to comply with HIPAA and its amendments, rules, procedures, and regulations. To that end, the Contractor shall
                            cooperate with and abide by any data privacy, security or other requirements mandated by HIPAA or any other applicable laws. The Contractor acknowledges that HIPAA requires the Contractor and ASES to sign documents for
                            compliance purposes, including but not limited to a business associate agreement. The parties agree to the terms of the HIPAA Business Associate Agreement included as Attachment 18 to this Contract, which is incorporated by
                            reference. The Contractor shall cooperate with ASES on these matters and sign whatever documents may be required for HIPAA compliance and abide by their terms and conditions. This Agreement, including the HIPAA Business
                            Associate Agreement, shall be construed in a manner that allows ASES to comply with applicable law. Contractor shall be responsible for ensuring that individuals have the right to access and amendment of PHI and accounting of
                            disclosures, with respect to PHI created, received, maintained or transmitted by Contractor. Contractor shall ensure that Enrollees receive a Notice of Privacy Practices as required by HIPAA.

                      


              

            

             

            
              Page 302 of 324

              
                


            

            
              
                	

                      	34.3	
                        Privacy of Information in Enrollment Database

                      


              

            

             

            
              
                	

                      	34.3.1	
                        Any individually identifiable health information held in the Enrollment Database described in Section 5.3.8 of this Contract shall be kept confidential and shall be
                            used and disclosed by the Contractor or its Network Providers only for purposes directly connected with performance of all obligations contained in this Contract and as permitted by the HIPAA Business Associate Agreement, and in
                            strict compliance with HIPAA’s privacy and security requirements and any applicable laws of Puerto Rico.

                      


              

            

             

            
              
                	

                      	34.4	
                        Data Breach

                      


              

            

             

            
              
                	

                      	34.4.1	
                        The Contractor shall Immediately report to ASES, as required in Section 13402 of the HITECH Act, of any actual or suspected event where ASES’s Data could be exposed
                            in a non-authorized or illegal circumstance, and/or when any Data Breach occurs. The Contractor must take all reasonable steps to mitigate the Breach, notify actual or potentially impacted Enrollees, and provide appropriate
                            notice to the applicable State and Federal regulatory agencies as required by law.

                      


              

            

             

            
              
                	

                      	34.4.2	
                        The Contractor agrees that without unreasonable delay, but no later than twenty-four (24) hours after it suspects or has determined that a Data Breach occurred, the
                            Contractor shall notify ASES of such Breach. The notification shall include sufficient information for ASES to understand the nature of the Breach. For instance, such notification must include, at a minimum, and to the extent
                            available at the time of the notification, the following information:

                      


              

            

             

            
              
                	

                      	34.4.2.1	
                        One or two sentence description of the event;

                      


              

            

             

            
              
                	

                      	34.4.2.2	
                        Description of the roles of the people involved in the Breach (e.g., employees, participant users, service Providers, unauthorized persons, etc.)

                      


              

            

             

            
              
                	

                      	34.4.2.3	
                        The type of Data/Information as well as Protected Health Information that was breached;

                      


              

            

             

            
              
                	

                      	34.4.2.4	
                        Enrollees likely impacted by the Breach;

                      


              

            

             

            
              
                	

                      	34.4.2.5	
                        Number of individuals or records impacted/estimated to be impacted by the Breach;

                      


              

            

             

            
              
                	

                      	34.4.2.6	
                        Actions taken by the Contractor to mitigate the Breach;

                      


              

            

             

            
              
                	

                      	34.4.2.7	
                        Current status of the Breach (under investigation or resolved);

                      


              

            

             

            
              Page 303 of 324

              
                


            

            
              
                	

                      	34.4.2.8	
                        Corrective action taken and steps planned to be taken to prevent a similar Breach.

                      


              

            

             

            
              
                	

                      	34.4.3	
                        The Contractor shall have a duty to supplement the information contained in the notification as it becomes available and to cooperate with ASES.

                      


              

            

             

            
              
                	ARTICLE 35	
                        TERMINATION OF CONTRACT

                      


              

            

             

            
              
                	

                      	35.1	
                        General Procedures

                      


              

            

             

            
              
                	

                      	35.1.1	
                        In addition to any other non-financial remedy set forth in this Contract or available by law, or in lieu of any financial Remedy contained in Articles 19 and 20 of
                            this Contract or available by law, and subject to compliance with the termination procedures set forth in Section 35.8 below, ASES may terminate this Contract for any or all of the following reasons:

                      


              

            

             

            
              
                	

                      	35.1.1.1	
                        Default by the Contractor, upon thirty (30) Calendar Days’ notice, unless ASES, in its reasonable discretion, determines that the Contractor has cured the default
                            to ASES’s satisfaction within the notice period;

                      


              

            

             

            
              
                	

                      	35.1.1.2	
                        Immediately, in the event of insolvency or declaration of bankruptcy by the Contractor;

                      


              

            

             

            
              
                	

                      	35.1.1.3	
                        Immediately, when sufficient appropriated funds no longer exist for the payment of ASES's obligation under this Contract; or

                      


              

            

             

            
              
                	

                      	35.1.1.4	
                        In the event that the Contractor or any of its shareholders, director, officers, or employees fall under the prohibition stated in Section 29.1 or 29.6 of this
                            Contract.

                      


              

            

             

            
              
                	

                      	35.1.2	
                        A decision by ASES not to renew this Contract, per Article 21, shall not constitute a Termination of the Contract.

                      


              

            

             

            
              
                	

                      	35.1.3	
                        The Contractor shall have a limited right of termination of this Contract only in the events described in Section 35.10 of this Contract.

                      


              

            

             

            
              
                	

                      	35.1.4	
                        Each Party shall have the opportunity to cure any default alleged in a termination notice sent pursuant to this Article 35, upon receiving a written termination
                            notice the other Party. With respect to termination by ASES, the Contractor shall have the right to submit to ASES a written Corrective Action Plan containing terms and conditions acceptable to ASES in its sole discretion to
                            cure such default or an explanation of non-default in the thirty (30) Calendar Day period from the date of receipt of ASES’ written termination notice and such plan or explanation of non-default is accepted by ASES, in ASES’
                            sole discretion, which acceptance shall not be unreasonably withheld, conditioned or delayed.

                      


              

            

             

            
              Page 304 of 324

              
                


            

            
              
                	

                      	35.1.5	
                        Notwithstanding the termination of this Contract pursuant to this Article 35 for any reason, the Contractor shall remain obligated to provide the Administrative
                            Functions as described in Article 36, including but not limited to the payment of Claims for Covered Services provided to Enrollees prior to the Termination Date and as specified in the Patient’s Bill of Rights Act through the
                            Runoff Period.

                      


              

            

             

            
              
                	

                      	35.1.6	
                        Continuing Obligations of ASES. Notwithstanding the termination of this Contract for pursuant to this Article 35 for any reason, ASES shall remain obligated to pay
                            to the Contractor the PMPM through the Termination Date (inclusive of the Transition Period).

                      


              

            

             

            
              
                	

                      	35.1.7	
                        Termination Procedures to be Strictly Followed. No termination of this Contract shall be effective unless the termination procedures under Section 35 of this
                            Contract have been strictly followed or waived by the Parties.

                      


              

            

             

            
              
                	

                      	35.2	
                        Termination by Default

                      


              

            

             

            
              
                	

                      	35.2.1	
                        In the event ASES determines that the Contractor has defaulted by failing to carry out the terms or conditions of this Contract or by failing to meet the applicable
                            requirements in sections 1932 and 1903(m) of the Social Security Act, or in the event that ASES determines that the Contractor falls within the prohibitions stated in Section 29.1 or 29.6, ASES may terminate the Contract in
                            addition to or in lieu of any other remedies set out in this Contract or available by law.

                      


              

            

             

            
              
                	

                      	35.2.2	
                        Before terminating this Contract, ASES will:

                      


              

            

             

            
              
                	

                      	35.2.2.1	
                        Provide written notice of the intent to terminate at least thirty (30) Calendar Days prior to the Termination Date, stating the reason for the termination and the
                            time and place of a hearing, to take place at least fifteen (15) Calendar Days after the date of mailing of the notice of intent to terminate, to give the Contractor an opportunity to appeal the determination or cure the
                            default;

                      


              

            

             

            
              
                	

                      	35.2.2.2	
                        Provide written notice of the decision affirming or reversing the proposed termination of the Contract, and for an affirming decision, the effective date of the
                            termination; and

                      


              

            

             

            
              
                	

                      	35.2.2.3	
                        For an affirming decision, give Enrollees of the Contractor notice of the termination and information consistent with 42 CFR 438.10 on their options for receiving
                            services following the Termination Date of the Contract.

                      


              

            

             

            
              
                	

                      	35.3	
                        Termination for Convenience

                      


              

            

             

            
              
                	

                      	35.3.1	
                        ASES may terminate this Contract for convenience and without cause upon thirty (30) Calendar Days written notice. Termination for convenience shall not be a breach
                            of the Contract by ASES. The Contractor shall be entitled to receive, and shall be limited to just and equitable compensation for any satisfactory authorized work performed as of the Termination Date of the Contract.

                      


              

            

             

            
              Page 305 of 324

              
                


            

            
              
                	

                      	35.4	
                        Termination for Insolvency or Bankruptcy

                      


              

            

             

            
              
                	

                      	35.4.1	
                        The Contractor’s insolvency, or the Contractor’s filing of a petition in bankruptcy, shall constitute grounds for termination for cause. In the event of the filing
                            of a petition in bankruptcy, the Contractor shall immediately advise ASES. If ASES reasonably determines that the Contractor's financial condition is not sufficient to allow the Contractor to provide the services as described
                            herein in the manner required by ASES, ASES may terminate this Contract in whole or in part, Immediately or in stages. The Contractor's financial condition shall be presumed not sufficient to allow the Contractor to provide the
                            services described herein, in the manner required by ASES if the Contractor cannot demonstrate to ASES's satisfaction that the Contractor has risk reserves and a minimum net worth sufficient to meet the statutory standards for
                            licensed health care plans, as required under this Contract. The Contractor shall cover continuation of services to Enrollees for the duration of period for which payment has been made, as well as for inpatient admissions up to
                            discharge.

                      


              

            

             

            
              
                	

                      	35.4.2	
                        In the event that this Contract is terminated because of the Contractor’s insolvency, the Contractor shall guarantee that Enrollees shall not be liable for:

                      


              

            

             

            
              
                	

                      	35.4.2.1	
                        The Contractor’s debts;

                      


              

            

             

            
              
                	

                      	35.4.2.2	
                        The Covered Services provided to the Enrollee, for which ASES does not pay the Contractor or its Network Providers;

                      


              

            

             

            
              
                	

                      	35.4.2.3	
                        The Covered Services provided to the Enrollee, for which ASES or the Contractor does not pay a Provider who furnishes the services under a contractual, Referral, or
                            other arrangement; or

                      


              

            

             

            
              
                	

                      	35.4.2.4	
                        Payment for Covered Services furnished under a contractual, Referral, or other arrangement, to the extent that those payments are in excess of the amount that the
                            Enrollee would owe if the Contractor provided the services directly.

                      


              

            

             

            
              
                	

                      	35.4.3	
                        The Contractor shall cover continuation of services to Enrollees for the duration of the period for which payment has been made by ASES, as well as for inpatient
                            admissions up to discharge.

                      


              

            

             

            
              
                	

                      	35.5	
                        Termination for Insufficient Funding

                      


              

            

             

            
              
                	

                      	35.5.1	
                        In the event that Federal and/or Puerto Rico funds to finance this Contract become unavailable or insufficient, ASES may terminate the Contract in writing, unless
                            both Parties agree, through a written amendment, to a modification of the obligations under this Contract.

                      


              

            

             

            
              Page 306 of 324

              
                


            

            
              
                	

                      	35.5.2	
                        The Termination Date of the Contract when the Contract is terminated due to insufficient funding shall be ninety (90) Calendar Days after ASES delivers written
                            notice to the Contractor, unless available funds are insufficient to continue payments in full during the ninety (90) Calendar Day period, in which case ASES shall give the Contractor written notice of an earlier date at which
                            the Contract shall terminate.

                      


              

            

             

            
              
                	

                      	35.5.3	
                        Upon termination, the Contractor shall comply with the phase-out obligations established in Article 36 of this Contract.

                      


              

            

             

            
              
                	

                      	35.5.4	
                        In the event of termination for insufficient funding, the Contractor shall be entitled to receive, and shall be limited to, just and equitable compensation for any
                            satisfactory authorized work performed as of the Termination Date of the Contract.

                      


              

            

             

            
              
                	

                      	35.5.5	
                        Availability of funds shall be determined solely by ASES.

                      


              

            

             

            
              
                	

                      	35.6	
                        Termination Under Section 29.3

                      


              

            

             

            
              
                	

                      	35.6.1	
                        If any of the events specified in Section 29.3 of this Contract occur, ASES may terminate this Contract as required under Act 458 and Act 84.

                      


              

            

             

            
              
                	

                      	35.6.2	
                        Upon Termination, the Contractor shall comply with the phase-out obligations established in Article 36 of this Contract.

                      


              

            

             

            
              
                	

                      	35.7	
                        ASES may terminate this Contract for any other just reason upon thirty (30) Calendar Days written notice.

                      


              

            

             

            
              
                	

                      	35.8	
                        Termination Procedures

                      


              

            

             

            
              
                	

                      	35.8.1	
                        ASES will issue a written notice of termination to the Contractor by certified mail, return receipt requested, or in person with evidence of delivery. The notice of
                            termination shall cite the provision of this Contract giving the right to terminate, the circumstances giving rise to termination, and the Termination Date of the Contract. Termination shall be effective at 11:59 p.m. EST on the
                            Termination Date of the Contract.

                      


              

            

             

            
              
                	

                      	35.8.2	
                        Upon receipt of notice of termination or on the date specified in the notice of termination and as directed by ASES, the Contractor shall:

                      


              

            

             

            
              
                	

                      	35.8.2.1	
                        Stop work under the Contract on the date and to the extent specified in the notice of termination;

                      


              

            

             

            
              
                	

                      	35.8.2.2	
                        Place no further orders or subcontract for materials, services, or facilities, except as may be necessary for completion of such portion of the work under the
                            Contract prior to termination that is already in process;

                      


              

            

             

            
              Page 307 of 324

              
                


            

            
              
                	

                      	35.8.2.3	
                        Terminate all orders and subcontracts to the extent that they relate to the performance of work terminated by the notice of termination;

                      


              

            

             

            
              
                	

                      	35.8.2.4	
                        Assign to ASES, in the manner and to the extent directed by ASES, all of the right, title, and interest of Contractor under the orders or subcontracts so
                            terminated, in which case ASES will have the right, at its discretion, to settle or pay any or all Claims arising out of the termination of such orders and subcontracts;

                      


              

            

             

            
              
                	

                      	35.8.2.5	
                        With the prior written approval of ASES, settle all outstanding liabilities and all Claims arising out of such termination or orders and subcontracts, the cost of
                            which would be reimbursable in whole or in part, in accordance with the provisions of this Contract;

                      


              

            

             

            
              
                	

                      	35.8.2.6	
                        Complete the performance of such part of the work that was not terminated by the notice of termination;

                      


              

            

             

            
              
                	

                      	35.8.2.7	
                        Take such action as may be necessary, or as ASES may direct, for the protection and preservation of any and all property or information related to the Contract that
                            is in the possession of the Contractor and in which ASES has or may acquire an interest;

                      


              

            

             

            
              
                	

                      	35.8.2.8	
                        Promptly make available to ASES, or to another MCO acting on behalf of ASES, any and all records, whether medical or financial, related to the Contractor's
                            activities undertaken pursuant to this Contract. Such records shall be provided at no expense to ASES;

                      


              

            

             

            
              
                	

                      	35.8.2.9	
                        Promptly supply all information necessary to ASES, or another ASES plan acting on behalf of ASES, for reimbursement of any outstanding Claims at the time of
                            termination; and

                      


              

            

             

            
              
                	

                      	35.8.2.10	
                        Submit a termination/transition plan to ASES for review and prior written approval that includes commitments to carry out at minimum the following obligations:

                      


              

            

             

            
              
                	

                      	35.8.2.10.1	
                        Provide Enrollees continuation of all the Covered Services and Benefits during a defined transition period, such transition period to be determined by ASES;

                      


              

            

             

            
              
                	

                      	35.8.2.10.2	
                        Comply with all duties and/or obligations incurred prior to the actual Termination Date of the Contract, including but not limited to, the Grievance and Appeal
                            process as described in Article 14;

                      


              

            

             

            
              
                	

                      	35.8.2.10.3	
                        Maintain Claims processing functions as necessary for ten (10) consecutive months from the Termination Date of the Contract in order to complete adjudication of all
                            Claims;

                      


              

            

             

            
              Page 308 of 324

              
                


            

            
              
                	

                      	35.8.2.10.4	
                        Create a task force to reconcile and certify any pending and outstanding balances in connection with services rendered by the Contractor under the Contract and
                            previous contracts between ASES and the Contractor.

                      


              

            

             

            
              
                	

                      	35.8.2.10.5	
                        File all reports concerning the Contractor’s operations during the term of the Contract in the manner described in this Contract;

                      


              

            

             

            
              
                	

                      	35.8.2.10.6	
                        Assist ASES in making all necessary notices to Enrollees and Providers at least thirty (30) Calendar Days prior to the effective date of change and as may be
                            required under the Contract, or otherwise required under applicable law, regarding notices to Enrollees;

                      


              

            

             

            
              
                	

                      	35.8.2.10.7	
                        Ensure the efficient and orderly transition of Enrollees from coverage under this Contract to coverage under any new arrangement developed or agreed to by ASES,
                            including cooperation with another contractor, as provided in Article 35;

                      


              

            

             

            
              
                	

                      	35.8.2.10.8	
                        Ensure the proper identification of the Enrollees requiring the authorization for either prescription medications or DME to avoid any interruptions in services by
                            providing such Data to ASES as contemplated in the transition plan;

                      


              

            

             

            
              
                	

                      	35.8.2.10.9	
                        Submit to ASES all scripts used at Call Centers to communicate with Enrollees during the transition period;

                      


              

            

             

            
              
                	

                      	35.8.2.10.10	
                        Maintain the financial requirements and insurance set forth in this Contract until ASES provides the Contractor written notice that all continuing obligations of
                            this Contract have been fulfilled;

                      


              

            

             

            
              
                	

                      	35.8.2.10.11	
                        Submit reports to ASES as directed but no less frequently than every thirty (30) Calendar Days, detailing the Contractor’s progress in completing its continuing
                            obligations under this Contract, until completion; and

                      


              

            

             

            
              
                	

                      	35.8.2.10.12	
                        Meet with ASES personnel, as requested, to ensure satisfactory completion of all obligations under the Termination Plan.

                      


              

            

             

            
              
                	

                      	35.8.3	
                        This Termination Plan shall be subject to review and approval by CMS.

                      


              

            

             

            
              
                	

                      	35.8.4	
                        Upon completion of these continuing obligations, the Contractor shall submit a final report to ASES describing how the Contractor has completed its continuing
                            obligations. ASES will advise, within twenty (20) Calendar Days of receipt of this report, if all of the Contractor’s obligations are discharged. If ASES finds that the final report does not evidence that the Contractor has
                            fulfilled its continuing obligations, then ASES will require the Contractor to submit a revised final report to ASES for approval, and take any other action necessary to discharge all of its duties under this Contract, as
                            directed by ASES.

                      


              

            

             

            
              Page 309 of 324

              
                


            

            
              
                	

                      	35.8.5	
                        Except as provided in this Article 35, a notification that ASES intends to terminate this Contract shall not release the Contractor from its obligations to pay for
                            Covered Services rendered or otherwise to perform under this Contract.

                      


              

            

             

            
              
                	

                      	35.9	
                        Termination Claims

                      


              

            

             

            
              
                	

                      	35.9.1	
                        After receipt of a notice of termination, the Contractor shall submit to ASES any termination claim in the form, and with the certification prescribed by, ASES.
                            Such claim shall be submitted promptly but in no event later than ten (10) months from the Termination Date of the Contract. Upon failure of the Contractor to submit its termination claim within the time allowed, ASES may
                            determine, on the basis of information available, the amount, if any, due to the Contractor by reason of the termination and shall thereupon cause to be paid to the Contractor the amount so determined.

                      


              

            

             

            
              
                	

                      	35.9.2	
                        Upon receipt of notice of termination, the Contractor shall have no entitlement to receive any amount for lost revenues or anticipated profits or for expenditures
                            associated with this Contract or any other contract. Upon termination the Contractor shall be paid in accordance with the following:

                      


              

            

             

            
              
                	

                      	35.9.2.1	
                        At the Contract price(s) for services delivered to and accepted by ASES; and/or

                      


              

            

             

            
              
                	

                      	35.9.2.2	
                        At a price mutually agreed upon by the Contractor and ASES for partially completed services.

                      


              

            

             

            
              
                	

                      	35.9.3	
                        In the event the Contractor and ASES fail to agree in whole or in part as to the amounts with respect to costs to be paid to the Contractor in connection with the
                            total or partial termination of work pursuant to this article, ASES will determine, on the basis of information available, the amount, if any, due to the Contractor by reason of termination and shall pay to the Contractor the
                            amount so determined.

                      


              

            

             

            
              
                	

                      	35.10	
                        Limited Right of Termination by the Contractor

                      


              

            

             

            
              
                	

                      	35.10.1	
                        Subject to compliance with the termination procedures set forth in Section 35.8, the Contractor may terminate this Contract under the following circumstances:

                      


              

            

             

            
              
                	

                      	35.10.1.1	
                        Termination Due to ASES’s Financial Breach. Upon fifteen (15) Calendar Days written
                            notice, in the event ASES defaults in making payment of three (3) consecutive monthly PMPM Payments and fails to cure such breach within the notice period. For purposes of this Section, a default in making payment does not
                            include instances where ASES has made any Withhold payments pursuant to the terms of this Contract, provided that ASES has given the Contractor advance written notice of any such Withhold.

                      


              

            

             

            
              Page 310 of 324

              
                


            

            
              
                	

                      	35.10.1.2	
                        Termination Due to Insufficient Funding. Immediately, upon receipt from ASES of a
                            written notice pursuant to Section 35.5 that appropriated federal and/or Puerto Rico funds become unavailable or that such funds will be insufficient for the payment of ASES's obligation under this Contract when due, unless both
                            Parties agree, through a written amendment, to a modification of the obligations under this Contract.

                      


              

            

              

            

            
              
                	

                      	35.10.1.3	
                        If forty-five (45) Calendar Days before the last day of each fiscal year covered under the Contract, the Contractor and ASES have not (as provided in Section 21.4
                            agreed to PMPM for the succeeding fiscal year, the Contractor may exercise an option to terminate the Contract by giving ASES written notice of the Contractor’s intent not to continue to provide services under the Contract no
                            later than forty-five (45) Calendar Days prior to the termination of the corresponding fiscal year. Once the Contractor has given ASES such written notice, the Contractor shall fully discharge the termination phase-out
                            obligations listed in Section 35.8. At any time before the end of the fiscal year, the Contractor may rescind its notice of termination, if the Parties reach an agreement on rates for the following fiscal year.

                      


              

            

             

            
              
                	ARTICLE 36	
                        PHASE-OUT AND COOPERATION WITH OTHER CONTRACTORS

                      


              

            

             

            
              
                	

                      	36.1	
                        If, in the best interest of Enrollees of GHP, ASES terminates any GHP contract, the Contractor shall, upon the request of ASES, assume responsibility for Enrollees
                            previously managed by any MCO or other Contractor whose contractual arrangement with ASES was terminated, in accordance with the contracted PMPM Payment, pursuant to the written amendment of the Contract, if required.

                      


              

            

             

            
              
                	

                      	36.2	
                        If in the best interest of Enrollees of GHP, ASES develops and implements new projects that impact the scope of services, the Contractor shall assist in the
                            transition process, after receiving at least ninety (90) Calendar Days written notice from ASES of such change, and pursuant to written amendment of the Contract, if required. PMPM Payments shall be adjusted accordingly.

                      


              

            

             

            
              
                	

                      	36.3	
                        In the event that ASES has entered into, or enters into, agreements with other contractors for additional work related to the Benefits rendered hereunder, the
                            Contractor agrees to cooperate fully with such other contractors. The Contractor shall not commit any act or omission that will interfere with the performance of work by any other contractor, or actions taken by ASES to
                            facilitate the work.

                      


              

            

             

            
              Page 311 of 324

              
                


            

            
              
                	

                      	36.4	
                        If ASES chooses not to renew this Contract, pursuant to Article 21, the Contractor agrees that it will not engage in any behavior or inaction that prevents or
                            hinders the work of another contractor or ASES, as the case may be. Upon receiving ASES’s notice that it does not intend to renew the Contract, the Contractor agrees to submit a written termination/transition plan to ASES within
                            thirty (30) Calendar Days of receiving the notice. The turn-over plan shall include all the elements listed in Section 35.8.2.9.1. The Parties agree that the Contractor has not successfully met this obligation until ASES accepts
                            its turn-over plan and/or transition plan, required under this Article 36.

                      


              

            

             

            
              
                	ARTICLE 37	
                        INSURANCE

                      


              

            

             

            
              
                	

                      	37.1	
                        The Contractor shall, at a minimum, prior to the commencement of work, procure the insurance policies identified below at the Contractor’s own cost and expense and
                            shall furnish ASES with proof of coverage at least in the amounts indicated. It shall be the responsibility of the Contractor to require any Subcontractor to secure the same insurance coverage as prescribed herein for the
                            Contractor, and to obtain a certificate evidencing that such insurance is in effect. In the event that any such insurance is proposed to be reduced, terminated or cancelled for any reason, the Contractor shall provide to ASES at
                            least thirty (30) Calendar Days prior written notice. Prior to the reduction, expiration and/or cancellation of any insurance policy required hereunder, the Contractor shall secure replacement coverage upon the same terms and
                            provisions to ensure no lapse in coverage, and shall furnish, at the request of ASES, a certificate of insurance indicating the required coverage. The Contractor shall maintain insurance coverage sufficient to insure against
                            claims arising at any time during the term of the Contract. The provisions of this Section shall survive the expiration or termination of this Contract for any reason. In addition, the Contractor shall indemnify and hold
                            harmless ASES and the Government from any liability arising out of the Contractor’s or its Subcontractor’s untimely failure in securing adequate insurance coverage as prescribed herein:

                      


              

            

             

            
              
                	

                      	37.2	
                        Workers’ Compensation Insurance, the policy(ies) to insure the statutory limits established by law of Puerto Rico. The Workers’ Compensation Policy must include
                            Coverage B – Employer’s Liability Limits of:

                      


              

            

             

            
              
                	

                      	37.2.1	
                        Bodily Injury by Accident. Five hundred thousand dollars ($500,000) each accident;

                      


              

            

             

            
              
                	

                      	37.2.2	
                        Bodily Injury by Disease. Five hundred thousand dollars ($500,000) each employee; and

                      


              

            

             

            
              
                	

                      	37.2.3	
                        One million dollars ($1,000,000) policy limits.

                      


              

            

             

            
              
                	

                      	37.3	
                        The Contractor shall require all Subcontractors performing work under this Contract to obtain an insurance certificate showing proof of Worker’s Compensation
                            Coverage.

                      


              

            

             

            
              
                	

                      	37.3.1	
                        The Contractor shall have commercial general liability policy(ies) as follows:

                      


              

            

             

            
              Page 312 of 324

              
                


            

            
              
                	

                      	37.3.1.1	
                        Combined single limits of one million dollars ($1,000,000) per person and three million dollars ($3,000,000) per occurrence;

                      


              

            

             

            
              
                	

                      	37.3.1.2	
                        On an “occurrence” basis; and

                      


              

            

             

            
              
                	

                      	37.3.1.3	
                        Liability for property damage in the amount of three million dollars ($3,000,000) including contents coverage for all records maintained pursuant to this Contract.

                      


              

            

             

            
              
                	ARTICLE 38	
                        COMPLIANCE WITH ALL LAWS

                      


              

            

             

            
              
                	

                      	38.1	
                        Nondiscrimination

                      


              

            

             

            
              
                	

                      	38.1.1	
                        The Contractor shall comply with applicable Federal and Puerto Rico laws, rules, and regulations, and the Puerto Rico policy relative to nondiscrimination in
                            employment practices because of political affiliation, religion, race, color, sex, physical handicap, age, or national origin. Applicable Federal nondiscrimination law includes, but is not limited to, Title VI of the Civil
                            Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972, as amended; the Age Discrimination Act of 1975, as amended; Equal Employment Opportunity and its implementing regulations (45 CFR 74 Appendix A (1),
                            Executive Order 11246 and 11375); the Rehabilitation Act of 1973; and the Americans with Disabilities Act of 1993 and its implementing regulations (including but not limited to 28 CFR § 35.100 et seq.). Nondiscrimination in
                            employment practices is applicable to employees for employment, promotions, dismissal and other elements affecting employment.

                      


              

            

             

            
              
                	

                      	38.1.2	
                        The Contractor shall comply with all provisions of the Puerto Rico Patient’s Bill of Rights and the implementing regulation, which prohibits discrimination against
                            any patient.

                      


              

            

             

            
              
                	

                      	38.2	
                        Compliance with All Laws in the Delivery of Service

                      


              

            

             

            
              
                	

                      	38.2.1	
                        The Contractor agrees that all work done under this Contract will comply fully with and abide by all applicable Federal and Puerto Rico laws, rules, regulations,
                            statutes, policies, or procedures that may govern the Contract, including but not limited to those listed in Attachment 1 to this Contract.

                      


              

            

             

            
              
                	

                      	38.2.2	
                        All applicable Puerto Rico and Federal laws, rules, and regulations, consent decrees, court orders, policy letters and normative letters, and policies and
                            procedures, including but not limited to those described in Attachment 1 to this Contract, are hereby incorporated by reference into this Contract. Any change in those applicable laws and requirements, including any new law,
                            regulations, policy guidance, or normative letter, shall be automatically incorporated into this Contract by reference as soon as it becomes effective.

                      


              

            

             

            
              
                	

                      	38.2.3	
                        At the request of either party, ASES will evaluate any enacted Federal, state or local legislative or regulatory changes with applicability to the GHIP program that
                            materially impact the PMPM Payment. If after a process of actuarial evaluation, using credible data, ASES determines that the enacted legislative and/or regulatory changes materially impact the PMPM Payment, ASES will adjust the
                            PMPM rates to reflect the above-referenced changes after the adjusted rates are approved by CMS. Any revisions to the PMPM Payments under this Section would be applicable from November 1, 2018 until October 31, 2019, or from the
                            effective date of any new law or regulation, whichever is later. “Materially impact” shall mean that a recalculation of current PMPM Payments is required in order to remain actuarially sound.

                      


              

            

             

            
              Page 313 of 324

              
                


            

            
              
                	

                      	38.2.4	
                        To the extent that applicable laws, rules, regulations, statutes, policies, or procedures require the Contractor to take action or inaction, any costs, expenses, or
                            fees associated with that action or inaction shall be borne and paid by the Contractor solely. Such compliance-associated costs include, but are not limited to, attorneys’ fees, accounting fees, research costs, or consultant
                            costs, where these costs are related to, arise from, or are caused by compliance with any and all laws. In the event of a disagreement on this matter, ASES’s determination on this matter shall be conclusive and not subject to
                            appeal.

                      


              

            

             

            
              
                	

                      	38.2.5	
                        The Contractor shall include notice of grantor agency requirements and regulations pertaining to reporting and patient rights under any contracts involving
                            research, developmental, experimental or demonstration work with respect to any discovery or invention which arises or is developed in the course of or under such contract, and of grantor agency requirements and regulations
                            pertaining to copyrights and rights in Data.

                      


              

            

             

            
              
                	

                      	38.2.6	
                        The Contractor certifies and warrants to ASES that at the time of execution of this Contract: (i) it is a corporation or entity duly authorized to conduct business
                            in Puerto Rico, and has filed all the required income tax returns for the preceding five years; and (ii) it filed its report due with the Office of the Commissioner of Insurance during the five (5) years preceding the Execution
                            Date of this Contract.

                      


              

            

             

            
              
                	ARTICLE 39	
                        CONFLICT OF INTEREST AND CONTRACTOR INDEPENDENCE

                      


              

            

             

            
              
                	

                      	39.1	
                        The duty to provide information about interests and conflicting relations is continuous and extends throughout the Contract Term.

                      


              

            

             

            
              
                	

                      	39.2	
                        The Contractor covenants that it presently has no interest and shall not acquire any interest, direct or indirect, that would conflict in any material manner or
                            degree with, or have a material adverse effect on the performance of its services hereunder. The Contractor further covenants that in the performance of the Contract no person having any such interest shall be employed. The
                            Contractor shall submit a conflict of interest form, attesting to these same facts, by January 10 of each calendar year; and at any time, within fifteen (15) Calendar Days of request by ASES.

                      


              

            

             

            
              Page 314 of 324

              
                


            

            
              
                	

                      	39.3	
                        It shall be the responsibility of the Contractor to maintain independence and to establish necessary policies and procedures to assist the Contractor in determining
                            if the actual individuals performing work under this Contract have any impairment to their independence.

                      


              

            

             

            
              
                	

                      	39.4	
                        The Contractor further agrees to take all necessary actions to eliminate threats to impartiality and independence, including but not limited to reassigning,
                            removing, or terminating Providers or Subcontractors.

                      


              

            

             

            
              
                	ARTICLE 40	
                        CHOICE OF LAW OR VENUE

                      


              

            

             

            
              
                	

                      	40.1	
                        This Contract shall be governed in all respects by the laws of Puerto Rico. Any lawsuit or other action brought against ASES or the Government based upon or arising
                            from this Contract shall be brought in a court of competent jurisdiction in Puerto Rico. Nothing in this Section shall be construed as a restriction on the ability of the Contractor to discuss matters relating to this Contract
                            in ASES’s administrative forum.

                      


              

            

             

            
              
                	ARTICLE 41	
                        ATTORNEY’S FEES

                      


              

            

             

            
              
                	

                      	41.1	
                        In the event that either Party deems it necessary to take legal action to enforce any provision of this Contract, and in the event ASES prevails, the Contractor
                            agrees to pay all expenses of such an action including reasonable attorney’s fees and costs at all stages of litigation as awarded by the court, a lawful tribunal, a hearing officer, or an administrative law judge. The term
                            legal action shall be deemed to include administrative proceedings of all kinds, as well as all actions regarding the law or equity.

                      


              

            

             

            
              
                	ARTICLE 42	
                        SURVIVABILITY

                      


              

            

             

            
              
                	

                      	42.1	
                        The terms, provisions, representations, and warranties contained in this Contract shall survive the delivery or provision of all services hereunder.

                      


              

            

             

            
              
                	ARTICLE 43	
                        PROHIBITED AFFILIATIONS WITH INDIVIDUALS DEBARRED AND SUSPENDED

                      


              

            

             

            
              
                	

                      	43.1	
                        The Contractor certifies that it is not presently debarred, suspended, proposed for debarment, or declared ineligible for award of contracts by any Federal or
                            Puerto Rico agency, as provided in Section 13.4. In addition, the Contractor certifies that it does not employ or subcontract with any person or entity that could be excluded from participation in the Medicaid Program under 42
                            CFR 1001.1001 (exclusion of entities owned or controlled by a sanctioned person) or 1001.1051 (exclusion of individuals with ownership or control interest in sanctioned entities), and that Contractor screens for such exclusions
                            on a monthly basis. Any violation of this Article shall be grounds for termination of the Contract.

                      


              

            

             

            
              Page 315 of 324

              
                


            

            
              
                	ARTICLE 44	
                        WAIVER

                      


              

            

             

            
              
                	

                      	44.1	
                        No covenant, condition, duty, obligation, or undertaking contained in or made a part of the Contract shall be waived except by the written agreement of the Parties.
                            Forbearance or indulgence in any form or manner by either Party in any regard whatsoever shall not constitute a waiver of the covenant, conditions, duties, obligations, and undertakings to be kept, performed, or discharged by
                            the Party to which the same may apply. Notwithstanding any such forbearance or indulgence, the other Party shall have the right to invoke any Remedy available under law or equity until complete performance or satisfaction of all
                            such covenants, conditions, duties, obligations, and undertakings.

                      


              

            

             

            
              
                	

                      	44.2	
                        The waiver by ASES of any breach of any provision contained in this Contract shall not be deemed to be a waiver of such provision or any subsequent breach of the
                            same or any other provision contained in this Contract and shall not establish a course of performance between the Parties contradictory to the terms hereof. No term or condition of the Contract shall be held to be waived,
                            modified, or deleted except by an instrument, in writing, signed by the Parties thereto.

                      


              

            

             

            
              
                	ARTICLE 45	
                        FORCE MAJEURE

                      


              

            

             

            
              
                	

                      	45.1	
                        Neither Party of this Contract shall be held responsible for delays or failures in performance resulting from acts beyond the control of each Party. Such acts shall
                            include, but not be limited to, acts of God, strikes, riots, lockouts, acts of war, epidemics, fire, earthquakes, or other disasters.

                      


              

            

             

            
              
                	ARTICLE 46	
                        BINDING

                      


              

            

             

            
              
                	

                      	46.1	
                        This Contract and all of its terms, conditions, requirements, and amendments shall be binding on ASES and the Contractor and for their respective successors and
                            permitted assigns.

                      


              

            

             

            
              
                	ARTICLE 47	
                        TIME IS OF THE ESSENCE

                      


              

            

             

            
              
                	

                      	47.1	
                        Time is of the essence in this Contract. Any reference to “days” shall be deemed Calendar Days unless otherwise specifically stated.

                      


              

            

             

            
              Page 316 of 324

              
                


            

            
              
                	ARTICLE 48	
                        AUTHORITY

                      


              

            

             

            
              
                	

                      	48.1	
                        ASES has full power and authority to enter into this Contract as does the person acting on behalf of and signing for the Contractor. Additionally, the person
                            signing on behalf of the Contractor has been properly authorized and empowered to enter into this Contract on behalf of the Contractor and to bind the Contractor to the terms of this Contract. Each Party further acknowledges
                            that it has had the opportunity to consult with and/or retain legal counsel of its choice and read this Contract. Each party acknowledges that it understands this Contract and agrees to be bound by it.

                      


              

            

             

            
              
                	ARTICLE 49	
                        ETHICS IN PUBLIC CONTRACTING

                      


              

            

             

            
              
                	

                      	49.1	
                        The Contractor understands, states, and certifies that it made its Proposal without collusion or Fraud and that it did not offer or receive any kickbacks or other
                            inducements from any other Contractor, supplier, manufacturer, or Subcontractor in connection with its Proposal.

                      


              

            

             

            
              
                	

                      	49.2	
                        The Contractor understands, states, and certifies that it will comply with the requirements of the Code of Ethics for Contractors, Suppliers and Applicants of
                            Economic Incentives of the Government of Puerto Rico, as described in Title III of Act 2 of January 4, 2018, known as the “Anticorruption Code for the New Puerto Rico.”

                      


              

            

             

            
              
                	ARTICLE 50	
                        CONTRACT LANGUAGE INTERPRETATION

                      


              

            

             

            
              
                	

                      	50.1	
                        The Contractor and ASES agree that in the event of a disagreement regarding, arising out of, or related to, Contract language interpretation, ASES’s interpretation
                            of the Contract language in dispute shall control and govern.

                      


              

            

             

            
              
                	ARTICLE 51	
                        ARTICLE AND SECTION TITLES NOT CONTROLLING

                      


              

            

             

            
              
                	

                      	51.1	
                        The Article and Section titles used in this Contract are for reference purposes only and shall not be deemed to be a part of this Contract.

                      


              

            

             

            
              
                	ARTICLE 52	
                        LIMITATION OF LIABILITY/EXCEPTIONS

                      


              

            

             

            
              
                	

                      	52.1	
                        Nothing in this Contract shall limit the Contractor’s indemnification liability or civil liability arising from, based on, or related to claims brought by ASES or
                            any Third Party or any claims brought against ASES or the Government by a Third Party or the Contractor.

                      


              

            

             

            
              Page 317 of 324

              
                


            

            
              
                	ARTICLE 53	
                        COOPERATION WITH AUDITS

                      


              

            

             

            
              
                	

                      	53.1	
                        The Contractor shall assist and cooperate with ASES in any and all matters and activities related to or arising out of any audit or review, whether Federal,
                            private, or internal in nature, at no cost to ASES.

                      


              

            

             

            
              
                	

                      	53.2	
                        The Parties also agree that the Contractor shall be solely responsible for any costs it incurs for any audit related inquiries or matters. Moreover, the Contractor
                            may not charge or collect any fees or compensation from ASES for any matter, activity, or inquiry related to, arising out of, or based on an audit or review.

                      


              

            

             

            
              
                	

                      	53.3	
                        ASES reserves the right to audit the Contractor and/or its Subcontractors at any time during the term of the Contract. The Contractor and/or its Subcontractors
                            shall be solely responsible for the cost of such audits.

                      


              

            

             

            
              
                	ARTICLE 54	
                        OWNERSHIP AND FINANCIAL DISCLOSURE

                      


              

            

             

            
              
                	

                      	54.1	
                        The Contractor and Subcontractors shall disclose, and ASES shall review, financial statements for each person or corporation with an ownership or control interest
                            of five percent (5%) or more of its entity. For the purposes of this Section, a person or corporation with an ownership or control interest shall mean a person or corporation:

                      


              

            

             

            
              
                	

                      	54.1.1	
                        That owns directly or indirectly five percent (5%) or more of the Contractor’s/Subcontractor’s capital or stock or received five percent (5%) or more of its
                            profits;

                      


              

            

             

            
              
                	

                      	54.1.2	
                        That has an interest in any mortgage, deed of trust, note, or other obligation secured in whole or in part by the Contractor/Subcontractor or by its property or
                            assets, and that interest is equal to or exceeds five percent (5%) of the total property and assets of the Contractor/Subcontractor; and

                      


              

            

             

            
              
                	

                      	54.1.3	
                        That is an officer or director of the Contractor/Subcontractor (if it is organized as a corporation) or is a partner in the Contractor’s/Subcontractor’s
                            organization (if it is organized as a partnership).

                      


              

            

             

            
              
                	

                      	54.2	
                        As per 42 CFR 455.104, disclosure by the Contractor will include the following information on ownership and control:

                      


              

            

             

            
              
                	

                      	54.2.1	
                        The name and address of any person (individual or corporation) with an ownership or control interest in the disclosing entity, fiscal agent, or Contractor. The
                            address for corporate entities must include as applicable primary business address, every business location, and P.O. Box address.

                      


              

            

             

            
              
                	

                      	54.2.2	
                        Date of birth and Social Security Number (in the case of an individual).

                      


              

            

             

            
              
                	

                      	54.2.3	
                        Other tax identification number (in the case of a corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or managed care
                            entity) or in any Subcontractor in which the disclosing entity (or fiscal agent or managed care entity) has a five percent (5%) or more interest.

                      


              

            

             

            
              Page 318 of 324

              
                


            

            
              
                	

                      	54.2.4	
                        Whether the person (individual or corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or MCO) is related to another person
                            with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any Subcontractor in which the
                            disclosing entity (or fiscal agent or managed care entity) has a five percent (5%) or more interest is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling.

                      


              

            

             

            
              
                	

                      	54.2.5	
                        The name of any other disclosing entity (or fiscal agent or MCO) in which an owner of the disclosing entity (or fiscal agent or managed care entity) has an
                            ownership or control interest.

                      


              

            

             

            
              
                	

                      	54.2.6	
                        The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity (or fiscal agent or managed care entity).

                      


              

            

             

            
              
                	

                      	54.2.7	
                        Disclosures from Providers or Disclosing Entities. Providers or disclosing entities shall comply with the information disclosure required by Section 54.2.
                            Disclosure from any provider or disclosing entity is due at any of the following times:

                      


              

            

             

            
              
                	

                      	54.2.7.1	
                        Upon the provider or disclosing entity submitting the provider application.

                      


              

            

             

            
              
                	

                      	54.2.7.2	
                        Upon the provider or disclosing entity executing the provider agreement.

                      


              

            

             

            
              
                	

                      	54.2.7.3	
                        Upon request of ASES during the re-validation of provider enrollment process under 42 CFR 455.414.

                      


              

            

             

            
              
                	

                      	54.2.7.4	
                        Within 35 Calendar Days after any change in ownership of the disclosing entity.

                      


              

            

             

            
              
                	

                      	54.2.8	
                        Disclosures from Fiscal Agents. Fiscal agents shall comply with the information disclosure required by Section 54.2. Disclosures from fiscal agents are due at any
                            of the following times:

                      


              

            

             

            
              
                	

                      	54.2.8.1	
                        Upon the fiscal agent submitting the proposal in accordance with the Government's procurement process.

                      


              

            

             

            
              
                	

                      	54.2.8.2	
                        Upon the fiscal agent executing the contract with the Government.

                      


              

            

             

            
              
                	

                      	54.2.8.3	
                        Upon renewal or extension of the Contract.

                      


              

            

             

            
              Page 319 of 324

              
                


            

            
              
                	

                      	54.2.8.4	
                        Within thirty-five (35) Calendar Days after any change in ownership of the fiscal agent.

                      


              

            

             

            
              
                	

                      	54.2.9	
                        Disclosures from the Contractor. The Contractor shall comply with the information disclosure required by Section 54.2. Disclosures from Contractors are due at any
                            of the following times:

                      


              

            

             

            
              
                	

                      	54.2.9.1	
                        Upon the managed care entity submitting the proposal in accordance with the Government's procurement process.

                      


              

            

             

            
              
                	

                      	54.2.9.2	
                        Upon the MCO executing the contract with the Government.

                      


              

            

             

            
              
                	

                      	54.2.9.3	
                        Upon renewal or extension of the Contract.

                      


              

            

             

            
              
                	

                      	54.2.9.4	
                        Within thirty-five (35) Calendar Days after any change in ownership of the Contractor.

                      


              

            

             

            
              
                	ARTICLE 55	
                        AMENDMENT IN WRITING

                      


              

            

             

            
              
                	

                      	55.1	
                        No amendment, waiver, termination, or discharge of this Contract, or any of the terms or provisions hereof, shall be binding upon either Party unless confirmed in
                            writing by ASES and any other appropriate governmental agency. Additionally, CMS approval shall be required before any such amendment is effective. Any agreement of the Parties to amend, modify, eliminate, or otherwise change
                            any part of this Contract shall not affect any other part of this Contract, and the remainder of this Contract shall continue to be in full force and effect as set out herein.

                      


              

            

             

            
              
                	

                      	55.2	
                        ASES reserves the authority to seek an amendment to this Contract at any time if such an amendment is necessary in order for the terms of this Contract to comply
                            with Federal law, the laws of Puerto Rico or the Government of Puerto Rico Fiscal Plan as certified by the Financial Oversight and Management Board for Puerto Rico pursuant to the Puerto Rico Oversight, Management and Economic
                            Stability Act of 2016. The Contractor shall consent to any such amendment.

                      


              

            

             

            
              
                	ARTICLE 56	
                        CONTRACT ASSIGNMENT

                      


              

            

             

            
              
                	

                      	56.1	
                        The Contractor shall not assign this Contract, in whole or in part, without the prior written consent of ASES, and any attempted assignment not in accordance
                            herewith shall be null and void and of no force or effect.

                      


              

            

             

            
              
                	ARTICLE 57	
                        SEVERABILITY

                      


              

            

             

            
              
                	

                      	57.1	
                        If any Article, Section, paragraph, term, condition, provision, or other part of this Contract (including items incorporated by reference) is judged, held,
                            declared, or found to be voidable, illegal, unenforceable, invalid or void, then both ASES and the Contractor shall be relieved of all obligations arising under such provision. However, if the remainder of the Contract is
                            capable of being performed, it shall not be affected by such declaration or finding and those duties and tasks shall be fully performed. To this end, the provisions of the Contract are declared to be severable.

                      


              

            

             

            
              Page 320 of 324

              
                


            

            
              
                	ARTICLE 58	
                        ENTIRE AGREEMENT

                      


              

            

             

            
              
                	

                      	58.1	
                        This Contract constitutes the entire agreement between the Parties with respect to the subject matter herein and supersedes all prior negotiations, representations,
                            or contracts. No written or oral agreements, representatives, statements, negotiations, understandings, or discussions that are not set out, referenced, or specifically incorporated in this Contract shall in any way be binding
                            or of effect between the Parties.

                      


              

            

             

            
              
                	

                      	58.2	
                        The terms of the Request for Proposals and of the Contractor’s Proposal are incorporated by reference, except as otherwise provided in this Contract. However, in
                            the event of a conflict between the terms of this Contract and the terms of the Request for Proposals or the terms of the Contractor’s Proposal, the terms of this Contract shall prevail.

                      


              

            

             

            
              
                	

                      	58.3	
                        All applicable laws are incorporated by reference into this Contract, as provided in Article 38.

                      


              

            

             

            
              
                	

                      	58.4	
                        Subject to Section 55, the Contractor acknowledges that it may be necessary or convenient during the Contract Term to clarify or supplement certain terms and
                            conditions of this Contract so that it conforms to the terms of the Request for Proposals or otherwise in order to incorporate CMS requirements. In any of these events, the Contractor agrees that ASES shall have the right to
                            issue from time to time normative letters which shall be then incorporated into the Contract. Such normative letters are advisory in nature, and shall not, absent an amendment to the Contract, effect a change in the Contractor’s
                            substantive obligations under this Contract.

                      


              

            

             

            
              
                	ARTICLE 59	
                        INDEMNIFICATION

                      


              

            

             

            
              
                	

                      	59.1	
                        The Contractor hereby releases and agrees to indemnify and hold ASES, the Government, and its departments, agencies, and instrumentalities harmless from and against
                            any and all claims, demands, liabilities, losses, costs or expenses, and attorneys' fees, caused by, growing out of, or arising from this Contract, due to any act or omission on the part of the Contractor, its Agents, employees,
                            customers, invitees, licensees, or others working at the direction of the Contractor or on its behalf, or due to any breach of this Contract by the Contractor, or due to the application or violation of any pertinent Federal,
                            Puerto Rico or local law, rule or regulation. This indemnification extends to the successors and assigns of the Contractor and survives the termination of the Contract and the dissolution or, to the extent allowed by the law,
                            the bankruptcy of the Contractor.

                      


              

            

             

            
              Page 321 of 324

              
                


            

            
              
                	ARTICLE 60	
                        NOTICES

                      


              

            

             

            
              
                	

                      	60.1	
                        All notices, consents, approvals, and requests required or permitted shall be given in writing and shall be effective for all purposes if hand delivered or sent by
                            (i) personal delivery, (ii) expedited prepaid delivery service, either commercial or US Postal Service, with proof of attempted delivery, (iii) telecopies, or (iv) electronic mail. In each case of (c) and (d), with answer back
                            acknowledged, addressed as follows:

                      


              

            

             

            
              
                	

                      	60.1.1	
                        If to ASES at:

                      


              

            

             

            	
                    Mailing Address:

                     

                      

                    Administración de Seguros de Salud

                    P.O. Box 195661

                    San Juan, PR 00919-5661

                  	
                    Physical Address:

                     

                      

                    Administración de Seguros de Salud

                    Urb. Caribe 1549

                    Ave. Ponce de León, Sec. El Cinco

                    San Juan, PR 00926-2706

                  
	
                    Attention: Executive Director

                  	 


             

            
              
                	

                      	60.1.2	
                        If to Contractor at:

                      


              

            

             

            	
                    Mailing Address:

                     

                      

                    Triple-S Salud, Inc.

                    P.O. Box 363628

                    San Juan, PR  00919-1580

                  	
                    Physical Address:

                     

                      

                    Triple-S Salud, Inc.

                    1441 Ave. Roosevelt, 6th
                        Floor

                    San Juan, PR  00920

                  
	
                     

                    Attention: President

                  	 


             

            
              
                	

                      	60.1.3	
                        All notices, elections, requests, and demands under this Contract shall be effective and deemed received upon the earliest of (i) the actual receipt of the item by
                            personal delivery or otherwise, (ii) two (2) Business Days after being deposited with a nationally recognized overnight courier service as required above, (iii) three (3) Business Days after being deposited in the US mail as
                            required above or (iv) on the day sent if sent by facsimile with voice confirmation on or before 4:00 p.m. Atlantic Time on any Business Day or on the next Business Day if so delivered after 4:00 p.m. Atlantic Time or on any day
                            other than a Business Day. Rejection or other refusal to accept or the inability to deliver because of changed address of which no notice was given as herein required shall be deemed to be receipt of the notice, election,
                            request, or demand sent.

                      


              

            

             

            
              Page 322 of 324

              
                


            

            
              
                	ARTICLE 61	
                        OFFICE OF THE COMPTROLLER

                      


              

            

             

            
              
                	

                      	61.1	
                        ASES will file this Contract in the Office of the Comptroller of Puerto Rico within fifteen (15) Calendar Days from the Effective Date of the Contract.

                      


              

            

             

            (Signatures on following page)

            

            

            
              Page 323 of 324

              
                


            

            SIGNATURE PAGE

            

            

            IN WITNESS WHEREOF, the Parties state and affirm that
                they are duly authorized to bind the respected entities designated below as of the day and year indicated.

            

            

            ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

            

            

            	
                    /s/ Angela M. Avila Marrero

                      

                  	 	
                    September 21, 2018

                  	 
	
                    Angela M. Avila Marrero

                  	 	
                    Date

                  	 
	
                    Executive Director

                  	 	 	 
	
                    EIN: 66-0500678

                  	 	 	 


            

            

            TRIPLE-S SALUD, INC.

            

            

            	
                    /s/ Madeline Hernández Urquiza

                  	 	
                    September 21, 2018

                  	 
	
                    Madeline Hernández Urquiza

                  	 	
                    Date

                  	 
	
                    President

                  	 	 	 
	
                    EIN: 66-0555677

                  	 	 	 


            

            

            

            

            
              Page 324 of 324

               

            

             

          

        

      

    

  








  
    Attachment 1

    

  

  
     

    

    This attachment is provided only as guidance to the Contractor. It is not an exhaustive list of all applicable laws and regulations. Contractor is responsible for
      ensuring compliance with all applicable state and federal laws.

    

    

    Applicable Government laws and regulations:

    

    

    
      
        	•	
                Act 72 of September 7, 1993, including all of its amendments, known as “Puerto Rico Health Insurance Administration Law”, and its applicable regulations.

              


      

    

    

    

    
      
        	•	
                ASES General Rules and Regulations, No. 5253 of June 19, 1995, and ASES Regulations for the Imposition of Fines and Economic Sanctions for Breach of Contract of
                    Underwriters and/or Health Services Organizations and to Establish the Procedure for Resolution and Adjudication of Related Complaints, Regulation No. 8446.

              


      

    

    

    

    
      
        	•	
                Act 77 of June 19, 1957, as amended, known as “Puerto Rico Insurance Code” and corresponding regulations, as applicable

              


      

    

    

    

    
      
        	•	
                Act 81 of March 14, 1912; as amended, known as “Organic Law for the Puerto Rico Health Department”, and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 194 of August 25, 2000, as amended, known as “The Declaration of Patient’s Rights and Responsibilities”, and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 408 of October 2, 2000, as amended, known as “Mental Health Code”, and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 77 of June 24, 2013, as amended, known as the “Law of the Patient Advocate”, and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 247 of September 3, 2004, as amended, known as the “Puerto Rico Pharmacy Law”, and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 139 of August 1, 2008, as amended, known as “Law for the Medical Licensing and Discipline Board”, and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 109 of June 28, 1962, as amended, known as “Law for the Puerto Rico Public Service”, and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 225 of July 23, 1974, as amended, known as “Law for Ambulance Operation and Services”, and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                The Public Services Commission’s Regulations for Ambulance Services in Puerto Rico”, Regulation No. 6737 of December 16, 2003, as applicable.

              


      

    

    

    

    
      
        


    

    
      
        	•	
                Act 86 of August 16, 1997, as amended, known as “Law Granting Priority for Individuals with Pending Business traveling between Puerto Rico and Vieques and/or Culebra”, and
                    corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 227 of August 12, 1999, as amended, known as “Law for the Commission to Implement the Public Policy on Suicide Prevention” and corresponding regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act 243 of November 10, 2006, known as “Law to Establish the Public Policy Concerning the Use of the Social Security Number for Identification”, and corresponding
                    regulations, as applicable.

              


      

    

    

    

    
      
        	•	
                Act. No. 2 de January 4, 2018, known as “Anticorruption Code for the New Puerto Rico”, and its applicable regulations.

              


      

    

    

    

    
      
        	•	
                Act No. 1 of January 3, 2012, as amended, known as the “Government Ethics Law of 2011”, and its applicable regulations.

              


      

    

    

    

    
      
        	•	
                Act 38 of June 30, 2017, known as the “Puerto Rico Uniform Administrative Proceeding Law”.

              


      

    

    

    

    
      
        	•	
                Act 111 of September 7, 2005, as amended, known as the “Law for Informing Citizens of the Security of Data Banks”, and its applicable regulations.

              


      

    

    

    

    
      
        	•	
                Act 80 of June 3, 2011, known as “Industrial and Trade Secret Protection Act of Puerto Rico”

              


      

    

    

    

    
      
        	•	
                Act No. 126 of October 31, 2013, as amended, known as “Law for the Protocol of Interagency Services for the Elderly Population Living in Infrahuman Conditions”.

              


      

    

    

    

    
      
        	•	
                Act No. 121 of July 12, 1986, as amended, known as “The Declaration of Elderly’s Rights”.

              


      

    

    

    

    
      
        	•	
                Act No. 352 of December 22, 1999, known as “Law Requiring Coverage of General Anesthesia for Minor and Disable Individuals”.

              


      

    

    

    

    
      
        	•	
                Act No. 212 of August 9, 2008, known as “Law for the Coverage of Clinical Services for Patients with Morbid Obesity and Metabolic Syndrome”.

              


      

    

    

    

    
      
        	•	
                Act No. 120 of July 16, 2015, known as “Law to Include Pulmonary Hypertension in the Special Coverage Provided by the Health Insurance Administration”.

              


      

    

    

    

    
      
        	•	
                Act No. 4 of June 23 of 1971, known as the “Controlled Substances Law of Puerto Rico”

              


      

    

    

    

    
      
        


    

    
      
        	•	
                ASES Normative Letters.

              


      

    

    

    

    Applicable Federal Laws and Regulations:

    

    

    
      
        	•	
                Puerto Rico Health Department’s State Plan (“Medicaid State Plan” and CHIP State Plan”).

              


      

    

    

    

    
      
        	•	
                The Social Security Act, including Titles VII, XI, XIX and XXI.

              


      

    

    

    

    
      
        	•	
                Federal regulations as established by the Center for Medicare & Medicaid Services (“CMS”) including, but not limited to: 42 CFR part 438 (managed care), 42 CFR part 431
                    (fair hearings and appeals); 42 CFR part 455 (fraud and abuse reporting); 42 CFR part 447 (timely claim payment);45 CFR part 75 (as applicable); 42 CFR part 433, Subpart D; 42 CFR 431.53 (ambulance services); and 42 CFR 405.2402 (rural
                    health clinic basic requirements).

              


      

    

    

    

    
      
        	•	
                Davis-Bacon Act, 40 U.S.C. 276a et seq.).

              


      

    

    

    

    
      
        	•	
                Federal False Claims Act, 31 U.S.C. § 3729.

              


      

    

    

    

    
      
        	•	
                Copeland Anti-Kickback Act, 40 U.S.C 3145.

              


      

    

    

    

    
      
        	•	
                Fair Labor Standards Act of 1938, 29 U.S.C 201 et seq.

              


      

    

    

    

    
      
        	•	
                Clean Air Act, 42 U.S.C. 7401 et seq.

              


      

    

    

    

    
      
        	•	
                Federal Water Pollution Control Act as Amended, 33 U.S.C. 1251 et seq.

              


      

    

    

    

    
      
        	•	
                Federal Rehabilitation Act of 1973.

              


      

    

    

    

    
      
        	•	
                Byrd Anti-Lobbing Amendment, 31 U.S.C. 1352

              


      

    

    

    

    
      
        	•	
                The Clinical Laboratory Improvement Amendments of 1988.

              


      

    

    

    

    
      
        	•	
                The Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, including its Omnibus Rule (“HIPAA”), applicable provisions of the Health Information
                    Technology for Economic and Clinical Health Act as incorporated in the American Recovery and Reinvestment Act of 2009 (“HITECH”), and their accompanying regulations, including the Privacy Rule (as defined herein) and the Security Rule
                    (as defined herein). “Privacy Rule” means the Standards for Privacy of Individually Identifiable Health Information at 45 CFR, part 160 and part 164, subparts A and E, providing for federal privacy protections for an individual’s PHI
                    held by entities subject to HIPAA requirements (each, a “Covered Entity”) and describing patient rights with respect to their PHI. “Security Rule” means HIPAA Security Standards (45 C.F.R. Parts 160, 162, and 164).

              


         

        

      

    

    
      
        


    

    
      
        	•	
                Americans with Disabilities Act, 42 U.S.C. 12101 et seq.

              


      

    

    

    

    
      
        	•	
                Medicare Modernization Act of 2003, P.L. 108-173.

              


      

    

    

    

    
      
        	•	
                Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343.

              


      

    

    

    

    
      
        	•	
                American Recovery and Reinvestment Act of 2009, P.L. 111-5.

              


      

    

    

    

    
      
        	•	
                Patient Protection and Affordable Care Act of 2010, P.L. 111-148.

              


         

        

         

        

         

      

    

  








  
    Attachment 2

    

  

   

  

   
    

    

    

    

     

  








  
  
    Attachment 3

    

  

  

    

     ___________, 2018

    

    

    

    

    Dear Enrollee:

    

    

    
      Hello and welcome to the Government Health Insurance Plan “MI Salud”! In MI Salud, you can choose your Insurer. If you do not have an Insurer you will be
          assigned one but you can change to a different Insurer if you want. Your Insurer works with you and your doctors to help you stay healthy.

       

        

      You can choose your doctor, or primary care physician (PCP), or your Insurer will assign you one. Your PCP’s name is on your ID card. Carry this card
          with you and show it whenever you visit your doctor. Visit your doctor often to help you stay healthy.

       

        

      This guide explains the benefits and services you can get through MI Salud. It also explains what to do if you have an emergency or urgent medical
          situation. Please read this guide carefully. It will help you learn about the services paid for by MI Salud. Keep this guide in a safe place so you can look up information later on.

       

        

      If you have trouble reading the guide, you can ask your Insurer for a free copy of the guide in other formats like large print, Braille or audio CD.

       

        

      Your Insurer can help answer any questions you have about your health care, ID card, benefits and doctors.

       

        

      Please make sure your Insurer and your Medicaid Office has your most recent address and personal information. You can call your Insurer at [x]. Call or
          visit your local Medicaid Office, or call the Medicaid program call center at 787-641-4224.

       

        

      Contact your Medicaid Office if your information changes. Make sure you go to your eligibility appointments so you can keep your MI Salud benefits.

       

        

      We invite you to use your MI Salud benefits so you can get the care you need.

      

      

    

    Cordially,

    

    

    Angela Ávila Marrero

    Executive Director

     

      

    
      1

      
        


    

    
      TABLE OF CONTENTS

    

     

    

    	
            TABLE OF CONTENTS

          	
            2

          
	
            WHO CAN I CALL FOR HELP?

          	
            4

          
	
            WHAT INFORMATION CAN I FIND ONLINE?

          	
            4

          
	
            YOUR RIGHT TO PRIVACY (HIPAA)

          	
            5

          
	
            DO YOU NEED HELP UNDERSTANDING THIS GUIDE?

          	
            5

          
	
            DO YOU NEED HELP TALKING WITH YOUR INSURER OR READING WHAT THEY
                  SEND YOU?

          	
            5

          
	
            PART 1: GETTING STARTED

          	
            6

          
	
            HOW DO I SIGN UP FOR MI SALUD?

          	
            6

          
	
            WHAT IF I HAVE A NEWBORN?

          	
            6

          
	
            HOW DO I KEEP MY MI SALUD BENEFITS?

          	
            6

          
	
            HOW DO I CHOOSE AN INSURER?

          	
            6

          
	
            CAN I CHANGE MY INSURER?

          	
            7

          
	
            CAN MY MEMBERSHIP WITH MY INSURER STOP?

          	
            7

          
	
            HOW DO I REPORT CHANGES?

          	
            8

          
	
            YOUR ID CARD

          	
            8

          
	
            PART 2: YOUR PRIMARY CARE PHYSICIAN AND OTHER DOCTORS

          	
            10

          
	
            HOW CAN I SEE MY PCP?

          	
            10

          
	
            WHAT IF IT’S AN EMERGENCY AND I NEED CARE AFTER MY PCP’S OFFICE
                  CLOSES?

          	
            11

          
	
            CAN I CHANGE MY PCP?

          	
            12

          
	
            WHAT HAPPENS AFTER I ASK FOR THE CHANGE?

          	
            13

          
	
            WHAT ABOUT OTHER DOCTORS OR PROVIDERS I NEED TO SEE?

          	
            13

          
	
            HELP WITH GETTING TO YOUR HEALTH CARE VISITS

          	
            15

          
	
            PART 3: SERVICES MI SALUD PAYS FOR

          	
            16

          
	
            GENERAL INFORMATION

          	
            16

          
	
            DENTAL SERVICES

          	
            17

          
	
            MENTAL HEALTH, ALCOHOL AND DRUG ABUSE SERVICES

          	
            17

          
	
            PHARMACY SERVICES

          	
            18

          
	
            NON-COVERED SERVICES

          	
            18

          
	
            PART 4: WILL I HAVE TO PAY TO GET HEALTH CARE SERVICES?

          	
            21

          
	
            COPAY CHARTS

          	
            21

          
	
            PART 5: SPECIAL PROGRAMS

          	23
	
            SPECIAL COVERAGE

          	
            23

          
	
            SPECIAL COVERAGE FOR HIV-AIDS

          	
            25

          
	
            CARE MANAGEMENT

          	
            26

          
	
            HIGH COST HIGH NEEDS PROGRAM

          	
            27

          


    

    

    
      2

      
        


    

    	
            [PLACEHOLDER for Insurer to add information about any other
                  special programs]

          	
            27

          
	
            PART 6: FOR YOUR PROTECTION

          	
            28

          
	
            YOUR RIGHTS

          	
            28

          
	
            YOUR RIGHT TO PRIVACY (HIPAA)

          	
            29

          
	
            YOUR RESPONSIBILITIES

          	
            29

          
	
            ADVANCE DIRECTIVES

          	
            29

          
	
            FRAUD AND ABUSE

          	
            30

          
	
            PART 7: COMPLAINTS AND APPEALS

          	
            32

          
	
            NEED TO MAKE A COMPLAINT ABOUT YOUR CARE?

          	
            32

          
	
            WHAT HAPPENS IF MY COMPLAINT ISN’T FIXED?

          	
            32

          
	
            WHAT IS AN APPEAL?

          	
            32

          
	
            WHAT WILL HAPPEN WHEN MY INSURER GETS THE APPEAL?

          	
            33

          
	
            WHAT CAN I DO IF I DON’T AGREE WITH THE DECISION?

          	
            33

          
	
            CAN I KEEP GETTING SERVICES DURING MY APPEAL OR HEARING?

          	
            34

          
	
            PART 8: HOW MI SALUD WORKS WITH OTHER HEALTH INSURANCE

          	
            35

          
	
            HOW MI SALUD WORKS WITH MEDICARE

          	
            35

          
	
            HOW MI SALUD WORKS WITH OTHER INSURANCE

          	
            36

          
	
            HOW MI SALUD WORKS IF YOU ARE A PUBLIC EMPLOYEE OR RETIREE

          	
            36

          
	
            HOW MI SALUD WORKS IF YOU ARE A MEMBER OF THE POLICE DEPARTMENT
                  OF PUERTO RICO

          	
            37

          
	
            DEFINITIONS

          	
            38

          


     

    

    
      3

      
        


    

    
      WHO CAN I CALL FOR HELP?

    

     

      

    If you are having an emergency, call 911.

     

      

    Insurer’s Member Services Line [PLACEHOLDER for Insurer’s Member Services
          Line phone number and hours]

     

        
      	

            	Medicaid Program Call Center 787-641-4224	 
	
               

            	
               

            	 
	
              

              

            	
              
                ASSMCA (Linea PAS) Mental Health Service Line

                1-800-981-0023

              

            	 
	
               

            	
               

            	 


      

        

    	
            

            

          	
            Patient Advocate Office

            Toll-free 1-800-981-0031

            TTY 787-710-7057

          	 
	 	 	 
	
            

          	
             

            Puerto Rico Health Insurance Administration (ASES)

            MI Salud Toll-free 1-800-981-2737

          	 


     

    

    
      WHAT INFORMATION CAN I FIND ONLINE?

    

     

      

    For provider directory, orientation and education materials and an electronic copy of this guide:

     

      

    [PLACEHOLDER for Insurer website]

    

    

    For information about Mi Salud: http://www.ases.pr.gov

     

      

    For information about Medicaid programs: http://www.medicaid.pr.gov

     

      

    
      4

      
        


    

    For more information on patient protections:  

     http://www2.pr.gov/Directorios/Pages/InfoAgencia.aspx?PRIFA=231

     

      

    
      YOUR RIGHT TO PRIVACY (HIPAA)

    

    
       

        

      There are laws that protect your privacy. The Government of Puerto Rico, your Insurer, and your doctors can’t tell others certain facts about you. Read more
          about your privacy rights in Part 6 of this guide.

      

      

    

    
      DO YOU NEED HELP UNDERSTANDING THIS GUIDE?

    

    
       

        

      If the information provided in this guide is confusing or if you have any questions, call your Insurer for help at [x].

      

      

    

    
      DO YOU NEED HELP TALKING WITH YOUR INSURER OR READING WHAT THEY SEND YOU?

    

     

      

    Your Insurer must make this guide and all written materials available to you in Spanish and English. You can also ask your Insurer to send this guide or any
        written materials in other languages or other formats like large print, audio CD or Braille. Materials in other languages or formats are free.

     

      

    If you speak another language, your Insurer must provide an interpreter to help you understand. The interpreter is free.

    

    

    Call your Insurer at [x] for help.

     

      

    
      5

      
        


    

    
      PART 1: GETTING STARTED

    

    

    

    
      HOW DO I SIGN UP FOR MI SALUD?

    

    
       

        

      Anyone who wants to see if they can sign up for MI Salud can visit their local Medicaid Office. They will look at the person’s information and tell them if
          they are eligible for MI Salud.

       

        

      To find out where your Medicaid Office is, call the Medicaid Program call center at 787-641-4224. The call is free. Or visit www.medicaid.pr.gov.

      

      

    

    
      WHAT IF I HAVE A NEWBORN?

    

    
       

        

      If you have a newborn, visit your Medicaid Office and give them a copy of the newborn’s birth certificate to enroll the newborn in MI Salud. If you do not
          do this, the newborn cannot get services under MI Salud. When you have a newborn, you also might be able to get other benefits, so it is important to visit the Medicaid Office so they can check.

      

      

    

    
      HOW DO I KEEP MY MI SALUD BENEFITS?

    

    
       

        

      To keep your MI Salud benefits, you have to go to all your Medicaid appointments. Your Insurer will send you a letter 90 days, 60 days and 30 days before
          the day when your MI Salud benefits stop. These letters will remind you that you have to go to your local Medicaid Office to maintain your eligibility in MI Salud.

       

        

      If you miss your appointment, call the Medicaid Program Call Center at 787-641-4224 or visit your local Medicaid Office to ask for a new appointment.

      

      

    

    
      HOW DO I CHOOSE AN INSURER?

    

    
       

        

      Once you sign up for MI Salud, you can choose your Insurer. Your Insurer will work with you and your doctors to keep you healthy.

       

        

      There is an enrollment counselor available in Medicaid offices and on the phone who can help you choose an Insurer. The enrollment counselor does not work
          for any Insurer or any providers. They are neutral. They can give you information about MI Salud and your benefits. They can tell you about the choices available to you and help answer your questions. They can’t choose for you.  They can help
          you:

      

      

    

    
      
        	

              	·	
                Choose a new Insurer or change Insurers;

              


      

    

    
      
        	

              	·	
                If you change your Insurer, they can also help you change your Primary Care Physician (PCP) or Primary Medical Group (see more information in Part 2 of this guide).

              


      

    

    
      

      

      
        6

        
          


      

      You can contact the Enrollment Counselor for support:

      

      

    

    
      
        	

              	·	
                By phone at 1-800-981-2737, Monday through Friday, 8 am to 6 pm

              


      

    

    
      
        	

              	·	
                In the Medicaid offices

              


      

    

    
      

      

      There are Enrollment Counselor staff in each of the Medicaid Offices. The offices are open Monday through Friday from 7:30am to 4:00pm. Your Insurer can
          tell you the Medicaid Office that is closest to you.

       

        

      If you do not choose an Insurer, one will be chosen for you.

      

      

    

    
      CAN I CHANGE MY INSURER?

    

    
       

        

      Yes, you can ask to change your Insurer. Once you have chosen an Insurer or one has been chosen for you, you have 90 days to change Insurers. You can also
          change your Insurer once a year during the “open enrollment period”, which is from November 1 to January 31.

       

        

      If you want to change your Insurer, call the Enrollment counselor at 1-800-981-2737 or visit your local Medicaid Office.

       

        

      You can also ask to change your Insurer at any time if you have certain reasons, like:

      

      

    

    
      
        
          	

                	·	
                  You are not able to access services or providers.

                


        

      

      
        
          	

                	·	
                  You cannot get all related services you need at one time from the doctors, healthcare professionals and service facilities that work with your Insurer.

                


        

      

      
        
          	

                	·	
                  You get poor-quality care.

                


        

      

      
        
          	

                	·	
                  You ask for a service that your Insurer does not cover because of moral or religious reasons.

                


        

      

      
        
          	

                	·	
                  Your Insurer does not have doctors that are experienced in dealing with your health care needs. 

                


        

      

      

      

    

    
      If you want to change your insurer for one of these reasons, you can ask for this change from the enrollment counselor or ASES. ASES will decide if you can
          change or if you have to wait until Open Enrollment. If you do not like the decision ASES makes, you can ask them to reconsider. If the decision is still not to your liking, you can ask for a hearing.

      

      

    

    
      CAN MY MEMBERSHIP WITH MY INSURER STOP?

    

    
       

        

      Yes, your membership with your Insurer will stop if you:

      

      

    

    
      
        	

              	·	
                Lose eligibility for MI Salud.

              


      

    

    
      
        	

              	·	
                Move outside of Puerto Rico.

              


      

    

    
      
        	

              	·	
                Go to prison.

              


         

        

        
          7

          
            


        

      

    

    
      
        	

              	·	
                Give your ID card to someone else to use.

              


      

    

    
      
        	

              	·	
                Move to a long-term care nursing facility or intermediate care facility for the developmentally disabled.

              


      

    

    
      

      

    

    
      You will not lose your membership with your Insurer if:

      

      

    

    
      
        	

              	·	
                You have changes in your health.

              


      

    

    
      
        	

              	·	
                You are using more health care services.

              


      

    

    
      

      

      You also might want to stop your membership with your Insurer if you no longer need your MI Salud benefits. If this happens, let your Medicaid Office and
          your Insurer know.

      

      

    

    
      HOW DO I REPORT CHANGES?

    

    
       

        

      MI Salud and your Insurer are committed to helping you. To support your needs, we need your help.

       

        

      Please remember to let your Medicaid Office and Insurer know of any changes that may affect your membership or benefits. Some examples include:

      

      

    

    
      
        	

              	·	
                You are pregnant.

              


      

    

    
      
        	

              	·	
                You have a newborn.

              


      

    

    
      
        	

              	·	
                You have changes in your family group (for example, you get married, someone in your family dies, and someone in your family reaches age 21).

              


      

    

    
      
        	

              	·	
                You move or your phone number changes.

              


      

    

    
      
        	

              	·	
                You or one of your children has other health insurance.

              


      

    

    
      
        	

              	·	
                You have a special medical condition.

              


      

    

    
      
        	

              	·	
                You move outside of Puerto Rico

              


      

    

    
      
        	

              	·	
                Your income changes (for example, you lose your job or get a new job)

              


      

    

    

    

    To report a change, call the Medicaid Program call center at 787-641-4224 or visit your local Medicaid Office.

     

      

    
      It is important to make sure your contact information is up to date with your local Medicaid Office. This is important because Medicaid and your Insurer
          send you important information about your MI Salud coverage and benefits in the mail. If they don’t have your current address, you could lose your MI Salud benefits. To report a change, call your Insurer or visit your local Medicaid Office.

      

      

    

    
      YOUR ID CARD

    

     

      

    Everyone in MI Salud has an ID card. This is an example of what it looks like:

     

      

    
      8

      
        


    

    

    

    

    Each insured person in your family will have his/her own ID card, even if he/she is a newborn. Your ID card has important information like:

     

      

    
      
        	

              	·	
                Your ID number (MPI)

              


      

    

    
      
        	

              	·	
                How to access emergency services

              


      

    

    
      
        	

              	·	
                Any money you will pay for health services

              


      

    

    
      
        	

              	·	
                Your Insurer’s free phone number (on the back of your card)

              


      

    

    
      
        	

              	·	
                The phone number for the free MI Salud Service Line and the free 24/7 MI Salud Medical Advice Line (on the back of your card).

              


      

    

     

      

    If you need to use your health benefits before you get your ID card, use your MA-10 form given to you by your Medicaid Office.

     

      

    Remember to:

     

      

    
      
        	

              	·	
                Always carry your ID card with you.

              


      

    

    
      
        	

              	·	
                Keep your card in a safe place so you don’t lose it.

              


      

    

    
      
        	

              	·	
                Take your ID card when you go to the doctor or to the emergency room.

              


      

    

    
      
        	

              	·	
                Be sure they give you your ID card back.

              


      

    

    

    

    Your ID card is only for you. Don’t let anyone else use your card. If your card is lost or stolen, you can ask your Insurer for a new card. You can visit your
        Insurer’s Service Centers or call them at [x]. The phone call is free.

     

      

    
      9

      
        


    

    
      PART 2: YOUR PRIMARY CARE PHYSICIAN AND OTHER DOCTORS

    

    
       

        

      When you sign up with your Insurer, you must choose a doctor or “primary care physician” (PCP). This is the main person you will see for most of your health
          care. This includes checkups, treatment for colds and flu, health concerns and health screenings. Your PCP can find and treat health problems early. He or she will have your medical records. Your PCP can see your whole health care picture. Your
          PCP keeps track of all of the care you get.

       

        

      There are different types of doctors who are PCPs, like:

      

      

    

    
      
        	

              	·	
                General Practitioners

              


      

    

    
      
        	

              	·	
                Family Physicians

              


      

    

    
      
        	

              	·	
                Pediatricians

              


      

    

    
      
        	

              	·	
                Gynecologists/Obstetricians

              


      

    

    
      
        	

              	·	
                Internists

              


      

    

    

    

    You must choose a PCP for each insured member in your family. Your family members can have different PCPs.

    

    

    If you are a woman over age 12, you can also choose a gynecologist to be your PCP. If you are pregnant, your PCP could be your obstetrician during your
        pregnancy. When your pregnancy ends you will go back to your regular doctor, but your gynecologist will still take care of your gynecological needs. You may choose a pediatrician or a family physician for your newborn or one will be chosen for you.

     

      

    
      To choose your PCP, call your Insurer at [x]. If you do not choose one, then one will be chosen for you.

       

        

      A Primary Medical Group is a group of doctors that help arrange your health care services and work with your Insurer to make sure you get the care you need.
          Your ID card shows the name of your PCP and your Primary Medical Group number.

      

      

    

    
      HOW CAN I SEE MY PCP?

    

     

      

    If you need an appointment, call your PCP. It is free to make appointments with them. It is important that you keep your appointments with your PCP. If you
        cannot make it for any reason, call the PCP’s office right away to let them know.

    

    

    If your PCP is new for you, you should get to know him/her. Call to get an appointment as soon as you can. This is even more important if you’ve been getting
        care or treatment from a different doctor. We want to make sure that you keep getting the care you need. If you feel OK, you should call to get a checkup with your PCP.

    

    

    
      10

      
        


    

    Before you go to your first appointment:

     

      

    
      
        	

              	1.	
                Ask your past doctor to give you your medical records. This will not cost you anything. Bring your medical records to your new PCP at your first visit. They will help your
                    new PCP learn about your health.

              


      

    

    
      
        	

              	2.	
                Call your PCP to schedule your appointment.

              


      

    

    
      
        	

              	3.	
                Have your ID card ready when you call.

              


      

    

    
      
        	

              	4.	
                Say you are a MI Salud member and give them your ID number.

              


      

    

    
      
        	

              	5.	
                Write down your appointment date and time. If you’re a new patient, the provider may ask you to come early. Write down the time they ask you to be there.

              


      

    

    
      
        	

              	6.	
                Make a list of questions you want to ask your doctor. List any health problems you have.

              


      

    

    
      
        	

              	7.	
                If you need a ride to the appointment and have no other way to get there, call your Insurer or your local Municipality. They can help you get a ride.

              


      

    

    

    

    On the day of your appointment:

     

      

    
      
        	

              	1.	
                Bring a list of all your medicines and your questions with you so your doctor will know how to help you.

              


      

    

    
      
        	

              	2.	
                Be on time for your visit. If you cannot keep your appointment, call your PCP to get a new time.

              


      

    

    
      
        	

              	3.	
                Take your ID card with you. Your PCP may make a copy of it.

              


      

    

    
      

      

    

    
      WHAT IF IT’S AN EMERGENCY AND I NEED CARE AFTER MY PCP’S OFFICE CLOSES?

    

    
       

        

      Most PCPs have regular office hours. Your Insurer’s Provider Directory will tell you when your doctors’ offices are open. Most Primary Medical Groups also
          have clinics that are open late. But, you can call your Insurer service line anytime.

       

        

      You can get emergency health care any time you need it. Always carry your ID card with you. In case of an emergency, doctors will know you have MI Salud. If
          you call your Insurer's Medical Advice Service Line before you go to the emergency room, you will not have to pay when you go to the emergency room.Your Insurer's Medical Advice Service Line number is [x].

       

        

      Emergencies are times when there could be serious danger or damage to your health if you don’t get medical care right away.

      

      

    

    	
            Emergencies might be things like:

          	
            These are usually not emergencies:

          
	 	 
	
            ·     Shortness of breath, not able to talk

          	
            ·     Sore throat

          


    

    

    
      11

      
        


    

    	
            ·     A bad cut, broken bone, or a burn

          	
            ·     Cold or flu

          
	 	 
	
            ·     Bleeding that cannot be stopped

          	
            ·     Lower back pain

          
	 	 
	
            ·     Strong chest pain that does not go
                away

          	
            ·     Earache

          
	 	 
	
            ·     Strong stomach pain that doesn’t stop

          	
            ·     Stomachache

          
	 	 
	
            ·     Seizures that cause someone to pass
                out

          	
            ·     Small, superficial, cuts

          
	 	 
	
            ·     Not able to move your legs or arms

          	
            ·     Bruise

          
	 	 
	
            ·     A person who will not wake up

          	
            ·     Headache, unless it is very bad and
                like you’ve never had before

          
	 	 
	
            ·     Drug overdose

          	
            ·     Arthritis

          


    
      

      

      If you think you have an emergency, go to the nearest hospital Emergency Room (ER). If you can’t get to the ER, call 911.

       

        

      If you need emergency care, you don’t have to get an OK from anyone before you get emergency care.

       

        

      If you are not sure if it’s an emergency, call your PCP. You can call your Insurer’s Medical Advice Service Line at any time. Your PCP can help you get
          emergency care if you need it.

       

        

      You can also call MI Salud call center for advice. Their phone number is on the back of your ID card. You can call 24 hours a day, 7 days a week.

      

      

    

    
      CAN I CHANGE MY PCP?

    

     

      

    Yes, you can change your PCP at least once a year. There are other reasons why you may need to change your PCP. For example, you may want to see one whose
        office is closer to you. To change your PCP you must call your Insurer to corroborate whether the change may be performed.

     

      

    You could also change to a new Primary Medical Group if the PCP you want to see is in a different Primary Medical Group.

     

      

    Most of the time, after the first 90 days of signing up with your Insurer, you can change your Primary Medical Group at any time for some reasons, like if:

     

      

    
      
        	

              	·	
                Your PCP can’t give you the care or treatment you need because of ethical (moral) or religious reasons.

              


      

    

    
      
        	

              	·	
                Your PCP can’t give you all the services you need at the same time, and not getting services at the same time is risky for your health.

              


      

    

    
      
        	

              	·	
                You get bad quality care.

              


         

        

        
          12

          
            


        

      

    

    
      
        	

              	·	
                You can’t access the services you need.

              


      

    

    
      
        	

              	·	
                Your PCP doesn’t have experience to take care of your health care needs.

              


      

    

     

      

    For orientation and to make the change, call your Insurer at [x].

    

    

    Another reason why your PCP or Primary Medical Group could change is if your PCP or Primary Medical Group stops working with your Insurer. If this happens,
        your Insurer will send you a letter letting you know your new PCP or Primary Medical Group. If you want to change your PCP or Primary Medical Group, call your Insurer at [x].

     

      

    
      WHAT HAPPENS AFTER I ASK FOR THE CHANGE?

    

     

      

    Once you make the change with your Insurer, it will take some time for the change to be effective. If you make the change in the first 5 days of a month, it
        will be effective in the next month. For example, if you make the change on January 5, it will be effective on February 1. But if you make the change after the first 5 days of the month, it will be effective the month after next. For example, if
        you make the change on January 6, it will be effective March 1.

     

      

    You should keep seeing your old PCP until the change is effective. You cannot start seeing your new PCP until the effective date.

     

      

    
      WHAT ABOUT OTHER DOCTORS OR PROVIDERS I NEED TO SEE?

    

     

      

    Besides your PCP, you may also need to see other doctors and health care providers, like specialists. A specialist is a doctor who gives care for a certain
        illness or part of the body. One kind of specialist is a cardiologist, who is a heart doctor. Another kind of specialist is an oncologist, who treats cancer. There are many kinds of specialists.

     

      

    Besides specialists, you may also need to go to other healthcare professionals and healthcare facilities to get care, like laboratories, x-ray facilities, or
        hospitals. The doctors, other health care professionals and service facilities that work with your Insurer and your Primary Medical Group are called the Preferred Provider Network.

     

      

    The other doctors, other health care professionals and service facilities that work with your Insurer are called the General Network. When you sign up with
        your Insurer, they will mail you a Provider Directory for the Preferred Provider Network and the General Network. These lists are also on your Insurer’s website at [x]. Your Primary Medical Group and your Insurer’s Service Centers also have a copy
        of the lists.

     

      

    For more information about how MI Salud works if you have Medicare, look at Part 8 of this guide.

     

      

    
      13

      
        


    

    Preferred Provider Network

     

      

    The doctors, other health care professionals and services facilities who work with your Primary Medical Group are called the Preferred Provider Network.

     

      

    There are benefits to seeing the doctors, other health care professionals and service facilities in the Preferred Provider Network:

     

      

    
      
        	

              	·	
                You can visit any of the doctors and service facilities in the Preferred Provider Network for free.

              


      

    

    
      
        	

              	·	
                If you visit the doctors, healthcare professionals and service facilities in your Preferred Provider Network, you don’t need to go to your PCP first to get a referral.

              


      

    

    
      
        	

              	·	
                If you get any of the following services within the Preferred Provider Network, you don’t need your PCP to sign off:

              


      

    

    
      
        	

              	·	
                Prescription medicine

              


      

    

    
      
        	

              	·	
                Laboratory tests

              


      

    

    
      
        	

              	·	
                X-rays

              


      

    

    

    

    To get more information about your Preferred Provider Network, you can:

     

      

    
      
        	

              	1.	
                Call your Insurer at [x].

              


      

    

    
      
        	

              	2.	
                Call MI Salud call center at 1-800-981-2737.

              


      

    

    
      
        	

              	3.	
                Go to your Insurer’s Service Centers.

              


      

    

    
      
        	

              	4.	
                Call your Primary Medical Group.

              


      

    

    

    

    General Network

     

      

    The general network is the health care professionals and services facilities that work with your Insurer and that support the Primary Medical Groups. If the
        doctor or provider you need to see isn’t in your Preferred Provider Network, they might be in your Insurer’s General Network. You can see any doctor or provider in your Insurer’s General Network as long as you go to your PCP first to get a
        referral. If you need a referral, your PCP must give you one during your visit or within 24 hours after you ask for one.

     

      

    Your PCP will coordinate your visits to doctors or providers in the General Network.

     

      

    You might need to pay money for these visits. Look at Part 4 of this guide for more information about payments.

     

      

    If you get any of the following by a provider in the General Network, your PCP will have to sign off:

     

      

    
      
        	

              	·	
                Prescription medicine

              


      

    

    
      
        	

              	·	
                Laboratory tests

              


      

    

    
      
        	

              	·	
                X-rays

              


      

    

    

    

    
      14

      
        


    

    Out-of-Network

     

      

    A doctor or other provider who does not work with your Insurer is called an Out-of-Network provider. If you need to see a doctor or other provider who is
        out-of-network, your PCP must get an OK from your Insurer first. This OK is called a prior authorization. Your Insurer must give the prior authorization within 72 hours of getting the request. If you need the prior authorization faster because of
        your health care needs, your Insurer must give the prior authorization within 24 hours.

     

      

    If you need services from an out-of-network community health clinic, you will first need a referral from your PCP. You can get care at an out-of-network
        community health clinic for free.

     

      

    If you feel that your Insurer or your doctors are not following these rules, you can call your Insurer at [x] and tell them that you need
        to make a complaint. You can also call the Patient Advocate Office at 1-800-981-0031 or ASES at 1-800-981-2737.

     

      

    
      HELP WITH GETTING TO YOUR HEALTH CARE VISITS

    

     

      

    If you don’t have a way to get to your health care visits, your Insurer and your Municipality can help with transportation. Each Municipality has some ways to
        help you get to your visits. Call your Insurer at [x] or call your local Municipality for help.

     

      

    Your Insurer and some providers also offer transportation for some members through care management. If you need the help of a care manager and you do not have
        one, call your Insurer at [x]. Part 5 of this guide has more information on care management.

    

    

    
      15

      
        


    

    
      PART 3: SERVICES MI SALUD PAYS FOR

    

    

    

    
      GENERAL INFORMATION

    

     

      

    MI Salud offers services to keep you healthy. MI Salud works with Insurers, who coordinate with you and your doctors to help you access services you need.

     

      

    You can start getting services as soon as your Medicaid Office tells that you are eligible for the Government Health Program. You don’t have to wait.

     

      

    As a MI Salud enrollee, you have a variety of health care benefits and services available to you. Not everyone in MI Salud has the same benefits. The benefits
        that are covered for you depend on the group you’re in. Your ID card will tell you what coverage you can get.

     

        

    Listed below are the services that MI Salud covers. Some services may have limits. Call
        your Insurer at [x] if you want more information.

     

      

    
      
        	

              	·	
                Routine doctor office visits, checkups, and sick visits

              


         

        

      

    

    
      
        	

              	·	
                Well-baby visits, well-child visits, and immunizations

              


         

        

      

    

    
      
        	

              	·	
                Tests and studies, laboratory work, and X-rays

              


         

        

      

    

    
      
        	

              	·	
                Preventive services, including mammogram, colonoscopy, and well visits for adults

              


         

        

      

    

    
      
        	

              	·	
                OB/GYN exams and annual Pap tests

              


         

        

      

    

    
      
        	

              	·	
                Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, including periodic preventive health screenings and other necessary diagnostic and treatment
                    services for members ages 21 and under

              


         

        

      

    

    
      
        	

              	·	
                Nutritional evaluations and tests

              


         

        

      

    

    
      
        	

              	·	
                Vision and hearing test

              


         

        

      

    

    
      
        	

              	·	
                Prenatal and postpartum care

              


         

        

      

    

    
      
        	

              	·	
                Family planning

              


         

        

      

    

    
      
        	

              	·	
                Health certificates

              


         

        

      

    

    
      
        	

              	·	
                Dental services

              


         

        

      

    

    
      
        	

              	·	
                Physical therapy

              


         

        

      

    

    
      
        	

              	·	
                Occupational therapy

              


         

        

      

    

    
      
        	

              	·	
                Speech therapy

              


         

        

      

    

    
      
        	

              	·	
                Physician home visits

              


         

        

        
          16

          
            


        

      

    

    
      
        	

              	·	
                Pharmacy

              


         

        

      

    

    
      
        	

              	·	
                Care management and care coordination services

              


         

        

      

    

    
      
        	

              	·	
                Emergency services

              


         

        

      

    

    
      
        	

              	·	
                Post-stabilization services

              


         

        

      

    

    
      
        	

              	·	
                Mental health services

              


         

        

      

    

    
      
        	

              	·	
                Visits to specialists

              


         

        

      

    

    
      
        	

              	·	
                Community health clinic services

              


         

        

      

    

    
      
        	

              	·	
                Hospital: inpatient and/or outpatient care

              


         

        

      

    

    
      
        	

              	·	
                Mental health hospitalization and partial hospitalization

              


         

        

      

    

    
      
        	

              	·	
                Ambulatory service center services

              


         

        

      

    

    
      
        	

              	·	
                Surgery: inpatient and/or outpatient

              


         

        

      

    

    
      
        	

              	·	
                Ambulance services

              


         

        

      

    

    
      
        	

              	·	
                Outpatient rehabilitation services

              


      

    

    

    

    [PLACEHOLDER for additional services that the Insurer covers]

    

    

    
      DENTAL SERVICES

    

     

      

    MI Salud offers dental services. You can see any dentist that accepts MI Salud. You can find information about participating dentists in your Insurer’s
        Provider Directory. When you sign up with your Insurer, they will mail you a Provider Directory. The list is also on your Insurer’s website at [x]. Your Primary Medical Group and your Insurer’s Service Centers also have a copy of the list.

     

      

    For questions about your dental benefits, call your Insurer at [x].

     

      

    
      MENTAL HEALTH, ALCOHOL AND DRUG ABUSE SERVICES

    

     

      

    MI Salud offers mental health, alcohol and substances abuse services. You do not have to see your PCP first to see a doctor or other provider for mental
        health, alcohol or substances abuse services. You can ask for these services whenever you feel like you need them.

     

      

    MI Salud wants to make it easy for you to get physical and mental health, alcohol, and substance abuse services in the same place. This is called integrated
        care.

     

      

    Your Primary Medical Group is one place you can go to get mental health, alcohol or drug abuse services. Your Primary Medical Group must have a psychologist
        and/or a social worker available at least from 4 to 16 hours per week during regular business hours.

     

      

    
      17

      
        


    

    If you get mental health, alcohol or drug abuse services at another place (like a mental health clinic or a psychiatric hospital), they must have services
        from a PCP in the office at least part of the time to care for your physical health needs.

     

      

    If you need help finding mental health, alcohol and substance abuse services, call your Insurer at [x].

     

      

    
      PHARMACY SERVICES

    

    

    

    MI Salud covers prescription medicines. If you need medicine, your provider will write you a prescription to take to a participating pharmacy. You can choose
        any pharmacy that works with your Insurer. You can find a list of participating pharmacies in your Insurer’s Provider Directory. Or you can call your Insurer at [x].

     

      

    Prescription medicines are free for children up to the age of 20 and for pregnant women that





        are Medicaid or CHIP beneficiaries. Other adults will need to pay for prescription drugs. For more information on payments for prescription medicines, look at Part 4 of this guide.

     

      

    Your Covered Drugs Formulary (CDF) is the list of medicines MI Salud covers. This list helps your doctor prescribe medicines for you. Brand-name and generic
        medicines are on the CDF. A generic version of a medicine is the first choice. If a generic version of a medicine is available, your doctor has to prescribe the generic version.

     

      

    If you have a chronic condition, your doctor can write a prescription for a 90-day supply of some medicines. This way, you only have to pay for the medicine
        once instead of paying three times (1 payment per month).

     

      

    
      NON-COVERED SERVICES

    

     

      

    Here is a general list of some services that are not covered by MI Salud. You can find a full list of services that MI Salud will not pay for online at [x].
        Or, you can call your Insurer at [x] for a full list.

     

      

    Some non-covered services are:

    

    

    
      
        	

              	1.	
                Services for non-covered illnesses or trauma.

              


         

        

      

    

    
      
        	

              	2.	
                Services for automobile accidents covered by the Administration of Compensation for Automobile Accidents (ACAA, for its acronym in Spanish).

              


         

        

      

    

    
      
        	

              	3.	
                Accidents on the job that are covered by the State Insurance Fund Corporation.

              


         

        

        
          18

          
            


        

      

    

    
      
        	

              	4.	
                Services covered by another insurance or entity with primary responsibility (third party liability).

              


         

        

      

    

    
      
        	

              	5.	
                Specialized nursing services for the comfort of the Patient when they are not medically necessary.

              


         

        

      

    

    
      
        	

              	6.	
                Hospitalizations for services that can be rendered on an outpatient basis.

              


         

        

      

    

    
      
        	

              	7.	
                Hospitalization of a Patient for diagnostic services only.

              


         

        

      

    

    
      
        	

              	8.	
                Expenses for services or materials for the Patient’s comfort such as telephone, television, admission kits, etc.

              


         

        

      

    

    
      
        	

              	9.	
                Services rendered by Patient’s relative (parents, children, siblings, grandparents, grandchildren, spouse, etc.).

              


         

        

      

    

    
      
        	

              	10.	
                Organ and tissue transplants, except skin, bone and corneal transplants.

              


         

        

      

    

    
      
        	

              	11.	
                Weight control Treatments (obesity or weight increase for aesthetic reasons).

              


         

        

      

    

    
      
        	

              	12.	
                Sports medicine, music therapy and natural medicine.

              


         

        

      

    

    
      
        	

              	13.	
                Cosmetic surgery to correct physical appearance defects.

              


         

        

      

    

    
      
        	

              	14.	
                Services, diagnostic tests ordered or provided by naturopaths, and iridologists.

              


         

        

      

    

    
      
        	

              	15.	
                Health Certificates except for (i) venereal disease research laboratory tests, (ii) tuberculosis tests and (iii) any certification related to the eligibility for the
                    Medicaid program.

              


         

        

      

    

    
      
        	

              	16.	
                Mammoplasty or plastic reconstruction of breast for aesthetic purposes only.

              


         

        

      

    

    
      
        	

              	17.	
                Outpatient use of fetal monitor.

              


         

        

      

    

    
      
        	

              	18.	
                Services, Treatment or hospitalization as a result of induced, non-therapeutic abortions or their complications.

              


         

        

      

    

    
      
        	

              	19.	
                Medications delivered by a provider that does not have a pharmacy license, with the exception of medications that are traditionally administered in a doctor’s office such
                    as an injection.

              


         

        

      

    

    
      
        	

              	20.	
                Epidural anesthesia services.

              


         

        

      

    

    
      
        	

              	21.	
                Educational tests, educational services.

              


         

        

      

    

    
      
        	

              	22.	
                Peritoneal dialysis or hemodialysis services (Covered under the Special Coverage).

              


         

        

      

    

    
      
        	

              	23.	
                New or experimental procedures not approved by ASES to be included in the Basic Coverage.

              


         

        

      

    

    
      
        	

              	24.	
                Custody, rest and convalescence once the disease is under control or in irreversible terminal cases (hospice care for members under 21 is part of basic coverage).

              


         

        

      

    

    
      
        	

              	25.	
                Services covered under the Special Coverage.

              


         

        

      

    

    
      
        	

              	26.	
                Services received outside the territorial limit of the Commonwealth of Puerto Rico, except for emergency services for Medicaid or CHIP beneficiaries.

              


         

        

      

    

    
      
        	

              	27.	
                Judicial order for evaluations for legal purposes.

              


         

        

        
          19

          
            


        

      

    

    
      
        	

              	28.	
                Counseling services or referrals based on moral or religious objections of the Insurer are excluded.

              


         

        

      

    

    
      
        	

              	29.	
                Travel expenses, even when ordered by the PCP, are excluded.

              


         

        

      

    

    
      
        	

              	30.	
                Eyeglasses, contact lenses and hearing aids (for members over age 21).

              


         

        

      

    

    
      
        	

              	31.	
                Acupuncture services.

              


         

        

      

    

    
      
        	

              	32.	
                Procedures for sex changes, including hospitalizations and complications.

              


         

        

      

    

    
      
        	

              	33.	
                Treatment for infertility and/or related to conception by artificial means including tuboplasty, vasovasectomy, and any other procedure to restore the ability to procreate.

              


         

        

      

    

    
      20

      
        


    

    
      PART 4: WILL I HAVE TO PAY TO GET HEALTH CARE SERVICES?

    

     

      

    Sometimes you will have to pay to get health care services. Preventive care is care that helps you stay well, like checkups, shots, pregnancy care, and
        childbirth. This kind of care is always free. You don’t have copays for preventive care.

     

      

    For other care like hospital stays or sick child visits, you may have to pay part of the cost. Copays are what you pay for each health care service you get.

        

      

    Not everyone in MI Salud has copays. Your ID card will tell you if you have copays and what they are. Copays depend on the type of MI Salud you have. Your ID
        card says what type of MI Salud you have.

        

      

    None of your doctors or providers can refuse to give you medically necessary services because you don’t pay your copays. But, your Insurer and your providers
        can take steps to collect any copays you owe.

     

      

    You should only have to pay your copay for your care. You should not be billed for the rest of the cost of your care. If you are billed for the rest of the
        cost, you can appeal. Look at Part 7 of this guide to find out what to do if you get a bill for your care.

     

      

    
      COPAY CHARTS

    

    

    

    Do you have to pay copays for a PCP, Specialist, ER visit, hospital stay, or other type of service? Not sure? Check the chart below, look at your ID card or
        call your Insurer at [x].

     

      

    
      21

      
        


    

    

    

    

    * Copays apply to diagnostic tests only.  Copays do not apply to tests required as part of a preventive service.

    ** Copays apply to each medicine included in the same prescription pad.

    

    

    
      22

      
        


    

    
      PART 5: SPECIAL PROGRAMS

    

    

    

    
      SPECIAL COVERAGE

    

     

      

    Enrollees with special health care needs can get Special Coverage that will provide services for the care they need. The special health care needs are:

     

      

    
      
        	

              	1.	
                Aplastic Anemia

              


      

    

    
      
        	

              	2.	
                Rheumatoid Arthritis

              


      

    

    
      
        	

              	3.	
                Autism

              


      

    

    
      
        	

              	4.	
                Cancer

              


      

    

    
      
        	

              	5.	
                Skin Cancer such as Invasive Melanoma or squamous cells with evidence of metastasis.

              


      

    

    
      
        	

              	6.	
                Skin Cancer - Carcinoma IN SITU

              


      

    

    
      
        	

              	7.	
                Chronic Renal Disease

              


      

    

    
      
        	

              	8.	
                Scleroderma

              


      

    

    
      
        	

              	9.	
                Multiple Sclerosis (MS) and Amiotrophic Lateral Sclerosis (ALS)

              


      

    

    
      
        	

              	10.	
                Cystic Fibrosis

              


      

    

    
      
        	

              	11.	
                Hemophilia

              


      

    

    
      
        	

              	12.	
                Leprosy

              


      

    

    
      
        	

              	13.	
                Systemic Lupus Erythematosus(SLE)

              


      

    

    
      
        	

              	14.	
                Children with Special Health Needs

              


      

    

    
      
        	

              	15.	
                Obstetric

              


      

    

    
      
        	

              	16.	
                Tuberculosis (Tb)

              


      

    

    
      
        	

              	17.	
                HIV/AIDS

              


      

    

    
      
        	

              	18.	
                Adults with phenylketonuria (PKU)

              


      

    

    
      
        	

              	19.	
                Pulmonary Hypertension

              


      

    

     

      

    Your PCP or your Primary Medical Group can give you more information on which people qualify for the special coverage. If you qualify for Special Coverage,
        they can also help you sign up for it.

     

      

    People with Special Coverage can choose any provider that works with your Preferred Provider Network or your Insurer’s General Network. People with Special
        Coverage can get prescription medications, tests and other services through the Special Coverage without a referral or needing their PCP to sign off.

     

      

    Your Insurer will let you know if you are qualified and will if you are must make sure that you get access to the services. MI Salud Special Coverage will
        begin when the enrollee reaches the limits of the Special Coverage for any other health plan.

     

      

    
      The benefits under Special Coverage include the list below. Some services may have limits. Contact your Insurer at [x] if you want more information.

      

      

    

    
      
        	

              	·	
                Coronary disease services and intensive care

              


         

        

      

    

    
      
        	

              	·	
                Maxillary surgery

              


         

        

      

    

    
      
        	

              	·	
                Neurosurgical and cardiovascular procedures

              


         

        

        
          23

          
            


        

      

    

    
      
        	

              	·	
                Peritoneal dialysis and related services

              


         

        

      

    

    
      
        	

              	·	
                Clinical services and laboratory tests

              


         

        

      

    

    
      
        	

              	·	
                Neonatal intensive care unit services

              


         

        

      

    

    
      
        	

              	·	
                Chemotherapy, radiology and related services

              


         

        

      

    

    
      
        	

              	·	
                Gastrointestinal conditions, allergies and nutritional evaluation for autistic patients

              


         

        

      

    

    
      
        	

              	·	
                Procedures and diagnostic tests, when medically necessary

              


         

        

      

    

    
      
        	

              	·	
                Physical therapy

              


         

        

      

    

    
      
        	

              	·	
                General Anesthesia

              


         

        

      

    

    
      
        	

              	·	
                Hyperbaric chamber

              


      

    

    
      
         

        

        	

              	·	
                Immunosuppressive medicines and laboratory tests for patients who have received transplants

              


      

    

    
      
         

        

        	

              	·	
                Treatment for specific conditions after diagnosis:

              


      

    

    
      
         

        

        	

              	✓	
                Positive HIV Factor and Acquired Immunodeficiency Syndrome (AIDS) – Ambulatory and hospitalization services are included. You do not need a Referral or Prior-Authorization from your Insurer or your PCP for visits and treatment at the Immunology
                    Regional Clinics of the Health Department;

              


         

        

      

    

    
      
        	

              	✓	
                Tuberculosis;

              


         

        

      

    

    
      
        	

              	✓	
                Leprosy;

              


         

        

      

    

    
      
        	

              	✓	
                Lupus;

              


         

        

      

    

    
      
        	

              	✓	
                Cystic fibrosis;

              


         

        

      

    

    
      
        	

              	✓	
                Cancer;

              


         

        

      

    

    
      
        	

              	✓	
                Hemophilia;

              


         

        

      

    

    
      
        	

              	✓	
                Aplastics Anemia;

              


         

        

      

    

    
      
        	

              	✓	
                Reumatoid Artritis ;

              


         

        

      

    

    
      
        	

              	✓	
                Autism;

              


         

        

      

    

    
      
        	

              	✓	
                OBG Obstetricians;

              


         

        

      

    

    
      
        	

              	✓	
                Post Organ Transplantation; and

              


         

        

      

    

    
      
        	

              	✓	
                Children with special needs. Except:

              


         

        

      

    

    
      
        	

              	o	
                Asthma and diabetes (Part of the Disease Management Program),

              


         

        

      

    

    
      
        	

              	o	
                Psychiatric disorders, and

              


         

        

      

    

    
      
        	

              	o	
                Catastrophic diseases for persons with Intellectual disabilities

              


         

        

      

    

    
      
        	

              	·	
                Scleroderma

              


         

        

      

    

    
      
        	

              	·	
                Multiple Sclerosis (MS) and Amyotrophic Lateral Sclerosis (ALS)

              


         

        

        
          24

          
            


        

      

    

    
      
        	

              	·	
                Services for the Treatment of conditions resulting from self-inflicted damage or as a result of a felony committed by a beneficiary or negligence.

              


         

        

      

    

    
      
        	

              	·	
                Chronic renal disease

              


         

        

      

    

    
      
        	

              	·	
                Medications required for the ambulatory Treatment of Tuberculosis and Leprosy

              


      

    

    

    

    
      SPECIAL COVERAGE FOR HIV-AIDS

    

     

      

    If you have HIV or AIDS, your PCP must ask your Insurer to give you Special Coverage. Once your Insurer adds you to Special Coverage, they will mail you a letter letting you know that you can get services under Special Coverage. The letter will let you know when the Special Coverage starts and when it will stop.

     

      

    Once you have the letter, you can get all services and treatments for your condition like prescription medicines, laboratory tests, x-rays and other services
        without your PCP needing to sign off.

     

      

    You must get your prescription medicines for HIV/AIDS at the Department of Health’s Centers for Prevention and Treatment of Communicable Diseases. Here they
        are:

     

      

    Centers for the Prevention and Treatment of Communicable Diseases
            (CPTET, for its acronym in Spanish)

            

          

    	
            REGION

          	 	
            TELEPHONE/FAX

          	 	
            ADDRESS

          
	 	 	 	 	 
	
            ARECIBO

          	 	
            (787)  878-7895

            Fax. (787) 881-5773

            Fax. (787)  878-8288

            Tel. (787)  879-3168

          	 	
            Antiguo Hosp. Distrito (Dr Cayetano Coll y Toste)

            Carretera 129 hacia Lares

            Arecibo, PR 00614

            

            

             

              

            PO Box 140370

            Arecibo, PR  00614

          
	 	 	 	 	 
	
            BAYAMON

          	 	
            (787)  787-5151

            Ext. 2224, 2475

            (787)  787-5154

            Fax. (787)   778-1209

            (787)  787-4211

          	 	
            Antigua Casa de Salud

            Hosp. Regional Bayamón

            Dr. Ramón Ruíz Arnau,

            Ave. Laurel Santa Juanita

            Bayamón, PR  00956

          
	 	 	 	 	 
	
            CAGUAS

             

              

            
              


             

              

            CLINICA SATELITE

            HUMACAO

          	 	
            (787)  653-0550

            Ext. 1142, 1150

            
              Fax (787)  746-2898;  744-8645

               
                


            

             

             (787)  285-5660

          	 	
            Hosp. San Juan Bautista

            PO Box 8548

            Caguas, PR    00726-8548

             

              

            
              
 

             

              

            CDT de Humacao, Dr. Jorge Franceshi

            
              Calle Sergio Peña Almodovar

              Esq. Flor Gerena

              Humacao, Puerto Rico 00791

            

          


    

    

    
      25

      
        


    

    	
            CAROLINA

          	 	
            (787)757-1800

             

              

            Ext. 454, 459

             

              

            Fax (787)765-5105

          	 	
            Hospital UPR Dr. Federico Trilla

            P. O. Box 6021

            Carolina, PR  00984-6021

            Carretera 3, Km. 8.3

          
	 	 	 	 	 
	
             

            CLETS

             

          	 	
            (787)754-8118

             

            (787)754-8128

             

            (787)754-8127

          	 	
            P. O. Box 70184

            San Juan, PR  00936-8523

             

              

            
              


             

              

            Calle José Celso Barbosa

            Centro Médico de PR

            Bo. Monacillos, San Juan

          
	 	 	 	 	 
	
            FAJARDO

             

          	 	
            (787)801-1992

             

            (787)801-1995

          	 	
            Calle San Rafael # 55

            Fajardo, PR  00738

          
	 	 	 	 	 
	
            MAYAGUEZ

             

          	 	
            (787)834-2115

             

              

            (787)834- 2118

             

          	 	
            Centro Médico de Mayagüez

            Hospital Ramón Emeterio Betances

            Carr.# 2 Suite 6

            Mayagüez, PR  00680

          
	 	 	 	 	 
	
            PONCE

             

             

             

             

          	 	
             (787)842-0948

             

            (787)842-2000

          	 	
            Departamento de Salud

            Región Ponce

            Antiguo Hosp. Distrito Ponce

            Dr. José Gándara

            Carretara Estatal 14

            Bo. Machuelo

            Ponce, PR  00731

          
	 	 	 	 	 
	
            CENTRAL

            OFFICE

          	 	
            (787)765-2929

             

              

            Ext. 4026, 4027

                

              

            Fax (787)274-5523

          	 	
            P.O.  Box 70184

            San Juan, PR  00936

             

            Ant. Hosp. Psiquiatría

            Pabellón 1, primer piso, 4ta. Puerta -  Terrenos de Centro Médico, Río Piedras

             

          


    

    

    
      CARE MANAGEMENT

    

     

      

    Some people with high needs and special conditions can receive Care Management. If you are eligible for Care Management, nurses, social workers and
        nutritionists are available to help you create a plan for your care. Your team will review your care plan with you at least once a year, if your health needs change, or if you ask for a review.

     

      

    
      26

      
        


    

    You can ask for help through this program by calling your Insurer at [x]. Your doctor, your family, your hospital can also ask for you.

     

      

    For more information call your Insurer at [x].

     

      

    
      HIGH COST HIGH NEEDS PROGRAM

    

     

      

    If you have certain conditions, you may benefit from your Insurer’s High Cost High Needs program to help you get all the care you need. This program is free.

     

      

    If your PCP tells you that you have:

        

      

    
      
        	

              	·	
                Cancer

              


      

    

    
      
        	

              	·	
                End-Stage Renal Disease (ESRD)

              


      

    

    
      
        	

              	·	
                Multiple Sclerosis

              


      

    

    
      
        	

              	·	
                Rheumatoid Arthritis

              


      

    

    
      
        	

              	·	
                Diabetes

              


      

    

    
      
        	

              	·	
                Asthma

              


      

    

    
      
        	

              	·	
                Severe Heart Failure

              


      

    

    
      
        	

              	·	
                Hypertension

              


      

    

    
      
        	

              	·	
                Chronic Obstructive Pulmonary Disease (COPD)

              


      

    

    
      
        	

              	·	
                Depression

              


      

    

    
      
        	

              	·	
                Attention-Deficit/Hyperactivity Disorder (ADHD)

              


      

    

    
      
        	

              	·	
                Substance Use Disorders

              


      

    

    
      
        	

              	·	
                Serious Mental Illness (SMI)

              


      

    

    
      
        	

              	·	
                Hemophilia

              


      

    

    
      
        	

              	·	
                Autism

              


      

    

    

    

    Your Insurer will offer you extra help with getting care. Your Insurer may want to send someone to your home to talk to you about your needs and learn which,
        doctors, tests or other help is needed. Talking to the Insurer about your needs will help them understand the best ways to help you.

     

      

    [PLACEHOLDER for Insurer to add information about High Cost High Needs
          Program]

     

      

    
      [PLACEHOLDER for Insurer to add information about any other special programs]

    

    

    

    
      27

      
        


    

    
      PART 6: FOR YOUR PROTECTION

    

    

    

    
      YOUR RIGHTS

    

     

      

    You have the right to:

     

      

    
      
        	

              	·	
                Be treated with respect and in a dignified way.

              


         

        

      

    

    
      
        	

              	·	
                Get written information from your Insurer in English and Spanish and translated into any other language. You also have the right to get written information in an alternative format. Afterwards, you have the right to get all future written information in that same format or language, unless you tell your Insurer otherwise.

              


         

        

      

    

    
      
        	

              	·	
                Get information about your Insurer, health care facilities, health care professionals, health
                    services covered, and how to access services.

              


         

        

      

    

    
      
        	

              	·	
                Choose a Primary Medical Group, your PCP, and other doctors and providers within your Preferred Provider Network.

              


         

        

      

    

    
      
        	

              	·	
                Choose a dentist and a pharmacy among your Insurer’s network.

              


         

        

      

    

    
      
        	

              	·	
                Contact your doctors when you want to and in private

              


         

        

      

    

    
      
        	

              	·	
                Get medically necessary care that is right for you, when you need it. This includes getting emergency services, 24 hours a day, 7 days a week.

              


         

        

      

    

    
      
        	

              	·	
                Be told in an easy-to-understand way about your care and all of the different kinds of treatment that could work for you, no matter what they cost or even if they aren’t
                    covered.

              


         

        

      

    

    
      
        	

              	·	
                Help to make decisions about your health care. You can turn down care.

              


         

        

      

    

    
      
        	

              	·	
                Ask for a second opinion for a diagnosis or treatment plan.

              


         

        

      

    

    
      
        	

              	·	
                Make an Advanced Directive. Look at Part 6 of this guide for more information.

              


         

        

      

    

    
      
        	

              	·	
                Get care without fear of physical restraint or seclusion used for bullying, discipline, convenience or revenge.

              


         

        

      

    

    
      
        	

              	·	
                Ask for and get information about your medical records as the federal and state laws say. You can see your medical records, get copies of your medical records, and ask to
                    correct your medical records if they are wrong.

              


         

        

      

    

    
      
        	

              	·	
                File a complaint or an appeal about your Insurer or your care. Look at Part 6 of this guide for more information. The complaint can be filed in your Insurer’s office or in
                    the Patience Advocate office.

              


         

        

      

    

    
      
        	

              	·	
                Get services without being treated in a different way because of race, color, birthplace, language, sex, age, religion, or disability. You have a right to file a complaint
                    if you think you have been treated unfairly. If you complain or appeal, you have the right to keep getting care without fear of bad treatment from your Insurer, providers, or MI Salud.

              


         

        

      

    

    
      
        	

              	·	
                Choose an Authorized Representative to be involved in making decisions.

              


      

    

    
      
         

        

        
          28

          
            


        

        	

              	·	
                Provide informed consent.

              


         

        

      

    

    
      
        	

              	·	
                Only have to pay the amounts for services listed in Part 4 of this guide. You can’t be charged more than those amounts.

              


         

        

      

    

    
      
        	

              	·	
                Be free from harassment by your Insurer or its Network Providers with respect to contractual disputes between the Insurer and its Providers;

              


         

        

      

    

    
      YOUR RIGHT TO PRIVACY (HIPAA)

    

     

      

    Your health information is private. The law says that ASES and your Insurer must protect your information. ASES and your Insurer can share your information
        for your care, to pay your health claims, and to run the program. But we can’t share your information with others unless you tell us we can. If you want to know more about what information we have, how we can share it, or what to do if you don’t
        want your health information shared with certain people, call your Insurer.

     

      

    
      YOUR RESPONSIBILITIES

    

     

      

    You have the responsibility to:

     

      

    
      
        	

              	·	
                Understand the information in your guide and other papers that your Insurer sends you.

              


         

        

      

    

    
      
        	

              	·	
                Give your doctor your health records and let them know about any changes in your health so that they can take care of you.

              


         

        

      

    

    
      
        	

              	·	
                Follow your doctor’s instructions. If you can’t follow your doctor’s instructions, let them know.

              


         

        

      

    

    
      
        	

              	·	
                Let your doctor know if you don’t understand something.

              


         

        

      

    

    
      
        	

              	·	
                Help to make decisions about your health care.

              


         

        

      

    

    
      
        	

              	·	
                Communicate your Advance Directive so your doctors know how you want to be treated if you are too sick to say
                      so.

              


         

        

      

    

    
      
        	

              	·	
                Treat your health care provider and your Insurer’s staff with respect and dignity.

              


         

        

      

    

    
      
        	

              	·	
                Let your Insurer know if you have another insurance company that should pay your medical care.

              


         

        

      

    

    
      
        	

              	·	
                Let ASES know if you find out about a case of fraud and abuse in MI Salud.

              


         

        

      

    

    
      ADVANCE DIRECTIVES

    

     

      

    Advance Directives are your written wishes about what you want to happen, if you get too sick to be able to say. The written document that states your Advance
        Directives is called a living will. You can use either word: advance directive or living will.

     

      

    Your doctor can give you information on how to make an Advance Directive. If you are in the hospital, the hospital staff can also give you information on
        Advance Directives. You can also call the Senior Citizens Advocate Office at 787-721-6121. They have free information about Advanced Directives.

     

      

    
      29

      
        


    

    A Durable Power of Attorney is a paper that lets you name another person to make medical decisions for you. This person can only make decisions if you are too
        sick to make your own. He or she can say your wishes for you if you can’t speak for yourself. Your illness can be temporary.

     

      

    You do not have to fill out these papers for an Advance Directive or Durable Power of Attorney. It is your choice. You may want to talk to a lawyer or friend
        before you fill out these papers.

     

      

    To make all of these papers legal, you need to have a lawyer watch you sign the form. Instead of a lawyer, you could also have your doctor plus two additional
        witnesses watch you sign the form. The two additional witnesses have to be of legal age and they can’t be related to you by blood or marriage.

     

      

    Once the papers are signed by everyone, it is your rule about what you want to happen to you if you get too sick to be able to say. It stays like this unless
        you change your mind.

    

    

    These papers will only be used if you get too sick to be able to say what you want to happen. As long as you can still think for yourself, you can decide
        about your health care yourself.

     

      

    Give a copy of the papers to your PCP and to your family members so they know what you want to happen to you if you are too sick to say.

     

      

    If you feel that your Insurer or your doctors aren’t complying with your wishes, or if you have any complaints, you have the right to call the MI Salud call
        center at 1-800-981-2737 or the Puerto Rico Patient Advocate Office at 1-800-981-0031. The phone call is free.

     

      

    
      FRAUD AND ABUSE

    

     

      

    Unfortunately, there could be a time when you see fraud or abuse related to MI Salud. Some examples are:

     

      

    
      
        	

              	·	
                A person lies about facts to get or keep MI Salud coverage

              


         

        

      

    

    
      
        	

              	·	
                A doctor bills you or makes you pay cash for covered services

              


         

        

      

    

    
      
        	

              	·	
                A person uses someone else’s ID card

              


         

        

      

    

    
      
        	

              	·	
                A doctor bills for services that you did not get

              


         

        

      

    

    
      
        	

              	·	
                A person sells or gives medications to someone else

              


      

    

    

    

    
      30

      
        


    

    If you find out about fraud or abuse, you must tell us about it. You can call your Insurer, the Patient’s Advocate Office or ASES. You do not need to tell us
        your name and we will keep your information private. You will not lose your MI Salud coverage if you report fraud or abuse.

     

      

    If you want more information, you can visit the ASES website at www.asespr.org. On the website there is a form that you can use to make your report. Your Insurer’s website also has more information.

     

          

    You can also help prevent fraud and abuse. Here are some things you can do:

     

      

    
      
        	

              	·	
                Don’t give your ID card to anyone else.

              


         

        

      

    

    
      
        	

              	·	
                Learn about your MI Salud benefits.

              


         

        

      

    

    
      
        	

              	·	
                Keep records of your doctor’s visits, laboratory tests and medications. Make sure you don’t get repeat services.

              


         

        

      

    

    
      
        	

              	·	
                Make sure your information is right on a form before you sign it.

              


         

        

      

    

    
      
        	

              	·	
                Request and review the quarterly summary of the services you receive. You may request the summary of services directly from your Insurer.

              


         

        

      

    

    
      31

      
        


    

    
      PART 7: COMPLAINTS AND APPEALS

    

    

    

    
      NEED TO MAKE A COMPLAINT ABOUT YOUR CARE?

    

     

      

    If you are not happy with the care that you are getting, call your Insurer at [x]. Tell them that you need to make a complaint. You can also visit your
        Insurer’s Service Centers. You can make a complaint at any time.

     

      

    Your doctor, a family member, or your representative can make a complaint for you if you authorize them to do so.

        

      

    You also have the right to call the Patient Advocate Office to make a complaint. Their number is 1-800-981-0031. You can also make a complaint to ASES. Their
        number is 1-800-981-2737.

     

      

    No one can do anything bad to you if you make a complaint.

     

      

    Your Insurer has 72 hours to fix your complaint. If they can’t fix your complaint quickly, it will become a “grievance”. In this case, your Insurer has up to
        90 days to fix it, but they have to decide faster if it’s important to your health. The Insurer must tell you how the complaint was fixed.

     

      

    
      WHAT HAPPENS IF MY COMPLAINT ISN’T FIXED?

    

     

      

    If your Insurer does not fix your complaint, you can ask for a hearing. A hearing is where you can tell a judge about the issue.

     

      

    
      WHAT IS AN APPEAL?

    

     

      

    If your doctors or your Insurer make a decision about your care that you don’t agree with, you can file an appeal. When you appeal, you’re asking your Insurer
        to take another look at a mistake you think was made.

     

      

    If your Insurer denies, reduces, limits, suspends, or ends your health care services, they will send you a letter in the mail. The letter will have
        information like:

     

      

    
      
        	

              	·	
                What decision your Insurer made

              


         

        

      

    

    
      
        	

              	·	
                Why they made the decision

              


         

        

      

    

    
      
        	

              	·	
                How to file an appeal

              


      

    

     

      

    If you don’t agree with the decision, you can file an appeal. You have 60
          days from the date of the letter to file an appeal. Your doctor or your representative can file the appeal for you if you authorize them to do so.

     

      

    
      32

      
        


    

    There are many ways to file an appeal. You can:

     

      

    
      
        	

              	·	
                Call your Insurer at [x]

              


         

        

      

    

    
      
        	

              	·	
                Visit any of your Insurer’s service centers

              


         

        

      

    

    
      
        	

              	·	
                Mail your Insurer your appeal at [x].

              


      

    

    

    

    [PLACEHOLDER for link to forms to mail for appeals or location]

     

      

    
      WHAT WILL HAPPEN WHEN MY INSURER GETS THE APPEAL?

    

     

      

    Your appeal will be reviewed by a team of experts that have not been involved with the issue of your appeal. Your Insurer will make a decision within 30 days.
        If you have an emergency and your Insurer agrees that you do, you can ask for an expedited or fast appeal. You, your doctor, or your representative can ask for a fast appeal by calling your Insurer at [x], visiting any of your Insurer’s service
        centers, or writing a letter to your Insurer at [x].

     

      

    If your Insurer agrees to give you a fast appeal, they will decide your case within 72 hours. If your Insurer does not agree to give you a fast appeal, they
        will call you within 2 days to let you know they will decide your case within 30 days.

     

      

    If your Insurer can’t make a decision within 30 days, they can ask for up to 14 more days. If they ask for more time, they have to let you know why. If you do
        not agree to give your Insurer more time, you can file a complaint.

     

      

    Once your Insurer makes a decision, they will send you a letter within 2 business days. The letter will tell you what they decided and that you have the right
        to ask for a hearing if you do not agree with the decision.

     

      

    
      WHAT CAN I DO IF I DON’T AGREE WITH THE DECISION?

    

     

      

    If you are not happy with your Insurer’s decision about a complaint or an appeal, you can ask for a hearing. A hearing is where you can tell an Official
        Examiner about the mistake you think your Insurer made. You have 120 days from the date of your Insurer’s decision to ask for an Administrative Hearing with ASES.

     

      

    You can get more information about hearings or request a hearing by:

     

      

     
      	
              Calling the MI Salud call center at: 

              

            	
              1-800-981-2737

            
	
               

            	
               

            
	
              Writing ASES at:

            	
               ASES

            
	 	PO Box 195661
	 	San Juan, PR 00919-5661
	 	 
	Sending ASES a fax to:  

            	787-474-3347


    

     

      

    
      33

      
        


    

    Before the hearing, you and your representative can ask to look at the papers and records that your Insurer will use. Your Insurer must give you access to
        those papers and records for free.

     

      

    During the hearing, you can give facts and proof about your health and medical care. An Official Examiner will listen to everyone’s side. At the hearing, you
        can talk for yourself or you can bring someone else to talk for you like a friend or a lawyer.

     

      

    The Official Examiner will decide your case within 90 days. If you need a fast decision, the Official Examiner will decide your case within 72 hours.

     

      

    If you do not agree with the Official Examiner’s decision, you can file an appeal with the Court of Appeals of Puerto Rico. More information about how to file
        an appeal will be in the papers you get after the hearing.

     

      

    
      CAN I KEEP GETTING SERVICES DURING MY APPEAL OR HEARING?

    

     

      

    If you are already getting services, you may be able to keep getting services during your appeal or hearing. To keep getting services, all of these things
        must be true:

     

      

    
      
        	

              	·	
                You file the appeal within 60 days of the date on the letter from your Insurer.

              


         

        

      

    

    
      
        	

              	·	
                You ask to keep getting services by the date your care will stop or change or within 10 days of the date on the letter from your Insurer (whichever date is later).

              


         

        

      

    

    
      
        	

              	·	
                You say in your appeal that you want to keep getting services during the appeal.

              


         

        

      

    

    
      
        	

              	·	
                The appeal is for the kind and amount of care you’ve been getting that has been stopped or changed.

              


         

        

      

    

    
      
        	

              	·	
                You have a doctor’s order for the services (if one is needed).

              


         

        

      

    

    
      
        	

              	·	
                The services are something that MI Salud still covers.

              


      

    

    

    

    If you keep getting services during your appeal or hearing and you lose, you might have to pay your Insurer back for the services you got during the appeal or
        hearing process.

     

      

    To ask to keep getting services during your appeal or hearing, call your Insurer at [x].

     

      

    
      34

      
        


    

    
      PART 8: HOW MI SALUD WORKS WITH OTHER HEALTH INSURANCE

    

    

    

    
      HOW MI SALUD WORKS WITH MEDICARE

    

     

      

    If you have Medicare, your MI Salud coverage works in a different way. Medicare is health insurance for people who are age 65 and older, and for some people
        of any age who Social Security says are disabled. People with end stage renal disease can have Medicare too.

     

      

    These are the different parts of Medicare:

     

      

    
      
        	

              	·	
                Part A is for hospital stays, skilled nursing facility care, home health care, and
                    hospice care.

              


      

    

    
      
        	

              	·	
                Part B is for your doctor’s services and outpatient care.

              


      

    

    
      
        	

              	·	
                Part D is for prescription medicines.

              


      

    

    

    

    There are also other ways to have Medicare. These are called Medicare Health Plans (these plans are sometimes called Medicare Part C). These plans put all of
        the parts A, B, and D together for you in one plan.

     

      

    To learn more about Medicare, call them at 1-800-633-4227. It’s a free call.

     

      

    If you have Medicare, your MI Salud coverage works differently:

     

      

    
      
        	

              	·	
                Your Medicare is your first (primary) insurance. Hospitals, doctors and other health care providers will bill Medicare first.

              


      

    

    
      
        	

              	·	
                Your MI Salud is your second (secondary) insurance. After your providers bill Medicare, they will also bill MI Salud.

              


      

    

    

    

    If you have Medicare Part A:

     

      

    
      
        	

              	·	
                MI Salud will pay once you have reached the limit of what Medicare pays for.

              


      

    

    
      
        	

              	·	
                MI Salud will not pay for your Part A deductibles.

              


      

    

    
      
        	

              	·	
                You will pay a copay for services depending on what type of MI Salud you have. See the copay chart on page [x] for more information.

              


      

    

    

    

    If you have Medicare Part A and Part B:

     

      

    
      
        	

              	·	
                MI Salud will pay for your pharmacy and dental services.

              


      

    

    
      
        	

              	·	
                MI Salud will not pay for your Part A deductibles.

              


      

    

    
      
        	

              	·	
                MI Salud will pay for your Part B Deductibles and Copayments.

              


      

    

    

    

    
      35

      
        


    

    If you have Medicare Part C:

     

      

    
      
        	

              	·	
                You have the option to choose a Platino plan, which will cover services your Medicare health plan doesn’t cover.

              


         

        

      

    

    
      HOW MI SALUD WORKS WITH OTHER INSURANCE

    

     

      

    If you have other health insurance, your other insurance is your first (primary) insurance. Hospitals, doctors and other health care providers will bill your
        other insurance first. Your MI Salud is your second (secondary) insurance. After your providers bill your other insurance, they will bill MI Salud.

     

      

    If you have other health insurance, you must let your Insurer and Medicaid Program know. Call your Insurer and the Medicaid Program at [x] to let them know.

     

      

    When you go to your health care visits, bring your MI Salud ID card and your ID cards for your other insurance.

     

      

    
      HOW MI SALUD WORKS IF YOU ARE A PUBLIC EMPLOYEE OR RETIREE

    

     

      

    If you are a public employee or a retiree from the Government of Puerto Rico, you can choose MI Salud as your health insurance. Your employer will pay ASES
        and you will pay the difference, if any.

     

      

    You can also visit your local Medicaid Office to see if you are eligible for MI Salud for other reasons. If you are eligible for MI Salud for other reasons,
        you will not have to pay the difference, if any. If you and your husband (or wife) are public employees or retirees from the Government of Puerto Rico, you can apply together for MI Salud. This is called “joint enrollment.”

     

      

    If at any time you lose eligibility for MI Salud, you can sign up for MI Salud in the ELA Puro group. That way, you can continue getting your MI Salud
        benefits until you can get insurance through your job. You do not have to continue as ELA Puro. It is your choice!

     

      

    If you get other health insurance from your job, you have to cancel your MI Salud benefits before you sign up for the other health insurance. Visit your local Medicaid office to cancel your MI Salud benefits. The change will be effective the first day of the next month after you cancel your benefits. If you
        do not cancel your benefits, you will have to pay for part of the cost of the premium for the new insurance you affiliate with.

     

      

    
      36

      
        


    

    
      HOW MI SALUD WORKS IF YOU ARE A MEMBER OF THE POLICE DEPARTMENT OF PUERTO RICO

    

     

      

    The members of the Police Department of Puerto Rico, their spouses and children may also enroll in MI Salud. The Police Department of Puerto Rico will pay.

     

      

    If you are a member of the Police Department of Puerto Rico, you must visit your local Medicaid Office to sign up for MI Salud.

        

      

    If a member of the Police Department of Puerto Rico dies, his/her widow can continue to get MI Salud benefits until he/she remarries. Children can continue to
        get MI Salud benefits up to the age of 26.

     

      

    
      37

      
        


    

    
      DEFINITIONS

    

     

        

    Appeal: A request from the enrollee for the review of a decision.
        It is a formal request made by the enrollee, his authorized representative or provider, acting on behalf of the enrollee with the consent of the enrollee, to reconsider a decision in the case that the provider does not agree.

     

      

    Authorization:  A written document through which  a person freely
        and voluntarily authorizes  another person or provider to represent, him/her for medical or treatment purposes or to initiate an action such as a grievance. It may also be used to end a previous authorization.

     

      

    Benefits: The health care services covered under MI Salud.

     

      

    CHIP:  Children Health Insurance Program, a federal program that provides medical services to low-income children age 21 and under, through Insurers qualified to offer coverage under this program.

        

      

    Commonwealth Population: Individuals, regardless of age, who meet
        State eligibility standards established by the Puerto Rico Medicaid Program but do not qualify for Medicaid or CHIP.

     

      

    Complaint: An expression of dissatisfaction about any issue that
        is not an Adverse Benefit Determination that is resolved at the point of contact.

     

      

    Coordinated Care:  Is the service provided to Enrollees by
        doctors who are part of the preferred network of providers in your Primary Medical Group. The PCP is the leading provider of services and is responsible to periodically evaluate your health and coordinate all medical services you need.

     

      

    Copayment: Money you need to pay at the time of service.

     

      

    Covered Services: Services and benefits included in MI Salud.

     

      

    ELA Puro: An option available to public employees so they can maintain medical coverage when they lose eligibility in the Medicaid Program and the enrollment for other Insurers contracted under Law 95 has ended. This
        coverage is the same as the coverage of MI Salud.

     

      

    Emergency Medical Condition: A medical problem so serious that
        you must seek care right away to avoid severe harm.

        

      

    Emergency Services: Treatment of an emergency medical condition
        to keep it from getting worse.

     

      

    Enrollee: A person who after being certified as eligible under
        the Medicaid program has completed the enrollment process with the Insurer and for whom the Insurer has issued the ID card that identifies the person as a MI Salud Enrollee.

     

      

    
      38

      
        


    

    Enrollment Counselor: An individual or entity that performs
        choice counseling, or enrollment activities, or both.

     

      

    Grievance: A formal claim made by the Enrollee in writing, by
        telephone or by visiting your Insurer or the Health Advocate Office, requesting a solution be granted when a service has been denied or allowed on a limited basis. A service;
        reduction, suspension or termination of a previously authorized service; total or partial denial of payment for a service; not having received services in a timely manner; when your Insurer has not acted on a situation according to the established
        terms, refusal of your Insurer to let the Enrollee exercise his/her right to receive services outside the network

     

      

    HIPAA (Health Insurance Portability and Accountability Act): The
        law that includes regulations for establishing safe electronic health records that will protect the privacy of a person’s medical information and prevent the misuse of this information.

     

      

    High Cost High Needs Program:  A specialized program of coordinated care for Enrollees with specific conditions that require additional management due to the cost or elevated needs associated with the condition.

     

      

    Hospital: A facility that provides medical-surgical services to
        patients.

     

      

    Insurer: The company contracted with ASES to provide your medical
        services under MI Salud.

     

      

    Medical Record: Detailed collection of data and information on
        the treatment and care the Patient receives from a health professional.

     

      

    Medically Necessary: Services related to (i) the prevention,
        diagnosis, and Treatment of health impairments; (ii) the ability to achieve age-appropriate growth and development; or (iii) the ability to attain, maintain, or regain functional capacity. Additionally, Medically Necessary services must be:

     

      

    
      
        	

              	·	
                Appropriate and consistent with the diagnosis of the treating provider and not getting could adversely affect your medical condition;

              


         

        

      

    

    
      
        	

              	·	
                Compatible with the standards of acceptable medical practice in the community;

              


         

        

      

    

    
      
        	

              	·	
                Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the symptoms;

              


         

        

      

    

    
      
        	

              	·	
                Not provided solely for your convenience or the convenience of the Provider or Hospital; and

              


         

        

      

    

    
      
        	

              	·	
                Not primarily custodial care (for example, foster care).

              


      

    

     

      

    In order for a service to be Medically Necessary, there must be no other effective and more conservative or substantially less costly Treatment, service,
        or setting available.

     

      

    Medicaid: Program that provides health insurance for people with
        low or no income and limited resources, according to federal regulations.

     

      

    
      39

      
        


    

    Primary Care Physician (PCP): A licensed medical doctor (MD) who
        is a provider and who, within the scope of practice and in accordance with Puerto Rico Certification and licensure requirements, is responsible for providing all required primary care to Enrollees.   The PCP is responsible for determining services
        required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary.  A PCP may be a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or pediatrician.

     

        

    Patient: Person receiving Treatment for his mental and physical
        health.

     

      

    Prescription: Original written order issued by a duly licensed
        health professional, ordering the dispensing of a product,  or formula.

     

      

    Preferred Provider Network: Health professionals duly licensed to
        practice medicine in Puerto Rico contracted by your Insurer for the Enrollee to use as the first option. Enrollees can access these providers without Referral or co-payments if
        they belong to their Primary Medical Group.

     

        

    Primary Medical Group: Health professionals grouped to contract
        with your Insurer to provide health services under a Coordinated Care model.

     

      

    Prior-Authorization: Permission your Insurer grants in writing to you, at the request of the PCP, Specialist or sub-specialist, to obtain a specialized service.

     

      

    Referral: Written authorization a PCP gives to an Enrollee to
        receive services from a Specialist, sub-specialist or facility outside the preferred network of the Primary Medical Group.

     

      

    Specialist: A health professional licensed to practice medicine and surgery in Puerto Rico that provides specialized medical and complementary services to the primary physicians. This category includes: cardiologists, endocrinologists,
        neurologists, surgeons, radiologists, psychiatrists, ophthalmologists, nephrologists, urologists, physiatrists, orthopedists, and other physicians not included in the definition of PCP.

     

      

    Second Opinion: Additional consultation the Enrollee makes to another
        physician with the same medical specialty to receive or confirm that the initially recommended medical procedure is the Treatment indicated for his condition.

     

        

    Treatment: To provide, coordinate or manage health care and related services offered by health care providers.

    

      40

     

  








  
     Attachment 4

    

     

    

    Ryan White Clinics

    

    

    Attachment 4

    

    

    Version 10.1.18
      

      

      
        
          


        
          
            PUERTO RICO DEPARTMENT OF HEALTH

            OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

            HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

            RYAN WHITE PART B PROGRAM

          

           

        

      

    

    TELEPHONE DIRECTORY

    CLINICS AND PHARMACIES

    ADAP

    

    

    Department of Health

    Ryan White Part B/ADAP

    

    

    
      

      

    

    
      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    TABLE OF CONTENTS

    

    

    	
            ARECIBO REGION

          	 
	
            CPTET Arecibo – Clínica de Inmunología

          	
            1

          
	
            Centro de Salud de Lares, Inc.

          	
            2

          
	
            Centro de Salud de Quebradillas

          	
            3

          
	
            Camuy Health Services, Inc.

          	
            4

          
	
            Corporación de Servicio Médicos Primarios y Prevención de Hatillo

          	
            5

          
	
            Ciales Primary Health Care Services, PRYMED

          	
            6

          
	
            Hospital General de Castañer

          	
            7

          
	
            Morovis Community Health Center

          	
            8

          
	 	 
	
            BAYAMÓN REGION

          	 
	
            Salud Integral en la Montaña, Inc. – SIM Oficina Central

          	
            9

          
	
            Centro de Salud Integral de Naranjito

          	
            10

          
	
            Centro de Salud Integral de Barranquitas

          	
            11

          
	
            Centro de Salud Integral de Comerío

          	
            12

          
	
            Centro de Salud Integral de Corozal

          	
            13

          
	
            Centro de Salud Integral de Orocovis

          	
            14

          
	
            CPTET Bayamón – Clínica de Inmunología

          	
            15

          
	
            Centro de Epidemiología de Bayamón

          	
            16

          
	
            Casa Joven del Caribe (Clínica Proyecto Renacer)

          	
            17

          
	 	 
	
            CAGUAS REGION

          	 
	
            CPTET Caguas – Clínica de Inmunología

          	
            18

          
	
            Neo Med Center, Inc.

          	
            19

          
	
            Hospital Ryder Memorial – Proyecto CIS

          	
            20

          
	
            Corporación de Servicios de Salud y Medicina Avanzada - COSSMA Cidra

          	
            21

          
	
            Corporación de Servicios de Salud y Medicina Avanzada - COSSMA Humacao

          	
            22

          
	
            Corporación de Servicios de Salud y Medicina Avanzada - COSSMA San Lorenzo

          	
            23

          
	
            Corporación de Servicios de Salud y Medicina Avanzada - COSSMA Yabucoa

          	
            24

          
	
            Corporación de Servicios de Salud y Medicina Avanzada – COSSMA Las Piedras

          	
            25

          
	 	 
	
            MAYAGÜEZ REGION

          	 
	
            Migrant Health Center – Región Oeste (Mayagüez, San Sebastián, Guánica)

          	
            26-27

          
	
            CPTET Mayagüez – Clínica de Inmunología

          	
            28

          
	
            Costa Salud – Rincón

          	
            29

          


    

    

    
      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    	
            FAJARDO REGION

          	 
	
            CPTET Fajardo – Clínica de Inmunología

          	
            30

          
	 	 
	
            PONCE REGION

          	 
	
            Centro ARARAT

          	
            31

          
	
            Centro ARARAT – Proyecto Faith CES – Juana Díaz

          	
            32

          
	
            Centro de Salud Fam. Dr. Julio Palmieri – Arroyo

          	
            33

          
	
            Med Centro PR, Inc.

          	
            34

          
	
            CPTET Ponce – Clínica de Inmunología

          	
            35

          
	
            Centro de Servicios Primarios de Salud de Patillas

          	
            36

          
	 	 
	
            SAN JUAN REGION

          	 
	
            Centro Latinoamericano de Enfermedades Transmisibles – CLET

          	
            37

          
	
            Concilio de Salud Integral de Loíza

          	
            38

          
	
            CPTET Carolina – Clínica de Inmunología

          	
            39

          
	
            Municipio de San Juan - Programa más Salud: Sida con Salud

          	
            40

          
	
            Puerto Rico CONCRA

          	
            41

          
	
            Iniciativa Comunitaria

          	
            42

          
	
            UPR-RCM Proyecto ACTU

          	
            43

          
	
            UPR-RCM Proyecto CEMI

          	
            44

          
	
            UPR-RCM Proyecto GAMMA

          	
            45

          
	
            Centro ARARAT – Hope Clinic & Wellness Center

          	
            46

          
	
            Aids Health Foundation PR (AHF)

          	
            47

          


    

    

    
      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    
    ARECIBO REGION

    

    

    CPTET ARECIBO

    Clínica de Inmunología - Departamento de Salud

    

    

    	
            Medical Director:

          	
            Dr. Adrián Pérez Medina

          
	
            Email Address:

          	
            adrianperez@salud.pr.gov

          
	
            Street Address:

          	
            Antiguo Hospital de Distrito, Carr. 129 hacia Lares, Arecibo, PR

          
	
            Mailing Address:

          	
            627 Ave. San Luis, Arecibo, PR 00612-3666

          
	
            Telephone No.:

          	
            787-765-2929 ext. 6531

          
	
            Fax No.:

          	
            787-881-5773

          


    

    

    PHARMACY THAT PROVIDES SERVICES

     

      

    
      FARMACIA GARCÍA

       

    

    

    	
            Street Address:

          	
            Calle Vidal Félix 121, Hatillo, PR 00659

          
	
            Mailing Address:

          	
            PO Box 67, Hatillo, PR 00659

          
	
            Telephone No.:

          	
            787-898-3975 / 787-820-5158 / 787-880-2122 (Arecibo)

          
	
            Fax No.:

          	
            787-820-9048

          


    

    

    
      1

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CENTRO DE SALUD DE LARES, INC.

    RYAN WHITE PART C

    

    

    	
            Executive Director:

          	
            Lcdo. Rigoberto Hernández Nieves

          
	
            Email Address:

          	
            rhernandez@cslpr.org

          
	
            RWC Administrator:

          	
            Sr. Gonzalo Maldonado R.N.

          
	
            Email Address:

          	
            rw_csl@hotmail.com

          
	
            Street Address:

          	
            Carr. 111 km 1.9, Ave. Los Patriotas, Lares, PR

          
	
            Mailing Address:

          	
            PO Box 379, Lares, PR 00669

          
	
            Telephone No.:

          	
            787-897-2727 / 787-897-1720 / 787-897-1730

          
	
            Fax No.:

          	
            787-897-2155 / 787-897-2725

          


    

    

    PHARMACY THAT PROVIDES SERVICES

     

      

    
      IN HOUSE PHARMACY

       

    

    

    	
            Street Address:

          	
            Carr. 111 km 1.9, Ave. Los Patriotas, Lares, PR

          
	
            Mailing Address:

          	
            PO Box 379, Lares, PR 00669

          
	
            Telephone No.:

          	
            787-897-3023 / 787-897-2727/ 787-897-2155 / 787-897-1720

          
	
            Fax No.:

          	
            787-897-2155 / 787-897-2725

          


    

    

    
      2

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CENTRO DE SALUD DE QUEBRADILLAS

    

    

    	
            Administrator:

          	
            Sr. Daniel González Rivera

          
	
            Email Address:

          	
            cdtquebradillas@hotmail.com

          
	
            Street Address:

          	
            Calle Muñoz Rivera Esq. San Justo 114, Quebradillas, PR 00678

          
	
            Mailing Address:

          	
            Apartado 1551, Quebradillas, PR 00678

          
	
            Telephone No.:

          	
            787-895-2660 ext. 1199/1100 / 787-895-2670 / 787-895-5679

          
	
            Fax No.:

          	 


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Calle Muñoz Rivera Esq. San Justo 114, Quebradillas, PR 00678

          
	
            Mailing Address:

          	
            Apartado 1551, Quebradillas, PR 00678

          
	
            Telephone No.:

          	
            787-895-2512

          
	
            Fax No.:

          	
            787-895-2512

          


    

    

    
      * CENTER BELONGS TO CENTRO DE SALUD DE LARES, INC., CONSORTIUM

    

    

    

    
      3

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CAMUY HEALTH SERVICES, INC.

    

    

    	
            Director:

          	
            Lcdo. Eddie Pérez Cabán

          
	
            Email Address:

          	
            camuy660@coqui.net

          
	
            Street Address:

          	
            Ave. Muñoz Rivera 63, Camuy, PR 00627

          
	
            Mailing Address:

          	
            PO Box 660, Camuy, PR 00627-0660

          
	
            Telephone No.:

          	
            787-898-2290 / 787-262-6603

          
	
            Fax No.:

          	
            787-262-1210 / 787-262-3789

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Ave. Muñoz Rivera 63, Camuy, PR 00627

          
	
            Mailing Address:

          	
            PO Box 660, Camuy, PR 00627-0660

          
	
            Telephone No.:

          	
            787-898-2660 ext. 227 / 787-898-2604 (DDI)

          
	
            Fax No.:

          	
            787-262-4822

          


    

    

    
      4

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CORPORACIÓN DE SERVICIOS MÉDICOS

    PRIMARIOS Y PREVENCIÓN DE HATILLO

    

    

    	
            Executive Director:

          	
            Sr. Armando Legarreta Raíces

          
	
            Email Address:

          	
            hatillomedical@yahoo.com / aldirector@csmpr.org

          
	
            Street Address:

          	
            Ave. Dr. Susoni 116, Hatillo, PR 00659

          
	
            Mailing Address:

          	
            PO Box 907, Hatillo, PR 00659

          
	
            Telephone No.:

          	
            787-898-3935 ext. 222, 308 / 787-898-4190

          
	
            Fax No.:

          	
            787-262-3984

          


    

    

    PHARMACY THAT PROVIDES SERVICES

     

      

    FARMACIA SAN MIGUEL

     

      

    	
            Street Address:

          	
            Ave. Dr. Susoni 116, Hatillo, PR 00659

          
	
            Mailing Address:

          	
            PO Box 907, Hatillo, PR 00659

          
	
            Telephone No.:

          	
            787-898-4190 / 787-898-5764 ext. 240

          
	
            Fax No.:

          	
            787-262-3984

          


    

    

    
      5

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CIALES PRIMARY HEALTH CARE SERVICES - PRYMED

     

      

    	
            Directora:

          	
            Sra. Gladys Rivera Estela

          
	
            Email Address:

          	
            prymed@prymedical.com

          
	
            Street Address:

          	
            Carr. 149 km 12.3, Ciales, PR

          
	
            Mailing Address:

          	
            PO Box 1427, Ciales, PR 00638

          
	
            Telephone No.:

          	
            787-871-0601 / 787-871-0602 / 787-871-0603

          
	
            Fax No.:

          	
            787-871-3960

          


    

    

    PHARMACY THAT PROVIDES SERVICES

     

      

    IN HOUSE PHARMACY

     

      

    	
            Street Address:

          	
            Carr. 149 km 12.3, Ciales, PR

          
	
            Mailing Address:

          	
            PO Box 1427, Ciales, PR 00638

          
	
            Telephone No.:

          	
            787-871-0601 ext. 210, 229

          
	
            Fax No.:

          	
            787-871-3960

          


    

    

    
      6

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * HOSPITAL GENERAL DE CASTAÑER

    

    

    	
            Executive Director:

          	
            Sr. Domingo Monroig

          
	
            Email Address:

          	
            hospital@hospitalcastaner.com

          
	
            Street Address:

          	
            Carr. 135 k.m 4.5, Castañer, PR

          
	
            Mailing Address:

          	
            PO Box 1003, Castañer, PR 00631

          
	
            Telephone No.:

          	
            787-829-5010 / 829-2055 / 829-7500 / 829-5600

          
	
            Fax No.:

          	
            787-829-2913 / 829-2166 / 829-4668

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Carr. 135 k.m 4.5, Castañer, PR

          
	
            Mailing Address:

          	
            PO Box 1003, Castañer, PR 00631

          
	
            Telephone No.:

          	
            787-829-5010 ext. 233/289 /787-829-2910

          
	
            Fax No.:

          	
            787-829-1479

          
	
            Adjuntas:

          	
            787-829-5656 ext. 250 / 787-829-5202

          


    

    

    
      7

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    MOROVIS COMMUNITY HEALTH CENTER, INC.

    

    

    	
            Executive Director:

          	
            Lcdo. William Rodríguez Castro

          
	
            Email Address:

          	
            william.rodriguez@mchcpr.org

          
	
            Street Address:

          	
            #2 Calle Patrón, Morovis, PR 00687

          
	
            Mailing Address:

          	
            PO Box 518, Morovis, PR 00687

          
	
            Telephone No.:

          	
            787-862-3000 ext. 2203 (Administration);

          
	 	
            ext. 2318 (Health Education); ext. 2212 (Case Management)

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            #2 Calle Patrón, Morovis, PR 00687

          
	
            Mailing Address:

          	
            PO Box 518, Morovis, PR 00687

          
	
            Telephone No.:

          	
            787-862-3000 ext. 2224

          
	
            Fax No.:

          	 


    

    

    
      8

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    BAYAMÓN REGION

    

    

    * SALUD INTEGRAL EN LA MONTAÑA INC (SIM) OFICINA CENTRAL

    

    

    	
            Executive Director:

          	
            Lcda. Gloria Amador

          
	
            Email Address:

          	
            gamador@simpr.org

          
	
            Street Address:

          	
            Carr. 152 km 12 hm 2 Bo. Cedro Arriba, Naranjito, PR 00719

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-869-5900 ext. 1103, 1108, 1105

          
	
            Fax No.:

          	
            787-869-6120

          


    

    

    
      9

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CENTRO DE SALUD INTEGRAL DE NARANJITO

    

    

    	
            Executive Director:

          	
            Lcda. Gloria Amador

          
	
            Email Address:

          	
            gamador@simpr.org

          
	
            Street Address:

          	
            Carr. 164 Sector el Desvío, Barrio Achiote, Naranjito, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-869-1290 ext. 2252, 2253

          
	
            Fax No.:

          	
            787-869-1800

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Carr. 164 Sector el Desvío, Barrio Achiote, Naranjito, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-869-1290 ext. 2208, 2238

          
	
            Fax No.:

          	
            787-869-1800

          


    

    

    
      10

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CENTRO DE SALUD INTEGRAL DE BARRANQUITAS

    

    

    	
            Executive Director:

          	
            Lcda. Gloria Amador

          
	
            Email Address:

          	
            gamador@simpr.org

          
	
            Street Address:

          	
            Carr. Barceló #53, Barranquitas, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-857-2688 ext. 1601, 1602, 1618, 1617

          
	
            Fax No.:

          	
            787-857-1730 / 857-3440

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Carr. Barceló #53, Barranquitas, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-857-2688 ext. 225

          
	
            Fax No.:

          	
            787-857-1730

          


    

    

    
      11

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CENTRO DE SALUD INTEGRAL DE COMERÍO

    

    

    	
            Executive Director:

          	
            Lcda. Gloria Amador

          
	
            Email Address:

          	
            gamador@simpr.org

          
	
            Street Address:

          	
            Calle Georgetti #18 Carr. 167, Comerío, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-875-3375

          
	
            Fax No.:

          	
            787-875-4230

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Calle Georgetti #18 Carr. 167, Comerío, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-875-3375 ext. 1247, 1236, 1209

          
	
            Fax No.:

          	
            787-875-4230

          


    

    

    
      12

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CENTRO DE SALUD INTEGRAL DE COROZAL

    

    

    	
            Executive Director:

          	
            Lcda. Gloria Amador

          
	
            Email Address:

          	
            gamador@simpr.org

          
	
            Street Address:

          	
            Carr. 891 km 15.1 Int. Bo. Pueblo, Corozal, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-859-2560

          
	
            Fax No.:

          	
            787-859-5390

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Carr. 159 Sector El Desvío, Corozal, PR

          
	
            Mailing Address:

          	
            PO Box 515 Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-859-2560 ext. 215

          
	
            Fax No.:

          	
            787-859-5390

          


    

    

    
      13

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    * CENTRO DE SALUD INTEGRAL DE OROCOVIS

    

    

    	
            Executive Director:

          	
            Lcda. Gloria Amador

          
	
            Email Address:

          	
            gamador@simpr.org

          
	
            Street Address:

          	
            Ave. Luis Muñoz Marín, Carr. 155 Sector El Desvío, Orocovis, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-867-6010

          
	
            Fax No.:

          	
            787-867-5210

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Ave. Luis Muñoz Marín, Carr. 155 Sector El Desvío, Orocovis, PR

          
	
            Mailing Address:

          	
            PO Box 515, Naranjito, PR 00719

          
	
            Telephone No.:

          	
            787-867-6010

          
	
            Fax No.:

          	
            787-867-6008

          


    

    

    
      14

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CPTET BAYAMÓN

    Clínica de Inmunología - Departamento de Salud

    

    

    	
            Medical Director:

          	
            Dra. Sandra N. Maldonado Rivera

          
	
            Email Address:

          	
            sandra.maldonado@salud.pr.gov

          
	
            Street/Mailing Address:

          	
            Hospital Universitario Dr. Ramón Ruiz Arnau

          
	 	
            Ave. Laurel #100, Santa Juanita

          
	 	
            Bayamón, PR 00956

          
	
            Telephone No.:

          	
            787-778-1209 ext. 4400, 4404, 4405

          
	
            Fax No.:

          	
            787-778-1209

          


    

    

    PHARMACIES THAT PROVIDE SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Hospital Universitario Dr. Ramón Ruiz Arnau

          
	 	
            Ave. Laurel #100 Santa Juanita

          
	 	
            Bayamón, PR 00956

          
	
            Telephone No.:

          	
            787-786-2125 / 787-778-1209 ext. 4426

          
	
            Fax No.:

          	
            787-269-6563

          


     

      

    FARMACIA CARIDAD 4

    

    

    	
            Street Address:

          	
            Barrio Hato Tejas Carr. 862 km 1.9, Bayamón, PR

          
	
            Mailing Address:

          	
            PO Box 4218, Bayamón, PR 00954

          
	
            Telephone No.:

          	
            787-785-3055 / 269-3140

          
	 	
            OFICINA CENTRAL 787-778-3399

          
	
            Fax No.:

          	
            787-740-5445 / 269-0022

          


    

    

    
      15

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CENTRO DE EPIDEMIOLOGÍA DE BAYAMÓN

    

    

    	
            Director:

          	
            Sra. Deborah Medina

          
	
            Email Address:

          	
            dmedina@bayamonpr.org

          
	
            Street Address:

          	
            Calle Isabel 2da Esq. Degetau Sótano

          
	 	
            (Antiguo CDT Bayamón Pueblo)

          
	 	
            Bayamón, PR

          
	
            Mailing Address:

          	
            PO Box 1588, Bayamón, PR 00961

          
	
            Telephone No.:

          	
            787-787-9831 / 787-798-2964

          
	
            Fax No.:

          	
            787-269-5230 / 787-785-2387

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    FARMACIA PLAZA III

    

    

    	
            Street/Mailing Address:

          	
            Calle Barbosa 57, Bayamón, PR 00961

          
	
            Telephone No.:

          	
            787-785-0000

          
	
            Fax No.:

          	
            787-785-2387

          


    

    

    
      16

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CASA JOVEN DEL CARIBE

    CLÍNICA PROYECTO RENACER

    

    

    	
            Executive Directors:

          	
            Rev. Alice Ayala

          
	 	
            Rev. Samuel Agosto López / Sam Agosto (hijo)

          
	
            Email Address:

          	
            sagostolopez@yahoo.com / sagosto123@gmail.com

          
	
            Street Address:

          	
            Carr. 820 Bo. Marzán Sector Río Lajas, Toa Alta, PR

          
	
            Mailing Address:

          	
            PO Box 694, Dorado, PR 00646

          
	
            Telephone No.:

          	
            787-870-1911

          
	
            Fax No.:

          	
            787-796-2832 / 787-870-1911

          


    

    

    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    FARMACIA CARIDAD 4

    

    

    	
            Street Address:

          	
            Barrio Hato Tejas Carr. 862 km 1.9, Bayamón, PR

          
	
            Mailing Address:

          	
            PO Box 4218, Bayamón, PR 00954

          
	
            Telephone No.:

          	
            787-785-3055 / 269-3140

          
	 	
            OFICINA CENTRAL 787-778-3399

          
	
            Fax No.:

          	
            787-740-5445 / 787-269-0022

          


    

    

    
      17

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CAGUAS REGION

    

    

    

    

    CPTET CAGUAS

    Clínica de Inmunología - Departamento de Salud

    

    

    	
            Administrator:

          	
            Lcdo. Jorge Buzainz

          
	
            Email Address:

          	
            jorge.buzainz@salud.pr.gov

          
	
            Street Address:

          	
            Hospital Menonita, Caguas, PR

          
	
            Mailing Address:

          	
            PO Box 8548, Caguas, PR 00726

          
	
            Telephone No.:

          	
            787-765-2929 ext. 5446

          
	
            Fax No.:

          	
            787-746-2898

          


    

    

    PHARMACIES THAT PROVIDE SERVICES

    

    

    FARMACIA ARLEEN

    

    

    	
            Street Address:

          	
            Carr. 172 3ra. Sección Villa del Rey, Caguas, PR

          
	
            Mailing Address:

          	
            PO Box 5986, Caguas, PR 00726

          
	
            Telephone No.:

          	
            787-746-5952 / 787-745-2838

          
	
            Fax No.:

          	
            787-744-3397

          


    

    

    FARMACIA CENTRAL

    

    

    	
            Street Address:

          	
            Calle Noya Hernández #12 Este, Humacao, PR 00791

          
	
            Mailing Address:

          	
            PO Box 669, Humacao, PR 00792

          
	
            Telephone No.:

          	
            787-852-0520

          
	
            Fax No.:

          	
            787-850-5500

          


    

    

    
      18

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    NEO MED CENTER, INC. (GURABO)

    PROGRAMA SIVIF

    

    

    	
            Executive Director:

          	
            Dra. Rosa Castro Vilá

          
	
            Email Address:

          	
            rcastro@neomedcenter.org

          
	
            Proyecto SIVIF Administrator:

          	
            Marlene Pérez / mperez@neomedcenter.org

          
	 	
            787-630-5564

          
	
            Street Address:

          	
            Ramal 941 Salida Barrio Jaguas, Gurabo, PR

          
	
            Mailing Address:

          	
            Apartado 1277, Gurabo, PR 00778

          
	
            Telephone No.:

          	
            787-737-1131

          
	
            Fax No.:

          	
            787-737-2365 / 787-737-2377

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Ramal 941 Salida Barrio Jaguas, Gurabo, PR

          
	
            Mailing Address:

          	
            Apartado 1277, Gurabo, PR 00778

          
	
            Telephone No.:

          	
            787-737-4449

          
	
            Fax No.:

          	
            787-737-1242

          


    

    

    
      19

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    HOSPITAL RYDER MEMORIAL

    PROYECTO CIS - RYAN WHITE PART C

    

    

    	
            Executive Director:

          	
            Lic. José R. Feliciano Sepúlveda

          
	
            Email Address:

          	
            jfeliciano@hryder.org

          
	
            Proyecto CIS Director:

          	
            Dra. Felicita de Jesús

          
	
            Email Address:

          	
            felicitadejesus35@yahoo.com / fdejesus@hryder.org

          
	
            Street Address:

          	
            Ave. Font Martelo 355, Salida Humacao a Las Piedras, Humacao, PR

          
	
            Mailing Address:

          	
            PO Box 859, Humacao, PR 00792-0859

          
	
            Telephone No.:

          	
            787-852-0768 ext. 4716, 4717, 4609

          
	
            Fax No.:

          	
            787-852-0157 / 787-656-0735 / 787-850-1444

          


    

    

     PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Ave. Font Martelo 355, Salida Humacao a Las Piedras, Humacao, PR

          
	
            Mailing Address:

          	
            PO Box 859, Humacao, PR 00792-0859

          
	
            Telephone No.:

          	
            787-852-0768 ext.4331, 4335, 4336

          
	
            Fax No.:

          	
            787-850-1444

          


    

    

    
      20

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    COSSMA CIDRA

    Corporación de Servicios de Salud y Medicina Avanzada

    

    

    	
            Executive Director:

          	
            Sra. Isolina Miranda

          
	
            Email Address:

          	
            isolina.miranda@cossma.org

          
	
            Street Address:

          	
            Ave. Industrial El Jibaro Lote #2 Carr. 172 km. 13.5, Cidra, PR

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182, ext. 1252

          
	
            Fax No.:

          	
            787-739-8190

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

     

      

    	
            Street Address:

          	
            Ave. Industrial El Jibaro Lote #2 Carr. 172 km. 13.5, Cidra, PR

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1230, 1261

          


    

    

    
      21

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    COSSMA HUMACAO

    Corporación de Servicios de Salud y Medicina Avanzada

    

    

    	
            Executive Director:

          	
            Sra. Isolina Miranda

          
	
            Email Address:

          	
            isolina.miranda@cossma.org

          
	
            Street Address:

          	
            Calle Ulises Martínez #50, Humacao, PR 00791

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1300, 1301

          
	
            Fax No.:

          	
            787-656-5406

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

     

      

    	
            Street Address:

          	
            Calle Ulises Martínez #50, Humacao, PR

          
	
            Mailing Address:

          	
            Apartado 1330 Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1307, 1312, 1321

          


    

    

    
      22

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    COSSMA SAN LORENZO

    Corporación de Servicios de Salud y Medicina Avanzada

    

    

    	
            Executive Director:

          	
            Sra. Isolina Miranda

          
	
            Email Address:

          	
            isolina.miranda@cossma.org

          
	
            Street Address:

          	
            Calle Muñoz Rivera #186, San Lorenzo, PR 00754

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1100

          
	
            Fax No.:

          	
            787-937-0059

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Calle Muñoz Rivera #186, San Lorenzo, PR

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1115, 1116

          


    

    

    
      23

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    COSSMA YABUCOA

    Corporación de Servicios de Salud y Medicina Avanzada

    

    

    	
            Executive Director:

          	
            Sra. Isolina Miranda

          
	
            Email Address:

          	
            isolina.miranda@cossma.org

          
	
            Street Address:

          	
            Juan Martin Villa Carr. 901 km 1.6, Yabucoa, PR

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1400, 1427

          
	
            Fax No.:

          	
            787-953-0229

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    	
            Street Address:

          	
            Juan Martin Villa Carr. 901 km 1.6, Yabucoa, PR

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1433, 1419, 1422

          
	
            Fax No.:

          	
            787-893-3060

          


    

    

    
      24

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    COSSMA LAS PIEDRAS

    Corporación de Servicios de Salud y Medicina Avanzada

    

    

    	
            Executive Director:

          	
            Sra. Isolina Miranda

          
	
            Email Address:

          	
            isolina.miranda@cossma.org

          
	
            Street Address:

          	
            Carr. Estatal PR 9921 Lote #8 Centro Industrial Tejas

          
	 	
            Las Piedras, PR 00771

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1600, 1602, 1603

          
	
            Fax No.:

          	
            787-912-0306

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Carr. Estatal PR 9921 Lote #8 Centro Industrial Tejas

          
	 	
            Las Piedras PR

          
	
            Mailing Address:

          	
            Apartado 1330, Cidra, PR 00739

          
	
            Telephone No.:

          	
            787-739-8182 ext. 1617, 1618, 1619

          
	
            Fax No.:

          	
            787-937-0068

          


    

    

    
      25

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    MAYAGÜEZ REGION

    

    

    MIGRANT HEALTH CENTER - Región Oeste (MAYAGÜEZ)

    Programa SSIMA - Servicios de Salud Integrados - Ryan White Part C

    

    

    	
            Executive Director:

          	
            Sra. Dolores Morales Torres

          
	
            Email Address:

          	
            dolores@migrantspr.com

          
	
            Street Address:

          	
            Calle Ramón E. Betances 392 Sur, Mayagüez, PR

          
	
            Mailing Address:

          	
            PO Box 7128, Mayagüez, PR 00681-7128

          
	
            Telephone No.:

          	
            787-805-2900 / 787-831-5800

          
	
            Fax No.:

          	
            787-805-4750

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY (MAYAGÜEZ)

    

    

    	
            Street Address:

          	
            Calle Ramón E. Betances 392 Sur, Mayagüez, PR

          
	
            Mailing Address:

          	
            PO Box 190, Mayagüez, PR 00681-7128

          
	
            Telephone No.:

          	
            787-805-2900 / 787-805-2920 ext. 237

          
	
            Fax No.:

          	
            787-805-4707

          


    

    

    
      26

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    MIGRANT HEALTH CENTER – Región Oeste (MAYAGÜEZ)

    

    

    FARMACIA CLÍNICA SATÉLITE DE SAN SEBASTIÁN

    

    

    	
            Street/Mailing Address:

          	
            Carr. 119 km 35.2 Bo. Piedras Blancas, San Sebastián, PR 00685

          
	
            Telephone No.:

          	
            787-896-1665 / 787-896-6975

          
	
            Fax No.:

          	
            787-896-4570 / 787-896-1690

          


    

    

    FARMACIA CLÍNICA SATÉLITE DE GUÁNICA

    

    	Street/Mailing Address: 

          	Calle Montalva 23 Bo. Ensenada, Guánica, PR 00647
	
            Telephone No.:

          	
            787-821-4511 / 787-821-3377 / 787-821-2144

          
	
            Fax No.:

          	
            787-821-4511

          


    

    

    
      27

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CPTET MAYAGÜEZ

    Clínica de Inmunología - Departamento de Salud

     

      

    	
            Medical Services Director:

          	
            Dra. Carmen Sánchez Cruz

          
	
            Email Address:

          	
            lcabassa@salud.pr.gov

          
	
            Street Address:

          	
            Centro Médico Ramón E. Betances

          
	 	
            (al lado de Salud Mental Carr. #2)

          
	 	
            Mayagüez, PR

          
	
            Mailing Address:

          	
            PO Box 400, Mayagüez, PR 00680

          
	
            Telephone No.:

          	
            787-765-2929 ext. 6306 / 787-834-2115 / 787-834-2118

          
	
            Fax No.:

          	
            787-806-1490

          


    
       

        

      PHARMACY THAT PROVIDES SERVICES

    

    

    

    
      IN HOUSE PHARMACY

    

    

    

    	
            Street Address:

          	
            Centro Médico Ramón E. Betances

          
	 	
            (al lado de Salud Mental Carr. #2)

          
	 	
            Mayagüez, PR

          
	
            Mailing Address:

          	
            PO Box 400, Mayagüez, PR 00680

          
	
            Telephone No.:

          	
            787-834-2118 / 787-765-2929 ext. 6306

          
	
            Fax No.:

          	 


    

    

    
      28

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    COSTA SALUD RINCÓN

    

    

    	
            Executive Director:

          	
            Lcda. Susana M. Pérez Maldonado

          
	
            Email Address:

          	
            sperez@costasalud.com

          
	
            Street Address:

          	
            Calle Muñoz Rivera #28, Rincón, PR

          
	
            Mailing Address:

          	
            PO Box 638, Rincón, PR 00677

          
	
            Telephone No.:

          	
            787-823-5555 / 787-823-5500 ext. 179

          
	
            Fax No.:

          	
            787-823-2990

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Calle Muñoz Rivera #28, Rincón, PR

          
	
            Mailing Address:

          	
            PO Box 638, Rincón, PR 00677

          
	
            Telephone No.:

          	
            787-823-5555 ext. 163, 181

          
	
            Fax No.:

          	
            787-823-2390

          


    

    

    
      29

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    FAJARDO REGION

    CPTET FAJARDO

    Clínica de Inmunología - Departamento de Salud

    

    

    	
            Contact:

          	
            Dr. Héctor Cabán Hernández

          
	
            Email Address:

          	
            hectorcaban@salud.pr.gov

          
	
            Street/Mailing Address:

          	
            Hosp. HIMA San Pablo

          
	 	
            2do Piso Clínicas Externas

          
	 	
            404 Ave. General Valero, Fajardo, PR 00738

          
	
            Telephone No.:

          	
            787-765-2929 ext. 6383, 6382

          
	
            Fax No.:

          	
            787-863-5437

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    FARMACIA DENIRKA

    

    

    	
            Street Address:

          	
            Ave. General Valero 305, Fajardo, PR 00738

          
	
            Mailing Address:

          	
            PO Box 850 Fajardo, PR 00738

          
	
            Telephone No.:

          	
            787-863-7788 / 787-860-7788

          
	
            Fax No.:

          	
            787-863-1422

          


    

    

    
      30

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    PONCE REGION

    

    

    CENTRO ARARAT

     

      

    	
            Administrator:

          	
            Dr. Iván Meléndez

          
	
            Email Address:

          	
            drmelendez@centroararat.org

          
	
            Street Address:

          	
            Condominio San Vicente Calle Concordia 8169 Suite 412, Ponce, PR

          
	
            Mailing Address:

          	
            PO Box 7793, Ponce, PR 00732

          
	
            Telephone No.:

          	
            787-284-5884 / 787-284-5887

          
	
            Fax No.:

          	
            787-284-5874

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    CA PHARMACY

     

      

    	
            Street Address:

          	
            Condominio San Vicente Calle Concordia 8169 Suite 410, Ponce, PR

          
	
            Mailing Address:

          	
            PO Box 7793, Ponce, PR 00732

          
	
            Telephone No.:

          	
            787-284-4488

          
	
            Fax No.:

          	
            787-284-4445

          


    

    

    
      31

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CENTRO ARARAT - PROYECTO FAITH CES - JUANA DÍAZ

    

    

    	
            Administrator:

          	
            Dr. Iván Meléndez

          
	
            Email Address:

          	
            drmelendez@centroararat.org

          
	
            Clinical Services Coordinator:

          	
            Samuel Cruz Serrano

          
	
            Email Address:

          	
            scruz@faith-ces.com

          
	
            Street Address:

          	
            Calle Hostos 23, Juana Díaz, PR

          
	
            Mailing Address:

          	
            PO Box 7793, Ponce, PR 00732-7793

          
	
            Telephone No.:

          	
            787-260-9446 ext. 405

          
	
            Fax No.:

          	
            787-260-2276

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    CA PHARMACY (ARARAT)

     

      

    	
            Street Address:

          	
            Condominio San Vicente Calle Concordia 8169 Suite 410

          
	 	
            Ponce, PR

          
	
            Mailing Address:

          	
            PO Box 7793, Ponce, PR 00732

          
	
            Telephone No.:

          	
            787-284-4488

          
	
            Fax No.:

          	
            787-284-4445

          


    

    

    
      32

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CENTRO DE SALUD FAMILIAR DR. JULIO PALMIERI – ARROYO

    

    

    	
            Director:

          	
            Sra. Rosa Milagros Rodríguez Santiago

          
	
            Email Address:

          	
            csfarroyo@prtc.net

          
	
            Street Address:

          	
            Calle Morse Esq. Valentina, Arroyo, PR

          
	
            Mailing Address:

          	
            PO Box 450, Arroyo, PR 00714

          
	
            Telephone No.:

          	
            787-839-4150 ext. 208, 229

          
	
            Fax No.:

          	
            787-839-3989

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Calle Morse Esq. Valentina, Arroyo, PR

          
	
            Mailing Address:

          	
            PO Box 450, Arroyo, PR 00714

          
	
            Telephone No.:

          	
            787-839-4150 ext. 234 / 251

          
	 	
            787-839-1001 (DDI)

          
	
            Fax No.:

          	
            787-839-3989

          


    

    

    
      33

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    MED CENTRO

    Consejo de Salud de Puerto Rico, Inc.

    

    

    	
            Executive Director:

          	
            Lcdo. Allan Cintrón Salichs

          
	
            Email Address:

          	
            allan.cintron@medcentro.org

          
	
            RW Clinical Director:

          	
            Dr. Ricardo Cedeño

          
	
            Email Address:

          	
            ricardo.cedeno@medcentro.org

          
	
            Street Address:

          	
            Ave. Hostos 1034, Ponce, PR

          
	
            Mailing Address:

          	
            PO Box 220, Mercedita, PR 00715-0220

          
	
            Telephone No.:

          	
            787-843-9393 ext. 258, 262

          
	
            Fax No.:

          	
            787-843-0899 / 787-841-0077

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Ave. Hostos 1034, Ponce, PR

          
	
            Mailing Address:

          	
            PO Box 220, Mercedita, PR 00715-0220

          
	
            Telephone No.:

          	
            787-843-9393 ext. 1030/1074/1072 / 787-843-9370

          
	
            Fax No.:

          	
            787-843-9395

          


    

    

    
      34

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CPTET PONCE

    Clínica de Inmunología - Departamento de Salud

    

    

    	
            Medical Director:

          	
            Dra. Gladys Sepúlveda

          
	
            Email Address:

          	
            mberrios@salud.pr.gov

          
	
            Street Address:

          	
            Hospital San Lucas Bo. Machuelo Carr. #14, Ponce, PR

          
	
            Mailing Address:

          	
            PO Box 330550, Ponce, PR 00733-0550

          
	
            Telephone No.:

          	
            787-259-4731, 787-3998/4046

          
	
            Fax No.:

          	
            787-259-4731

          


    

    

    PHARMACIES THAT PROVIDE SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Hosp. San Lucas Bo. Machuelo Carr. #14, Ponce, PR

          
	
            Mailing Address:

          	
            PO Box 330550, Ponce, PR 00733-0550

          
	
            Telephone No.:

          	
            787-843-2188 Fax No.:

          


    

    

    FARMACIA EL APOTECARIO

    

    

    	
            Street Address:

          	
            625 Ave. Tito Castro Suite 101, Ponce, PR

          
	
            Mailing Address:

          	
            PMB 381 #609 Ave. Tito Castro, Ponce, PR 00716

          
	
            Telephone No.:

          	
            787-844-2135 / 787-290-4654

          
	
            Fax No.:

          	
            787-284-2135

          


    

    

    
      35

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CENTRO DE SERVICIOS PRIMARIOS

    DE SALUD DE PATILLAS

    

    

    	
            Executive Director:

          	
            Sra. Mildred Morel Ortiz

          
	
            Email Address:

          	
            pphsc_inc@yahoo.com

          
	
            Street Address:

          	
            Calle Riefhkol #99, Patillas, PR

          
	
            Mailing Address:

          	
            PO Box 697, Patillas, PR 00723

          
	
            Telephone No.:

          	
            787-839-4320 ext. 1241, 1280

          
	 	
            787-839-4360

          
	
            Fax No.:

          	
            787-271-0004

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Calle Riefhkol #99, Patillas, PR

          
	
            Mailing Address:

          	
            PO Box 697, Patillas, PR 00723

          
	
            Telephone No.:

          	
            787-839-4320 ext. 1224, 1293, 1277

          
	
            Fax No.:

          	
            787-839-4337

          


    

    

    
      36

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    SAN JUAN REGION

    

    

    CENTRO LATINOAMERICANO DE

    ENFERMEDADES TRANSMISIBLES (CLET) - Departamento de Salud

    

    

    	
            Medical Director:

          	
            Dr. Hermes García

          
	
            Email Address:

          	
            mercedesbaez@salud.pr.gov

          
	
            Administrator:

          	
            Lcdo. Ramfis Vélez Rosario

          
	
            Email Address:

          	
            rvelez5@salud.pr.gov

          
	
            Street Address:

          	
            Bo. Monacillos Paseo Celso Barbosa Centro Médico

          
	 	
            San Juan, PR 00936

          
	
            Mailing Address:

          	
            PO Box 7018, San Juan, PR 00936

          
	
            Telephone No.:

          	
            787-765-2929 ext. 5550, 5551, 5552, 5554

          
	
            Fax No.:

          	
            787-754-8127

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Bo. Monacillos Paseo Celso Barbosa Centro Médico

          
	 	
            San Juan, PR 00936

          
	
            Mailing Address:

          	
            PO Box 7018, San Juan, PR 00936

          
	
            Telephone No.:

          	
            787-754-8118 / 787-765-2929 ext. 5553

          
	
            Fax No.:

          	
            787-754-8127

          


    

    

    
      37

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CONCILIO DE SALUD INTEGRAL DE LOÍZA

    Programa SIPP

    

    

    	
            Executive Director:

          	
            Lcdo. César A. Rodríguez Román

          
	
            Email Address:

          	
            crodriguez@concilioloiza.org

          
	
            Street Address:

          	
            Carr. 188 Int. #187, Loíza, PR

          
	
            Mailing Address:

          	
            Apartado 509, Loíza, PR 00772

          
	
            Telephone No.:

          	
            787-876-3130 ext. 261, 226, 325 / 787-876-2042

          
	
            Fax No.:

          	
            787-876-2003 / 787-256-1900

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Carr. 188 Int. #187, Loíza, PR

          
	
            Mailing Address:

          	
            Apartado 509, Loíza, PR 00772

          
	
            Telephone No.:

          	
            787-876-2005, 2042 ext. 258

          
	
            Fax No.:

          	
            787-876-6613, 1120, 1900

          


    

    

    
      38

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CPTET CAROLINA

    Clínica de Inmunología - Departamento de Salud

    

    

    	
            Contact:

          	
            Dr. Héctor Cabán Hernández

          
	
            Email Address:

          	
            hectorcaban@salud.pr.gov

          
	
            Street Address:

          	
            Hospital Universitario Dr. Federico Trilla

          
	 	
            Ave. 65 de Infantería km 8.4 (al lado de Plaza Carolina)

          
	 	
            Carolina, PR

          
	
            Mailing Address:

          	
            Hospital Universitario Dr. Federico Trilla

          
	 	
            PO Box 6021

          
	 	
            Carolina, PR 00984-6021

          
	
            Telephone No.:

          	
            787-757-1800 ext. 454, 459

          
	
            Fax No.:

          	
            787-257-3615

          


    

    

    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    SUPER FARMACIA CAROLINA

    

    

    	
            Street Address:

          	
            Ave. Roberto Clemente Esq. Sánchez Castaño, Carolina, PR 00985

          
	
            Telephone No.:

          	
            787-257-8540

          
	
            Fax No.:

          	
            787-257-6760

          


    

    

    
      39

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    MUNICIPIO DE SAN JUAN

    Programa Más Salud: SIDA con Salud

    CDT - Dr. Manuel Díaz García

    

    

    	
            Director:

          	
            Sr. Pedro Julio Serrano

          
	
            Email Address:

          	
            pserrano@sanjuanciudadpatria.com

          
	
            Street Address:

          	
            Ave. Fernández Juncos 1306 Pda. 19, Santurce, PR

          
	
            Mailing Address:

          	
            PO Box 13964, San Juan, PR 00908

          
	
            Telephone No.:

          	
            787-480-3000, 787-480-3001

          
	
            Fax No.:

          	
            787-724-5104

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    IN HOUSE PHARMACY

    

    

    	
            Street Address:

          	
            Ave. Fernández Juncos 1306 Pda. 19, Santurce, PR 00908

          
	
            Mailing Address:

          	
            PO Box 13964, San Juan, PR 00908

          
	
            Telephone No.:

          	
            787-480-3074 / 787-480-3076

          
	
            Fax No.:

          	 


    

    

    
      40

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    PUERTO RICO CONCRA

    Ryan White Part C Program

    

    

    	
            Executive Director:

          	
            Sra. Rosaura López

          
	
            Street Address:

          	
            Urb. García Ubarry Calle Brumbaugh 162, San Juan, PR

          
	
            Mailing Address:

          	
            PO Box 20850, San Juan, PR 00928-0850

          
	
            Telephone No.:

          	
            787-753-9443 / 787-753-9463 ext. 32, 11

          
	
            Fax No.:

          	
            787-753-2894 / 787-753-9463

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    CARIDAD 9

     

      

    	
            Street/Mailing Address:

          	
            Ave. Jesús T. Piñeiro 282 Suite 100, San Juan, PR 00982

          
	
            Telephone No.:

          	
            787-523-3555

          
	
            Fax No.:

          	 


    

    

    
      41

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    INICIATIVA COMUNITARIA

    

    

    	
            Executive Director:

          	
            Sra. Yorelis Rivera Amador

          
	
            Email Address:

          	
            yrivera@inicitivacomunitaria.org

          
	
            Street Address:

          	
            Calle Quisqueya 61 Esq. Chile, Hato Rey, PR

          
	
            Mailing Address:

          	
            PO Box 366535, San Juan, PR 00936-366535

          
	
            Telephone No.:

          	
            787-250-8629 ext. 204

          
	
            Fax No.:

          	
            787-753-4454

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    PHARMACY- SAN RAFAEL

     

      

    	
            Street Address:

          	
            851 Lafayette Esq. San Rafael Urb. Hipódromo Pda. 20

          
	 	
            Santurce, PR 00909

          
	
            Mailing Address:

          	
            851 Lafayette Esq. San Rafael Urb. Hipódromo Pda. 20

          
	 	
            Santurce, PR 00909

          
	
            Telephone No.:

          	
            787-724-3307

          
	
            Fax No.:

          	
            787-721-4165

          


    

    

    
      42

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    UNIVERSIDAD DE PUERTO RICO

    RECINTO DE CIENCIAS MÉDICAS

    

    

    PROYECTO ACTU *

     

      

    	
            Director:

          	
            Dr. Jorge L. Santana Bagur

          
	
            Email Address:

          	
            jorge.santana3@upr.edu

          
	
            Street Address:

          	
            Edificio Biomédico II UPR RCM

          
	 	
            al lado de Medicina Nuclear

          
	 	
            Río Piedras, PR 00935

          
	
            Mailing Address:

          	
            U.P.R. RCM Proyecto ACTU PO Box 365067

          
	 	
            San Juan, PR 00936-5067

          
	
            Telephone No.:

          	
            787-767-9192, 787-767-9193, 787-767-9194, 787-767-9195

          
	
            Fax No.:

          	
            787-754-8002

          


    

    

    PHARMACIES THAT PROVIDE SERVICES

    

    

    * The patients of this Project can pick up their prescriptions at the CLET - Centro Médico pharmacy and the 7 pharmacies contracted by
        the Program: Farmacia Arleen - Caguas, Farmacia Denirka - Fajardo, Farmacia Central - Humacao, Farmacia García - Arecibo, Caridad 4 - Bayamón, Súper Farmacia Carolina - Carolina, and Farmacia El Apotecario - Ponce.

     

      

    
      43

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    UNIVERSIDAD DE PUERTO RICO

    RECINTO DE CIENCIAS MÉDICAS

    PROYECTO CEMI

    

    

    	
            Director:

          	
            Dra. Carmen Zorrilla

          
	
            Email Address:

          	
            carmen.zorrilla@upr.edu

          
	
            Street Address:

          	
            Recinto de Ciencias Médicas Edif. Biomédico II Piso 1

          
	 	
            Rio Piedras, PR 00935

          
	
            Mailing Address:

          	
            Univ. de PR RCM Proyecto CEMI PO Box 365067

          
	 	
            San Juan, PR 00936-5067

          
	
            Telephone No.:

          	
            787-771-4740, 787-766-0025, 787-766-0030, 787-753-5913

          
	 	
            SIDA Pediátrico 787-274-5762

          
	
            Fax No.:

          	
            787-771-4739

          


    

    

    PHARMACIES THAT PROVIDE SERVICES

    

    

    * The patients of this Project can pick up their prescriptions at the CLET - Centro Médico pharmacy and the 7 pharmacies contracted by
        the Program: Farmacia Arleen - Caguas, Farmacia Denirka - Fajardo, Farmacia Central - Humacao, Farmacia García - Arecibo, Caridad 4 - Bayamón, Súper Farmacia Carolina - Carolina, and Farmacia El Apotecario - Ponce.

    

    

    
      44

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    UNIVERSIDAD DE PUERTO RICO

    RECINTO DE CIENCIAS MÉDICAS

    PROYECTO GAMMA

    

    

    	
            Director:

          	
            Dra. Irma L. Febo

          
	
            Email Address:

          	
            irma.febo2@upr.edu

          
	
            Street Address:

          	
            Centro Cardiovascular de PR Proyecto GAMMA Piso 8 Ofic. 814

          
	 	
            San Juan, PR

          
	
            Mailing Address:

          	
            Univ. de PR RCM Proyecto GAMMA PO Box 365067

          
	 	
            San Juan, PR 00936-5067

          
	
            Telephone No.:

          	
            787-759-9595

          
	
            Fax No.:

          	
            787-767-4798

          


    

    

    PHARMACIES THAT PROVIDE SERVICES

    

    

    * The patients of this Project can pick up their prescriptions at the CLET - Centro Médico pharmacy and the 7 pharmacies contracted by
        the Program: Farmacia Arleen - Caguas, Farmacia Denirka - Fajardo, Farmacia Central - Humacao, Farmacia García - Arecibo, Caridad 4 - Bayamón, Súper Farmacia Carolina - Carolina, and Farmacia El Apotecario - Ponce.

     

      

    
      45

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    CENTRO ARARAT

    HOPE CLINIC & WELLNESS CENTER

    

    

    	
            Administrator:

          	
            María T. Lugo

          
	
            Email Address:

          	
            mlugo@hopeclinicpr.com

          
	
            Medical Director:

          	
            Dr. Iván Meléndez Rivera

          
	
            Street/Mailing Address:

          	
            1503 Calle Prof. Augusto Rodríguez Cond. Asia 6to Piso

          
	 	
            San Juan, PR 00909

          
	
            Telephone No.:

          	
            787-268-7078 / 787-497-0800

          
	
            Fax No.:

          	
            787-982-6464

          


    

    

    PHARMACY THAT PROVIDES SERVICES

     

    

    CA PHARMACY II (SAN JUAN)

    

    

    	
            Street Address:

          	
            1507 Calle Profesor Augusto Rodriguez, San Juan, PR 00909

          
	
            Telephone No.:

          	
            787.705.3905 / 787.705.3900

          
	
            Fax No.:

          	
            787.727.2140

          


    

    

    
      46

      
        


      
        
          PUERTO RICO DEPARTMENT OF HEALTH

          OFFICE OF THE ASSISTANT SECRETARY FOR FAMILY HEALTH AND INTEGRATED SERVICES

          HEAD OFFICE FOR AIDS AND COMMUNICABLE DISEASES AFFAIRS

          RYAN WHITE PART B PROGRAM

        

         

      

    

    AIDS HEALTHCARE FOUNDATION, HCC PR (AHF)

    

    

    	
            Regional Medical Director:

          	
            Dr. Milton Garland Cansobre

          
	
            Email Address:

          	
            milton-garland@aidshealth.org

          
	
            Telephone No.:

          	
            787-305-5216

          
	
            Street Address:

          	
            Carr. 848 km 1.0 Bo. Saint Just, Trujillo Alto, PR 00978

          
	
            Mailing Address:

          	
            PO Box 340 Saint Just, Trujillo Alto, PR 00978

          
	
            Telephone No.:

          	
            787-810-1444

          


    

    

    PHARMACY THAT PROVIDES SERVICES

    

    

    FARMACIA CARIDAD 4

    

    

    	
            Street Address:

          	
            Barrio Hato Tejas Carr. 862 km 1.9, Bayamón, PR

          
	
            Mailing Address:

          	
            PO Box 4218 Bayamón, PR 00954

          
	
            Telephone No.:

          	
            787-785-3055 / 269-3140

          
	 	
            OFICINA CENTRAL 787-778-3399

          
	
            Fax No.:

          	
            787-740-5445 / 269-0022

          


    

    

    

    

    
      47

    

  








  
    
    
      
         Attachment 5

         

            

        GOVERNMENT HEALTHCARE PLAN

        List of Drugs by Exception (LME)

        2017

        	
                Therapeutic Category 

                [Categoría Terapéutica]

              	
                Therapeutic Class

                [Clase Terapéutica]

              	
                Drug Description

                [Descripción de la Droga]

              	
                Preautorization

                [Preautorización]

                Y=Yes

              
	
                ADHD/ANTI-

                NARCOLEPSY/ANTIOBESITY/ANOREXIANTS

              	
                Stimulants - Misc.

              	
                Modafinil Oral Tablet 100 MG

              	
                Y

              
	
                ADHD/ANTI-

                NARCOLEPSY/ANTIOBESITY/ANOREXIANTS

              	
                Stimulants - Misc.

              	
                Modafinil Oral Tablet 200 MG

              	
                Y

              
	
                ADHD/ANTI-

                NARCOLEPSY/ANTIOBESITY/ANOREXIANTS

              	
                Stimulants - Misc.

              	
                Provigil Oral Tablet 100 MG

              	
                Y

              
	
                ADHD/ANTI-

                NARCOLEPSY/ANTIOBESITY/ANOREXIANTS

              	
                Stimulants - Misc.

              	
                Provigil Oral Tablet 200 MG

              	
                Y

              
	
                ANALGESICS - ANTIINFLAMMATORY

              	
                Interleukin-1

                Receptor Antagonist (IL-1Ra)

              	
                Kineret Subcutaneous

                Solution Prefilled

                Syringe 100

                MG/0.67ML

              	
                Y

              
	
                ANTHELMINTICS

              	
                ANTHELMINTICS

              	
                Albenza Oral Tablet 200 MG

              	
                Y

              
	
                ANTHELMINTICS

              	
                ANTHELMINTICS

              	
                Ivermectin Oral Tablet 3 MG

              	
                Y

              
	
                ANTHELMINTICS

              	
                ANTHELMINTICS

              	
                Stromectol Oral Tablet 3 MG

              	
                Y

              
	
                ANTIDOTES AND SPECIFIC ANTAGONISTS

              	
                Antidotes -

                Chelating Agents

              	
                Exjade Oral Tablet

                 Soluble 125 MG

              	
                Y

              
	
                ANTIDOTES AND SPECIFIC ANTAGONISTS

              	
                Antidotes -

                Chelating Agents

              	
                Exjade Oral Tablet

                Soluble 250 MG

              	
                Y

              
	
                ANTIDOTES AND SPECIFIC ANTAGONISTS

              	
                Antidotes -

                Chelating Agents

              	
                Exjade Oral Tablet

                Soluble 500 MG

              	
                Y

              
	
                ANTIDOTES AND SPECIFIC ANTAGONISTS

              	
                Antidotes -

                Chelating Agents

              	
                Jadenu Oral Tablet 90 MG

              	
                Y

              
	
                ANTIDOTES AND SPECIFIC ANTAGONISTS

              	
                Antidotes -

                Chelating Agents

              	
                Jadenu Oral Tablet 180 MG

              	
                Y

              
	
                ANTIDOTES AND SPECIFIC ANTAGONISTS

              	
                Antidotes -

                Chelating Agents

              	
                Jadenu Oral Tablet 360 MG

              	
                Y

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Aprepitant Oral Capsule 80 MG

              	
                Y

              


        

        

        
          
            


        

        	
                 Therapeutic Category

                [Categoría Terapéutica]

              	
                Therapeutic Class

                [Clase Terapéutica]

              	
                Drug Description

                [Descripción de la Droga]

              	
                Preautorization

                [Preautorización]

                Y=Yes

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Aprepitant Oral Capsule 125 MG

              	
                Y

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Emend Oral Capsule 80 MG

              	
                Y

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Emend Oral Capsule 125 MG

              	
                Y

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Aprepitant Oral Capsule 40 MG

              	
                Y

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Emend Oral Capsule 40 MG

              	
                Y

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Emend Oral Capsule 80 & 125 MG

              	
                Y

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Emend Oral Suspension Reconstituted 125 MG

              	
                Y

              
	
                ANTIEMETICS

              	
                Substance

                P/Neurokinin 1

                (NK1) Receptor Antagonists

              	
                Aprepitant Oral Capsule 80 & 125 MG

              	
                Y

              
	
                ANTI-INFECTIVE AGENTS - MISC.

              	
                Antiprotozoal Agents

              	
                Mepron Oral Suspension 750 MG/5ML

              	
                Y

              
	
                ANTI-INFECTIVE AGENTS - MISC.

              	
                Antiprotozoal Agents

              	
                Atovaquone Oral Suspension 750 MG/5ML

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Alkylating Agents

              	
                Cyclophosphamide Oral Capsule 25 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Alkylating Agents

              	
                Cyclophosphamide Oral Capsule 50 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Antibiotics

              	
                Novantrone Intravenous Concentrate 20 MG/10ML

              	
                Y

              


        

        

        
          
            


        

        	
                Therapeutic Category

                [Categoría Terapéutica]

              	
                Therapeutic Class

                [Clase Terapéutica]

              	
                Drug Description

                [Descripción de la Droga]

              	
                Preautorization

                [Preautorización]

                Y=Yes

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Antibiotics

              	
                Mitoxantrone HCl

                Intravenous Concentrate 25 MG/12.5ML

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Antibiotics

              	
                Mitoxantrone HCl

                Intravenous Concentrate 20 MG/10ML

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Antibiotics

              	
                Mitoxantrone HCl

                Intravenous Concentrate 30 MG/15ML

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antimetabolites

              	
                Tabloid Oral Tablet 40 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic - Antibodies

              	
                Rituxan Intravenous Solution 100 MG/10ML

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic - Antibodies

              	
                Rituxan Intravenous Solution 500 MG/50ML

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic -

                Hedgehog Pathway

                Inhibitors

              	
                Erivedge Oral Capsule 150

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic -

                Hormonal and

                Related Agents

              	
                Xtandi Oral Capsule 40

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic -

                Hormonal and

                Related Agents

              	
                Lysodren Oral Tablet 500

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic -

                Hormonal and

                Related Agents

              	
                Fareston Oral Tablet 60

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Sutent Oral Capsule 37.5

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Votrient Oral Tablet 200

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Tykerb Oral Tablet 250

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Sutent Oral Capsule 12.5

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Sutent Oral Capsule 50

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Sutent Oral Capsule 25

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Tarceva Oral Tablet 25

                MG

              	
                Y

              


        

        

        
          
            


        

        	
                Therapeutic Category

                [Categoría Terapéutica]

              	
                Therapeutic Class

                [Clase Terapéutica]

              	
                Drug Description

                [Descripción de la Droga]

              	
                Preautorization

                [Preautorización]

                Y=Yes

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Tarceva Oral Tablet 100 MG

              	
                Y

              
	
                
                  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

                

              	
                Antineoplastic Enzyme Inhibitors

              	
                Tarceva Oral Tablet 150 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Bosulif Oral Tablet 500

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Bosulif Oral Tablet 100

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Afinitor Disperz Oral Tablet Soluble 2 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Afinitor Disperz Oral Tablet Soluble 3 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Afinitor Disperz Oral Tablet Soluble 5 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Tafinlar Oral Capsule 50 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Tafinlar Oral Capsule 75 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Mekinist Oral Tablet 0.5 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Mekinist Oral Tablet 2

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Imbruvica Oral Capsule 140 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Zelboraf Oral Tablet 240 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Ibrance Oral Capsule 75 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Ibrance Oral Capsule 100 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Ibrance Oral Capsule 125 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Cotellic Oral Tablet 20

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Ninlaro Oral Capsule 2.3 MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Ninlaro Oral Capsule 3

                MG

              	
                Y

              
	
                ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

              	
                Antineoplastic Enzyme Inhibitors

              	
                Ninlaro Oral Capsule 4

                MG

              	
                Y

              


        

        

        
          
            


        

        	
                Therapeutic Category

                [Categoría Terapéutica]

              	
                Therapeutic Class

                [Clase Terapéutica]

              	
                Drug Description

                [Descripción de la Droga]

              	
                Preautorization Preautorización]

                Y=Yes

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Benzisoxazoles

              	
                Risperdal Consta

                Intramuscular Suspension Reconstituted 12.5 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Benzisoxazoles

              	
                Risperdal Consta

                Intramuscular Suspension Reconstituted 37.5 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Benzisoxazoles

              	
                Risperdal Consta

                Intramuscular Suspension Reconstituted 50 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Benzisoxazoles

              	
                Risperdal Consta

                Intramuscular Suspension Reconstituted 25 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Quetiapine Fumarate ER Oral Tablet Extended

                Release 24 Hour 200 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Quetiapine Fumarate ER Oral Tablet Extended

                Release 24 Hour 300 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Quetiapine Fumarate ER Oral Tablet Extended

                Release 24 Hour 400 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Quetiapine Fumarate ER

                Oral Tablet Extended

                Release 24 Hour 50 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Quetiapine Fumarate ER Oral Tablet Extended

                Release 24 Hour 150 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Clozaril Oral Tablet 100 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Clozaril Oral Tablet 25 MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Clozapine Oral Tablet 100

                MG

              	
                Y

              
	
                ANTIPSYCHOTICS/ANTIMANIC AGENTS

              	
                Dibenzapines

              	
                Clozapine Oral Tablet 25

                MG

              	
                Y

              
	
                ANTIVIRALS

              	
                Hepatitis Agents

              	
                Hepsera Oral Tablet 10 MG

              	
                Y

              
	
                ANTIVIRALS

              	
                Hepatitis Agents

              	
                Adefovir Dipivoxil Oral Tablet 10 MG

              	
                Y

              
	
                ANTIVIRALS

              	
                Hepatitis Agents

              	
                Entecavir Oral Tablet 0.5

                MG

              	
                Y

              


        

        

        
          
            


        

        	
                Therapeutic Category

              	
                Therapeutic Class

              	
                Drug Description

              	
                Preauthorization Y=Yes

              
	
                ANTIVIRALS

              	
                Hepatitis Agents

              	
                Entecavir Oral Tablet 1 MG

              	
                Y

              
	
                ANTIVIRALS

              	
                Hepatitis Agents

              	
                Baraclude Oral Tablet 0.5 MG

              	
                Y

              
	
                ANTIVIRALS

              	
                Hepatitis Agents

              	
                Baraclude Oral Tablet 1 MG

              	
                Y

              
	
                CORTICOSTEROIDS

              	
                Glucocorticosteroids

              	
                Entocort EC Oral Capsule Delayed Release Particles 3 MG

              	
                Y

              
	
                CORTICOSTEROIDS

              	
                Glucocorticosteroids

              	
                Budesonide Oral Capsule Delayed Release Particles 3 MG

              	
                Y

              
	
                DERMATOLOGICALS

              	
                Antipsoriatics

              	
                Tazorac External Gel 0.05 %

              	
                Y

              
	
                DERMATOLOGICALS

              	
                Antipsoriatics

              	
                Tazorac External Gel 0.1 %

              	
                Y

              
	
                DERMATOLOGICALS

              	
                Antipsoriatics

              	
                Tazorac External Cream 0.05 %

              	
                Y

              
	
                DERMATOLOGICALS

              	
                Antipsoriatics

              	
                Tazorac External Cream 0.1 %

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Forteo Subcutaneous Solution 600 MCG/2.4ML

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Reclast Intravenous Solution 5 MG/100ML

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Zoledronic Acid

                Intravenous Solution 5

                MG/100ML

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Pamidronate Disodium

                Intravenous Solution 30 MG/10ML

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Pamidronate Disodium

                Intravenous Solution 90 MG/10ML

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Pamidronate Disodium Intravenous Solution 6 MG/ML

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Alendronate Sodium Oral Tablet 40 MG

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Fosamax Oral Tablet 40 MG

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Bone Density Regulators

              	
                Prolia Subcutaneous Solution 60 MG/ML

              	
                Y

              


        

        

        
          
            


        

        	
                Therapeutic Category

                [Categoría Terapéutica]

              	
                Therapeutic Class

                [Clase Terapéutica]

              	
                Drug Description

                [Descripción de la Droga]

              	
                Preautorization

                [Preautorización]

                Y=Yes

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Hormone Receptor Modulators

              	
                Raloxifene HCl Oral Tablet 60 MG

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Hormone Receptor Modulators

              	
                Evista Oral Tablet 60 MG

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Growth Hormone

                Receptor

                Antagonists

              	
                Somavert Subcutaneous

                Solution Reconstituted 10 MG

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Growth Hormone

                Receptor

                Antagonists

              	
                Somavert Subcutaneous

                Solution Reconstituted 15 MG

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Growth Hormone

                Receptor

                Antagonists

              	
                Somavert Subcutaneous

                Solution Reconstituted 20 MG

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Growth Hormone

                Receptor

                Antagonists

              	
                Somavert Subcutaneous

                Solution Reconstituted 25 MG

              	
                Y

              
	
                ENDOCRINE AND METABOLIC AGENTS - MISC.

              	
                Growth Hormone

                Receptor

                Antagonists

              	
                Somavert Subcutaneous

                Solution Reconstituted 30 MG

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Feiba NF Intravenous Solution Reconstituted

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Feiba VH Immuno

                Intravenous Solution Reconstituted

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Feiba Intravenous Solution Reconstituted

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Eloctate Intravenous

                Solution Reconstituted 250 UNIT

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Eloctate Intravenous

                Solution Reconstituted 500 UNIT

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Eloctate Intravenous

                Solution Reconstituted 750 UNIT

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Eloctate Intravenous

                Solution Reconstituted 1000 UNIT

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Eloctate Intravenous

                Solution Reconstituted 1500 UNIT

              	
                Y

              


        

        

        
          
            


        

        	
                Therapeutic Category

              	
                Therapeutic Class

              	
                Drug Description

              	
                Preautorization Y=Yes

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Eloctate Intravenous

                Solution Reconstituted 2000 UNIT

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Antihemophilic Products

              	
                Eloctate Intravenous

                Solution Reconstituted 3000 UNIT

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Platelet Aggregation Inhibitors

              	
                Effient Oral Tablet 5 MG

              	
                Y

              
	
                HEMATOLOGICAL AGENTS - MISC.

              	
                Platelet Aggregation Inhibitors

              	
                Effient Oral Tablet 10 MG

              	
                Y

              
	
                MISCELLANEOUS THERAPEUTIC

                CLASSES

              	
                Immunosuppressive Agents

              	
                Zortress Oral Tablet 0.25 MG

              	
                Y

              
	
                MISCELLANEOUS THERAPEUTIC

                CLASSES

              	
                Immunosuppressive Agents

              	
                Zortress Oral Tablet 0.75 MG

              	
                Y

              
	
                MISCELLANEOUS THERAPEUTIC

                CLASSES

              	
                Immunosuppressive Agents

              	
                Zortress Oral Tablet 0.5 MG

              	
                Y

              
	
                MISCELLANEOUS THERAPEUTIC

                CLASSES

              	
                Systemic Lupus

                Erythematosus Agents

              	
                Benlysta Intravenous

                Solution Reconstituted 120 MG

              	
                Y

              
	
                MISCELLANEOUS THERAPEUTIC

                CLASSES

              	
                Systemic Lupus

                Erythematosus Agents

              	
                Benlysta Intravenous

                Solution Reconstituted 400 MG

              	
                Y

              
	
                NEUROMUSCULAR AGENTS

              	
                Neuromuscular

                Blocking Agent - Neurotoxins

              	
                Botox Injection Solution Reconstituted 200 UNIT

              	
                Y

              
	
                NEUROMUSCULAR AGENTS

              	
                Neuromuscular

                Blocking Agent - Neurotoxins

              	
                Botox Injection Solution Reconstituted 100 UNIT

              	
                Y

              
	
                OPHTHALMIC AGENTS

              	
                Ophthalmic Steroids

              	
                Tobradex Ophthalmic Suspension 0.3-0.1 %

              	
                Y

              
	
                OPHTHALMIC AGENTS

              	
                Ophthalmic Steroids

              	
                Tobramycin-

                Dexamethasone

                Ophthalmic Suspension

                0.3-0.1 %

              	
                Y

              
	
                OPHTHALMIC AGENTS

              	
                Prostaglandins - Ophthalmic

              	
                Travatan Z Ophthalmic Solution 0.004 %

              	
                Y

              
	
                OPHTHALMIC AGENTS

              	
                Prostaglandins - Ophthalmic

              	
                Lumigan Ophthalmic Solution 0.01 %

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard S/D

                Intravenous Solution

                Reconstituted 5 GM

              	
                Y

              


        

        

        
          
            


        

        	
                Therapeutic Category

              	
                Therapeutic Class

              	
                Drug Description

              	
                Preautorization

                Y=Yes

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard S/D

                Intravenous Solution

                Reconstituted 10 GM

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard S/D Less IgA

                Intravenous Solution

                Reconstituted 5 GM

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard S/D Less IgA

                Intravenous Solution

                Reconstituted 10 GM

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gamunex-C Injection Solution 1 GM/10ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gamunex-C Injection Solution 2.5 GM/25ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gamunex-C Injection Solution 5 GM/50ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gamunex-C Injection Solution 20 GM/200ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gamunex-C Injection Solution 10 GM/100ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammaked Injection Solution 1 GM/10ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammaked Injection Solution 2.5 GM/25ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammaked Injection Solution 5 GM/50ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammaked Injection Solution 10 GM/100ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammaked Injection Solution 20 GM/200ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard Injection Solution 1 GM/10ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard Injection Solution 2.5 GM/25ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard Injection Solution 5 GM/50ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard Injection Solution 10 GM/100ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard Injection Solution 20 GM/200ML

              	
                Y

              
	
                PASSIVE IMMUNIZING AND TREATMENT AGENTS

              	
                Immune Serums

              	
                Gammagard Injection Solution 30 GM/300ML

              	
                Y

              


        

        

        
          
            


        

        	
                Therapeutic Category

                [Categoría Terapéutica]

              	
                Therapeutic Class

                [Clase Terapéutica]

              	
                Drug Description

                [Descripción de la Droga]

              	
                Preautorization

                [Preautorización]

                Y=Yes

              
	
                RESPIRATORY AGENTS - MISC.

              	
                Cystic Fibrosis Agents

              	
                Pulmozyme Inhalation Solution 1 MG/ML

              	
                Y

              
	
                TETRACYCLINES

              	
                TETRACYCLINES

              	
                Tetracycline HCl Oral Capsule 250 MG

              	
                Y

              
	
                TETRACYCLINES

              	
                TETRACYCLINES

              	
                Tetracycline HCl Oral Capsule 500 MG

              	
                Y

              
	
                TETRACYCLINES

              	
                TETRACYCLINES

              	
                Demeclocycline HCl Oral Tablet 150 MG

              	
                Y

              
	
                TETRACYCLINES

              	
                TETRACYCLINES

              	
                Demeclocycline HCl Oral Tablet 300 MG

              	
                Y

              
	
                TETRACYCLINES

              	
                TETRACYCLINES

              	
                Declomycin Oral Tablet 300 MG

              	
                Y

              
	
                VASOPRESSORS

              	
                Anaphylaxis Therapy Agents

              	
                Epinephrine Injection

                Solution Auto-injector

                0.15 MG/0.3ML

              	
                Y

              
	
                VASOPRESSORS

              	
                Anaphylaxis Therapy Agents

              	
                Epinephrine Injection

                Solution Auto-injector

                0.15 MG/0.15ML

              	
                Y

              
	
                VASOPRESSORS

              	
                Anaphylaxis Therapy Agents

              	
                Epinephrine Injection

                Solution Auto-injector 0.3 MG/0.3ML

              	
                Y

              


        

        

        
          
            


        

        

        

        ASES

         

          

        Puerto Rico Healthcare Insurance Administration

        

        

        Integrated Emergency

         

          

        Formulary (IEF)

         

          

        2017

            

          

        Formulary of Drugs Covered by

         

          

        the Government Healthcare Plan (GHP)

        

        

        Authorized by the P.R. Elections Commission CEE-SA-16-2732

         

          

        
          
            


        

        

        

        	
                

              	
                GOVERNMENT OF PUERTO RICO

              	
                Hon. Ricardo A. Rosselló Nevares

              
	
                Healthcare Insurance Administration

              	Governor
	 	 	
                Ms. Ángela M. Ávila Marrero

                Executive Director

              


        

        

        May 1, 2017

         

          

        TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

         

          

        Dear provider:

         

          

        I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its corresponding
            sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

         

          

        The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and Sub-physical. Moreover, the
            Mental Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health Sub-formulary will be used by
            participating primary care physicians (PCPs) in Primary Care Medical Groups.

         

          

        The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare Insurance Administration
            (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical aspects. The FDC is a dynamic document
            that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

         

          

        I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

         

            

        Cordially,

        

        

        [signed]

         

          

        Ángela M. Ávila Marrero

         

          

        Executive Director

         

          

         
          	

                	 

                
	
                  
                     

                        

                    PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                  

                


        

         

          

        
          
            


        

        
        GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

        OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

         

          

        
          
            	1.	
                    Drug Formulary

                  


          

        

        

        

        The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and reviewing the Formulary of
            Drugs Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee is constituted by healthcare
            professionals, including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES for the drug formulary based on scientific
            evidence, clinical aspects, and a cost-effectiveness analysis.

        

        

        The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the prescription drug coverage. The
            purpose of the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

        

        

        ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator or PPA based on the most recent
            clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

        

        

        Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain in point number 2.

        

        

        
          
            	2.	
                    Exception Process

                  


          

        

        

        

        In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as applicable, insurance companies
            must use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

        

        

        
          
            	

                  	a.	
                    Contraindication to the drug(s) included in the FDC;

                  


          

        

        
          
            	

                  	b.	
                    History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                  


          

        

        
          
            	

                  	c.	
                    Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                  


          

        

        
          
            	

                  	d.	
                    Lack of a therapeutic alternative in the FDC.

                  


          

        

        

        

        This exception process requires a clinical justification that is duly documented by the service provider with the clinical reasons
            justifying the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

         

          

        
          
            	3.	
                    Other Aspects of the Prescription Drug Coverage

                  


          

        

        

        

        
          
            	

                  	A.	
                    The prescription drug coverage of the GHP establishes that using generic bioequivalent products as the
                          first option is mandatory.

                  


          

        

        

        

        
          
            	

                  	B.	
                    Insurance companies or the TPA (Third Party Administrator) and healthcare service providers will only
                          process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                  


          

        

        

        

        
          Page 13 of 38

          
            


        

        
          
            	

                  	C.	
                    ASES has an active process to continually review the prescription drug coverage in accordance with
                          changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES may require that
                          drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will safeguard adequate access to
                          services and maintain continuity of care.

                  


          

        

        

        

        
          
            	

                  	D.	
                    No entity contracted by ASES or by healthcare companies or organizations (for example, primary care
                          medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES. Furthermore, they may not limit the
                          drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be responsible for supervising their providers and
                          employees with regard to their compliance with these provisions.

                  


          

        

        

        

        
          
            	

                  	E.	
                    The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The treatment
                          period may be extended, as applicable, when medically necessary.

                  


          

        

        

        

        
          
            	

                  	F.	
                    The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty (30) day
                          therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating adherence and tolerance. The
                          Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case of narcotics, which will be dispensed only
                          one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms of adherence, tolerance, and dosage within ninety (90)
                          days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                  


          

        

        

        

        
          
            	

                  	G.	
                    ASES requires the use of generic bioequivalent drugs approved by the Food and Drug Administration (FDA)
                          coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                  


          

        

        

        

        
          
            	

                  	H.	
                    The lack of appropriate bioequivalent drug inventories does not exempt providers from dispensing the
                          prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the corresponding brand-name drug, unless,
                          in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception mechanism.

                  


          

        

        

        

        
          
            	

                  	I.	
                    Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized under the
                          law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                  


          

        

        

        

        
          
            	

                  	J.	
                    The right to freedom of choice requires the availability of a pharmacy that is reasonably accessible to
                          each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                  


          

        

        

        

        
          Page 14 of 38

          
            


        

        
          
            
              Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or when an electronic
                  prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24 hours. If a drug is not
                  available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her physician to have the
                  prescription sent to another pharmacy of his or her choice.

               

                

            

            	4.	
                    Emergency Rule

                  


          

        

        

        

        The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except as otherwise
            specified.

        

        

        The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will also be dispensed in
            amounts sufficient for five (5) business days.

        

        

        Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for continuity of treatment,
            including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the IEF.

        

        

        If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES in your region
            and/or the Pharmacy Benefit Manager (PBM) contracted by ASES.

        

        

        
          Page 15 of 38

          
            


        

         

        INTEGRATED EMERGENCY FORMULARY

         

          

        GOVERNMENT HEALTHCARE PLAN

        FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

        2017

        TABLE OF CONTENTS

        

        

        	
                GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE GOVERNMENT HEALTHCARE PLAN

              	
                3

              
	
                DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

              	
                11

              
	 	
                MONTHLY NET COST RANGE

              	
                11

              
	 	
                GENERIC DRUGS

              	
                12

              
	
                THERAPEUTIC CATEGORY

              	
                13

              
	
                ANALGESICS

              	
                13

              
	 	
                Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

              	
                13

              
	 	
                Short-Acting Opioid Analgesics

              	
                13

              
	
                ANESTHETICS

              	
                14

              
	 	
                Local Anesthetics

              	
                14

              
	
                ANTIANXIETY AGENTS

              	
                14

              
	 	
                Benzodiazepines

              	
                14

              
	 	
                Miscellaneous Anxiolytics

              	
                14

              
	
                ANTIBACTERIALS

              	
                14

              
	 	
                First Generation Cephalosporins

              	
                14

              
	 	
                Macrolides

              	
                14

              
	 	
                Miscellaneous Antibacterials

              	
                15

              
	 	
                Penicillins

              	
                15

              
	 	
                Quinolones

              	
                16

              
	 	
                Second Generation Cephalosporins

              	
                16

              
	 	
                Sulfonamides

              	
                16

              
	 	
                Third Generation Cephalosporins

              	
                17

              
	
                ANTICONVULSANTS

              	
                17

              
	 	
                Anticonvulsants

              	
                17

              


        

        

        
          Page 16 of 38

          
            


        

        
           

          INTEGRATED EMERGENCY FORMULARY

           

            

        

        	
                ANTIDEMENTIA AGENTS

              	
                18

              
	 	
                Cholinesterase Inhibitors

              	
                18

              
	
                ANTIDEPRESSANTS

              	
                19

              
	 	
                Miscellaneous Antidepressants

              	
                19

              
	
                ANTIDIABETIC AGENTS

              	
                19

              
	 	
                Alpha-Glucosidase Inhibitors

              	
                19

              
	 	
                Biguanides

              	
                19

              
	 	
                Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors

              	
                19

              
	 	
                Insulin Mixtures

              	
                19

              
	 	
                Insulin Sensitizing Agents

              	
                19

              
	 	
                Intermediate-Acting Insulins

              	
                19

              
	 	
                Short-Acting Insulins

              	
                19

              
	 	
                Sulfonylureas

              	
                20

              
	
                ANTIEMETICS

              	
                20

              
	 	
                Miscellaneous Antiemetics

              	
                20

              
	 	
                Phenothiazines

              	
                20

              
	
                ANTIGOUT AGENTS

              	
                20

              
	 	
                Antigout Agents

              	
                20

              
	 	
                Uricosurics

              	
                20

              
	
                ANTIHYPERTENSIVES

              	
                20

              
	 	
                Alpha-Adrenergic Agonists

              	
                20

              
	 	
                Alpha-Adrenergic Blocking Agents

              	
                21

              
	 	
                Angiotensin II Receptor Blockers (ARB)

              	
                21

              
	 	
                Angiotensin-Converting Enzyme (ACE) Inhibitors

              	
                21

              
	 	
                Calcium Channel Blocking Agents

              	
                21

              
	 	
                Carbonic Anhydrase Inhibitors Diuretics

              	
                21

              
	 	
                Cardioselective Beta Blocking Agents

              	
                21

              
	 	
                Cardioselective Beta-Adrenergic Blocking Agents

              	
                22

              
	 	
                Loop Diuretics

              	
                22

              
	 	
                Nonselective Beta Blocking Agents

              	
                22

              
	 	
                Potassium-Sparing Diuretics

              	
                22

              


        

        

        
          
            Page 17 of 38

            
              


          

          

          INTEGRATED EMERGENCY FORMULARY

           

            

        

        	 	
                Thiazide Diuretics

              	
                23

              
	 	
                Vasodilator Beta Blockers

              	
                23

              
	 	
                Vasodilators

              	
                23

              
	
                ANTIMIGRAINE AGENTS

              	
                23

              
	 	
                Beta-Adrenergic Blocking Agents

              	
                23

              
	
                ANTIMYASTHENIC AGENTS

              	
                23

              
	 	
                Parasympathomimetics

              	
                23

              
	
                ANTIMYCOBACTERIALS

              	
                24

              
	 	
                Antituberculars

              	
                24

              
	
                ANTIPARASITICS

              	
                24

              
	 	
                Antimalarials

              	
                24

              
	
                ANTIPARKINSON AGENTS

              	
                24

              
	 	
                Anticholinergics

              	
                24

              
	 	
                Antiparkinson Dopaminergics

              	
                24

              
	 	
                Dopamine Precursors

              	
                25

              
	
                ANTIPSYCHOTICS

              	
                25

              
	 	
                Atypical - Second Generation

              	
                25

              
	 	
                Typical - First Generation

              	
                26

              
	
                ANTIVIRALS

              	
                26

              
	 	
                Anti-Cytomegalovirus (Cmv) Agents

              	
                26

              
	 	
                Antiherpetic Agents

              	
                26

              
	 	
                Anti-Influenza Agents

              	
                26

              
	
                BENIGN PROSTATIC HYPERTROPHY AGENTS

              	
                26

              
	 	
                Alpha-Adrenergic Blocking Agents

              	
                26

              
	
                BLOOD MODIFIERS

              	
                26

              
	 	
                Anticoagulants

              	
                26

              
	 	
                Colony Stimulating Factors

              	
                27

              
	 	
                Platelet Modifying Agents

              	
                27

              
	
                CARDIOVASCULAR AGENTS

              	
                27

              
	 	
                Antiarrhythmics Class Ii

              	
                27

              
	 	
                Antiarrhythmics Type I-A

              	
                27

              


        

        

        
          Page 18 of 38

          
            


        

        
          

          INTEGRATED EMERGENCY FORMULARY

        

        

        

        	 	
                Antiarrhythmics Type I-B

              	
                28

              
	 	
                Antiarrhythmics Type I-C

              	
                28

              
	 	
                Antiarrhythmics Type Iii

              	
                28

              
	 	
                Miscellaneous Cardiovascular Agents

              	
                28

              
	 	
                Vasodilators

              	
                28

              
	
                DENTAL AND ORAL AGENTS

              	
                28

              
	 	
                Antifungals

              	
                28

              
	
                DERMATOLOGICAL AGENTS

              	
                29

              
	 	
                Pediculicides and Scabicides

              	
                29

              
	 	
                Topical Antibiotics

              	
                29

              
	
                DYSLIPIDEMICS

              	
                29

              
	 	
                Bile Acid Sequestrants

              	
                29

              
	 	
                Fibric Acid Derivatives

              	
                29

              
	 	
                Hmg-Coa Reductase Inhibitors

              	
                29

              
	
                GASTROINTESTINAL AGENTS

              	
                29

              
	 	
                Histamine2 (H2) Receptor Antagonists

              	
                29

              
	 	
                Miscellaneous Gastrointestinal Agents

              	
                29

              
	 	
                Proton Pump Inhibitors

              	
                30

              
	
                GENITOURINARY AGENTS

              	
                30

              
	 	
                Miscellaneous Genitourinary Agents

              	
                30

              
	
                HORMONAL AGENTS

              	
                30

              
	 	
                Antithyroid Agents

              	
                30

              
	 	
                Calcimimetic Agents

              	
                30

              
	 	
                Dopamine Agonists

              	
                30

              
	 	
                Thyroid Hormones

              	
                30

              
	
                IMMUNOSUPPRESSANTS

              	
                31

              
	 	
                Glucocorticosteroids

              	
                31

              
	 	
                Immune Globulins

              	
                31

              
	
                INFLAMMATORY BOWEL DISEASE

              	
                31

              
	 	
                Aminosalicylates

              	
                31

              
	 	
                Sulfonamides

              	
                31

              


        

        

        
          Page 19 of 38

          
            


        

        
          
            

            INTEGRATED EMERGENCY FORMULARY

          

        

        

        

        	
                MINERALS & ELECTROLYTES

              	
                31

              
	 	
                Calcium Regulating Agents

              	
                31

              
	
                MUSCLE RELAXANTS

              	
                31

              
	 	
                Antispasticity Agents

              	
                31

              
	 	
                Skeletal Muscle Relaxants

              	
                32

              
	
                OPHTHALMIC AGENTS

              	
                32

              
	 	
                Antiglaucoma Agents

              	
                32

              
	 	
                Ophthalmic Antibiotics

              	
                32

              
	 	
                Ophthalmic Prostaglandins

              	
                32

              
	 	
                Ophthalmic Steroids

              	
                33

              
	
                OTIC AGENTS

              	
                33

              
	 	
                Miscellaneous Otic Agents

              	
                33

              
	 	
                Otic Antibiotics

              	
                33

              
	
                RESPIRATORY AGENTS

              	
                33

              
	 	
                Anticholinergic Bronchodilators

              	
                33

              
	 	
                Antileukotrienes

              	
                33

              
	 	
                Antitussive-Expectorant

              	
                33

              
	 	
                Inhaled Corticosteroids

              	
                33

              
	 	
                Sedating Histamine1 Blocking Agents

              	
                34

              
	 	
                Sympathomimetic Bronchodilators

              	
                34

              


        

        

        
          Page 20 of 38

          
            


        

        
          
            

          

        

        INTEGRATED EMERGENCY FORMULARY

        

        

        DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

         

          

        The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their safety profile,
            proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

         

          

        The example below illustrates the information provided for the drugs included in the FDC.

         

          

        	 	
                Drug Name

              	
                Net Cost

              	
                Tier

              	
                Reference

                Name

              	
                Requirements/ Limits

              
	 	
                THERAPEUTIC CATEGORY

              
	 	
                Therapeutic Class

              
	 	
                ANALGESICS

              
	 	
                Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

              
	 	
                ibuprofen 400 mg tab, 600 mg tab, 800 mg tab

              	
                1

              	
                Preferred

              	
                MOTRIN

              	
                QL = 5 days

              
	 	
                indomethacin 25 mg cap, 50 mg cap

              	
                1

              	
                Non-preferred

              	
                INDOCIN

              	
                QL = 5 days

              
	 	
                nabumetone 500 mg tab, 750 mg tab

              	
                1

              	
                Preferred

              	
                RELAFEN

              	
                QL = 5 days

              
	 	
                naproxen 250 mg tab, 375 mg tab, 500 mg tab

              	
                1

              	
                Preferred

              	
                NAPROSYN

              	
                QL = 5 days

              
	 	
                naproxen sodium 275 mg tab, 550 mg tab

              	
                1

              	
                Preferred

              	
                ANAPROX

              	
                QL = 5 days

              
	 	
                salsalate 500 mg tab, 750 mg tab

              	
                1

              	
                Preferred

              	
                DISALCID

              	
                QL = 5 days

              
	 	
                indomethacin er 75 mg cap er

              	
                2

              	
                Non- preferred

              	
                INDOCIN

              	
                QL = 5 days

              


        

        

        For each drug included in the FDC, the First Column shows the
            name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

        The Second Column shows the Monthly Net Cost Range per Average
            Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

         

          

        MONTHLY NET COST RANGE

            

          

        The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly net cost of the
            therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy for thirty (30) days. The cost
            comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost and must be interpreted as follows:

         

          

        
          Page 21 of 38

          
            


        

        
          
            
              

            

          

          INTEGRATED EMERGENCY FORMULARY

        

        

        

        
          	
                  1

                	
                  less than $20

                	
                  Least costly per month

                
	
                  2

                	
                  $20 - $49

                	 
	
                  3

                	
                  $50 - $99

                	 
	
                  4

                	
                  $100 - $199

                	 
	
                  5

                	
                  $200 - $349

                	 
	
                  6

                	
                  $350 - $549

                	 
	
                  7

                	
                  $550 - $799

                	 
	
                  8

                	
                  $800 - $1,099

                	 
	
                  9

                	
                  $1,100 - $1,499

                	 
	
                  10

                	
                  $1,500 - $1,999

                	 
	
                  11

                	
                  $2,000 - $2,499

                	 
	
                  12

                	
                  $2,500 - $2,999

                	 
	
                  13

                	
                  $3,000 - $3,499

                	 
	
                  14

                	
                  $3,500 - $3,999

                	 
	
                  15

                	
                  $4,000 - $4,499

                	 
	
                  16

                	
                  $4,500 - $4,999

                	 
	
                  17

                	
                  $5,000 - $5,499

                	 
	
                  18

                	
                  $5,500 - $5,999

                	 
	
                  19

                	
                  $6,000 - $6,499

                	 
	
                  20

                	
                  $6,500 - $6,999

                	 
	
                  21

                	
                  $7,000 - $7,499

                	 
	
                  22

                	
                  $7,500 - $7,999

                	 
	
                  23

                	
                  $8,000 - $8,499

                	 
	
                  24

                	
                  $8,500 - $9,000

                	 
	
                  25

                	
                  more than $9,000

                	
                  Most costly per month

                


          

        

        We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic category (the one with the
            lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

        The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of this edition of the
            FDC.

         

          

        GENERIC DRUGS

            

          

        Generic bioequivalent drugs are identified with lower-case letters. Certain









            generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the generic product, but not the brand-name product. The products
            selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

         

          

        
          Page 22 of 38

          
            


        

        
          
            

          

          
            INTEGRATED EMERGENCY FORMULARY

          

          

          

        
          Page 23 of 38

          
            


        

        INTEGRATED EMERGENCY FORMULARY

        
          

           

         

          

        	
                 Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

              
	
                Therapeutic Class [Clase Terapéutica]

              
	
                ANALGESICS [ANALG ÉSICOS]

              
	
                Nonsteroidal Anti-Inflammatory Agents
                      (Nsaids) [ Anti-Inflamatorios No Esteroidales]

              
	
                ibuprofen 400 mg tab, 600 mg tab, 800 mg tab

              	
                1

              	
                Preferred

              	
                MOTRIN

              	
                QL = 5 días

              
	
                indomethacin 25 mg cap, 50 mg cap

              	
                1

              	
                Non-Preferred

              	
                INDOCIN

              	
                QL = 5 días

              
	
                nabumetone 500 mg tab, 750 mg tab

              	
                1

              	
                Preferred

              	
                RELAFEN

              	
                QL = 5 días

              
	
                naproxen 250 mg tab, 375 mg tab, 500 mg tab

              	
                1

              	
                Preferred

              	
                NAPROSYN

              	
                QL = 5 días

              
	
                naproxen sodium 275 mg tab, 550 mg tab

              	
                1

              	
                Preferred

              	
                ANAPROX

              	
                QL = 5 días

              
	
                salsalate 500 mg tab, 750 mg tab

              	
                1

              	
                Preferred

              	
                DISALCID

              	
                QL = 5 días

              
	
                Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]

              
	
                acetaminophen          -codeine 120-12 mg/5ml soln, 300-15 mg tab, 300-30 mg tab, 300-60 mg tab

              	
                1

              	
                Preferred

              	
                TYLENOL-

                CODEINE

              	
                QL = 5 días

              
	
                acetaminophen-codeine #2 300-15 mg tab

              	
                1

              	
                Preferred

              	
                TYLENOL-

                CODEINE

              	
                QL = 5 días

              
	
                acetaminophen-codeine #3 300-30 mg tab

              	
                1

              	
                Preferred

              	
                TYLENOL-

                CODEINE

              	
                QL = 5 días

              
	
                acetaminophen-codeine #4 300-60 mg tab

              	
                1

              	
                Preferred

              	
                TYLENOL-

                CODEINE

              	
                QL = 5 días

              
	
                butalbital-apap-caffeine 50-325-40 mg tab

              	
                1

              	
                Preferred

              	
                FIORICET

              	
                QL = 5 días

              
	
                tramadol hcl 50 mg tab

              	
                1

              	
                Preferred

              	
                ULTRAM

              	
                QL = 5 días

              
	
                butalbital-apap-caffeine 50-325-40 mg cap

              	
                2

              	
                Preferred

              	
                FIORICET

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 24 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            
              

              

            

          

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                ANESTHETICS [ANESTÉSICOS]

              
	
                Local Anesthetics [Anestésicos Locales]

              
	
                lidocaine viscous 2 %  mouth/throat soln

              	
                1

              	
                Preferred

              	
                XYLOCAINE

              	
                QL = 5 días

              
	
                ANTIANXIETY AGENTS [AGENTES PARA LA ANXIEDAD]

              
	
                Benzodiazepines [Benzodiazepinas]

              
	
                clonazepam 0.5 mg tab, 1  mg tab, 2mg tab

              	
                1

              	
                Preferred

              	
                KLONOPIN

              	
                QL = 5 días

              
	
                diazepam 10 mg tab, 2 mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                VALIUM

              	
                QL = 5 días

              
	
                lorazepam 0.5 mg tab, 1 mg tab

              	
                1

              	
                Preferred

              	
                ATIVAN

              	
                QL = 5 días

              
	
                temazepam 15 mg cap, 30 mg cap

              	
                1

              	
                Preferred

              	
                RESTORIL

              	
                QL = 5 días

              
	
                Miscellaneous Anxiolytics [Ansiolíticos Misceláneos]

              
	
                hydroxyzine pamoate 100  mg cap, 25 mg cap, 50 mg cap

              	
                1

              	
                Preferred

              	
                VISTARIL

              	
                QL = 5 días

              
	
                ANTIBACTERIALS [ANTIBACTERIANOS]

              
	
                First Generation Cephalosporins
                      [Cefalosporinas De Primera Generación]

              
	
                cephalexin 125 mg/5ml  susp, 250 mg cap, 500 mg cap

              	
                1

              	
                Preferred

              	
                KEFLEX

              	
                QL = 5 días

              
	
                cefadroxil 250 mg/5ml susp

              	
                2

              	
                Non-Preferred

              	
                DURICEF

              	
                QL = 5 días, AL ≤ 12

              
	
                cephalexin 250 mg/5ml susp

              	
                2

              	
                Preferred

              	
                KEFLEX

              	
                QL = 5 días

              
	
                cefadroxil 500 mg/5ml susp

              	
                3

              	
                Non-Preferred

              	
                DURICEF

              	
                QL = 5 días, AL ≤ 12

              
	
                Macrolides [Macrólidos]

              
	
                azithromycin 250 mg tab,  500 mg tab

              	
                1

              	
                Preferred

              	
                ZITHROMAX

              	
                QL = 5 días

              
	
                azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab

              	
                2

              	
                Preferred

              	
                ZITHROMAX

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 25 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab

              	
                2

              	
                Preferred

              	
                BIAXIN

              	
                QL = 5 días

              
	
                clarithromycin 250 mg/5ml susp

              	
                3

              	
                Preferred

              	
                BIAXIN

              	
                QL = 5 días

              
	
                erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab

              	
                3

              	
                Preferred

              	
                ERY-TAB

              	
                QL = 5 días

              
	
                erythromycin ethylsuccinate 400 mg tab

              	
                3

              	
                Preferred

              	
                E.E.S.

              	
                QL = 5 días

              
	
                ERYTHROCIN STEARATE

                250 mg tab

              	
                4

              	
                Non-Preferred

              	 	
                QL = 5 días

              
	
                Miscellaneous Antibacterials [Antibacterianos Misceláneos]

              	 
	
                clindamycin hcl 150 mg cap,  300 mg cap, 75 mg cap

              	
                1

              	
                Preferred

              	
                CLEOCIN

              	
                QL = 5 días

              
	
                MACRODANTIN 25 mg cap

              	
                1

              	
                Preferred

              	 	
                QL = 5 días

              
	
                metronidazole 250 mg tab, 500 mg tab

              	
                1

              	
                Preferred

              	
                FLAGYL

              	
                QL = 5 días

              
	
                nitrofurantoin macrocrystal 50 mg cap

              	
                1

              	
                Preferred

              	
                MACRODANTIN

              	
                QL = 5 días

              
	
                nitrofurantoin macrocrystal 100 mg cap

              	
                2

              	
                Preferred

              	
                MACRODANTIN

              	
                QL = 5 días

              
	
                nitrofurantoin oral

                suspension 25 MG/5ML

              	
                6

              	
                Non-Preferred

              	
                FURADANTIN

              	 
	
                nitrofurantoin monohyd macro 100 mg cap

              	
                2

              	
                Preferred

              	
                MACROBID

              	
                QL = 5 días

              
	
                Penicillins [Penicilinas]

              	 
	
                amoxicillin 125 mg/5ml susp,  200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp,
                      400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab

              	
                1

              	
                Preferred

              	
                AMOXIL

              	
                QL = 5 días

              


        

        

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 26 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 600-42.9 mg/5ml susp, 875-125
                    mg tab

              	
                1

              	
                Preferred

              	
                AUGMENTIN

              	
                QL = 5 días

              
	
                ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap

              	
                1

              	
                Preferred

              	
                PRINCIPEN

              	
                QL = 5 días

              
	
                penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab

              	
                1

              	
                Preferred

              	
                VEETIDS

              	
                QL = 5 días

              
	
                amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp

              	
                3

              	
                Preferred

              	
                AUGMENTIN

              	
                QL = 5 días

              
	
                Quinolones [Quinolonas]

              
	
                ciprofloxacin hcl 250 mg tab,  500 mg tab, 750 mg tab

              	
                1

              	
                Preferred

              	
                CIPRO

              	
                QL = 5 días

              
	
                levofloxacin 250 mg tab, 500 mg tab, 750 mg tab

              	
                1

              	
                Preferred

              	
                LEVAQUIN

              	
                QL = 5 días

              
	
                ciprofloxacin 500 mg/5ml (10%) susp

              	
                3

              	
                Preferred

              	
                CIPRO

              	
                QL = 5 días

              
	
                ciprofloxacin 250 mg/5ml (5%) susp

              	
                4

              	
                Preferred

              	
                CIPRO

              	
                QL = 5 días

              
	
                Second Generation Cephalosporins [Cefalosporinas De Segunda Generación]

              
	
                cefaclor 250 mg cap, 500  mg cap

              	
                2

              	
                Preferred

              	
                CECLOR

              	
                QL = 5 días

              
	
                cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab

              	
                2

              	
                Preferred

              	
                CEFZIL

              	
                QL = 5 días

              
	
                Sulfonamides [Sulfonamidas]

              
	
                sulfamethoxazole          -tmp ds 800-160 mg tab

              	
                1

              	
                Preferred

              	
                SEPTRA

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 27 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab

              	
                1

              	
                Preferred

              	
                SEPTRA

              	
                QL = 5 días

              
	
                Third Generation Cephalosporins [Cefalosporinas De Tercera Generación]

              
	
                cefdinir 125 mg/5ml susp,  300 mg cap

              	
                2

              	
                Preferred

              	
                OMNICEF

              	
                QL = 5 días

              
	
                cefdinir 250 mg/5ml susp

              	
                3

              	
                Preferred

              	
                OMNICEF

              	
                QL = 5 días

              
	
                ANTICONVULSANTS [ANTICONVULSIVANTES]

              
	
                 Anticonvulsants [Anticonvulsivantes]

              
	
                carbamazepine 100 mg tab  chew, 200 mg tab

              	
                1

              	
                Preferred

              	
                TEGRETOL

              	
                QL = 5 días

              
	
                clonazepam 0.5 mg tab, 1 mg tab, 2mg tab

              	
                1

              	
                Preferred

              	
                KLONOPIN

              	
                QL = 5 días

              
	
                divalproex sodium 125 mg tab dr, 250 mg tab dr, 500 mg tab dr

              	
                1

              	
                Preferred

              	
                DEPAKOTE

              	
                QL = 5 días

              
	
                gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab

              	
                1

              	
                Preferred

              	
                NEURONTIN

              	
                QL = 5 días

              
	
                lamotrigine 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab

              	
                1

              	
                Preferred

              	
                LAMICTAL

              	
                QL = 5 días

              
	
                lamotrigine chew tab 5 mg, 25 mg

              	
                3

              	
                Non-Preferred

              	
                LAMICTAL

              	 
	
                levetiracetam 250 mg tab, 500 mg tab

              	
                1

              	
                Preferred

              	
                KEPPRA

              	
                QL = 5 días

              
	
                levetiracetam er 24 hrs 500 mg tab, 750 mg

              	
                3

              	
                Non-Preferred

              	
                KEPPRA XR

              	 
	
                oxcarbazepine 150 mg tab

              	
                1

              	
                Preferred

              	
                TRILEPTAL

              	
                QL = 5 días

              
	
                phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab

              	
                1

              	
                Preferred

              	
                PHENOBARBITAL

              	
                QL = 5 días

              


        

        

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

            

          

        
          Page 28 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                primidone 250 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                MYSOLINE

              	
                QL = 5 días

              
	
                topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                TOPAMAX

              	
                QL = 5 días

              
	
                valproic acid 250 mg cap, 250 mg/5ml soln, 250 mg/5ml syr

              	
                1

              	
                Preferred

              	
                DEPAKENE

              	
                QL = 5 días

              
	
                zonisamide 50 mg cap

              	
                1

              	
                Preferred

              	
                ZONEGRAN

              	
                QL = 5 días

              
	
                DILANTIN 30 mg cap

              	
                2

              	
                Preferred

              	 	
                QL = 5 días

              
	
                levetiracetam 1000 mg tab, 750 mg tab

              	
                2

              	
                Preferred

              	
                KEPPRA

              	
                QL = 5 días

              
	
                oxcarbazepine 300 mg tab, 600 mg tab

              	
                2

              	
                Preferred

              	
                TRILEPTAL

              	
                QL = 5 días

              
	
                phenytoin 125 mg/5ml susp, 50 mg tab chew

              	
                2

              	
                Preferred

              	
                DILANTIN

              	
                QL = 5 días

              
	
                phenytoin sodium extended

                100 mg cap, 200 mg cap,

                300 mg cap

              	
                2

              	
                Preferred

              	
                DILANTIN

              	
                QL = 5 días

              
	
                zonisamide 100 mg cap, 25 mg cap

              	
                2

              	
                Preferred

              	
                ZONEGRAN

              	
                QL = 5 días

              
	
                ethosuximide 250 mg cap, 250 mg/5ml soln

              	
                3

              	
                Preferred

              	
                ZARONTIN

              	
                QL = 5 días

              
	
                phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln

              	
                3

              	
                Preferred

              	
                PHENOBARBITAL

              	
                QL = 5 días

              
	
                ANTIDEMENTIA AGENTS [AGENTES ANTIDEMENCIA]

              	 
	
                Cholinesterase Inhibitors [Inhibidores De
                      Colinesterasa

              	
                ]

              
	
                donepezil hcl 10 mg tab, 5  mg tab

              	
                1

              	
                Preferred

              	
                ARICEPT

              	
                QL = 5 días

              
	
                rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap

              	
                3

              	
                Preferred

              	
                EXELON

              	
                QL = 5 días

              


        

            • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] •
            Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 29 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                ANTIDEPRESSANTS [ANTIDEPRESIVOS]

              
	
                 Miscellaneous Antidepressants
                      [Antidepresivos Misceláneos]

              
	
                trazodone hcl 100 mg tab,  150 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                DESYREL

              	
                QL = 5 días

              
	
                Monoamine Oxidase (Mao) Inhibitors [Inhibidores De Mao]

              
	
                selegiline hcl 5 mg tab

              	
                3

              	
                Non-Preferred

              	
                CARBEX

              	
                QL = 5 días

              
	
                ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]

              
	
                 Alpha-Glucosidase Inhibitors [Inhibidores
                      De Alfa Glucosidasa]

              
	
                acarbose 100 mg tab, 25 mg  tab, 50 mg tab

              	
                2

              	
                Preferred

              	
                PRECOSE

              	
                QL = 5 días

              
	
                Biguanides [Biguanidas]

              
	
                metformin hcl 1000 mg tab,  500 mg tab, 850 mg tab

              	
                1

              	
                Preferred

              	
                GLUCOPHAGE

              	
                QL = 5 días

              
	
                Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors [Inhibidores De Dpp-4]

              
	
                KOMBIGLYZE XR 2.5          -1000 mg tab er 24 hr, 5-1000
                    mg tab er 24 hr, 5-500 mg tab er 24 hr

              	
                3

              	
                Preferred

              	 	
                QL = 5 días, ST, P

              
	
                ONGLYZA 2.5 mg tab, 5 mg tab

              	
                3

              	
                Preferred

              	 	
                QL = 5 días, ST, P

              
	
                Insulin Mixtures [Mezclas De Insulinas]

              
	
                HUMULIN 70/30 (70          -30) 100 unit/ml sc susp

              	
                2

              	
                Preferred

              	 	
                QL = 1 Vial 10 ML/30 días, P

              
	
                Insulin Sensitizing Agents [Agentes Sensibilizantes De Insulin]

              
	
                pioglitazone hcl 15 mg tab,  30 mg tab, 45 mg tab

              	
                1

              	
                Preferred

              	
                ACTOS

              	
                QL = 5 días

              
	
                Intermediate-Acting Insulins [Insulinas De Duración Intermedia]

              
	
                HUMULIN N 100 unit/ml sc  susp

              	
                2

              	
                Preferred

              	 	
                QL = 1 Vial 10 ML/30 días, P

              
	
                Short-Acting Insulins [Insulinas De Corta Duración]

              
	
                HUMULIN R 100 unit/ml inj  soln

              	
                2

              	
                Preferred

              	 	
                QL = 1 Vial 10 ML/30 días, P

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 30 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                Sulfonylureas [Sulfonilureas]

              	 
	
                glimepiride 1 mg tab, 2 mg  tab, 4 mg tab

              	
                1

              	
                Preferred

              	
                AMARYL

              	 	
                QL = 5 días

              
	
                glipizide 10 mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                GLUCOTROL

              	 	
                QL = 5 días

              
	
                ANTIEMETICS [ANTIEMÉTICOS]

              	 
	
                Miscellaneous Antiemetics [Antieméticos
                      Misceláneos]

              	 
	
                metoclopramide hcl 10 mg  tab, 5 mg tab, 5 mg/ml inj soln

              	
                1

              	
                Preferred

              	
                REGLAN

              	 	
                QL = 5 días

              
	
                ormir 50 mg cap

              	
                1

              	
                Preferred

              	
                BENADRYL

              	 	
                QL = 5 días

              
	
                pharbedryl 50 mg cap

              	
                1

              	
                Preferred

              	
                BENADRYL

              	 	
                QL = 5 días

              
	
                trimethobenzamide hcl 300 mg cap

              	
                1

              	
                Preferred

              	
                TIGAN

              	 	
                QL = 5 días

              
	
                Phenothiazines [Fenotiazinas]

              	 
	
                prochlorperazine maleate 10  mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                COMPAZINE

              	 	
                QL = 5 días

              
	
                prochlorperazine 25 mg rect supp

              	
                4

              	
                Non-Preferred

              	
                COMPAZINE

              	 	
                QL = 5 días

              
	
                ANTIGOUT AGENTS [AGENTES ANTIGOTA]

              	 
	
                Antigout Agents [Agentes Antigota]

              	 
	
                allopurinol 100 mg tab, 300  mg tab

              	
                1

              	
                Preferred

              	
                ZYLOPRIM

              	 	
                QL = 5 días

              
	
                colchicine 0.6 mg cap

              	
                3

              	
                Preferred

              	
                MITIGARE

              	 	
                PA

              
	
                COLCRYS 0.6 mg tab

              	
                4

              	
                Non-Preferred

              	 	 	
                QL= 3 tab, 15días

              
	
                Uricosurics [Uricosúricos]

              	 
	
                probenecid 500 mg tab

              	
                1

              	
                Preferred

              	
                BENEMID

              	 	
                QL = 5 días

              
	
                ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]

              	 
	
                Alpha-Adrenergic Agonists [Agonistas Alfa
                      Adrenérgico

              	
                s]

              
	
                clonidine hcl 0.1 mg tab, 0.2  mg tab, 0.3 mg tab

              	
                1

              	
                Preferred

              	
                CATAPRESS

              	 	
                QL = 5 días

              
	
                methyldopa 250 mg tab, 500 mg tab

              	
                1

              	
                Preferred

              	
                ALDOMET

              	 	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 31 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]

              
	
                terazosin hcl 1 mg cap, 10  mg cap, 2 mg cap, 5 mg cap

              	
                1

              	
                Preferred

              	
                HYTRIN

              	
                QL = 5 días

              
	
                Angiotensin II Receptor Blockers (ARB) [Antagonistas Del Receptor Angiotensina II] 

                

              
	
                losartan potassium 100 mg  tab, 25 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                COZAAR

              	
                QL = 5 días

              
	
                losartan potassium-hctz 100-12.5 mg tab, 100-25 mg

                tab, 50-12.5 mg tab

              	
                1

              	
                Preferred

              	
                HYZAAR

              	
                QL = 5 días

              
	
                Angiotensin-Converting Enzyme (ACE) Inhibitors [Inhibidores De La Enzima Convertidora

                De Angiotensina]

              
	
                lisinopril 10 mg tab, 2.5 mg  tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                ZESTRIL

              	
                QL = 5 días

              
	
                lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab

              	
                1

              	
                Preferred

              	
                ZESTORETIC

              	
                QL = 5 días

              
	
                Calcium Channel Blocking Agents [Bloqueadores De Canales De Calcio]

              
	
                amlodipine besylate 10 mg  tab, 2.5 mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                NORVASC

              	
                QL = 5 días

              
	
                diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab

              	
                1

              	
                Preferred

              	
                CARDIZEM

              	
                QL = 5 días

              
	
                verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab

              	
                1

              	
                Preferred

              	
                CALAN

              	
                QL = 5 días

              
	
                Carbonic Anhydrase Inhibitors Diuretics [Diuréticos Inhibidores De Anhidrasa Carbónica]

              
	
                acetazolamide 125 mg tab, 250 mg tab

              	
                3

              	
                  

                Preferred

              	
                DIAMOX

              	
                QL = 5 días

              
	
                Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]

              
	
                atenolol 100 mg tab, 25 mg  tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                TENORMIN

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 32 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr

              	
                1

              	
                Preferred

              	
                LOPRESSOR

              	
                QL = 5 días

              
	
                metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                LOPRESSOR

              	
                QL = 5 días

              
	
                metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr

              	
                2

              	
                Preferred

              	
                LOPRESSOR

              	
                QL = 5 días

              
	
                Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos

                Cardioselectivos]

              
	
                atenolol          -chlorthalidone 10025 mg tab, 50-25 mg tab

              	
                1

              	
                Preferred

              	
                TENORETIC

              	
                QL = 5 días

              
	
                metoprolol-

                hydrochlorothiazide 50-25 mg tab

              	
                2

              	
                Non-Preferred

              	
                LOPRESSOR HCT

              	
                QL = 5 días

              
	
                metoprololhydrochlorothiazide 100-25 mg tab, 100-50 mg tab

              	
                3

              	
                Non-Preferred

              	
                LOPRESSOR HCT

              	
                QL = 5 días

              
	
                Loop Diuretics [Diuréticos Del Asa]

              
	
                furosemide 10 mg/ml soln,  20 mg tab, 40 mg tab, 80 mg tab

              	
                1

              	
                Preferred

              	
                LASIX

              	
                QL = 5 días

              
	
                Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]

              
	
                propranolol hcl 10 mg tab,  20 mg tab, 40 mg tab, 80 mg tab

              	
                1

              	
                Preferred

              	
                INDERAL

              	
                QL = 5 días

              
	
                propranolol hcl 60 mg tab

              	
                2

              	
                Preferred

              	
                INDERAL

              	
                QL = 5 días

              
	
                Potassium-Sparing Diuretics [Diuréticos Conservadores De Potasio]

              
	
                spironolactone 100 mg tab,  25 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                ALDACTONE

              	
                QL = 5 días

              
	
                triamterene-hctz 37.5-25 mg cap, 37.5-25 mg tab, 75-50 mg tab

              	
                1

              	
                Preferred

              	
                MAXZIDE

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 33 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                Thiazide Diuretics [Diuréticos Tiazidas]

              
	
                chlorothiazide 250 mg tab,  500 mg tab

              	
                1

              	
                Preferred

              	
                DIURIL

              	
                QL = 5 días

              
	
                chlorthalidone 25 mg tab, 50 mg tab

              	
                1

              	
                Non-Preferred

              	
                HYGROTON

              	
                QL = 5 días

              
	
                DIURIL 250 mg/5ml susp

              	
                1

              	
                Preferred

              	 	
                QL = 5 días

              
	
                hydrochlorothiazide 12.5 mg tab, 25 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                MICROZIDE

              	
                QL = 5 días

              
	
                indapamide 1.25 mg tab, 2.5 mg tab

              	
                1

              	
                Preferred

              	
                LOZOL

              	
                QL = 5 días

              
	
                metolazone 2.5 mg tab, 5 mg tab

              	
                1

              	
                Non-Preferred

              	
                ZAROXOLYN

              	
                QL = 5 días

              
	
                chlorthalidone 100 mg tab

              	
                2

              	
                Non-Preferred

              	
                HYGROTON

              	
                QL = 5 días

              
	
                metolazone 10 mg tab

              	
                2

              	
                Non-Preferred

              	
                ZAROXOLYN

              	
                QL = 5 días

              
	
                Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]

              
	
                carvedilol 12.5 mg tab, 25  mg tab, 3.125 mg tab, 6.25 mg tab

              	
                1

              	
                Preferred

              	
                COREG

              	
                QL = 5 días

              
	
                Vasodilators [Vasodilatadores]

              
	
                hydralazine hcl 10 mg tab,  100 mg tab, 25 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                APRESOLINE

              	
                QL = 5 días

              
	
                ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]

              
	
                Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos]

              
	
                divalproex sodium 125 mg  tab dr, 250 mg tab dr, 500 mg tab dr

              	
                1

              	
                Preferred

              	
                DEPAKOTE

              	
                QL = 5 días

              
	
                topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                TOPAMAX

              	
                QL = 5 días, ST

              
	
                ANTIMYASTHENIC AGENTS [AGENTES ANTIMIASTÉNICOS]

              
	
                 Parasympathomimetics
                      [Parasimpatomiméticos]

              
	
                pyridostigmine bromide 60  mg tab

              	
                2

              	
                Preferred

              	
                MESTINON

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 34 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name

              	
                Net

                Cost

                  

              	
                Tier

              	
                Reference Name 

                

              	
                Requirements/

                Limits 

                

              
	
                MESTINON 60 mg/5ml syr

              	
                4

              	
                Non-Preferred

              	 	
                QL = 5 días

              
	
                pyridostigmine bromide 180 mg tab er

              	
                6

              	
                Non-Preferred

              	
                MESTINON

              	
                QL = 5 días

              
	
                ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]

              
	
                Antituberculars [Antituberculosos]

              
	
                CAPASTAT SULFATE 1 gm 

                inj soln

              	 	 	 	
                QL = 5 días

                Puerto Rico

                Department

                Tuberculosis

                Control Program

              
	
                cycloserine 250 mg cap

              	 	 	
                SEROMYCIN

              
	
                RIFAMATE 150-300 mg cap

              	 	 	 
	
                TRECATOR 250 mg tab

              	 	 	 
	
                rifabutin 150 mg cap

              	
                7

              	 	
                MYCOBUTIN

              
	
                isoniazid 100 mg tab, 300 mg tab

              	
                1

              	
                Preferred

              	
                ISONIAZID

              	
                QL = 5 días

              
	
                rifampin 150 mg cap

              	
                1

              	
                Preferred

              	
                RIFADIN

              	
                QL = 5 días

              
	
                ethambutol hcl 100 mg tab

              	
                2

              	
                Non-Preferred

              	
                MYAMBUTOL

              	
                QL = 5 días

              
	
                pyrazinamide 500 mg tab

              	
                2

              	
                Non-Preferred

              	
                PYRAZINAMIDE

              	
                QL = 5 días

              
	
                rifampin 300 mg cap

              	
                2

              	
                Preferred

              	
                RIFADIN

              	
                QL = 5 días

              
	
                ethambutol hcl 400 mg tab

              	
                3

              	
                Non-Preferred

              	
                MYAMBUTOL

              	
                QL = 5 días

              
	
                isoniazid 50 mg/5ml syr

              	
                5

              	
                Non-Preferred

              	
                ISONIAZID

              	
                QL = 5 días

              
	
                ANTIPARASITICS [ANTIPARASITARIOS]

              
	
                 Antimalarials [Antimaláricos]

              
	
                chloroquine phosphate 250  mg tab, 500 mg tab

              	
                1

              	
                Preferred

              	
                ARALEN

              	
                QL = 5 días

              
	
                hydroxychloroquine sulfate 200 mg tab

              	
                1

              	
                Preferred

              	
                PLAQUENIL

              	
                QL = 5 días

              
	
                quinine sulfate 324 mg cap

              	
                4

              	
                Preferred

              	
                QUININE

              	
                QL = 5 días

              
	
                DARAPRIM 25 mg tab

              	
                7

              	
                Non-Preferred

              	 	
                PA, QL = 5 días

              
	
                ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]

              
	
                 Anticholinergics [Anticolinérgicos]

              
	
                benztropine mesylate 0.5  mg tab, 1 mg tab, 2 mg tab

              	
                1

              	
                Preferred

              	
                COGENTIN

              	
                QL = 5 días

              
	
                Antiparkinson Dopaminergics [Dopaminérgicos Antiparkinson]

              
	
                amantadine hcl 50 mg/5ml  syr

              	
                1

              	
                Preferred

              	
                SYMMETREL

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 35 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name

              	
                Net

                Cost

                  

              	
                Tier

              	
                Reference Name

                 

              	
                Requirements/

                Limits

                 

              
	
                pramipexole dihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab

              	
                1

              	
                Preferred

              	
                MIRAPEX

              	
                QL = 5 días

              
	
                ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 3 mg tab, 4 mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                REQUIP

              	
                QL = 5 días

              
	
                ropinirole hcl 2 mg tab

              	
                2

              	
                Preferred

              	
                REQUIP

              	
                QL = 5 días

              
	
                amantadine hcl 100 mg cap

              	
                3

              	
                Preferred

              	
                SYMMETREL

              	
                QL = 5 días

              
	
                bromocriptine mesylate 2.5 mg tab

              	
                3

              	
                Preferred

              	
                PARLODEL

              	
                QL = 5 días

              
	
                carbidopa-levodopaentacapone 18.75-75-200 mg tab

              	
                4

              	
                Non-Preferred

              	
                STALEVO

              	
                QL = 5 días

              
	
                carbidopa-levodopaentacapone 12.5-50-200 mg tab, 25-100-200 mg tab, 31.25-125-200 mg tab, 37.5150-200 mg tab,
                    50-200-200 mg tab

              	
                5

              	
                Non-Preferred

              	
                STALEVO

              	
                QL = 5 días

              
	
                Dopamine Precursors [Precursores De Dopamina]

              
	
                carbidopa          -levodopa 10-100 mg tab, 25-100 mg tab

              	
                1

              	
                Preferred

              	
                SINEMET

              	
                QL = 5 días

              
	
                carbidopa-levodopa 25-250 mg tab

              	
                2

              	
                Preferred

              	
                SINEMET

              	
                QL = 5 días

              
	
                carbidopa-levodopa er 25100 mg tab er, 50-200 mg tab er

              	
                2

              	
                Preferred

              	
                SINEMET CR

              	
                QL = 5 días

              
	
                ANTIPSYCHOTICS [ANTIPSICÓTICOS]

              
	
                Atypical - Second Generation [Atípicos -
                      Segunda Generación]

              
	
                risperidone 0.25 mg tab, 0.5  mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab

              	
                1

              	
                Preferred

              	
                RISPERDAL

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 36 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                Typical - First Generation [Típicos - Primera Generación]

              
	
                haloperidol 0.5 mg tab, 1 mg  tab, 2 mg tab

              	
                1

              	
                Preferred

              	
                HALDOL

              	
                QL = 5 días

              
	
                haloperidol 5 mg tab

              	
                2

              	
                Preferred

              	
                HALDOL

              	
                QL = 5 días

              
	
                haloperidol 10 mg tab

              	
                3

              	
                Preferred

              	
                HALDOL

              	
                QL = 5 días

              
	
                haloperidol 20 mg tab

              	
                4

              	
                Preferred

              	
                HALDOL

              	
                QL = 5 días

              
	
                ANTIVIRALS [ANTIVIRALES]

              
	
                Anti-Cytomegalovirus (Cmv) Agents [Agentes
                      Anti-Citomegalovirus]

              
	
                valganciclovir hcl 450 mg  tab

              	
                13

              	
                Non-Preferred

              	
                VALCYTE

              	
                PA, QL = 5 días

              
	
                Antiherpetic Agents [Agentes Antiherpéticos]

              
	
                acyclovir 200 mg cap, 400  mg tab, 800 mg tab

              	
                1

              	
                Preferred

              	
                ZOVIRAX

              	
                QL = 5 días

              
	
                acyclovir 200 mg/5ml susp

              	
                2

              	
                Preferred

              	
                ZOVIRAX

              	
                QL = 5 días

              
	
                Anti-Influenza Agents [Agentes Antiinfluenza]

              
	
                amantadine hcl 50 mg/5ml  syr

              	
                1

              	
                Preferred

              	
                SYMMETREL

              	
                QL = 5 días

              
	
                amantadine hcl 100 mg cap

              	
                3

              	
                Preferred

              	
                SYMMETREL

              	
                QL = 5 días

              
	
                oseltamivir phosphate 30 mg cap, 45 mg cap, 75 mg

              	
                4

              	
                Preferred

              	
                TAMIFLU

              	 
	
                TAMIFLU 6 mg/ ml susp

              	
                5

              	
                Non-Preferred

              	 	 
	
                BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA

                PROSTÁTICA BENIGNA]

              
	
                Alpha-Adrenergic Blocking Agents
                      [Bloqueadores Alfa Adrenérgicos]

              
	
                terazosin hcl 1 mg cap, 10  mg cap, 2 mg cap, 5 mg cap

              	
                1

              	
                Preferred

              	
                HYTRIN

              	
                QL = 5 días

              
	
                BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]

              
	
                Anticoagulants [Anticoagulantes]

              
	
                warfarin sodium 1 mg tab,  10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg
                      tab, 7.5 mg tab

              	
                1

              	
                Preferred

              	
                COUMADIN

              	
                QL = 5 días

              
	
                heparin sodium (porcine) 1000 unit/ml inj soln

              	
                2

              	
                Preferred

              	
                HEPARIN

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 37 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name

              	
                Net

                Cost

              	
                Tier

              	
                Reference Name

              	
                Requirements/

                Limits 

                

              
	
                heparin sodium (porcine) 10000 unit/ml inj soln, 5000 unit/ml inj soln

              	
                3

              	
                Preferred

              	
                HEPARIN

              	
                QL = 5 días

              
	
                heparin sodium (porcine) pf 5000 unit/0.5ml inj soln

              	
                3

              	
                Preferred

              	
                HEPARIN

              	
                QL = 5 días

              
	
                heparin sodium (porcine) 2000 unit/ml iv soln

              	
                8

              	
                Preferred

              	
                HEPARIN

              	
                QL = 5 días

              
	
                Colony Stimulating Factors [Estimulantes Mieloides]

              
	
                NEULASTA 6 mg/0.6ml sc  soln

              	
                12

              	
                Preferred

              	 	
                PA, QL = 5 días, P

              
	
                NEULASTA DELIVERY KIT

                6 mg/0.6ml sc soln

              	
                12

              	
                Preferred

              	 	
                PA, QL = 5 días, P

              
	
                Platelet Modifying Agents [Modificadores De Plaquetas]

              
	
                cilostazol 100 mg tab, 50 mg  tab

              	
                1

              	
                Preferred

              	
                PLETAL

              	
                QL = 5 días

              
	
                clopidogrel bisulfate 75 mg tab

              	
                1

              	
                Preferred

              	
                PLAVIX

              	
                QL = 5 días

              
	
                CARDIOVASCULAR AGENTS [AGENTES CARDIOVASCULARES]

              
	
                Antiarrhythmics Class Ii [Antiar rítmicos
                      Clase Ii]

              
	
                propranolol hcl 10 mg tab,  20 mg tab, 40 mg tab, 80 mg tab

              	
                1

              	
                Preferred

              	
                INDERAL

              	
                QL = 5 días

              
	
                sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab

              	
                1

              	
                Preferred

              	
                BETAPACE

              	
                QL = 5 días

              
	
                sotalol hcl (af) 120 mg tab, 160 mg tab, 80 mg tab

              	
                1

              	
                Preferred

              	
                BETAPACE

              	
                QL = 5 días

              
	
                propranolol hcl 60 mg tab

              	
                2

              	
                Preferred

              	
                INDERAL

              	
                QL = 5 días

              
	
                Antiarrhythmics Type I-A [Antiarrítmicos Tipo I-A]

              
	
                quinidine sulfate 200 mg tab,  300 mg tab

              	
                1

              	
                Preferred

              	
                QUINIDINE SULFATE

              	
                QL = 5 días

              
	
                quinidine gluconate er 324 mg tab er

              	
                2

              	
                Preferred

              	
                QUINAGLUTE

              	
                QL = 5 días

              
	
                quinidine sulfate er 300 mg tab er

              	
                2

              	
                Preferred

              	
                QUINIDINE SULFATE

              	
                QL = 5 días

              


        

        

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 38 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                Antiarrhythmics Type I-B [Antiarrítmicos Tipo I-B]

              
	
                mexiletine hcl 150 mg cap

              	
                2

              	
                Preferred

              	
                MEXITIL

              	
                QL = 5 días

              
	
                mexiletine hcl 200 mg cap

              	
                3

              	
                Preferred

              	
                MEXITIL

              	
                QL = 5 días

              
	
                Antiarrhythmics Type I-C [Antiarrítmicos Tipo I-C]

              
	
                flecainide acetate 100 mg  tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                TAMBOCOR

              	
                QL = 5 días

              
	
                propafenone hcl 150 mg tab, 225 mg tab

              	
                1

              	
                Preferred

              	
                RYTHMOL

              	
                QL = 5 días

              
	
                flecainide acetate 150 mg tab

              	
                2

              	
                Preferred

              	
                TAMBOCOR

              	
                QL = 5 días

              
	
                propafenone hcl 300 mg tab

              	
                3

              	
                Preferred

              	
                RYTHMOL

              	
                QL = 5 días

              
	
                Antiarrhythmics Type Iii [Antiarrítmicos Tipo Iii]

              
	
                amiodarone hcl 200 mg tab

              	
                1

              	
                Preferred

              	
                CORDARONE

              	
                QL = 5 días

              
	
                Miscellaneous Cardiovascular Agents [Agentes Cardiovasculares Misceláneos]

              
	
                digoxin 125           mcg tab, 250 mcg tab

              	
                2

              	
                Preferred

              	
                LANOXIN

              	
                QL = 5 días

              
	
                Vasodilators [Vasodilatadores]

              
	
                isosorbide mononitrate 10  mg tab, 20 mg tab

              	
                1

              	
                Preferred

              	
                ISORDIL

              	
                QL = 5 días

              
	
                isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr

              	
                1

              	
                Preferred

              	
                IMDUR

              	
                QL = 5 días

              
	
                NITROSTAT 0.3 mg tab

                subl, 0.4 mg tab subl, 0.6

                mg tab subl

              	
                1

              	
                Preferred

              	 	
                QL = 5 días

              
	
                DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]

              
	
                 Antifungals [Antifungales]

              
	
                clotrimazole 10 mg  mouth/throat lozenge, 10 mg mouth/throat troche

              	
                1

              	
                Preferred

              	
                MYCELEX

              	
                QL = 5 días

              
	
                nystatin 100000 unit/ml mouth/throat susp, 100000 unit/ml crm

              	
                1

              	
                Preferred

              	
                NYSTATIN

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 39 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                 DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]

              
	
                 Pediculicides And Scabicides
                      [Pediculicidas Y Escabicidas]

              
	
                permethrin 5 % crm 

                

              	
                3

              	
                Preferred

              	
                ELIMITE

              	
                QL = 5 días

              
	
                Topical Antibiotics [Antibióticos Tópicos]

              
	
                mupirocin 2 % oint

              	
                1

              	
                Preferred

              	
                BACTROBAN

              	
                QL = 5 días

              
	
                silver sulfadiazine 1 % crm

              	
                1

              	
                Preferred

              	
                SILVADENE

              	
                QL = 5 días

              
	
                terbinafine 1% crm

              	
                1

              	
                Preferred

              	
                LAMISIL

              	
                OTC, QL = 5días

              
	
                DYSLIPIDEMICS [DISLIPIDÉMICOS]

              
	
                 Bile Acid Sequestrants [Secuestradores De
                      Ácidos Biliares]

              
	
                cholestyramine 4 gm pckt, 4  gm/dose oral pwdr

              	
                3

              	
                Preferred

              	
                QUESTRAN

              	
                QL = 5 días

              
	
                cholestyramine light 4 gm pckt, 4 gm/dose oral pwdr

              	
                3

              	
                Preferred

              	
                QUESTRAN

              	
                QL = 5 días

              
	
                Fibric Acid Derivatives [Derivados De Ácido Fíbrico]

              
	
                gemfibrozil 600 mg tab

              	
                1

              	
                Preferred

              	
                LOPID

              	
                QL = 5 días

              
	
                Hmg-Coa Reductase Inhibitors [Inhibidores De La Hmg-Coa Reductasa]

              
	
                atorvastatin           calcium 10 mg tab, 20 mg tab, 40 mg tab, 80 mg tab

              	
                1

              	
                Preferred

              	
                LIPITOR

              	
                QL = 5 días

              
	
                simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                ZOCOR

              	
                QL = 5 días

              
	
                GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]

              
	
                 Histamine2 (H2) Receptor Antagonists
                      [Antagonistas Del Receptor De H2]

              
	
                famotidine 20 mg tab, 40 mg  tab

              	
                1

              	
                Preferred

              	
                PEPCID

              	
                QL = 5 días

              
	
                ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr

              	
                1

              	
                Preferred

              	
                ZANTAC

              	
                QL = 5 días

              
	
                Miscellaneous Gastrointestinal Agents [Agentes Gastrointestinales Misceláneos]

              
	
                ursodiol 300 mg cap

              	
                2

              	
                Preferred

              	
                ACTIGALL

              	
                PA, QL = 5 días

              


        

        

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 40 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]

              
	
                  

                omeprazole 10 mg cap dr, 20 mg cap dr, 40 mg cap dr

              	
                1

              	
                Preferred

              	
                PRILOSEC

              	
                QL=180 caps/ 365 días

              
	
                GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]

              
	
                Miscellaneous Genitourinary Agents
                      [Agentes Genitourinarios Misceláneos]

              
	
                phenazopyridine hcl 100 mg  tab, 200 mg tab

              	
                1

              	
                Preferred

              	
                PYRIDIUM

              	
                QL = 3 días

              
	
                HORMONAL AGENTS [AGENTES HORMONALES]

              
	
                Antithyroid Agents [Agentes Antitiroide]

              
	
                methimazole 10 mg tab, 5  mg tab

              	
                1

              	
                Preferred

              	
                TAPAZOLE

              	
                QL = 5 días

              
	
                propylthiouracil 50 mg tab

              	
                2

              	
                Preferred

              	
                PROPYLTHIOURA

                CIL

              	
                QL = 5 días

              
	
                Calcimimetic Agents [Agentes Calcimiméticos]

              
	
                SENSIPAR 30  mg tab

              	
                7

              	
                Preferred

              	 	
                PA, QL = 5 días

              
	
                SENSIPAR 60 mg tab

              	
                9

              	
                Preferred

              	 	
                PA, QL = 5 días

              
	
                SENSIPAR 90 mg tab

              	
                10

              	
                Preferred

              	 	
                PA, QL = 5 días

              
	
                Dopamine Agonists [Agonistas De Dopamina]

              
	
                bromocriptine mesylate 2.5  mg tab

              	
                3

              	
                Preferred

              	
                PARLODEL

              	
                QL = 5 días

              
	
                Thyroid Hormones [Hormona Tiroidea]

              
	
                SYNTHROID 100 mcg tab, 

                112 mcg tab, 125 mcg tab,

                137 mcg tab, 150 mcg tab,

                175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

              	
                1

              	
                Preferred

              	 	
                QL = 5 días, P

              


        

        

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 41 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]

              
	
                Glucocorticosteroids [Glucocorticoides]

              
	
                dexamethasone 0.5 mg tab,  0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg
                      tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab

              	
                1

              	
                Preferred

              	
                DECADRON

              	
                QL = 5 días

              
	
                methylprednisolone 32 mg tab, 4 mg tab

              	
                1

              	
                Preferred

              	
                MEDROL

              	
                QL = 5 días

              
	
                prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab

              	
                1

              	
                Preferred

              	
                DELTASONE

              	
                QL = 5 días

              
	
                prednisone (pak) 10 mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                DELTASONE

              	
                QL = 5 días

              
	
                methylprednisolone 16 mg tab, 8 mg tab

              	
                2

              	
                Preferred

              	
                MEDROL

              	
                QL = 5 días

              
	
                Immune Globulins [Immunoglobulinas]

              
	
                RHOGAM ultra-filtered plus im soln 1500
                      unit

              	
                4

              	
                Preferred

              	 	 
	
                INFLAMMATORY BOWEL DISEASE [ENFERMEDAD INFLAMATORIA INTESTINAL]

              
	
                 Aminosalicylates [Aminosalicilatos]

              
	
                DELZICOL 400 mg cap dr

              	
                5

              	
                Preferred

              	 	
                QL = 5 días, P

              
	
                ASACOL HD 800 mg tab dr

              	
                6

              	
                Preferred

              	 	
                QL = 5 días, P

              
	
                Sulfonamides [Sulfonamidas]

              
	
                sulfasalazine 500 mg tab,  500 mg tab dr

              	
                1

              	
                Preferred

              	
                AZULFIDINE

              	
                QL = 5 días

              
	
                MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]

              
	
                 Calcium Regulating Agents [Agentes
                      Reguladores De Calcio]

              
	
                vitamin d 400 unit cap

              	
                1

              	
                Preferred

              	
                VITAMIN D

              	
                QL = 5 días

              
	
                MUSCLE RELAXANTS [RELAJANTES MUSCULARES]

              
	
                 Antispasticity Agents [Agentes
                      Antiespasticidad]

              
	
                baclofen 10 mg tab, 20 mg  tab

              	
                1

              	
                Preferred

              	
                LIORESAL

              	
                QL = 5 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 42 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                dantrolene sodium 25 mg cap, 50 mg cap

              	
                2

              	
                Preferred

              	
                DANTRIUM

              	
                QL = 5 días

              
	
                dantrolene sodium 100 mg cap

              	
                3

              	
                Preferred

              	
                DANTRIUM

              	
                QL = 5 días

              
	
                Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]

              
	
                cyclobenzaprine hcl 10 mg  tab

              	
                1

              	
                Preferred

              	
                FLEXERIL

              	
                QL = 5 días

              
	
                OPHTHALMIC AGENTS [AGENTES OFTÁLMICOS]

              
	
                Antiglaucoma Agents [Agentes Antiglaucoma]

              
	
                brimonidine tartrate 0.2 %  ophth soln

              	
                1

              	
                Preferred

              	
                ALPHAGAN

              	
                QL = 1 Frasco 5 ML/15 días

              
	
                dorzolamide hcl 2 % ophth soln

              	
                1

              	
                Preferred

              	
                TRUSOPT

              	
                QL = Frasco 10 ML/30 días

              
	
                levobunolol hcl 0.5 % ophth soln

              	
                1

              	
                Preferred

              	
                BETAGAN

              	
                QL = 1 Frasco 5 ML/25 días

              
	
                levobunolol hcl 0.25 % ophth soln

              	
                1

              	
                Preferred

              	
                BETAGAN

              	
                QL = 1 Frasco 5 ML/15 días

              
	
                timolol maleate 0.5 % ophth soln

              	
                1

              	
                Preferred

              	
                TIMOPTIC

              	
                QL = 1 Frasco 5 ML/30 días

              
	
                dorzolamide hcl-timolol mal ophth sol 22.3-6.8 mg/ml

              	
                1

              	
                Preferred

              	
                COSOPT

              	
                QL = 1 Frasco 5 ML/30 días

              
	
                timolol maleate 0.25 % ophth soln

              	
                1

              	
                Preferred

              	
                TIMOPTIC

              	
                QL = 1 Frasco 5 ML/25 días

              
	
                betaxolol hcl 0.5 % ophth soln

              	
                2

              	
                Non-Preferred

              	
                BETOPTIC

              	
                QL = 1 Frasco 5 ML/15 días

              
	
                Ophthalmic Antibiotics [Antibióticos Oftálmicos]

              
	
                gentamicin sulfate 0.3 %  ophth oint

              	
                1

              	
                Preferred

              	
                GARAMYCIN

              	
                QL = 1 Tubo 3.5 GM/5 días

              
	
                gentamicin sulfate 0.3 % ophth soln

              	
                1

              	
                Preferred

              	
                GARAMYCIN

              	
                QL = 1 Frasco 5 ML/5 días

              
	
                tobramycin 0.3 % ophth soln

              	
                1

              	
                Preferred

              	
                TOBREX

              	
                QL = 1 Frasco 5 ML/5 días

              
	
                Ophthalmic Prostaglandins [Prostaglandinas Oftálmicas]

              
	
                latanoprost 0.005 % ophth  soln

              	
                1

              	
                Preferred

              	
                XALATAN

              	
                QL = 1 Frasco/25 días

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

         

          

        
          Page 43 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                    /Límites]

              
	
                Ophthalmic Steroids [Esteroides Oftálmicos]

              
	
                neomycin -polymyxindexamethasone 3.5-100000.1 ophth oint, 3.5-100000.1
                      ophth susp

              	
                1

              	
                Preferred

              	
                MAXITROL

              	
                QL = 1

                Frasco 5

                ML/5 días

              
	
                prednisolone acetate 1 % ophth susp

              	
                2

              	
                Preferred

              	
                PRED FORTE

              	
                QL = 1

                Frasco 5

                ML/5 días

              
	
                OTIC AGENTS [AGENTES OTICOS]

              
	
                 Miscellaneous Otic Agents [Agentes Oticos Misceláneos]

              
	
                  

                acetic acid 2 % otic soln

              	
                2

              	
                Preferred

              	
                VOSOL

              	
                QL = 1 Frasco 15 ML/10 días

              
	
                Otic Antibiotics [Antibióticos Oticos]

              
	
                neomycin          -polymyxin-hc 1 % otic soln, 3.5-10000-1 otic soln, 3.5-10000-1 otic susp

              	
                2

              	
                Preferred

              	
                CORTISPORIN

              	
                QL = 1

                Frasco 10

                ML/10 días

              
	
                RESPIRATORY AGENTS [AGENTES RESPIRATORIOS]

              
	
                Anticholinergic Bronchodilators [Broncodilatadores Anticolinérgicos]

              
	
                ipratropium bromide 0.02 %  inh soln

              	
                1

              	
                Non-Preferred

              	
                ATROVENT

              	
                QL = 5 días

              
	
                Antileukotrienes [Antileukotrienos]

              
	
                montelukast sodium 10 mg  tab, 4 mg tab chew, 5 mg

                tab chew 1 Preferred SINGULAIR QL
                    = 5 días

              
	
                Antitussive-Expectorant [Expectorantes Antitusivos]

              
	
                benzonatate  100 mg cap

              	
                1

              	
                Preferred

              	
                TESSALON

              	
                QL = 5 días

              
	
                guaifenesin-codeine 100-10 mg/5ml soln

              	
                1

              	
                Preferred

              	
                CHERATUSSIN

              	
                QL = 5 días

              
	
                Inhaled Corticosteroids [Corticosteroides Inhalados]

              
	
                FLOVENT DISKUS 100 

                mcg/blist inh aer pwdr, 250 mcg/blist inh aer pwdr, 50 mcg/blist inh aer pwdr

              	
                3

              	
                Preferred

              	 	
                QL = 1 Inh 60 EA/30 días, P

              


         

          

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

            

          

        
          Page 44 of 38

          
            


        

        
          INTEGRATED EMERGENCY FORMULARY

          
            

          

        

        

        

        	
                Drug Name [Nombre del

                Medicamento]

              	
                Net

                Cost

                [Costo

                Neto]

              	
                Tier [Tier]

              	
                Reference Name

                [Nombre de

                Referencia]

              	
                Requirements/

                Limits

                [Requerimientos

                /Límites]

              
	
                FLOVENT HFA 110 mcg/act

                inh aer

              	
                3

              	
                Preferred

              	 	
                QL = 1 Inh 12 EA/30 días, P

              
	
                FLOVENT HFA 44 mcg/act

                inh aer

              	
                3

              	
                Preferred

              	 	
                QL = 1 Inh 10.6 EA/30 días, P

              
	
                budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp,

                1mg/2ml inh susp

              	
                4

              	
                  

                  

                  

                  

                Non-Preferred

              	
                PULMICORT

              	
                AL </=12

              
	
                budesonide 1mg/2ml inh susp

              	
                8

              	
                  

                  

                Non-Preferred

              	
                PULMICORT

              	
                AL </=12

              
	
                FLOVENT HFA 220 mcg/act

                inh aer

              	
                4

              	
                Preferred

              	 	
                QL = 1 Inh 12

                EA/30 días, P

              
	
                Sedating Histamine1 Blocking Agents [Sedantes Bloqueadores Histamine1]

              
	
                promethazine hcl 12.5 mg  tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln,
                      6.25 mg/5ml syr

              	
                1

              	
                Preferred

              	
                PHENERGAN

              	
                QL = 5 días

              
	
                Sympathomimetic Bronchodilators [Broncodilatadores Simpatomiméticos]

              
	
                albuterol sulfate (2.5  mg/3ml) 0.083% inh neb soln, (5 mg/ml) 0.5% inh
                      neb soln, 2 mg/5ml syr

              	
                1

              	
                Dl

                  

              	
                ALBUTEROL

              	
                QL = 5 días

              
	
                terbutaline sulfate 2.5 mg tab, 5 mg tab

              	
                1

              	
                Preferred

              	
                BRETHINE

              	
                QL = 5 días

              
	
                VENTOLIN HFA 108 (90 base) mcg/act inh aer

              	
                1

              	
                Preferred

              	 	
                QL = 1 Inh 18 EA/30 días, P

              


         

        

        • PA - Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL - Quantity Limit
            [Límite de Cantidad] • ST - Step Therapy [Terapia Escalonada] • AL - Age Limit [Límite de Edad] • Net Cost [Costo Neto] - Please refer to page #12 for monthly net cost range [Ver página #12 para rangos de costo neto mensual] • P – Preferred
            Contracted Product [Producto Contratado Preferido]

        

        

        
          Page 45 of 38

          
            


        

        
          
            	
                    A

                  	 
	
                    acarbose

                  	
                    19

                  
	
                    acetaminophen-codeine

                  	
                    13

                  
	
                    acetaminophen-codeine #2

                  	
                    13

                  
	
                    acetaminophen-codeine #3

                  	
                    13

                  
	
                    acetaminophen-codeine #4

                  	
                    13

                  
	
                    acetazolamide

                  	
                    21

                  
	
                    acetic acid

                  	
                    33

                  
	
                    acyclovir

                  	
                    26

                  
	
                    albuterol sulfate

                  	
                    34

                  
	
                    allopurinol .

                  	
                    20

                  
	
                    amantadine hcl

                  	
                    24, 25, 26

                  
	
                    amiodarone hcl

                  	
                    28

                  
	
                    amlodipine besylate

                  	
                    21

                  
	
                    amoxicillin

                  	
                    15

                  
	
                    amoxicillin-pot clavulanate

                  	
                    16

                  
	
                    ampicillin

                  	
                    16

                  
	
                    ASACOL HD

                  	
                    31

                  
	
                    atenolol

                  	
                    21

                  
	
                    atenolol-chlorthalidone

                  	
                    22

                  
	
                    atorvastatin calcium

                  	
                    29

                  
	
                    azithromycin

                  	
                    14

                  
	
                    B

                  	 
	
                    baclofen

                  	
                    31

                  
	
                    benzonatate

                  	
                    33

                  
	
                    benztropine mesylate

                  	
                    24

                  
	
                    betaxolol hcl

                  	
                    32

                  
	
                    brimonidine tartrate

                  	
                    32

                  
	
                    bromocriptine mesylate

                  	
                    25, 30

                  
	
                    budesonide

                  	
                    34

                  
	
                    butalbital-apap-caffeine

                  	
                    13

                  
	
                    C

                  	 
	
                    CAPASTAT SULFATE

                  	
                    24

                  
	
                    carbamazepine

                  	
                    17

                  
	
                    carbidopa-levodopa

                  	
                    25

                  
	
                    carbidopa-levodopa er

                  	
                    25

                  
	
                    carbidopa-levodopa-entacapone

                  	
                    25

                  
	
                    carvedilol

                  	
                    23

                  
	
                    cefaclor

                  	
                    16

                  
	
                    cefadroxil

                  	
                    14

                  
	
                    cefdinir

                  	
                    17

                  
	
                    cefprozil

                  	
                    16

                  


          

        

        
          
            	
                    cephalexin

                  	
                    14

                  
	
                    chloroquine phosphate

                  	
                    24

                  
	
                    chlorothiazide

                  	
                    23

                  
	
                    chlorthalidone

                  	
                    23

                  
	
                    cholestyramine

                  	
                    29

                  
	
                    cholestyramine light

                  	
                    29

                  
	
                    cilostazol

                  	
                    27

                  
	
                    ciprofloxacin

                  	
                    16

                  
	
                    ciprofloxacin hcl

                  	
                    16

                  
	
                    clarithromycin

                  	
                    15

                  
	
                    clindamycin hcl

                  	
                    15

                  
	
                    clonazepam

                  	
                    14, 17

                  
	
                    clonidine hcl

                  	
                    20

                  
	
                    clopidogrel bisulfate

                  	
                    27

                  
	
                    clotrimazole

                  	
                    28

                  
	
                    colchicine

                  	
                    20

                  
	
                    COLCRYS

                  	
                    20

                  
	
                    cyclobenzaprine hcl

                  	
                    32

                  
	
                    cycloserine

                  	
                    24

                  
	
                    D

                  	 
	
                    dantrolene sodium

                  	
                    32

                  
	
                    DARAPRIM

                  	
                    24

                  
	
                    DELZICOL

                  	
                    31

                  
	
                    dexamethasone

                  	
                    31

                  
	
                    diazepam

                  	
                    14

                  
	
                    digoxin

                  	
                    28

                  
	
                    DILANTIN

                  	
                    18

                  
	
                    diltiazem hcl

                  	
                    21

                  
	
                    DIURIL

                  	
                    23

                  
	
                    divalproex sodium

                  	
                    17, 23

                  
	
                    donepezil hcl

                  	
                    18

                  
	
                    dorzolamide hcl

                  	
                    32

                  
	
                    E

                  	 
	
                    ERYTHROCIN STEARATE

                  	
                    15

                  
	
                    erythromycin base

                  	
                    15

                  
	
                    erythromycin ethylsuccinate

                  	
                    15

                  
	
                    ethambutol hcl

                  	
                    24

                  
	
                    ethosuximide

                  	
                    18 F

                  
	
                    famotidine

                  	
                    29

                  
	
                    flecainide acetate

                  	
                    28

                  
	
                    FLOVENT DISKUS

                  	
                    33

                  
	
                    FLOVENT HFA

                  	
                    34

                  


          

        

        
          	
                   

                


        

        
          Page 46 of 38

          
            


        

        
          	
                  furosemide

                	
                  22

                
	
                  G

                	 
	
                  gabapentin

                	
                  17

                
	
                  gemfibrozil

                	
                  29

                
	
                  gentamicin sulfate

                	
                  32

                
	
                  glimepiride

                	
                  20

                
	
                  glipizide

                	
                  20

                
	
                  guaifenesin-codeine

                	
                  33

                
	
                  H

                	 
	
                  haloperidol

                	
                  26

                
	
                  heparin sodium (porcine)

                	
                  26, 27

                
	
                  heparin sodium (porcine) pf

                	
                  27

                
	
                  HUMULIN 70/30

                	
                  19

                
	
                  HUMULIN N

                	
                  19

                
	
                  HUMULIN R

                	
                  19

                
	
                  hydralazine hcl

                	
                  23

                
	
                  hydrochlorothiazide

                	
                  23

                
	
                  hydroxychloroquine sulfate

                	
                  24

                
	
                  hydroxyzine pamoate

                	
                  14

                
	
                  I

                	 
	
                  ibuprofen

                	
                  13

                
	
                  indapamide

                	
                  23

                
	
                  indomethacin

                	
                  13

                
	
                  ipratropium bromide

                	
                  33

                
	
                  isoniazid

                	
                  24

                
	
                  isosorbide mononitrate

                	
                  28

                
	
                  isosorbide mononitrate er

                	
                  . 28

                
	
                  K

                	 
	
                  KOMBIGLYZE XR

                	
                  19

                
	 L	 
	
                  lamotrigine

                	
                  17

                
	
                  lamotrigine chew tab

                	
                  17

                
	
                  latanoprost

                	
                  32

                
	
                  levetiracetam

                	17, 18 

                
	
                  levetiracetam er 24 hrs

                	
                  17

                
	
                  levobunolol hcl

                	
                  32

                
	
                  levofloxacin

                	
                  16

                
	
                  lidocaine viscous

                	
                  14

                
	
                  lisinopril

                	
                  21

                
	
                  lisinopril-hydrochlorothiazide

                	
                  21

                
	
                  lorazepam

                	
                  14

                
	
                  losartan potassium

                	
                  21

                
	
                  losartan potassium-hctz

                	
                  21

                


        

        
          	
                  M

                	 
	
                  MACRODANTIN

                	
                  15

                
	
                  MESTINON

                	
                  24

                
	
                  metformin hcl

                	
                  19

                
	
                  methimazole

                	
                  30

                
	
                  methyldopa

                	
                  20

                
	
                  methylprednisolone

                	
                  31

                
	
                  metoclopramide hcl

                	
                  20

                
	
                  metolazone

                	
                  23

                
	
                  metoprolol succinate er

                	
                  22

                
	
                  metoprolol tartrate

                	
                  22

                
	
                  metoprolol-hydrochlorothiazide

                	
                  22

                
	
                  metronidazole

                	
                  15

                
	
                  mexiletine hcl

                	
                  28

                
	
                  montelukast sodium

                	
                  33

                
	
                  mupirocin

                	
                  29

                
	
                  N

                	 
	
                  nabumetone

                	
                  13

                
	
                  naproxen

                	
                  13

                
	
                  naproxen sodium

                	
                  13

                
	
                  neomycin-polymyxin-dexamethasone

                	
                  33

                
	
                  neomycin-polymyxin-hc

                	
                  33

                
	
                  NEULASTA

                	
                  27

                
	
                  NEULASTA DELIVERY KIT

                	
                  27

                
	
                  nitrofurantoin macrocrystal

                	
                  15

                
	
                  nitrofurantoin monohyd macro

                	
                  15

                
	
                  nitrofurantoin oral suspension

                	
                  15

                
	
                  NITROSTAT

                	
                  28

                
	
                  nystatin

                	
                  28

                
	
                  O

                	 
	
                  omeprazole

                	
                  30

                
	
                  ONGLYZA

                	
                  19

                
	
                  ormir

                	
                  20

                
	
                  oseltamivir phosphate

                	
                  26

                
	
                  oxcarbazepine

                	
                  17, 18 

                
	P	 
	
                  penicillin v potassium

                	
                  16

                
	
                  permethrin

                	
                  29

                
	
                  pharbedryl

                	
                  20

                
	
                  phenazopyridine hcl

                	
                  30

                
	
                  phenobarbital

                	
                  17, 18

                
	
                  phenytoin

                	
                  18

                
	
                  phenytoin sodium extended

                	
                  18

                


        

        
          	
                   

                


        

        
          Page 47 of 38

          
            


        

        
          
            	
                    pioglitazone hcl

                  	
                    19

                  
	
                    pramipexole dihydrochloride

                  	
                    25

                  
	
                    prednisolone acetate

                  	
                    33

                  
	
                    prednisone

                  	
                    31

                  
	
                    prednisone (pak)

                  	
                    31

                  
	
                    primidone

                  	
                    18

                  
	
                    probenecid

                  	
                    20

                  
	
                    prochlorperazine

                  	
                    20

                  
	
                    prochlorperazine maleate

                  	
                    20

                  
	
                    promethazine hcl

                  	
                    34

                  
	
                    propafenone hcl

                  	
                    28

                  
	
                    propranolol hcl

                  	
                    22, 27

                  
	
                    propylthiouracil

                  	
                    30

                  
	
                    pyrazinamide

                  	
                    24

                  
	
                    pyridostigmine

                  	
                    24

                  
	
                    pyridostigmine bromide

                  	
                    23

                  
	
                    Q

                  	 
	
                    quinidine gluconate er

                  	
                    27

                  
	
                    quinidine sulfate

                  	
                    27

                  
	
                    quinidine sulfate er

                  	
                    27

                  
	
                    quinine sulfate

                  	
                    24

                  
	
                    R

                  	 
	
                    ranitidine hcl

                  	
                    29

                  
	
                    RHOGAM

                  	
                    31

                  
	
                    RHOGAM ultra-filtered plus im soln 1500 unit

                  	
                    31

                  
	
                    rifabutin

                  	
                    24

                  
	
                    RIFAMATE

                  	
                    24

                  
	
                    rifampin

                  	
                    24

                  
	
                    risperidone

                  	
                    25

                  
	
                    rivastigmine tartrate

                  	
                    18

                  
	
                    ropinirole hcl

                  	
                    25

                  
	
                    S

                  	 
	
                    salsalate

                  	
                    13

                  
	
                    selegiline hcl

                  	
                    19

                  
	
                    SENSIPAR

                  	
                    30

                  
	
                    silver sulfadiazine

                  	
                    29

                  
	
                    simvastatin

                  	
                    29

                  
	
                    sotalol hcl

                  	
                    27

                  
	
                    sotalol hcl (af)

                  	
                    27

                  
	
                    spironolactone

                  	
                    22

                  


          

          
            	
                    sulfamethoxazole-tmp ds

                  	
                    16

                  
	
                    sulfamethoxazole-trimethoprim

                  	
                    17

                  
	
                    sulfasalazine

                  	
                    31

                  
	
                    SYNTHROID

                  	
                    30

                  
	
                    T

                  	 
	
                    TAMIFLU

                  	
                    26

                  
	
                    temazepam

                  	
                    14

                  
	
                    terazosin hcl

                  	
                    21, 26

                  
	
                    terbutaline sulfate

                  	
                    34

                  
	
                    timolol maleate

                  	
                    32

                  
	
                    tobramycin

                  	
                    32

                  
	
                    topiramate

                  	
                    18, 23

                  
	
                    tramadol hcl

                  	
                    13

                  
	
                    trazodone hcl

                  	
                    19

                  
	
                    TRECATOR

                  	
                    24

                  
	
                    triamterene-hctz

                  	
                    22

                  
	
                    trimethobenzamide hcl

                  	
                    20

                  
	
                    U

                  	 
	
                    ursodiol

                  	
                    29

                  
	
                    V

                  	 
	
                    valganciclovir hcl

                  	
                    26

                  
	
                    valproic acid

                  	
                    18

                  
	
                    VENTOLIN HFA

                  	
                    34

                  
	
                    verapamil hcl

                  	
                    21

                  
	
                    vitamin d

                  	
                    31

                  
	
                    W

                  	 
	
                    warfarin sodium

                  	
                    26

                  
	
                    Z

                  	 
	
                    zonisamide

                  	
                    18

                  


          

          	
                   

                


        

        
          Page 48 of 38

          
            


        

        ASES

        Puerto Rico Healthcare Insurance Administration

        

        

        Dental

         

          

        2017

         

          

        Formulary of Drugs Covered by

         

          

        the Government Healthcare Plan (GHP)

        

        

        Authorized by the P.R. Elections Commission CEE-SA-16-2732

         

          

        
          Page 49 of 38

          
            


        

        	
                

              	 	
                GOVERNMENT OF PUERTO RICO

              	
                Hon. Ricardo A. Rosselló Nevares

              
	 	
                Healthcare Insurance Administration

              	Governor
	 	 	 	
                Ms. Ángela M. Ávila Marrero

                Executive Director

              


        

        

        May 1, 2017

         

          

        TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

         

          

        Dear provider:

         

          

        I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its corresponding
            sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

         

          

        The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and Sub-physical. Moreover, the Mental
            Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health Sub-formulary will be used by participating
            primary care physicians (PCPs) in Primary Care Medical Groups.

         

          

        The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare Insurance Administration
            (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical aspects. The FDC is a dynamic document
            that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

         

          

        I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

        

        

        Cordially,

        

        

        [signed]

         

          

        Ángela M. Ávila Marrero

         

          

        Executive Director

         

          

        
          	

                	 

                
	
                  
                    
                      PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                    

                  

                


          

          

        

        
          Page 50 of 38

          
            


        

        
        
          GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE 

          OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

          

          

          
            
              	1.	
                      Drug Formulary

                    


            

          

          

          

          The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and reviewing the Formulary of Drugs
              Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee is constituted by healthcare professionals,
              including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES for the drug formulary based on scientific evidence,
              clinical aspects, and a cost-effectiveness analysis.

          

          

          The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the prescription drug coverage. The purpose of
              the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

          

          

          ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator or PPA based on the most recent
              clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

          

          

          Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain in point number 2.

          

          

          
            
              	2.	
                      Exception Process

                    


            

          

          

          

          In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as applicable, insurance companies must
              use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

          

          

          
            
              	

                    	e.	
                      Contraindication to the drug(s) included in the FDC;

                    


            

          

          
            
              	

                    	f.	
                      History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                    


            

          

          
            
              	

                    	g.	
                      Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                    


            

          

          
            
              	

                    	h.	
                      Lack of a therapeutic alternative in the FDC.

                    


            

          

          

          

          This exception process requires a clinical justification that is duly documented by the service provider with the clinical reasons justifying
              the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

          

          

          
            
              	3.	
                      Other Aspects of the Prescription Drug Coverage

                    


            

          

          

          

          
            
              	

                    	A.	
                      The prescription drug coverage of the GHP establishes that using generic bioequivalent products as the
                            first option is mandatory.

                    


            

          

          

          

          
            Page 51 of 12

            
              


          

          
            
              	

                    	B.	
                      Insurance companies or the TPA (Third Party Administrator) and healthcare service providers will only
                            process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                    


            

          

          

          

          
            
              	

                    	C.	
                      ASES has an active process to continually review the prescription drug coverage in accordance with
                            changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES may require
                            that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will safeguard adequate access
                            to services and maintain continuity of care.

                    


            

          

          

          

          
            
              	

                    	D.	
                      No entity contracted by ASES or by healthcare companies or organizations (for example, primary care
                            medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES. Furthermore, they may not limit
                            the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be responsible for supervising their providers and
                            employees with regard to their compliance with these provisions.

                    


            

          

          

          

          
            
              	

                    	E.	
                      The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The treatment
                            period may be extended, as applicable, when medically necessary.

                    


            

          

          

          

          
            
              	

                    	F.	
                      The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty (30) day
                            therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating adherence and tolerance.
                            The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case of narcotics, which will be
                            dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms of adherence, tolerance, and dosage
                            within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                    


            

          

          

          

          
            
              	

                    	G.	
                      ASES requires the use of generic bioequivalent drugs approved by the Food and Drug Administration (FDA)
                            coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                    


            

          

          

          

          
            
              	

                    	H.	
                      The lack of appropriate bioequivalent drug inventories does not exempt providers from dispensing the
                            prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the corresponding brand-name drug,
                            unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception mechanism.

                    


            

          

          

          

          
            
              	

                    	I.	
                      Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized under the
                            law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                    


            

          

          

          

          
            Page 52 of 12

            
              


          

          
            
              	

                    	J.	
                      The right to freedom of choice requires the availability of a pharmacy that is reasonably accessible to
                            each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                    


            

          

          

          

          Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or when an electronic
              prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24 hours. If a drug is not
              available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her physician to have the prescription
              sent to another pharmacy of his or her choice.

          

          

          
            
              	4.	
                      Emergency Rule

                    


            

          

          

          

          The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except as otherwise
              specified.

          

          

          The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will also be dispensed
              in amounts sufficient for five (5) business days.

          

          

          Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for continuity of treatment,
              including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the IEF.

          

          

          If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES in your region
              and/or the Pharmacy Benefit Manager (PBM) contracted by ASES.

          
            Page 53 of 12

            
              


          

           
          
            		
                     DENTAL

                  


            

            

          GOVERNMENT HEALTHCARE PLAN

          FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

          2017

          TABLE OF CONTENTS

          

          

          	
                  GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE GOVERNMENT HEALTHCARE PLAN

                	
                  3

                
	
                  
                    DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND
                        REFERENCE GUIDES

                  

                	
                  7

                
	 	
                  MONTHLY NET COST RANGE

                	
                  7

                
	 	
                  GENERIC DRUGS

                	
                  8

                
	
                  ANALGESICS

                	
                  9

                
	 	
                  Nonsteroidal Anti-Inflammatory Agents (Nsaids)

                	
                  9

                
	 	
                  Short-Acting Opioid Analgesics

                	
                  9

                
	
                  ANTIBACTERIALS

                	
                  9

                
	 	
                  First Generation Cephalosporins

                	
                  9

                
	 	
                  Macrolides

                	
                  9

                
	 	
                  Miscellaneous Antibacterials

                	
                  10

                
	 	
                  Penicillins

                	
                  10

                


          

          

          
            Page 54 of 12

            
              


          

          
            		
                     DENTAL

                  


          

           

            

          DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

           

            

          The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their safety profile,
              proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

           

            

          The example below illustrates the information provided for the drugs included in the FDC.

          

          

          	
                  Drug Name

                	
                  Net

                  Cost

                	
                  Tier

                	
                  Reference

                  Name

                	
                  Requirements/

                  Limits

                
	
                  THERAPEUTIC CATEGORY

                
	
                  Therapeutic Class

                
	
                  ANALGESICS

                
	
                  Nonsteroidal Anti-Inflammatory Agents (Nsaids)

                
	
                  ibuprofen 400 mg tab, 600 mg tab, 800 mg tab

                	
                  1

                	
                  Preferred

                	
                  MOTRIN

                	 
	
                  naproxen 250 mg tab, 375 mg tab, 500 mg tab

                	
                  1

                	
                  Preferred

                	
                  NAPROSYN

                	 
	
                  naproxen dr 375 mg tab dr, 500 mg tab dr

                	
                  1

                	
                  Preferred

                	
                  NAPROSYN

                	 
	
                  naproxen sodium 275 mg tab, 550 mg tab

                	
                  1

                	
                  Preferred

                	
                  ANAPROX

                	 


          

          

          For each drug included in the FDC, the First Column shows the
              name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

           

            

          The Second Column shows the Monthly Net Cost Range per Average
              Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

           

            

          MONTHLY NET COST RANGE

           

            

          The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly net cost of the
              therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy for thirty (30) days. The
              cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost and must be interpreted as follows:

           

            

          
            Page 55 of 12

            
              


          

          
            		
                     DENTAL

                  


             

            

          

          	
                  1

                	
                  less than $20

                	
                  Least costly per month

                
	
                  2

                	
                  $20 - $49

                	 
	
                  3

                	
                  $50 - $99

                	 
	
                  4

                	
                  $100 - $199

                	 
	
                  5

                	
                  $200 - $349

                	 
	
                  6

                	
                  $350 - $549

                	 
	
                  7

                	
                  $550 - $799

                	 
	
                  8

                	
                  $800 - $1,099

                	 
	
                  9

                	
                  $1,100 - $1,499

                	 
	
                  10

                	
                  $1,500 - $1,999

                	 
	
                  11

                	
                  $2,000 - $2,499

                	 
	
                  12

                	
                  $2,500 - $2,999

                	 
	
                  13

                	
                  $3,000 - $3,499

                	 
	
                  14

                	
                  $3,500 - $3,999

                	 
	
                  15

                	
                  $4,000 - $4,499

                	 
	
                  16

                	
                  $4,500 - $4,999

                	 
	
                  17

                	
                  $5,000 - $5,499

                	 
	
                  18

                	
                  $5,500 - $5,999

                	 
	
                  19

                	
                  $6,000 - $6,499

                	 
	
                  20

                	
                  $6,500 - $6,999

                	 
	
                  21

                	
                  $7,000 - $7,499

                	 
	
                  22

                	
                  $7,500 - $7,999

                	 
	
                  23

                	
                  $8,000 - $8,499

                	 
	
                  24

                	
                  $8,500 - $9,000

                	 
	
                  25

                	
                  more than $9,000

                	
                  Most costly per month

                


          

          

          We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic category (the one with
              the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

          

          

          The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of this edition of the
              FDC.

           

            

          GENERIC DRUGS

           

            

          Generic bioequivalent drugs are identified with lower-case letters. Certain












              generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the generic product, but not the brand-name product. The products
              selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

          

          

          
            Page 56 of 12

            
              


          

          
            	
                    DENTAL

                  	
                    

                    

                  


          

           

          

          	
                  Drug Name [Nombre del

                   Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                   

                  Tier [Tier]

                   

                	
                  Reference Name

                  [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/

                  Límites]

                
	
                  THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                
	
                            Therapeutic Class [Clase Terapéutica]

                
	
                  ANALGESICS [ANALGÉSICOS]

                
	
                   Nonsteroidal Anti-Inflammatory Agents (Nsaids) [Anti-Inflamatorios No Esteroidales]

                
	
                  ibuprofen 400 mg tab, 600  mg tab, 800 mg tab

                	
                  1

                	
                  Preferred

                	
                  MOTRIN

                	
                  QL=7 días

                
	
                  naproxen 250 mg tab, 375 mg tab, 500 mg tab

                	
                  1

                	
                  Preferred

                	
                  NAPROSYN

                	
                  QL=7 días

                
	
                  naproxen dr 375 mg tab dr, 500 mg tab dr

                	
                  1

                	
                  Preferred

                	
                  NAPROSYN

                	
                  QL=7 días

                
	
                  Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]

                
	
                  acetaminophen          -codeine 120-12 mg/5ml soln, 300-15 mg tab, 300-30 mg tab, 300-

                  60 mg tab

                	
                  1

                	
                  Preferred

                	
                  TYLENOL-

                  CODEINE

                	
                  QL=7 días

                
	
                  acetaminophen-codeine #2 300-15 mg tab

                	
                  1

                	
                  Preferred

                	
                  TYLENOL-

                  CODEINE

                	
                  QL=7 días

                
	
                  acetaminophen-codeine #3 300-30 mg tab

                	
                  1

                	
                  Preferred

                	
                  TYLENOL-

                  CODEINE

                	
                  QL=7 días

                
	
                  acetaminophen-codeine #4 300-60 mg tab

                	
                  1

                	
                  Preferred

                	
                  TYLENOL-

                  CODEINE

                	
                  QL=7 días

                
	
                  hydrocodone-

                  acetaminophen 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab

                	
                  1

                	
                  Preferred

                	
                  VICODIN

                	
                  QL=7 días

                
	
                  ANTIBACTERIALS [ANTIBACTERIANOS]

                
	
                  First Generation Cephalosporins [Cefalosporinas De Primera Generación]

                
	
                  cephalexin 125 mg/5ml  susp, 250 mg cap, 500 mg cap

                	
                  1

                	
                  Preferred

                	
                  KEFLEX

                	 
	
                  cefadroxil 250 mg/5ml susp

                	
                  2

                	
                  Non-Preferred

                	
                  DURICEF

                	
                  AL ≤ 12 años

                
	
                  cephalexin 250 mg/5ml susp

                	
                  2

                	
                  Preferred

                	
                  KEFLEX

                	 
	
                  cefadroxil 500 mg/5ml susp

                	
                  3

                	
                  Non-Preferred

                	
                  DURICEF

                	
                  AL ≤ 12 años

                
	
                  Macrolides [Macrólidos]

                
	
                  ERY -TAB 500 mg tab dr

                	
                  3

                	
                  Preferred

                	 	 


          
            
              	•	
                      PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 7 for monthly net cost range [Ver página
                          7 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]      Página 9 de 12

                    


               

              

            

          

          
            
              


          

           
            

            

          

          	
                  Drug Name [Nombre del

                  Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                    

                  Tier [Tier]

                	
                  Reference Name

                  [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/

                  Límites]

                
	
                  erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab

                	
                  3

                	
                  Preferred

                	
                  ERY-TAB

                	 
	
                  erythromycin ethylsuccinate 400 mg tab

                	
                  3

                	
                  Preferred

                	
                  E.E.S.

                	 
	
                  ERYTHROCIN STEARATE

                  250 mg tab

                	
                  4

                	
                  Non-Preferred

                	 	 
	
                  E.E.S. GRANULES 200 mg/5ml susp

                	
                  5

                	
                  Preferred

                	 	 
	
                  ERYPED 200 200 mg/5ml susp

                	
                  5

                	
                  Preferred

                	 	 
	
                  ERYPED 400 400 mg/5ml susp

                	
                  6

                	
                  Preferred

                	 	 
	
                  Miscellaneous Antibacterials [Antibacterianos Misceláneos]

                
	
                  clindamycin hcl 150 mg cap,  300 mg cap, 75 mg cap

                	
                  1

                	
                  Preferred

                	
                  CLEOCIN

                	 
	
                  Penicillins [Penicilinas]

                
	
                  amoxicillin 125 mg/5ml susp,  200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp,
                        400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab

                	
                  1

                	
                  Preferred

                	
                  AMOXIL

                	 
	
                  ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap

                	
                  1

                	
                  Preferred

                	
                  PRINCIPEN

                	 
	
                  penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab

                	
                  1

                	
                  Preferred

                	
                  VEETIDS

                	 
	 	 	 	
                  
                    naproxen d

                    Página 10 de 12

                  

                  Revisado 5/12/2017

                	 


          

          

          
            
              


          

          
            	
                    

                    

                  


          

           

            

          ASES

          Puerto Rico Healthcare Insurance Administration

          

          

          Nephrology

          2017

          Formulary of Drugs Covered by

          the Government Healthcare Plan (GHP)

          

          

          Authorized by the P.R. Elections Commission CEE-SA-16-2732

           

            

          
            
              


          

          	
                  

                	 	
                  GOVERNMENT OF PUERTO RICO

                	 	
                  Hon. Ricardo A. Rosselló Nevares

                  Governor 

                  

                  Ms. Ángela M. Ávila Marrero

                  Executive Director

                
	 	
                  Healthcare Insurance Administration

                


          

          

          May 1, 2017

          

          

          TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

           

            

          Dear provider:

           

            

          I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its corresponding
              sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

           

            

          The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and Sub-physical. Moreover, the Mental
              Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health Sub-formulary will be used by participating
              primary care physicians (PCPs) in Primary Care Medical Groups.

           

            

          The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare Insurance Administration
              (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical aspects. The FDC is a dynamic document
              that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

           

            

          I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

          

          

          Cordially,

          

          

          [signed]

          Ángela M. Ávila Marrero

          Executive Director

          
            

            

          

           
            		
                     

                  
	 	 
	 
	
                    PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                  


          

          

          

          
            
              


            
              	
                       

                    		
                       

                    


            

          

          
          GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

          OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

          

          

          
            
              	1.	
                      Drug Formulary

                    


            

          

          

          

          The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and reviewing the Formulary of Drugs
              Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee is constituted by healthcare professionals,
              including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES for the drug formulary based on scientific evidence,
              clinical aspects, and a cost-effectiveness analysis.

          

          

          The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the prescription drug coverage. The purpose of
              the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

          

          

          ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator or PPA based on the most recent
              clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

          

          

          Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain in point number 2.

          

          

          
            
              	2.	
                      Exception Process

                    


            

          

          

          

          In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as applicable, insurance companies must
              use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

          

          

          
            
              	

                    	a.	
                      Contraindication to the drug(s) included in the FDC;

                    


            

          

          
            
              	

                    	b.	
                      History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                    


            

          

          
            
              	

                    	c.	
                      Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                    


            

          

          
            
              	

                    	d.	
                      Lack of a therapeutic alternative in the FDC.

                    


            

          

          

          

          This exception process requires a clinical justification that is duly documented by the service provider with the clinical reasons justifying
              the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

           

            

          
            
              	3.	
                      Other Aspects of the Prescription Drug Coverage

                    


            

          

          

          

          
            
              	

                    	A.	
                      The prescription drug coverage of the GHP establishes that using generic bioequivalent products as the
                            first option is mandatory.

                    


               

              

            

          

          
            

            Page 61 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          
            
               

              

              	

                    	B.	
                      Insurance companies or the TPA (Third Party Administrator) and healthcare service providers will only
                            process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                    


            

          

          

          

          
            
              	

                    	C.	
                      ASES has an active process to continually review the prescription drug coverage in accordance with
                            changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES may require
                            that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will safeguard adequate access
                            to services and maintain continuity of care.

                    


            

          

          

          

          
            
              	

                    	D.	
                      No entity contracted by ASES or by healthcare companies or organizations (for example, primary care
                            medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES. Furthermore, they may not limit
                            the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be responsible for supervising their providers and
                            employees with regard to their compliance with these provisions.

                    


            

          

          

          

          
            
              	

                    	E.	
                      The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The treatment
                            period may be extended, as applicable, when medically necessary.

                    


            

          

          

          

          
            
              	

                    	F.	
                      The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty (30) day
                            therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating adherence and tolerance.
                            The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case of narcotics, which will be
                            dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms of adherence, tolerance, and dosage
                            within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                    


            

          

          

          

          
            
              	

                    	G.	
                      ASES requires the use of generic bioequivalent drugs approved by the Food and Drug Administration (FDA)
                            coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                    


            

          

          

          

          
            
              	

                    	H.	
                      The lack of appropriate bioequivalent drug inventories does not exempt providers from dispensing the
                            prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the corresponding brand-name drug,
                            unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception mechanism.

                    


            

          

          

          

          
            

            Page 62 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          
            
              	

                    	I.	
                      Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized under the
                            law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                    


            

          

          

          

          
            
              	

                    	J.	
                      The right to freedom of choice requires the availability of a pharmacy that is reasonably accessible to
                            each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                    


            

          

          

          

          Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or when an electronic
              prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24 hours. If a drug is not
              available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her physician to have the prescription
              sent to another pharmacy of his or her choice.

          

          

          
            
              	4.	
                      Emergency Rule

                    


            

          

          

          

          The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except as otherwise
              specified.

          

          

          The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will also be dispensed
              in amounts sufficient for five (5) business days.

          

          

          Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for continuity of treatment,
              including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the IEF.

          

          

          If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES in your region
              and/or the Pharmacy Benefit Manager (PBM) contracted by ASES.

          

          

          
            

            Page 63 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          
            GOVERNMENT HEALTHCARE PLAN

            FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

            2017

            
              TABLE OF CONTENTS

               

                

               

            	
                    GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE GOVERNMENT HEALTHCARE PLAN

                  	
                    3

                  
	
                    DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                  	
                    9

                  
	 	
                    MONTHLY NET COST RANGE

                  	
                    9

                  
	 	
                    GENERIC DRUGS

                  	
                    10

                  
	
                    ANALGESICS

                  	
                    11

                  
	 	
                    Nonsteroidal Anti-Inflammatory Agents (Nsaids)

                  	
                    11

                  
	
                    ANTIBACTERIALS

                  	
                    11

                  
	 	
                    First Generation Cephalosporins

                  	
                    11

                  
	 	
                    Macrolides

                  	
                    11

                  
	 	
                    Penicillins

                  	
                    12

                  
	 	
                    Quinolones

                  	
                    12

                  
	 	
                    Second Generation Cephalosporins

                  	
                    13

                  
	 	
                    Sulfonamides

                  	
                    13

                  
	 	
                    Third Generation Cephalosporins

                  	
                    13

                  
	
                    ANTIDIABETIC AGENTS

                  	
                    13

                  
	 	
                    Alpha-Glucosidase Inhibitors

                  	
                    13

                  
	 	
                    Biguanides

                  	
                    13

                  
	 	
                    Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors

                  	
                    13

                  
	 	
                    Insulin Mixtures

                  	
                    13

                  
	 	
                    Insulin Sensitizing Agents

                  	
                    14

                  
	 	
                    Intermediate-Acting Insulins

                  	
                    14

                  
	 	
                    Long-Acting Insulins

                  	
                    14

                  
	 	
                    Rapid-Acting Insulins

                  	
                    14

                  
	 	
                    Short-Acting Insulins

                  	
                    14

                  
	 	
                    Sulfonylureas

                  	
                    14

                  


            

            

            
              

              Page 64 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            

            

            	
                    ANTIEMETICS

                  	
                    14

                  
	 	
                    Miscellaneous Antiemetics

                  	
                    14

                  
	
                    ANTIHYPERTENSIVES

                  	
                    15

                  
	 	
                    Alpha-Adrenergic Blocking Agents

                  	
                    15

                  
	 	
                    Angiotensin-Converting Enzyme (Ace) Inhibitors

                  	
                    15

                  
	 	
                    Calcium Channel Blocking Agents

                  	
                    15

                  
	 	
                    Cardioselective Beta Blocking Agents

                  	
                    16

                  
	 	
                    Cardioselective Beta-Adrenergic Blocking Agents

                  	
                    16

                  
	 	
                    Loop Diuretics

                  	
                    17

                  
	 	
                    Nonselective Beta Blocking Agents

                  	
                    17

                  
	 	
                    Nonselective Beta-Adrenergic Blocking Agents

                  	
                    17

                  
	 	
                    Thiazide Diuretics

                  	
                    17

                  
	 	
                    Vasodilator Beta Blockers

                  	
                    17

                  
	
                    BENIGN PROSTATIC HYPERTROPHY AGENTS

                  	
                    17

                  
	 	
                    Alpha 1-Adrenoceptor Antagonists

                  	
                    17

                  
	
                    BLOOD MODIFIERS

                  	
                    18

                  
	 	
                    Cobalamins

                  	
                    18

                  
	 	
                    Erythropoiesis-Stimulating Agents

                  	
                    18

                  
	 	
                    Folates

                  	
                    18

                  
	 	
                    Iron

                  	
                    19

                  
	
                    CHEMOTHERAPIES

                  	
                    19

                  
	 	
                    Antineoplastic Progestins

                  	
                    19

                  
	
                    DIABETES SUPPLIES

                  	
                    19

                  
	 	
                    Needles & Syringes

                  	
                    19

                  
	
                    DYSLIPIDEMICS

                  	
                    19

                  
	 	
                    Bile Acid Sequestrants

                  	
                    19

                  
	 	
                    Fibric Acid Derivatives

                  	
                    19

                  
	 	
                    Hmg Coa Reductase Inhibitors

                  	
                    19

                  


            

            

            
              

              Page 65 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    GASTROINTESTINAL AGENTS

                  	
                    19

                  
	 	
                    Histamine2 (H2) Receptor Antagonists

                  	
                    19

                  
	
                    GENITOURINARY AGENTS

                  	
                    20

                  
	 	
                    Phosphate Binder Agents

                  	
                    20

                  


            	
                    HORMONAL AGENTS

                  	
                    20

                  
	 	
                    Calcimimetics

                  	
                    20

                  
	 	
                    Mineralocorticoids

                  	
                    20

                  
	 	
                    Vasopressin Analogs

                  	
                    20

                  
	
                    IMMUNOSUPPRESSANTS

                  	
                    20

                  
	 	
                    Cyclosporine Analogs

                  	
                    20

                  
	 	
                    Glucocorticosteroids

                  	
                    21

                  
	 	
                    Organ Transplant Agents

                  	
                    21

                  
	
                    MINERALS & ELECTROLYTES

                  	
                    22

                  
	 	
                    Calcium Regulating Agents

                  	
                    22

                  
	 	
                    Electrolytes/Minerals Replacement

                  	
                    22

                  
	 	
                    Potassium Removing Resins

                  	
                    22

                  


            

            

            
              

              Page 66 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

             

              

            The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their safety profile,
                proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

             

              

            The example below illustrates the information provided for the drugs included in the FDC.

            

            

            	
                    Drug Name

                  	
                    Net 

                    Cost

                  	
                    Tier

                  	
                    Reference

                     Name

                  	
                    Requirements/ 

                    Limits

                  
	
                    THERAPEUTIC CATEGORY

                  
	
                    Therapeutic Class

                  
	
                    ANALGESICS

                  
	
                    Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

                  
	
                    indomethacin 25 mg cap, 50 mg cap

                  	
                    1

                  	
                    Non-preferred

                  	
                    INDOCIN

                  	 
	
                    indomethacin er 75 mg cap er

                  	
                    2

                  	
                    Non- preferred

                  	
                    INDOCIN

                  	 
	
                    ANTIBACTERIALS

                  
	
                    First Generation Cephalosporins

                  
	
                    cephalexin 125 mg/5 ml susp, 250 mg cap, 500 mg cap

                  	
                    1

                  	
                    Preferred

                  	
                    KEFLEX

                  	 
	
                    cefadroxil 250 mg/5 ml susp

                  	
                    2

                  	
                    Non-preferred

                  	
                    DURICEF

                  	
                    AL ≤ 12 years

                  
	
                    cephalexin 250 mg/5 ml susp

                  	
                    2

                  	 	
                    KEFLEX

                  	 
	
                    cefadroxil 500 mg/5 ml susp

                  	
                    3

                  	
                    Non-preferred

                  	
                    DURICEF

                  	
                    AL ≤ 12 years

                  


            

            

            For each drug included in the FDC, the First Column shows
                the name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

             

              

            The Second Column shows the Monthly Net Cost Range per
                Average Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

             

              

            MONTHLY NET COST RANGE

             

              

            The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly net cost of the
                therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy for thirty (30) days. The
                cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost and must be interpreted as follows:

            

            

            
              

              Page 67 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    1

                  	
                    less than $20

                  	
                    Least costly per month

                  
	
                    2

                  	
                    $20 - $49

                  	 
	
                    3

                  	
                    $50 - $99

                  	 
	
                    4

                  	
                    $100 - $199

                  	 
	
                    5

                  	
                    $200 - $349

                  	 
	
                    6

                  	
                    $350 - $549

                  	 
	
                    7

                  	
                    $550 - $799

                  	 
	
                    8

                  	
                    $800 - $1,099

                  	 
	
                    9

                  	
                    $1,100 - $1,499

                  	 
	
                    10

                  	
                    $1,500 - $1,999

                  	 
	
                    11

                  	
                    $2,000 - $2,499

                  	 
	
                    12

                  	
                    $2,500 - $2,999

                  	 
	
                    13

                  	
                    $3,000 - $3,499

                  	 
	
                    14

                  	
                    $3,500 - $3,999

                  	 
	
                    15

                  	
                    $4,000 - $4,499

                  	 
	
                    16

                  	
                    $4,500 - $4,999

                  	 
	
                    17

                  	
                    $5,000 - $5,499

                  	 
	
                    18

                  	
                    $5,500 - $5,999

                  	 
	
                    19

                  	
                    $6,000 - $6,499

                  	 
	
                    20

                  	
                    $6,500 - $6,999

                  	 
	
                    21

                  	
                    $7,000 - $7,499

                  	 
	
                    22

                  	
                    $7,500 - $7,999

                  	 
	
                    23

                  	
                    $8,000 - $8,499

                  	 
	
                    24

                  	
                    $8,500 - $9,000

                  	 
	
                    25

                  	
                    more than $9,000

                  	
                    Most costly per month

                  


            

            

            We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic category (the one with
                the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

             

              

            The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of this edition of
                the FDC.

             

              

            GENERIC DRUGS

             

              

            Generic bioequivalent drugs are identified with lower-case letters.
                Certain generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the generic product, but not the brand-name product.
                The products selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

             

              

            
              

              Page 68 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                      Drug Name [Nombre del

                     Medicamento]

                  	
                    Net Cost

                    [Costo

                    Neto]

                      

                  	
                    Tier [Tier]

                  	
                    Reference Name

                     [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                  
	
                    Therapeutic Class [Clase Te rapéutica]

                  
	
                    ANALGESICS [ANALGÉ SICOS]

                  
	
                    Nonsteroidal Anti-Inflammatory Agents (Nsaids) [Anti-Inflamatorios No Esteroidales]

                  
	
                    indomethacin 25 mg cap, 50 mg cap

                  	
                    1

                  	
                    Non-Preferred

                  	
                    INDOCIN

                  	 
	
                    ANTIBACTERIALS [ANTIBACTERIANOS]

                  
	
                    First Generation Cephalosporins [Cefalosporinas De Primera Generación]

                  
	
                    cephalexin 125 mg/5ml  susp, 250 mg cap, 500 mg cap

                  	
                    1

                  	
                    Preferred

                  	
                    KEFLEX

                  	 
	
                    cefadroxil 250 mg/5ml susp

                  	
                    2

                  	
                    Non-Preferred

                  	
                    DURICEF

                  	
                    AL ≤ 12 años

                  
	
                    cephalexin 250 mg/5ml susp

                  	
                    2

                  	 	
                    KEFLEX

                  	 
	
                    cefadroxil 500 mg/5ml susp

                  	
                    3

                  	
                    Non-Preferred

                  	
                    DURICEF

                  	
                    AL≤ 12 años

                  
	
                    Macrolides [Macrólidos]

                  
	
                    azithromycin 250 mg tab,  500 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    ZITHROMAX

                  	 
	
                    azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab

                  	
                    2

                  	
                    Preferred

                  	
                    ZITHROMAX

                  	 
	
                    clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab

                  	
                    2

                  	
                    Preferred

                  	
                    BIAXIN

                  	 
	
                    clarithromycin 250 mg/5ml susp

                  	
                    3

                  	
                    Preferred

                  	
                    BIAXIN

                  	 
	
                    ERY-TAB 500 mg tab dr

                  	
                    3

                  	
                    Preferred

                  	 	 
	
                    XI ycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab

                  	
                    3

                  	
                    Preferred

                  	
                    ERY-TAB

                  	 
	
                    erythromycin ethylsuccinate 400 mg tab

                  	
                    3

                  	
                    Preferred

                  	
                    E.E.S.

                  	 
	
                    ERYTHROCIN STEARATE 250 mg tab

                  	
                    4

                  	
                    Non-Preferred

                  	 	 
	
                    E.E.S. GRANULES 200 mg/5ml susp

                  	
                    5

                  	
                    Preferred

                  	 	 
	
                    ERYPED 200 200 mg/5ml susp

                  	
                    5

                  	
                    Preferred

                  	 	 


            

            

            
              

              Page 69 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del

                    Medicamento]

                  	
                    Net Cost

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name

                    [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/

                     Límites]

                  
	
                    ERYPED 400 400 mg/5ml susp

                  	
                    6

                  	
                    Preferred

                  	 	 
	
                    Penicillins [Penicilinas]

                  
	
                    amoxicillin 125 mg/5ml susp,  200 mg/5ml susp, 250 mg cap, 250 mg/5ml
                          susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    AMOXIL

                  	 
	
                    amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 875-125 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    AUGMENTIN

                  	 
	
                    ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap

                  	
                    1

                  	
                    Preferred

                  	
                    PRINCIPEN

                  	 
	
                    penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    VEETIDS

                  	 
	
                    amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp

                  	
                    3

                  	
                    Preferred

                  	
                    AUGMENTIN

                  	 
	
                    BICILLIN L-A 600000 unit/ml im susp

                  	
                    3

                  	
                    Non-Preferred

                  	 	 
	
                    penicillin g procaine 600000 unit/ml im susp

                  	
                    3

                  	
                    Non-Preferred

                  	
                    BICILLIN LA

                  	 
	
                    BICILLIN L-A 1200000 unit/2ml im susp

                  	
                    4

                  	
                    Non-Preferred

                  	 	 
	
                    BICILLIN L-A 2400000 unit/4ml im susp

                  	
                    5

                  	
                    Non-Preferred

                  	 	 
	
                    Quinolones [Quinolonas]

                  
	
                    ciprofloxacin hcl 250 mg tab,  500 mg tab, 750 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    CIPRO

                  	 
	
                    levofloxacin 250 mg tab, 500 mg tab, 750 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    LEVAQUIN

                  	 
	
                    ciprofloxacin 500 mg/5ml (10%) susp

                  	
                    3

                  	
                    Preferred

                  	
                    CIPRO

                  	 


            

            

            
              

              Page 70 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del 

                    Medicamento]

                  	
                    Net Cost 

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name

                     [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    ciprofloxacin 250 mg/5ml (5%) susp

                  	
                    4

                  	
                    Preferred

                  	
                    CIPRO

                  	 
	
                    Second Generation Cephalosporins [Cefalosporinas De Segunda Generación]

                  
	
                    cefaclor 250 mg cap, 500  mg cap

                  	
                    2

                  	
                    Preferred

                  	
                    CECLOR

                  	 
	
                    cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab

                  	
                    2

                  	
                    Preferred

                  	
                    CEFZIL

                  	 
	
                    Sulfonamides [Sulfonamidas]

                  
	
                    sulfamethoxazole          -tmp ds 800-160 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    SEPTRA

                  	 
	
                    sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    SEPTRA

                  	 
	
                    Third Generation Cephalosporins [Cefalosporinas De Tercera Generación]

                  
	
                    cefdinir 125 mg/5ml susp,  300 mg cap

                  	
                    2

                  	
                    Preferred

                  	
                    OMNICEF

                  	 
	
                    cefdinir 250 mg/5ml susp

                  	
                    3

                  	
                    Preferred

                  	
                    OMNICEF

                  	 
	
                    ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]

                  
	
                     Alpha-Glucosidase Inhibitors
                          [Inhibidores De Alfa Glucosidasa]

                  
	
                    acarbose 100 mg tab, 25 mg  tab, 50 mg tab

                  	
                    2

                  	
                    Preferred

                  	
                    PRECOSE

                  	 
	
                    Biguanides [Biguanidas]

                  
	
                    metformin hcl 1000 mg tab,  500 mg tab, 850 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    GLUCOPHAGE

                  	 
	
                    metformin hcl er 500 mg tab er 24 hr, 750 mg tab er 24 hr

                  	
                    1

                  	
                    Preferred

                  	
                    GLUCOPHAGE XR

                  	 
	
                    Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors [Inhibidores De Dpp-4]

                  
	
                    KOMBIGLYZE XR 2.5          -1000 mg tab er 24 hr,
                        5-1000 mg tab er 24 hr, 5-500 mg tab er 24 hr

                  	
                    3

                  	
                    Preferred

                  	 	
                    ST, P

                  
	
                    ONGLYZA 2.5 mg tab, 5 mg tab

                  	
                    3

                  	
                    Preferred

                  	 	
                    ST, P

                  
	
                    Insulin Mixtures [Mezclas De Insulinas]

                  
	
                    HUMULIN 70/30 (70          -30) 100 unit/ml sc
                        susp

                  	
                    2

                  	
                    Preferred

                  	 	
                    P

                  


            

            

            
              

              Page 71 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del 

                    Medicamento]

                  	
                    Net Cost 

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name

                     [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    HUMALOG MIX 75/25 (7525) 100 unit/ml sc susp

                  	
                    3

                  	
                    Preferred

                  	 	
                    P

                  
	
                    HUMALOG MIX 50/50 (5050) 100 unit/ml sc susp

                  	
                    4

                  	
                    Preferred

                  	 	
                    P

                  
	
                    Insulin Sensitizing Agents [Agentes Sensibilizantes De Insulin]

                  
	
                    pioglitazone hcl 15 mg tab,  30 mg tab, 45 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    ACTOS

                  	 
	
                    Intermediate-Acting Insulins [Insulinas De Duración Intermedia]

                  
	
                    HUMULIN N 100 unit/ml sc  susp

                  	
                    2

                  	
                    Preferred

                  	 	
                    P

                  
	
                    Long-Acting Insulins [Insulinas De Larga Duración]

                  
	
                    LANTUS SOLOSTAR 100  unit/ml
                        subcutaneous solution pen-injector

                  	
                    2

                  	
                    Preferred

                  	 	
                    P

                  
	
                    LANTUS 100 unit/ml sc soln

                  	
                    3

                  	
                    Preferred

                  	 	
                    P

                  
	
                    Rapid-Acting Insulins [Insulinas De Rápida Duración]

                  
	
                    HUMALOG 100 unit/ml  subcutaneous









                        solution cartridge

                  	
                    2

                  	
                    Preferred

                  	 	
                    P

                  
	
                    HUMALOG 100 unit/ml sc soln

                  	
                    3

                  	
                    Preferred

                  	 	
                    P

                  
	
                    Short-Acting Insulins [Insulinas De Corta Duración]

                  
	
                    HUMULIN R 100 unit/ml inj  soln

                  	
                    2

                  	
                    Preferred

                  	 	
                    P

                  
	
                    Sulfonylureas [Sulfonilureas]

                  
	
                    glimepiride 1 mg tab, 2 mg  tab, 4 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    AMARYL

                  	 
	
                    glipizide 10 mg tab, 5 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    GLUCOTROL

                  	 
	
                    ANTIEMETICS [ANTIEMÉTICOS]

                  
	
                     Miscellaneous Antiemetics
                          [Antieméticos Misceláneos]

                  
	
                    metoclopramide hcl 10 mg  tab, 10 mg/10ml soln, 5 mg tab, 5 mg/5ml
                          soln, 5 mg/ml inj soln

                  	
                    1

                  	
                    Preferred

                  	
                    REGLAN

                  	 


            

            

            
              

              Page 72 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del 

                    Medicamento]

                  	
                    Net Cost 

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name 

                    [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]

                  
	
                     Alpha-Adrenergic Blocking Agents
                          [Bloqueadores Alfa Adrenérgicos]

                  
	
                    terazosin hcl 1 mg cap, 10  mg cap, 2 mg cap, 5 mg cap

                  	
                    1

                  	
                    Preferred

                  	
                    HYTRIN

                  	 
	
                    Angiotensin II Receptor Blockers (Arb) [Antagonistas Del Receptor Angiotensina II]

                  
	
                    losartan potassium 100 mg tab, 25 mg tab, 50 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    COZAAR

                  	 
	
                    losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    HYZAAR

                  	 
	
                    Angiotensin-Converting Enzyme (Ace) Inhibitors [Inhibidores De La Enzima Convertidora De

                    Angiotensin]

                  
	
                    fosinopril sodium 10 mg tab,  20 mg tab, 40 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    MONOPRIL

                  	 
	
                    lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    ZESTRIL

                  	 
	
                    lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    ZESTORETIC

                  	 
	
                    Calcium Channel Blocking Agents [Bloqueadores De Canales De Calcio]

                  
	
                    amlodipine besylate 10 mg  tab, 2.5 mg tab, 5 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    NORVASC

                  	 
	
                    diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    CARDIZEM

                  	 
	
                    diltiazem hcl er 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr

                  	
                    1

                  	
                    Preferred

                  	
                    DILACOR XR

                  	 
	
                    diltiazem hcl er beads 120 mg cap er 24 hr

                  	
                    1

                  	
                    Preferred

                  	
                    TIAZAC

                  	 
	
                    diltiazem hcl er coated beads 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr

                  	
                    1

                  	
                    Preferred

                  	
                    CARDIZEM CD

                  	 
	
                    dilt-xr 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr

                  	
                    1

                  	
                    Preferred

                  	
                    DILACOR XR

                  	 


            

            

            
              

              Page 73 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del 

                    Medicamento]

                  	
                    Net Cost 

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name 

                    [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    nifedipine er osmotic 30 mg tab er 24 hr

                  	
                    1

                  	
                    Preferred

                  	
                    PROCARDIA XL

                  	 
	
                    verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    CALAN

                  	 
	
                    verapamil hcl er 120 mg tab er, 180 mg tab er, 240 mg tab er

                  	
                    1

                  	
                    Preferred

                  	
                    CALAN SR

                  	 
	
                    diltiazem hcl er beads 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg cap er 24 hr

                  	
                    2

                  	
                    Preferred

                  	
                    TIAZAC

                  	 
	
                    diltiazem hcl er coated beads 300 mg cap er 24 hr

                  	
                    2

                  	
                    Preferred

                  	
                    CARDIZEM CD

                  	 
	
                    nifedipine er osmotic 60 mg tab er 24 hr, 90 mg tab er 24 hr

                  	
                    2

                  	
                    Preferred

                  	
                    PROCARDIA XL

                  	 
	
                    Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]

                  
	
                    atenolol 100 mg tab, 25 mg  tab, 50 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    TENORMIN

                  	 
	
                    metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr

                  	
                    1

                  	
                    Preferred

                  	
                    LOPRESSOR

                  	 
	
                    metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    LOPRESSOR

                  	 
	
                    metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr

                  	
                    2

                  	
                    Preferred

                  	
                    LOPRESSOR

                  	 
	
                    Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos

                    Cardioselectivos]

                  
	
                    atenolol          -chlorthalidone 10025 mg tab, 50-25 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    TENORETIC

                  	 
	
                    metoprolol-

                    hydrochlorothiazide 50-25 mg tab

                  	
                    2

                  	
                    Non-Preferred

                  	
                    LOPRESSOR HCT

                  	 
	
                    metoprololhydrochlorothiazide 100-25 mg tab, 100-50 mg tab

                  	
                    3

                  	
                    Non-Preferred

                  	
                    LOPRESSOR HCT

                  	 


            

            

            
              

              Page 74 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del

                         Medicamento]

                  	
                    Net Cost [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    Loop Diuretics [Diuréticos Del Asa]

                  
	
                    bumetanide 0.5 mg tab, 1  mg tab, 2 mg tab

                  	
                    1

                  	
                    Non-Preferred

                  	
                    BUMEX

                  	 
	
                    furosemide 10 mg/ml soln, 20 mg tab, 40 mg tab, 80 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    LASIX

                  	 
	
                    Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]

                  
	
                    propranolol hcl 10 mg tab,  20 mg tab, 20 mg/5ml soln, 40 mg tab, 40
                          mg/5ml soln,

                    80 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    INDERAL

                  	 
	
                    propranolol hcl 60 mg tab

                  	
                    2

                  	
                    Preferred

                  	
                    INDERAL

                  	 
	
                    Nonselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos No-

                    Selectivos]

                  
	
                              Thiazide Diuretics
                          [Diuréticos Tiazidas]

                  
	
                    chlorothiazide 250 mg tab,  500 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    DIURIL

                  	 
	
                    chlorthalidone 25 mg tab, 50 mg tab

                  	
                    1

                  	
                    Non-Preferred

                  	
                    HYGROTON

                  	 
	
                    DIURIL 250 mg/5ml susp

                  	
                    1

                  	
                    Preferred

                  	 	 
	
                    hydrochlorothiazide 25 mg tab, 50 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    MICROZIDE

                  	 
	
                    metolazone 2.5 mg tab, 5 mg tab

                  	
                    1

                  	
                    Non-Preferred

                  	
                    ZAROXOLYN

                  	 
	
                    chlorthalidone 100 mg tab

                  	
                    2

                  	
                    Non-Preferred

                  	
                    HYGROTON

                  	 
	
                    metolazone 10 mg tab

                  	
                    2

                  	
                    Non-Preferred

                  	
                    ZAROXOLYN

                  	 
	
                    Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]

                  
	
                    carvedilol 12.5 mg tab, 25  mg tab, 3.125 mg tab, 6.25 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    COREG

                  	 
	
                    BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA

                    PROSTÁTICA BENIGNA]

                  
	
                              Alpha 1-Adrenoceptor
                          Antagonists [Bloqueadores Alfa1-Adrenérgicos]

                  
	
                    tamsulosin hcl 0.4 mg cap          

                  	
                    1

                  	
                    Preferred

                  	
                    FLOMAX

                  	 


            

            

            
              

              Page 75 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del 

                    Medicamento]

                  	
                    Net Cost

                     [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name 

                    [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]

                  
	
                     Cobalamins [Cobalaminas]

                  
	
                    cyanocobalamin 1000  mcg/ml inj soln

                  	
                    1

                  	
                    Preferred

                  	
                    VIT B-12

                  	 
	
                    Erythropoiesis-Stimulating Agents [Agentes Estimulantes De Eritropoiesis]

                  
	
                    ARANESP (ALBUMIN FREE) 100 mcg/0.5ml inj soln

                  	
                    1

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    PROCRIT 2000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln

                  	
                    5

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    ARANESP (ALBUMIN FREE) 25 mcg/0.42ml inj soln, 25 mcg/ml inj soln

                  	
                    6

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    PROCRIT 10000 unit/ml inj soln

                  	
                    6

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    ARANESP (ALBUMIN FREE) 40 mcg/0.4ml inj soln

                  	
                    7

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    ARANESP (ALBUMIN FREE) 40 mcg/ml inj soln, 60 mcg/ml inj soln

                  	
                    8

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    ARANESP (ALBUMIN FREE) 150 mcg/0.75ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj soln, 300 mcg/ml inj
                        soln, 500 mcg/ml inj soln, 60 mcg/0.3ml inj soln

                  	
                    9

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    PROCRIT 20000 unit/ml inj soln

                  	
                    9

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    ARANESP (ALBUMIN FREE) 100 mcg/ml inj soln

                  	
                    11

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    PROCRIT 40000 unit/ml inj soln

                  	
                    11

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    Folates [Folatos]

                  
	
                     folic acid 1 mg tab, 400 mcg  tab, 800 mcg tab

                  	
                    1

                  	
                    Preferred

                  	
                    FOLIC ACID

                  	
                    OTC

                  


            

            

            
              

              Page 76 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del 

                    Medicamento]

                  	
                    Net Cost 

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name 

                    [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    Iron [Hierro]

                  
	
                    iron 325 (65 fe) mg tab          

                  	
                    1

                  	
                    Preferred

                  	
                    IRON

                  	 
	
                    DEXFERRUM 50 mg/ml inj soln

                  	
                    5

                  	
                    Non-Preferred

                  	 	 
	
                    INFED 50 mg/ml inj soln

                  	
                    5

                  	 	 	 
	
                    CHEMOTHERAPIES [QUIMIOTERAPIAS]

                  
	
                     Antineoplastic Progestins
                          [Antineoplásicos De Progestina]

                  
	
                    megestrol acetate 20 mg  tab, 40 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    MEGACE

                  	 
	
                    megestrol acetate 40 mg/ml susp, 400 mg/10ml susp

                  	
                    2

                  	
                    Preferred

                  	
                    MEGACE

                  	 
	
                    DIABETES SUPPLIES [SUMINISTROS PARA DIABETES]

                  
	
                     Needles & Syringes [Agujas Y
                          Jeringuillas]

                  
	
                    insulin syringe/needle          

                  	
                    1

                  	
                    Preferred

                  	
                    .

                  	 
	
                    DYSLIPIDEMICS [DISLIPIDÉMICOS]

                  
	
                     Bile Acid Sequestrants
                          [Secuestradores De Acidos Biliares]

                  
	
                    cholestyramine 4 gm pckt, 4  gm/dose oral pwdr

                  	
                    3

                  	
                    Preferred

                  	
                    QUESTRAN

                  	 
	
                    Fibric Acid Derivatives [Derivados De Ácido Fíbrico]

                  
	
                    gemfibrozil 600 mg tab          

                  	
                    1

                  	
                    Preferred

                  	
                    LOPID

                  	 
	
                    Hmg Coa Reductase Inhibitors [Inhibidores De La Reductasa De Hmg Coa]

                  
	
                    atorvastatin calcium 10 mg  tab, 20 mg tab, 40 mg tab, 80 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    LIPITOR

                  	 
	
                    pravastatin sodium 10 mg tab, 20 mg tab, 80 mg tab

                  	
                    1

                  	
                    Non-Preferred

                  	
                    PRAVACHOL

                  	 
	
                    simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab, 80 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    ZOCOR

                  	 
	
                    pravastatin sodium 40 mg tab

                  	
                    2

                  	
                    Non-Preferred

                  	
                    PRAVACHOL

                  	 
	
                    GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]

                  
	
                    Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]

                  
	
                    famotidine           20 mg tab, 40 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    PEPCID

                  	 


            

            

            
              

              Page 77 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del 

                    Medicamento]

                  	
                    Net Cost 

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name 

                    [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr

                  	
                    1

                  	
                    Preferred

                  	
                    ZANTAC

                  	 
	
                    GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]

                  
	
                     Phosphate Binder Agents [Enlazadores De Fosfato]

                  
	
                    RENVELA 0.8 gm pckt          

                  	
                    6

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    RENVELA 2.4 gm pckt, 800 mg tab

                  	
                    7

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    calcium acetate 667 mg cap.

                  	
                    3

                  	
                    Non-Preferred

                  	
                    PHOSLO

                  	 
	
                    HORMONAL AGENTS [AGENTES HORMONALES]

                  
	
                     Calcimimetics [Calcimiméticos]

                  
	
                    SENSIPAR 30 mg tab

                  	
                    7

                  	
                    Preferred

                  	 	
                    PA

                  
	
                    SENSIPAR 60 mg tab

                  	
                    9

                  	
                    Preferred

                  	 	
                    PA

                  
	
                    SENSIPAR 90 mg tab

                  	
                    10

                  	
                    Preferred

                  	 	
                    PA

                  
	
                    Mineralocorticoids [Mineralocorticoides]

                  
	
                    fludrocortisone acetate 0.1  mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    FLORINEF

                  	 
	
                    Vasopressin Analogs [Análogos De Vasopresina]

                  
	
                    desmopressin acetate 4  mcg/ml inj soln

                  	
                    2

                  	
                    Non-Preferred

                  	
                    DDAVP

                  	 
	
                    desmopressin acetate 0.2 mg tab

                  	
                    3

                  	
                    Non-Preferred

                  	
                    DDAVP

                  	 
	
                    desmopressin ace spray refrig 0.01 % nasal soln

                  	
                    4

                  	
                    Non-Preferred

                  	
                    DDAVP

                  	 
	
                    desmopressin acetate 0.1 mg tab

                  	
                    4

                  	
                    Non-Preferred

                  	
                    DDAVP

                  	 
	
                    desmopressin acetate spray 0.01 % nasal soln

                  	
                    4

                  	
                    Non-Preferred

                  	
                    DDAVP

                  	 
	
                    STIMATE 1.5 mg/ml nasal soln

                  	
                    7

                  	
                    Non-Preferred

                  	 	
                    PA

                  
	
                    IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]

                  
	
                     Cyclosporine Analogs [Análogos De Ciclosporina]

                  
	
                    cyclosporine modified 25 mg  cap, 50 mg cap

                  	
                    3

                  	
                    Preferred

                  	
                    NEORAL

                  	
                    PA, P

                  
	
                    cyclosporine modified 25 mg cap, 50 mg cap

                  	
                    3

                  	
                    Preferred

                  	
                    NEORAL

                  	
                    PA

                  
	
                    NEORAL 25 mg cap

                  	
                    3

                  	
                    Preferred

                  	 	
                    PA, P

                  


            

            

            
              

              Page 78 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del

                     Medicamento]

                  	
                    Net Cost 

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name 

                    [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    cyclosporine 25 mg cap

                  	
                    4

                  	
                    Preferred

                  	
                    SANDIMMUNE

                  	
                    PA

                  
	
                    cyclosporine modified 100 mg cap, 100 mg/ml soln

                  	
                    4

                  	
                    Preferred

                  	
                    NEORAL

                  	
                    PA

                  
	
                    cyclosporine 100 mg cap

                  	
                    5

                  	
                    Preferred

                  	
                    SANDIMMUNE

                  	
                    PA

                  
	
                    cyclosporine modified 100 mg cap

                  	
                    5

                  	
                    Preferred

                  	
                    NEORAL

                  	
                    PA, P

                  
	
                    NEORAL 100 mg cap

                  	
                    5

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    cyclosporine 100 mg cap, 25 mg cap

                  	
                    6

                  	
                    Preferred

                  	
                    SANDIMMUNE

                  	
                    PA, P

                  
	
                    SANDIMMUNE 100 mg cap, 100 mg/ml soln, 25 mg cap

                  	
                    6

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    cyclosporine modified 100 mg/ml soln

                  	
                    7

                  	
                    Preferred

                  	
                    NEORAL

                  	
                    PA, P

                  
	
                    NEORAL 100 mg/ml soln

                  	
                    7

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    Glucocorticosteroids [Glucocorticoides]

                  
	
                    dexamethasone 0.5 mg tab          , 0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    DECADRON

                  	 
	
                    MEDROL 2 mg tab

                  	
                    1

                  	
                    Preferred

                  	 	 
	
                    methylprednisolone 32 mg tab, 4 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    MEDROL

                  	 
	
                    methylprednisolone (pak) 4 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    MEDROL

                  	 
	
                    prednisolone 15 mg/5ml soln, 15 mg/5ml syr

                  	
                    1

                  	
                    Preferred

                  	
                    PRELONE

                  	 
	
                    prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    DELTASONE

                  	 
	
                    prednisone (pak) 10 mg tab, 5 mg tab

                  	
                    1

                  	
                    Preferred

                  	
                    DELTASONE

                  	 
	
                    hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab

                  	
                    2

                  	
                    Preferred

                  	
                    CORTEF

                  	 
	
                    methylprednisolone 16 mg tab, 8 mg tab

                  	
                    2

                  	
                    Preferred

                  	
                    MEDROL

                  	 
	
                    Organ Transplant Agents [Agentes Para Trasplantes]

                  
	
                    azathioprine 50 mg tab          

                  	
                    1

                  	
                    Preferred

                  	
                    IMURAN

                  	 


            

            

            
              

              Page 79 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    Drug Name [Nombre del

                     Medicamento]

                  	
                    Net Cost 

                    [Costo

                    Neto]

                  	
                    Tier [Tier]

                  	
                    Reference Name

                     [Nombre de

                    Referencia]

                  	
                    Requirements/

                    Limits

                    [Requerimientos/ 

                    Límites]

                  
	
                    mycophenolate mofetil 250 mg cap, 500 mg tab

                  	
                    2

                  	
                    Preferred

                  	
                    CELLCEPT

                  	
                    PA

                  
	
                    tacrolimus 0.5 mg cap

                  	
                    3

                  	
                    Non-Preferred

                  	
                    PROGRAF

                  	
                    PA

                  
	
                    MYFORTIC 180 mg tab dr

                  	
                    4

                  	
                    Preferred

                  	 	
                    PA, P

                  
	
                    tacrolimus 1 mg cap

                  	
                    4

                  	
                    Non-Preferred

                  	
                    PROGRAF

                  	
                    PA

                  
	
                    mycophenolic acid 180 mg tab dr

                  	
                    5

                  	
                    Preferred

                  	
                    MYFORTIC

                  	
                    PA

                  
	
                    sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab

                  	
                    5

                  	
                    Non-Preferred

                  	
                    RAPAMUNE

                  	
                    PA

                  
	
                    MYFORTIC 360 mg tab dr

                  	
                    6

                  	 	 	
                    PA, P

                  
	
                    tacrolimus 5 mg cap

                  	
                    6

                  	
                    Non-Preferred

                  	
                    PROGRAF

                  	
                    PA

                  
	
                    mycophenolic acid 360 mg tab dr

                  	
                    7

                  	
                    Preferred

                  	
                    MYFORTIC

                  	
                    PA

                  
	
                    RAPAMUNE 1 mg/ml soln

                  	
                    8

                  	
                    Non-Preferred

                  	 	
                    PA

                  
	
                    MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]

                  
	
                     Calcium Regulating Agents [Agentes Reguladores De Calcio]

                  
	
                    calcitriol 0.25 mcg cap          

                  	
                    1

                  	
                    Preferred

                  	
                    ROCALTROL

                  	 
	
                    calcitriol 0.5 mcg cap

                  	
                    2

                  	
                    Preferred

                  	
                    ROCALTROL

                  	 
	
                    calcitriol 1 mcg/ml soln

                  	
                    5

                  	
                    Preferred

                  	
                    ROCALTROL

                  	 
	
                    Electrolytes/Minerals Replacement [Reemplazo De Electrolitos/Minerales]

                  
	
                    potassium chloride 20  meq/15ml (10%) oral liquid, 20 meq/15ml (10%) soln

                  	
                    1

                  	
                    Preferred

                  	
                    KAY-CIEL

                  	 
	
                    potassium chloride crys er 10 meq tab er, 20 meq tab er

                  	
                    1

                  	
                    Preferred

                  	
                    KLOR-CON

                  	 
	
                    potassium chloride er 10 meq tab er, 8 meq tab er

                  	
                    1

                  	
                    Preferred

                  	
                    KLOR-CON

                  	 
	
                    potassium chloride er 10 meq cap er, 8 meq cap er

                  	
                    2

                  	
                    Preferred

                  	
                    MICRO-K

                  	 
	
                    potassium chloride 40 meq/15ml (20%) oral liquid

                  	
                    4

                  	
                    Preferred

                  	
                    KAON CL

                  	 
	
                    Potassium Removing Resins [Resinas Removedoras De Potasio]

                  
	
                    kalexate oral pwdr          

                  	
                    3

                  	
                    Preferred

                  	
                    KAYEXALATE

                  	 
	
                    sodium polystyrene sulfonate oral pwdr, 15 gm/60ml susp

                  	
                    3

                  	
                    Preferred

                  	
                    KAYEXALATE

                  	 


            

            

            
              

              Page 80 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            
              	
                      A

                    	 
	
                      acarbose 

                        

                    	
                      13

                    
	
                      amlodipine besylate 

                        

                    	
                      15

                    
	
                      amoxicillin 

                        

                    	
                      12

                    
	
                      amoxicillin-pot clavulanate 

                        

                    	
                      12

                    
	
                      ampicillin 

                        

                    	
                      12

                    
	
                      ARANESP (ALBUMIN FREE) 

                        

                    	
                      18

                    
	
                      atenolol 

                        

                    	
                      16

                    
	
                      atenolol-chlorthalidone 

                        

                    	
                      16

                    
	
                      atorvastatin calcium 

                        

                    	
                      19

                    
	
                      azathioprine 

                        

                    	
                      21

                    
	
                      azithromycin

                    	
                      11

                    
	
                      B

                    	 
	
                      BICILLIN L-A 

                        

                    	
                      12

                    
	
                      bumetanide 

                        

                    	
                      17

                    
	
                      C

                    	 
	
                      calcitriol 

                        

                    	
                      22

                    
	
                      calcium acetate 

                        

                    	
                      20

                    
	
                      carvedilol 

                        

                    	
                      17

                    
	
                      cefaclor 

                        

                    	
                      13

                    
	
                      cefadroxil

                    	
                      11

                    
	
                      cefdinir 

                        

                    	
                      13

                    
	
                      cefprozil

                    	
                      13

                    
	
                      cephalexin 

                        

                    	
                      11

                    
	
                      chlorothiazide 

                        

                    	
                      17

                    
	
                      chlorthalidone 

                        

                    	
                      17

                    
	
                      cholestyramine 

                        

                    	
                      .19

                    
	
                      ciprofloxacin 

                        

                    	
                      12, 13

                    
	
                      ciprofloxacin hcl 

                        

                    	
                      12

                    
	
                      clarithromycin 

                        

                    	
                      11

                    
	
                      cyanocobalamin 

                        

                    	
                      18

                    
	
                      cyclosporine 

                        

                    	
                      21

                    
	
                      cyclosporine modified 

                        

                    	
                      20, 21

                    
	
                      D

                    	 
	
                      desmopressin ace spray refrig 

                        

                    	
                      20

                    
	
                      desmopressin acetate 

                        

                    	
                      20

                    
	
                      desmopressin acetate spray 

                        

                    	
                      20

                    
	
                      dexamethasone 

                        

                    	
                      21

                    
	
                      DEXFERRUM 

                        

                    	
                      19

                    
	
                      diltiazem hcl 

                        

                    	
                      15

                    
	
                      diltiazem hcl er

                    	
                      15

                    


            

            
              	
                      diltiazem hcl er beads 

                      

                    	
                      15, 16

                    
	
                      diltiazem hcl er coated beads 

                        

                    	
                      15, 16

                    
	
                      dilt-xr 

                        

                    	
                      15

                    
	
                      DIURIL 

                        

                    	
                      17

                    
	
                      E

                    	 
	
                      E.E.S. GRANULES 

                        

                    	
                      11

                    
	
                      ERYPED 200 

                        

                    	
                      11

                    
	
                      ERYPED 400 

                        

                    	
                      12

                    
	
                      ERY-TAB 

                        

                    	
                      11

                    
	
                      ERYTHROCIN STEARATE 

                        

                    	
                      11

                    
	
                      erythromycin base 

                        

                    	
                      11

                    
	
                      erythromycin ethylsuccinate 

                        

                    	
                      11

                    
	
                      F

                    	 
	
                      famotidine 

                        

                    	
                      19

                    
	
                      fludrocortisone acetate 

                        

                    	
                      20

                    
	
                      folic acid 

                        

                    	
                      18

                    
	
                      fosinopril sodium 

                        

                    	
                      15

                    
	
                      furosemide 

                        

                    	
                      17

                    
	
                      G

                    	 
	
                      gemfibrozil 

                        

                    	
                      19

                    
	
                      glimepiride 

                        

                    	
                      14

                    
	
                      glipizide 

                        

                    	
                      14

                    
	
                      H

                    	 
	
                      HUMALOG

                    	
                      14

                    
	
                      HUMALOG MIX 50/50 

                        

                    	
                      14

                    
	
                      HUMALOG MIX 50/50 (50-50) 100 unit/ml sc susp 

                          

                    	
                      14

                    
	
                      HUMALOG MIX 75/25 

                        

                    	
                      14

                    
	
                      HUMALOG MIX 75/25 (75-25) 100 unit/ml sc susp 

                          

                    	
                      14

                    
	
                      HUMULIN 70/30 

                        

                    	
                      13

                    
	
                      HUMULIN N 

                        

                    	
                      14

                    
	
                      HUMULIN R 

                        

                    	
                      14

                    
	
                      hydrochlorothiazide 

                        

                    	
                      17

                    
	
                      hydrocortisone 

                        

                    	
                      21

                    
	
                      I

                    	 
	
                      indomethacin 

                        

                    	
                      11

                    
	
                      INFED 

                        

                    	
                      19

                    
	
                      insulin syringe/needle 

                        

                    	
                      19

                    
	
                      iron 

                        

                    	
                      19

                    


            

          

          
            	
                     

                  


            

          

          
            

            Page 81 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          
            	
                    K

                  	 
	
                    kalexate

                  	
                    22

                  
	
                    KOMBIGLYZE XR 

                      

                  	
                    13

                  
	
                    L

                  	 
	
                    LANTUS 

                      

                  	
                    14

                  
	
                    LANTUS SOLOSTAR 

                      

                  	
                    14

                  
	
                    levofloxacin 

                      

                  	
                    12

                  
	
                    lisinopril 

                      

                  	
                    15

                  
	
                    lisinopril-hydrochlorothiazide 

                      

                  	
                    15

                  
	
                    losartan potassium 

                      

                  	
                    15

                  
	
                    losartan potassium-hctz 

                      

                  	
                    15

                  
	
                    M

                  	 
	
                    MEDROL

                  	
                    21

                  
	
                    megestrol acetate 

                      

                  	
                    . 19

                  
	
                    metformin hcl 

                      

                  	
                    13

                  
	
                    metformin hcl er 

                      

                  	
                    13

                  
	
                    methylprednisolone 

                      

                  	
                    21

                  
	
                    methylprednisolone (pak) 

                      

                  	
                    21

                  
	
                    metoclopramide hcl 

                      

                  	
                    14

                  
	
                    metolazone 

                      

                  	
                    17

                  
	
                    metoprolol succinate er 

                      

                  	
                    16

                  
	
                    metoprolol tartrate 

                      

                  	
                    16

                  
	
                    metoprolol-hydrochlorothiazide 

                      

                  	
                    16

                  
	
                    mycophenolate mofetil 

                      

                  	
                    22

                  
	
                    mycophenolic acid 

                      

                  	
                    22

                  
	
                    N

                  	 
	
                    NEORAL 

                      

                  	
                    20, 21

                  
	
                    nifedipine er osmotic 

                      

                  	
                    16

                  
	
                    O

                  	 
	
                    ONGLYZA 

                      

                  	
                    13

                  
	
                    P

                  	 
	
                    penicillin g procaine 

                      

                  	
                    12

                  
	
                    penicillin v potassium 

                      

                  	
                    12

                  


          

          
            	
                    pioglitazone hcl 

                    

                  	
                    14

                  
	
                    potassium chloride 

                      

                  	
                    22

                  
	
                    potassium chloride crys er 

                      

                  	
                    22

                  
	
                    potassium chloride er 

                      

                  	
                    22

                  
	
                    pravastatin sodium 

                      

                  	
                    19

                  
	
                    prednisolone 

                      

                  	
                    21

                  
	
                    prednisone 

                      

                  	
                    21

                  
	
                    prednisone (pak) 

                      

                  	
                    21

                  
	
                    PROCRIT 

                      

                  	
                    18

                  
	
                    propranolol hcl 

                      

                  	
                    17

                  
	
                    R

                  	 
	
                    ranitidine hcl 

                      

                  	
                    20

                  
	
                    RAPAMUNE 

                      

                  	
                    22

                  
	
                    RENVELA 

                      

                  	
                    20

                  
	
                    S

                  	 
	
                    SANDIMMUNE 

                      

                  	
                    21

                  
	
                    SENSIPAR

                  	
                    20

                  
	
                    simvastatin 

                      

                  	
                    19

                  
	
                    sirolimus 

                      

                  	
                    22

                  
	
                    sodium polystyrene sulfonate 

                      

                  	
                    22

                  
	
                    STIMATE 

                      

                  	
                    20

                  
	
                    sulfamethoxazole-tmp ds 

                      

                  	
                    13

                  
	
                    sulfamethoxazole-trimethoprim 

                      

                  	
                    13

                  
	
                    T

                  	 
	
                    tacrolimus 

                      

                  	
                    22

                  
	
                    tamsulosin hcl 

                      

                  	
                    17

                  
	
                    terazosin hcl

                  	
                    15

                  
	
                    V

                  	 
	
                    verapamil hcl 

                      

                  	
                    16

                  
	
                    verapamil hcl er 

                      

                  	
                    16

                  


          

                    

          
            
              
                	
                         

                      


              

            

            
              

              Page 82 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            Puerto Rico Healthcare Insurance Administration

            

            

            Ob-Gyn

            2017

            Formulary of Drugs Covered by

            the Government Healthcare Plan (GHP)

            

            

            Authorized by the P.R. Elections Commission CEE-SA-16-2732

             

              

            
              

              Page 83 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            	
                    

                  	 	
                    GOVERNMENT OF PUERTO RICO

                  	 	
                    Hon. Ricardo A. Rosselló Nevares

                    Governor

                    Ms. Ángela M. Ávila Marrero

                    Executive Director

                  
	 	
                    Healthcare Insurance Administration

                  


            

            

            May 1, 2017

             

              

            TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

             

              

            Dear provider:

             

              

            I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its corresponding
                sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

             

              

            The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and Sub-physical. Moreover, the
                Mental Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health Sub-formulary will be used by
                participating primary care physicians (PCPs) in Primary Care Medical Groups.

             

              

            The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare Insurance Administration
                (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical aspects. The FDC is a dynamic document
                that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

             

              

            I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

             

              

            Cordially,

            

            

            [signed]

            Ángela M. Ávila Marrero

            Executive Director

            

            

            
              	
                      

                    	
                       

                    
	 	 
	 
	
                      PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                    


            

            

            
              

              Page 84 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

          OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

          

          

          
            
              	1.	
                      Drug Formulary

                    


            

          

          

          

          The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and reviewing the Formulary of Drugs
              Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee is constituted by healthcare professionals,
              including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES for the drug formulary based on scientific evidence,
              clinical aspects, and a cost-effectiveness analysis.

          

          

          The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the prescription drug coverage. The purpose of
              the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

          

          

          ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator or PPA based on the most recent
              clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

          

          

          Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain in point number 2.

          

          

          
            
              	2.	
                      Exception Process

                    


            

          

          

          

          In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as applicable, insurance companies must
              use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

          

          

          
            
              	

                    	i.	
                      Contraindication to the drug(s) included in the FDC;

                    


            

          

          
            
              	

                    	j.	
                      History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                    


            

          

          
            
              	

                    	k.	
                      Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                    


            

          

          
            
              	

                    	l.	
                      Lack of a therapeutic alternative in the FDC.

                    


            

          

           

            

          This exception process requires a clinical justification that is duly documented by the service provider with the clinical reasons justifying the use of
              a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

          

          

          
            
              	3.	
                      Other Aspects of the Prescription Drug Coverage

                    


            

          

          

          

          
            
              	

                    	A.	
                      The prescription drug coverage of the GHP establishes that using generic bioequivalent products as the
                            first option is mandatory.

                    


            

          

          

          

          
            

            Page 85 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          
            
              	

                    	B.	
                      Insurance companies or the TPA (Third Party Administrator) and healthcare service providers will only
                            process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                    


            

          

          

          

          
            
              	

                    	C.	
                      ASES has an active process to continually review the prescription drug coverage in accordance with
                            changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES may require
                            that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will safeguard adequate access
                            to services and maintain continuity of care.

                    


            

          

          

          

          
            
              	

                    	D.	
                      No entity contracted by ASES or by healthcare companies or organizations (for example, primary care
                            medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES. Furthermore, they may not limit
                            the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be responsible for supervising their providers and
                            employees with regard to their compliance with these provisions.

                    


            

          

          

          

          
            
              	

                    	E.	
                      The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The treatment
                            period may be extended, as applicable, when medically necessary.

                    


            

          

          

          

          
            
              	

                    	F.	
                      The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty (30) day
                            therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating adherence and tolerance.
                            The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case of narcotics, which will be
                            dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms of adherence, tolerance, and dosage
                            within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                    


            

          

          

          

          
            
              	

                    	G.	
                      ASES requires the use of generic bioequivalent drugs approved by the Food and Drug Administration (FDA)
                            coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                    


            

          

          

          

          
            
              	

                    	H.	
                      The lack of appropriate bioequivalent drug inventories does not exempt providers from dispensing the
                            prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the corresponding brand-name drug,
                            unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception mechanism.

                    


            

          

          

          

          
            

            Page 86 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          
            
              	

                    	I.	
                      Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized under the
                            law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                    


            

          

          

          

          
            
              	

                    	J.	
                      The right to freedom of choice requires the availability of a pharmacy that is reasonably accessible to
                            each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                    


            

          

          

          

          Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or when an electronic
              prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24 hours. If a drug is not
              available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her physician to have the prescription
              sent to another pharmacy of his or her choice.

          

          

          
            
              	4.	
                      Emergency Rule

                    


            

          

          

          

          The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except as otherwise specified.

          

          

          The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will also be dispensed in amounts
              sufficient for five (5) business days.

          

          

          Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for continuity of treatment, including
              pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the IEF.

          

          

          If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES in your region and/or the
              Pharmacy Benefit Manager (PBM) contracted by ASES.

          

          

          
            

            Page 87 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          GOVERNMENT HEALTHCARE PLAN

          FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

          2017

          TABLE OF CONTENTS

          

          

          	
                  GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE GOVERNMENT HEALTHCARE PLAN

                	
                  3

                
	
                  
                    DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND
                        REFERENCE GUIDES

                  

                	
                  9

                
	 	
                  MONTHLY NET COST RANGE

                	
                  9

                
	 	
                  GENERIC DRUGS

                	
                  10

                
	
                  THERAPEUTIC CATEGORY

                	
                  11

                
	
                  ANALGESICS

                	
                  11

                
	 	
                  Short-Acting Opioid Analgesics

                	
                  11

                
	
                  ANTIANXIETY AGENTS

                	
                  11

                
	 	
                  Miscellaneous Anxiolytics

                	
                  11

                
	
                  ANTIBACTERIALS

                	
                  11

                
	 	
                  First Generation Cephalosporins

                	
                  11

                
	 	
                  Macrolides

                	
                  11

                
	 	
                  Miscellaneous Antibacterials

                	
                  12

                
	 	
                  Penicillins

                	
                  12

                
	 	
                  Second Generation Cephalosporins

                	
                  13

                
	 	
                  Sulfonamides

                	
                  13

                
	 	
                  Third Generation Cephalosporins

                	
                  13

                
	 	
                  Vaginal Antibiotics

                	
                  13

                
	
                  ANTIDIABETIC AGENTS

                	
                  14

                
	 	
                  Insulin Mixtures

                	
                  14

                
	 	
                  Intermediate-Acting Insulins

                	
                  14

                
	 	
                  Long-Acting Insulins

                	
                  14

                
	 	
                  Rapid-Acting Insulins

                	
                  14

                
	 	
                  Short-Acting Insulins

                	
                  14

                


          

          

          
            

            Page 88 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  ANTIEMETICS

                	
                  14

                
	 	
                  Miscellaneous Antiemetics

                	
                  14

                
	 	
                  Phenothiazines

                	
                  15

                
	
                  ANTIHYPERTENSIVES

                	
                  15

                
	 	
                  Alpha-Adrenergic Agonists

                	
                  15

                
	 	
                  Cardioselective Beta Blocking Agents

                	
                  15

                
	 	
                  Cardioselective Beta-Adrenergic Blocking Agents

                	
                  15

                
	 	
                  Nonselective Beta Blocking Agents

                	
                  16

                
	 	
                  Vasodilator Beta Blockers

                	
                  16

                
	 	
                  Vasodilators

                	
                  16

                
	
                  ANTIMYCOBACTERIALS

                	
                  16

                
	 	
                  Antituberculars

                	
                  16

                
	 	
                  Miscellaneous Antimycobacterials

                	
                  16

                
	
                  ANTIMYCOTIC AGENTS

                	
                  16

                
	 	
                  Vaginal Antifungals

                	
                  16

                
	
                  ANTIPARASITICS

                	
                  17

                
	 	
                  Antiprotozoals - Non-Antimalarials

                	
                  17

                
	
                  ANTIVIRALS

                	
                  17

                
	 	
                  Antiherpetic Agents

                	
                  17

                
	 	
                  Anti-Influenza Agents

                	
                  17

                
	 	
                  Nucleoside/Nucleotide Reverse Transcriptase Inhibitors

                	
                  17

                
	
                  BLOOD MODIFIERS

                	
                  17

                
	 	
                  Anticoagulants

                	
                  17

                
	 	
                  Cobalamins

                	
                  17

                
	 	
                  Folates

                	
                  18

                
	 	
                  Iron

                	
                  18

                
	
                  BONE DENSITY REGULATORS

                	
                  18

                
	 	
                  Bisphosphonates

                	
                  18

                
	 	
                  CHEMOTHERAPIES

                	
                  18

                
	 	
                  Folic Acid Antagonists Rescue Agents

                	
                  18

                
	 	
                  Luteinizing Hormone-Releasing (Lhrh) Analogs

                	
                  18

                


          

          

          
            

            Page 89 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  DERMATOLOGICAL AGENTS

                	
                  18

                
	 	
                  Antihistamines

                	
                  18

                
	 	
                  Topical Antifungals

                	
                  19

                
	
                  DIABETES SUPPLIES

                	
                  19

                
	 	
                  Needles & Syringes

                	
                  19

                
	
                  GASTROINTESTINAL AGENTS

                	
                  19

                
	 	
                  Anti-Ulcer Agents

                	
                  19

                
	 	
                  Histamine2 (H2) Receptor Antagonists

                	
                  19

                
	 	
                  Rectal Anti-Inflammatories

                	
                  19

                
	
                  HORMONAL AGENTS

                	
                  19

                
	 	
                  Dysmenorrhea Agents

                	
                  19

                
	 	
                  Estrogens

                	
                  20

                
	 	
                  Estrogens and Progestins

                	
                  20

                
	 	
                  Glucocorticosteroids

                	
                  20

                
	 	
                  Mineralocorticoids

                	
                  20

                
	 	
                  Thyroid Hormones

                	
                  20

                
	 	
                  Vaginal Estrogens

                	
                  20

                
	
                  IMMUNOSUPPRESSANTS

                	
                  21

                
	 	
                  Glucocorticosteroids

                	
                  21

                
	 	
                  Immune Globulins

                	
                  21

                
	
                  MINERALS & ELECTROLYTES

                	
                  22

                
	 	
                  Prenatal Vitamins

                	
                  22

                
	
                  RESPIRATORY AGENTS

                	
                  22

                
	 	
                  Anticholinergic Bronchodilators

                	
                  22

                
	 	
                  Inhaled Corticosteroids

                	
                  22

                
	 	
                  Nonsedating Histamine1 Blocking Agents

                	
                  22

                
	 	
                  Sedating Histamine1 Blocking Agents

                	
                  23

                
	 	
                  Sympathomimetic Bronchodilators

                	
                  23

                


           

          

          
            

            Page 90 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

          

          

          The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their safety profile,
              proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

           

            

          The example below illustrates the information provided for the drugs included in the FDC.

           

            

          	
                  Drug Name

                	
                  Net 

                  Cost

                	
                  Tier

                	
                  Reference 

                  Name

                	
                  Requirements/

                   Limits

                
	
                  THERAPEUTIC CATEGORY

                
	
                  Therapeutic Class

                
	
                  ANALGESICS

                
	
                  Short-Acting Opioid Analgesics

                
	
                  oxycodone-acetaminophen 5-325 mg tab

                	
                  1

                	
                  Preferred

                	
                  PERCOCET

                	 
	
                  oxycodone-acetaminophen 10-325 mg tab, 7.5-325 mg tab

                	
                  3

                	
                  Preferred

                	
                  PERCOCET

                	 
	
                  ANTIANXIETY AGENTS

                
	
                  Miscellaneous Anxiolytics

                
	
                  hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap

                	
                  1

                	
                  Preferred

                	
                  VISTARIL

                	 


          

          

          For each drug included in the FDC, the First Column shows the
              name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

           

            

          The Second Column shows the Monthly Net Cost Range per Average
              Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

           

            

          MONTHLY NET COST RANGE

           

            

          The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly net cost of the
              therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy for thirty (30) days. The
              cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost and must be interpreted as follows:

          

          

          
            

            Page 91 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  1

                	
                  less than $20

                	
                  Least costly per month

                
	
                  2

                	
                  $20 - $49

                	 
	
                  3

                	
                  $50 - $99

                	 
	
                  4

                	
                  $100 - $199

                	 
	
                  5

                	
                  $200 - $349

                	 
	
                  6

                	
                  $350 - $549

                	 
	
                  7

                	
                  $550 - $799

                	 
	
                  8

                	
                  $800 - $1,099

                	 
	
                  9

                	
                  $1,100 - $1,499

                	 
	
                  10

                	
                  $1,500 - $1,999

                	 
	
                  11

                	
                  $2,000 - $2,499

                	 
	
                  12

                	
                  $2,500 - $2,999

                	 
	
                  13

                	
                  $3,000 - $3,499

                	 
	
                  14

                	
                  $3,500 - $3,999

                	 
	
                  15

                	
                  $4,000 - $4,499

                	 
	
                  16

                	
                  $4,500 - $4,999

                	 
	
                  17

                	
                  $5,000 - $5,499

                	 
	
                  18

                	
                  $5,500 - $5,999

                	 
	
                  19

                	
                  $6,000 - $6,499

                	 
	
                  20

                	
                  $6,500 - $6,999

                	 
	
                  21

                	
                  $7,000 - $7,499

                	 
	
                  22

                	
                  $7,500 - $7,999

                	 
	
                  23

                	
                  $8,000 - $8,499

                	 
	
                  24

                	
                  $8,500 - $9,000

                	 
	
                  25

                	
                  more than $9,000

                	
                  Most costly per month

                


          

          

          We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic category (the one with
              the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

           

            

          The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of this edition of the
              FDC.

           

            

          GENERIC DRUGS

           

            

          Generic bioequivalent drugs are identified with lower-case letters. Certain












              generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the generic product, but not the brand-name product. The products
              selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

          

          

          
            

            Page 92 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                   Drug Name [Nombre del

                  Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                  Tier [Tier]

                	
                  Reference Name 

                  [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/

                   Límites]

                
	
                  THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                
	
                            Therapeutic Class [Clase Terapéutica]

                
	
                            ANALGESICS [ANALGÉSICOS]

                
	
                   Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]

                
	
                  oxycodone          -acetaminophen 5-325 mg tab

                	
                  1

                	
                  Preferred

                	
                  PERCOCET

                	
                  QL=15 días

                  No refills

                
	
                  oxycodone-acetaminophen 10-325 mg tab, 7.5-325 mg tab

                	
                  3

                	
                  Preferred

                	
                  PERCOCET

                	
                  QL=15 días

                  No refills

                
	
                  ANTIANXIETY AGENTS [AGENTES PARA LA ANXIEDAD]

                
	
                  Miscellaneous Anxiolytics [Ansiolíticos Misceláneos]

                
	
                  hydroxyzine pamoate 100  mg cap, 25 mg cap, 50 mg cap

                	
                  1

                	
                  Preferred

                	
                  VISTARIL

                	 
	
                  ANTIBACTERIALS [ANTIBACTERIANOS]

                
	
                   First Generation Cephalosporins [Cefalosporinas De Primera Generación]

                
	
                  cephalexin 125 mg/5ml  susp, 250 mg cap, 500 mg cap

                	
                  1

                	
                  Preferred

                	
                  KEFLEX

                	 
	
                  cephalexin 250 mg/5ml susp

                	
                  2

                	
                  Preferred

                	
                  KEFLEX

                	 
	
                  Macrolides [Macrólidos]

                
	
                  azithromycin 250 mg tab,  500 mg tab

                	
                  1

                	
                  Preferred

                	
                  ZITHROMAX

                	 
	
                  azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab

                	
                  2

                	
                  Preferred

                	
                  ZITHROMAX

                	 
	
                  ERY-TAB 500 mg tab dr

                	
                  3

                	
                  Preferred

                	 	 
	
                  erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab

                	
                  3

                	
                  Preferred

                	
                  ERY-TAB

                	 
	
                  erythromycin ethylsuccinate 400 mg tab

                	
                  3

                	
                  Preferred

                	
                  E.E.S.

                	 
	
                  ERYTHROCIN STEARATE 250 mg tab

                	
                  4

                	
                  Non-Preferred

                	 	 


          

          

          
            

            Page 93 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  Drug Name [Nombre del

                   Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                  Tier [Tier]

                	
                  Reference Name

                   [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/ 

                  Límites]

                
	
                  E.E.S. GRANULES 200 mg/5ml susp

                	
                  5

                	
                  Preferred

                	 	 
	
                  ERYPED 200 200 mg/5ml susp

                	
                  5

                	
                  Preferred

                	 	 
	
                  ERYPED 400 400 mg/5ml susp

                	
                  6

                	
                  Preferred

                	 	 
	
                  Miscellaneous Antibacterials [Antibacterianos Misceláneos]

                
	
                  clindamycin hcl 150 mg cap,  300 mg cap, 75 mg cap

                	
                  1

                	
                  Preferred

                	
                  CLEOCIN

                	 
	
                  MACRODANTIN 25 mg cap

                	
                  1

                	
                  Preferred

                	 	 
	
                  metronidazole 250 mg tab, 500 mg tab

                	
                  1

                	
                  Preferred

                	
                  FLAGYL

                	 
	
                  nitrofurantoin macrocrystal 50 mg cap

                	
                  1

                	
                  Preferred

                	
                  MACRODANTIN

                	 
	
                  nitrofurantoin macrocrystal 100 mg cap

                	
                  2

                	
                  Preferred

                	
                  MACRODANTIN

                	 
	
                  nitrofurantoin monohyd macro 100 mg cap

                	
                  2

                	
                  Preferred

                	
                  MACROBID

                	 
	
                  nitrofurantoin oral

                  suspension 25 MG/5ML

                	
                  6

                	
                  Non-Preferred

                	
                  FURADANTIN

                	 
	
                  Penicillins [Penicilinas]

                
	
                  amoxicillin 125 mg/5ml susp          , 200 mg/5ml susp, 250 mg cap, , 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab

                	
                  1

                	
                  Preferred

                	
                  AMOXIL

                	 
	
                  amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 875-125 mg tab

                	
                  1

                	
                  Preferred

                	
                  AUGMENTIN

                	 
	
                  ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap

                	
                  1

                	
                  Preferred

                	
                  PRINCIPEN

                	 


          

          

          
            
              • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                  Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] •
                  P – Preferred Contracted Product [Producto Contratado Preferido]

            

          

          

          

          
            

            Page 94 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  Drug Name [Nombre del 

                  Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                  Tier [Tier]

                	
                  Reference Name 

                  [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/ 

                  Límites]

                
	
                  penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab

                	
                  1

                	
                  Preferred

                	
                  VEETIDS

                	 
	
                  amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp

                	
                  3

                	
                  Preferred

                	
                  AUGMENTIN

                	 
	
                  BICILLIN L-A 600000 unit/ml im susp

                	
                  3

                	
                  Non-Preferred

                	 	 
	
                  penicillin g procaine 600000 unit/ml im susp

                	
                  3

                	
                  Non-Preferred

                	
                  BICILLIN LA

                	 
	
                  BICILLIN L-A 1200000 unit/2ml im susp

                	
                  4

                	
                  Non-Preferred

                	 	 
	
                  BICILLIN L-A 2400000 unit/4ml im susp

                	
                  5

                	
                  Non-Preferred

                	 	 
	
                  Second Generation Cephalosporins [Cefalosporinas De Segunda Generación]

                
	
                  cefaclor 250 mg cap, 500  mg cap

                	
                  2

                	
                  Preferred

                	
                  CECLOR

                	 
	
                  cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab

                	
                  2

                	
                  Preferred

                	
                  CEFZIL

                	 
	
                  Sulfonamides [Sulfonamidas]

                
	
                  sulfamethoxazole          -tmp ds 800-160 mg tab

                	
                  1

                	
                  Preferred

                	
                  SEPTRA

                	 
	
                  sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab

                	
                  1

                	
                  Preferred

                	
                  SEPTRA

                	 
	
                  Third Generation Cephalosporins [Cefalosporinas De Tercera Generación]

                
	
                  cefdinir 125 mg/5ml susp,  300 mg cap

                	
                  2

                	
                  Preferred

                	
                  OMNICEF

                	 
	
                  cefdinir 250 mg/5ml susp

                	
                  3

                	
                  Preferred

                	
                  OMNICEF

                	 
	
                  Vaginal Antibiotics [Antibióticos Vaginales]

                
	
                  metronidazole 0.75 % vag  gel

                	
                  2

                	
                  Preferred

                	
                  VANDAZOLE

                	 


          

          

          
            • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P
                – Preferred Contracted Product [Producto Contratado Preferido]

          

          

          

          
            

            Page 95 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  Drug Name [Nombre del

                   Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                  Tier [Tier]

                	
                  Reference Name 

                  [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/ 

                  Límites]

                
	
                  clindamycin phosphate 2 % vag crm

                	
                  3

                	
                  Preferred

                	
                  CLEOCIN

                	 
	
                  ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]

                
	
                   Insulin Mixtures [Mezclas De Insulinas]

                
	
                  HUMULIN 70/30 (70          -30) 100 unit/ml sc susp

                	
                  3

                	
                  Preferred

                	 	
                  P

                
	
                  HUMALOG MIX 75/25 (7525) 100 unit/ml sc susp

                	
                  4

                	
                  Preferred

                	 	
                  P

                
	
                  HUMALOG MIX 50/50 (5050) 100 unit/ml sc susp

                	
                  4

                	
                  Preferred

                	 	
                  P

                
	
                  Intermediate-Acting Insulins [Insulinas De Duración Intermedia]

                
	
                  HUMULIN N 100 unit/ml sc  susp

                	
                  2

                	
                  Preferred

                	 	
                  P

                
	
                  Long-Acting Insulins [Insulinas De Larga Duración]

                
	
                  LANTUS SOLOSTAR 100  unit/ml
                      subcutaneous solution pen-injector

                	
                  3

                	
                  Preferred

                	 	
                  P

                
	
                  LANTUS 100 unit/ml sc soln

                	
                  3

                	
                  Preferred

                	 	
                  P

                
	
                  Rapid-Acting Insulins [Insulinas De Rápida Duración]

                
	
                  HUMALOG 100 unit/ml sc  soln

                	
                  4

                	
                  Preferred

                	 	
                  P

                
	
                  Short-Acting Insulins [Insulinas De Corta Duración]

                
	
                  HUMULIN R 100 unit/ml inj  soln

                	
                  2

                	
                  Preferred

                	 	
                  P

                
	
                  ANTIEMETICS [ANTIEMÉTICOS]

                
	
                   Miscellaneous Antiemetics [Antieméticos
                        Misceláneos]

                
	
                  metoclopramide hcl 10 mg  tab, 10 mg/10ml soln, 5 mg tab, 5 mg/5ml soln, 5 mg/ml inj soln

                	
                  1

                	
                  Preferred

                	
                  REGLAN

                	 
	
                  trimethobenzamide hcl 300 mg cap

                	
                  1

                	
                  Preferred

                	
                  TIGAN

                	 


          

          

          
            • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P
                – Preferred Contracted Product [Producto Contratado Preferido]

          

          

          

          
            

            Page 96 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  Drug Name [Nombre del 

                  Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                  Tier [Tier]

                	
                  Reference Name 

                  [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/ 

                  Límites]

                
	
                  Phenothiazines [Fenotiazinas]

                
	
                  prochlorperazine edisylate 5  mg/ml inj soln

                	
                  1

                	
                  Preferred

                	
                  COMPAZINE

                	 
	
                  prochlorperazine maleate 10 mg tab, 5 mg tab

                	
                  1

                	
                  Preferred

                	
                  COMPAZINE

                	 
	
                  prochlorperazine 25 mg rect supp

                	
                  4

                	
                  Non-Preferred

                	
                  COMPAZINE

                	 
	
                  ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]

                
	
                   Alpha-Adrenergic Agonists [Agonistas
                        Alfa Adrenérgicos]

                
	
                  methyldopa 250 mg tab, 500  mg tab

                	
                  1

                	
                  Preferred

                	
                  ALDOMET

                	 
	
                  Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]

                
	
                  atenolol 100 mg tab, 25           mg tab, 50 mg tab

                	
                  1

                	
                  Preferred

                	
                  TENORMIN

                	 
	
                  metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr

                	
                  1

                	
                  Preferred

                	
                  LOPRESSOR

                	 
	
                  metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab

                	
                  1

                	
                  Preferred

                	
                  LOPRESSOR

                	 
	
                  metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr

                	
                  2

                	
                  Preferred

                	
                  LOPRESSOR

                	 
	
                  Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos

                  Cardioselectivos]

                
	
                  atenolol          -chlorthalidone 10025 mg tab, 50-25 mg tab

                	
                  1

                	
                  Preferred

                	
                  TENORETIC

                	 
	
                  metoprolol-

                  hydrochlorothiazide 50-25 mg tab

                	
                  2

                	
                  Non-Preferred

                	
                  LOPRESSOR HCT

                	 
	
                  metoprololhydrochlorothiazide 100-25 mg tab, 100-50 mg tab

                	
                  3

                	
                  Non-Preferred

                	
                  LOPRESSOR HCT

                	 


          

          

          
            • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P
                – Preferred Contracted Product [Producto Contratado Preferido]

          

          

          

          
            

            Page 97 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  Drug Name [Nombre del 

                  Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                  Tier [Tier]

                	
                  Reference Name 

                  [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/ 

                  Límites]

                
	
                  Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]

                
	
                  propranolol hcl 10 mg tab          , 20 mg tab, 40 mg tab, 80 mg tab

                	
                  1

                	
                  Preferred

                	
                  INDERAL

                	 
	
                  propranolol hcl 60 mg tab

                	
                  2

                	
                  Preferred

                	
                  INDERAL

                	 
	
                  Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]

                
	
                  carvedilol 12.5 mg tab, 25  mg tab, 3.125 mg tab, 6.25

                  mg tab 1 Preferred COREG

                
	
                  Vasodilators [Vasodilatadores]

                
	
                  hydralazine hcl 10 mg tab,  100 mg tab, 25 mg tab, 50 mg tab

                	
                  1

                	
                  Preferred

                	
                  APRESOLINE

                	 
	
                  ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]

                
	
                   Antituberculars [Antituberculosos]

                
	
                  isoniazid 100 mg tab, 300  mg tab

                	
                  1

                	
                  Preferred

                	
                  ISONIAZID

                	 
	
                  rifampin 150 mg cap

                	
                  1

                	
                  Preferred

                	
                  RIFADIN

                	 
	
                  ethambutol hcl 100 mg tab

                	
                  2

                	
                  Non-Preferred

                	
                  MYAMBUTOL

                	 
	
                  rifampin 300 mg cap

                	
                  2

                	
                  Preferred

                	
                  RIFADIN

                	 
	
                  ethambutol hcl 400 mg tab

                	
                  3

                	
                  Non-Preferred

                	
                  MYAMBUTOL

                	 
	
                  isoniazid 50 mg/5ml syr

                	
                  5

                	
                  Non-Preferred

                	
                  ISONIAZID

                	 
	
                  rifabutin 150 mg cap

                	
                  6

                	
                  Preferred

                	
                  MYCOBUTIN

                	
                  Puerto Rico Health

                  Department

                  Tuberculosis

                  Control Program

                
	
                  RIFAMATE 50-300 mg cap

                	 	 	 
	
                  TRECATOR 250 mg tab

                	 	 	 
	
                  Miscellaneous Antimycobacterials [Antimicobacterianos Misceláneos]

                
	
                  dapsone 100 mg tab, 25 mg  tab

                	
                  2

                	
                  Preferred

                	
                  DAPSONE

                	 
	
                  ANTIMYCOTIC AGENTS [ANTIMICÓTICOS]

                
	
                   Vaginal Antifungals [Antifungales Vaginales]

                
	
                  terconazole 0.4 % vag crm, 

                  0.8 % vag crm

                	
                  2

                	
                  Preferred

                	
                  TERAZOL

                	 


          

          

          
            • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P
                – Preferred Contracted Product [Producto Contratado Preferido]

          

          

          

          
            

            Page 98 of 25

            
              


            
              	
                       

                    		
                       

                    


            

          

          	
                  Drug Name [Nombre del 

                  Medicamento]

                	
                  Net

                  Cost

                  [Costo

                  Neto]

                	
                  Tier [Tier]

                	
                  Reference Name 

                  [Nombre de

                  Referencia]

                	
                  Requirements/

                  Limits

                  [Requerimientos/ 

                  Límites]

                
	
                  ANTIPARASITICS [ANTIPARASITARIOS]

                
	
                   Antiprotozoals - Non-Antimalarials [Antiprotozoarios No-Antimalaráricos]

                
	
                  NEBUPENT 300 mg inh soln          

                	
                  4

                	
                  Preferred

                	 	
                  PA

                
	
                  ANTIVIRALS [ANTIVIRALES]

                
	
                   Antiherpetic Agents [Agentes Antiherpéticos]

                
	
                  acyclovir 200 mg cap, 400  mg tab, 800 mg tab

                	
                  1

                	
                  Preferred

                	
                  ZOVIRAX

                	 
	
                  acyclovir 200 mg/5ml susp

                	
                  2

                	
                  Preferred

                	
                  ZOVIRAX

                	 
	
                  Anti-Influenza Agents [Agentes Antiinfluenza]

                
	
                  RELENZA DISKHALER 5 

                  mg/blister inh aer pwdr

                	
                  3

                	
                  Preferred

                	 	 
	
                  oseltamivir phosphate 30 mg cap,
                      45 mg cap, 75 mg cap

                	
                  4

                	
                  Preferred

                	
                  TAMIFLU

                	 
	
                  TAMIFLU 6 mg/ ml susp

                	
                  5

                	
                  Non-Preferred

                	 	 
	
                  Nucleoside/Nucleotide Reverse Transcriptase Inhibitors [Inhibidores Nucleósidos/Nucleótidos De La Transcriptasa
                      Reversa]

                
	
                  zidovudine 300 mg tab          

                	
                  2

                	
                  Non-Preferred

                	
                  RETROVIR

                	 
	
                  zidovudine 100 mg cap, 50 mg/5ml syr

                	
                  4

                	
                  Non-Preferred

                	
                  RETROVIR

                	 
	
                  BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]

                
	
                   Anticoagulants [Anticoagulantes]

                
	
                  heparin sodium (porcine)  1000 unit/ml inj soln

                	
                  2

                	
                  Preferred

                	
                  HEPARIN

                	 
	
                  heparin sodium (porcine) 10000 unit/ml inj soln, 5000 unit/ml inj soln

                	
                  3

                	
                  Preferred

                	
                  HEPARIN

                	 
	
                  heparin sodium (porcine) pf 5000 unit/0.5ml inj soln

                	
                  3

                	
                  Preferred

                	
                  HEPARIN

                	 
	
                  heparin sodium (porcine) 2000 unit/ml iv soln

                	
                  8

                	
                  Preferred

                	
                  HEPARIN

                	 
	
                  Cobalamins [Cobalaminas]

                
	
                  cyanocobalamin 1000  mcg/ml inj soln

                	
                  1

                	
                  Preferred

                	
                  VIT B-12

                	 


           

            
              • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                  Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] •
                  P – Preferred Contracted Product [Producto Contratado Preferido]

            

            

            

            
              

              Page 99 of 25

              
                


            

            
              
                Revisado: 1 de mayo de 2017 

                 
                

                 
                OB-GYN 

                

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      Folates [Folatos]

                    
	
                       folic acid 1 mg tab, 400 mcg  tab, 800 mcg tab

                    	
                      1

                    	
                      Preferred

                    	
                      FOLIC ACID

                    	
                      OTC

                    
	
                      Iron [Hierro]

                    
	
                      iron 325 (65 fe) mg tab          

                    	
                      1

                    	
                      Preferred

                    	
                      IRON

                    	 
	
                      DEXFERRUM 50 mg/ml inj soln

                    	
                      5

                    	
                      Non-Preferred

                    	 	 
	
                      INFED 50 mg/ml inj soln

                    	
                      5

                    	
                      Preferred

                    	 	 
	
                      BONE DENSITY REGULATORS [REGULADORES DE DENSIDAD ÓSEA]

                    
	
                       Bisphosphonates [Bifosfonatos]

                    
	
                      alendronate sodium 10 mg  tab, 35 mg tab, 5 mg tab, 70 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      FOSAMAX

                    	 
	
                      CHEMOTHERAPIES [QUIMIOTERAPIAS]

                    
	
                       Folic Acid Antagonists Rescue Agents [Antagonistas De Ácido Fólico]

                    
	
                      leucovorin calcium 5 mg tab          

                    	
                      3

                    	
                      Preferred

                    	
                      LEUCOVORIN

                    	 
	
                      leucovorin calcium 10 mg tab, 15 mg tab

                    	
                      4

                    	
                      Preferred

                    	
                      LEUCOVORIN

                    	 
	
                      leucovorin calcium 25 mg tab

                    	
                      9

                    	
                      Preferred

                    	
                      LEUCOVORIN

                    	 
	
                      leucovorin calcium 50 mg inj, 100 mg inj, 200 mg inj, 350 mg inj, 500 mg inj

                    	
                      9

                    	
                      Non-Preferred

                    	
                      LEUCOVORIN

                    	 
	
                      Luteinizing Hormone-Releasing (Lhrh) Analogs [Análogos De Lhrh]

                    
	
                      LUPRON DEPOT 11.25 mg 

                      im kit, 3.75 mg im kit

                    	
                      6

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      ZOLADEX 3.6 mg, 10.8 mg subcutaneous implant

                    	
                      7

                    	
                      Non-preferred

                    	 	
                      PA

                    
	
                      DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]

                    
	
                      Antihistamines [Antihistamínicos]

                    
	
                      hydroxyzine hcl 10 mg tab,  10 mg/5ml soln, 10 mg/5ml syr, 25 mg tab, 50 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      ATARAX

                    	 


              

              

              • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                  Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] •
                  P – Preferred Contracted Product [Producto Contratado Preferido]

               

                

              
                Page 100 of 25

                
                  


              

              
                Revisado: 1 de mayo de 2017 

                 
                

                 
                OB-GYN 

                

                

                

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      Topical Antifungals [Antifungales Tópicos]

                    
	
                      clotrimazole 1 % crm          

                    	
                      1

                    	
                      Preferred

                    	
                      LOTRIMIN

                    	
                      OTC (crm)

                    
	
                      nystatin 100000 unit/gm oint

                    	
                      1

                    	
                      Preferred

                    	
                      MYCOSTATIN

                    	 
	
                      DIABETES SUPPLIES [SUMINISTROS PARA DIABETES]

                    
	
                       Needles & Syringes [Agujas Y Jeringuillas]

                    
	
                      insulin syringe/needle           

                    	
                      1

                    	
                      Preferred

                    	
                      .

                    	 
	
                      GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]

                    
	
                       Anti-Ulcer Agents [Agentes Anti-Ulceras]

                    
	
                      sucralfate 1 gm tab          

                    	
                      1

                    	
                      Preferred

                    	
                      CARAFATE

                    	 
	
                      CARAFATE 1 gm/10ml susp

                    	
                      3

                    	
                      Non-Preferred

                    	 	 
	
                      Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]

                    
	
                      famotidine 20 mg tab, 40 mg  tab

                    	
                      1

                    	
                      Preferred

                    	
                      PEPCID

                    	 
	
                      ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr

                    	
                      1

                    	
                      Preferred

                    	
                      ZANTAC

                    	 
	
                      Rectal Anti-Inflammatories [Anti-Inflamatorios Rectales]

                    
	
                      hydrocortisone ace pramoxine 1-1 % rect crm, 2.5-1 % rect crm

                    	
                      2

                    	
                      Preferred

                    	
                      ANALPRAM-HC

                    	 
	
                      pramcort 1-1 % rect crm

                    	
                      2

                    	
                      Preferred

                    	
                      ANALPRAM-HC

                    	 
	
                      HORMONAL AGENTS [AGENTES HORMONALES]

                    
	
                       Dysmenorrhea Agents [Agentes Para La Dismenorrea]

                    
	
                      medroxyprogesterone  acetate 10 mg tab, 2.5 mg tab, 5 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      PROVERA

                    	 
	
                      alyacen 1/35 1-35 mg-mcg tab

                    	
                      2

                    	
                      Preferred

                    	
                      ARANELLE

                    	
                      PA

                    
	
                      CRYSELLE-28 0.3-30 mgmcg tab

                    	
                      2

                    	
                      Preferred

                    	 	
                      PA

                    
	
                      ELINEST 0.3-30 mg-mcg tab

                    	
                      2

                    	
                      Preferred

                    	 	
                      PA

                    
	
                      LOW-OGESTREL 0.3-30 mg-mcg tab

                    	
                      2

                    	
                      Preferred

                    	 	
                      PA

                    


               

                

              • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                  Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] •
                  P – Preferred Contracted Product [Producto Contratado Preferido]

              

              

              
                Page 101 of 25

                
                  


              

              
                Revisado: 1 de mayo de 2017 

                 
                

                 
                OB-GYN 

                 

                  

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      Estrogens [Estrógenos]

                    
	
                      estradiol 1 mg tab, 2 mg tab          

                    	
                      1

                    	
                      Preferred

                    	
                      ESTRACE

                    	 
	
                      estropipate 0.75 mg tab, 1.5 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      ESTROPIPATE

                    	 
	
                      estropipate 3 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      ESTROPIPATE

                    	 
	
                      Estrogens and Progestins [Estrógenos y Progestinas]

                    
	
                      estradiol          -norethindrone acet 1-0.5 mg tab

                    	
                      4

                    	
                      Non-Preferred

                    	
                      ACTIVELLA

                    	 
	
                      Glucocorticosteroids [Glucocorticoides]

                    	 
	
                      betamethasone sod phos &  acet 6 (3-3) mg/ml inj susp

                    	
                      2

                    	
                      Preferred

                    	
                      CELESTONE

                    	 
	
                      Mineralocorticoids [Mineralocorticoides]

                    	 
	
                      fludrocortisone acetate 0.1  mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      FLORINEF

                    	 
	
                      Thyroid Hormones [Hormona Tiroidea]

                    	 
	
                      levothyroxine sodium 100  mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab,
                            175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

                    	
                      1

                    	
                      Preferred

                    	
                      SYNTHROID

                    	 
	
                      SYNTHROID 100 mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300
                          mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

                    	
                      1

                    	
                      Preferred

                    	 	
                      P

                    
	
                      Vaginal Estrogens [Estrógenos Vaginal]

                    	 
	
                      VAGIFEM 10 mcg vag tab          

                    	
                      3

                    	
                      Non-Preferred

                    	 	 


              

              

              • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                  Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] •
                  P – Preferred Contracted Product [Producto Contratado Preferido]

               

                

              
                Page 102 of 25

                
                  


              

              
                Revisado: 1 de mayo de 2017

                

                OB-GYN

                 

                  

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]

                    
	
                      Glucocorticosteroids [Glucocorticoides]

                    
	
                      dexamethasone 0.5 mg tab,  0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg
                            tab, 4 mg tab, 6 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      DECADRON

                    	 
	
                      dexamethasone sodium phosphate 120 mg/30ml inj soln, 20 mg/5ml inj soln, 4 mg/ml inj soln

                    	
                      1

                    	
                      Preferred

                    	
                      DECADRON

                    	 
	
                      KENALOG 10 mg/ml inj susp

                    	
                      1

                    	
                      Non-Preferred

                    	 	 
	
                      MEDROL 2 mg tab

                    	
                      1

                    	
                      Preferred

                    	 	 
	
                      methylprednisolone 32 mg tab, 4 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MEDROL

                    	 
	
                      methylprednisolone (pak) 4 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MEDROL

                    	 
	
                      prednisolone 15 mg/5ml soln, 15 mg/5ml syr

                    	
                      1

                    	
                      Preferred

                    	
                      PRELONE

                    	 
	
                      prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      DELTASONE

                    	 
	
                      prednisone (pak) 10 mg tab, 5 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      DELTASONE

                    	 
	
                      hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      CORTEF

                    	 
	
                      methylprednisolone 16 mg tab, 8 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      MEDROL

                    	 
	
                      KENALOG 40 mg/ml inj susp

                    	
                      5

                    	
                      Non-Preferred

                    	 	 
	
                      Immune Globulins [Immunoglobulinas]

                    
	
                      RHOGAM ultra-filtered plus im soln 1500 unit

                    	
                      4

                    	
                      Preferred

                    	 	 


              

              • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                  Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] •
                  P – Preferred Contracted Product [Producto Contratado Preferido]

              

              

              
                Page 103 of 25

                
                  


              

              
                Revisado: 1 de mayo de 2017

                

                OB-GYN

                    

                  

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]

                    
	
                       Prenatal Vitamins [Vitaminas Prenatales]

                    
	
                      prenatal tab

                    	
                      1

                    	
                      Preferred

                    	
                      PRENATAL

                      VITAMINS

                    	 
	
                      RESPIRATORY AGENTS [AGENTES RESPIRATORIOS]

                    
	
                       Anticholinergic Bronchodilators [Broncodilatadores Anticolinérgicos]

                    
	
                      ipratropium bromide 0.02 %  inh soln

                    	
                      1

                    	
                      Non-Preferred

                    	
                      ATROVENT

                    	 
	
                      Inhaled Corticosteroids [Corticosteroides Inhalados]

                    
	
                      FLOVENT DISKUS 100 

                      mcg/blist inh aer pwdr, 250 mcg/blist inh aer pwdr, 50 mcg/blist inh aer pwdr

                    	
                      3

                    	
                      Preferred

                    	 	
                      QL = 1 pompa / 30 días, P

                    
	
                      FLOVENT HFA 110 mcg/act inh aer, 44 mcg/act inh aer

                    	
                      3

                    	
                      Preferred

                    	 	
                      QL = 1 pompa

                      / 30 días, P

                    
	
                      ADVAIR DISKUS 100-50 mcg/dose inh aer pwdr, 25050 mcg/dose inh aer pwdr

                    	
                      4

                    	
                      Preferred

                    	 	
                      QL = 1 pompa / 30 días, ST, P

                    
	
                      ADVAIR HFA 115-21

                      mcg/act inh aer, 45-21 mcg/act inh aer

                    	
                      4

                    	
                      Preferred

                    	 	
                      QL = 1 pompa / 30 días, ST, P

                    
	
                      budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp,

                    	
                      4

                    	
                      Non-Preferred

                    	
                      PULMICORT

                    	
                      AL ≤ 12 años

                    
	
                      budesonide 1mg/2ml inh susp

                    	
                      8

                    	
                      Non-Preferred

                    	
                      PULMICORT

                    	
                      AL ≤ 12 años

                    
	
                      FLOVENT HFA 220 mcg/act

                      inh aer

                    	
                      4

                    	
                      Preferred

                    	 	
                      QL = 1 pompa

                      / 30 días, P

                    
	
                      ADVAIR DISKUS 500-50 mcg/dose inh aer pwdr

                    	
                      5

                    	
                      Preferred

                    	 	
                      QL = 1 pompa / 30 días, ST, P

                    
	
                      ADVAIR HFA 230-21 mcg/act inh aer

                    	
                      5

                    	
                      Preferred

                    	 	
                      QL = 1 pompa / 30 días, ST, P

                    
	
                      Nonsedating Histamine1 Blocking Agents [Bloqueadores De Histamina1 No-Sedantes]

                    
	
                      loratadine 10 mg tab          

                    	
                      1

                    	
                      Preferred

                    	
                      CLARITIN

                    	
                      OTC

                    


              

              

              • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                  Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] •
                  P – Preferred Contracted Product [Producto Contratado Preferido]

              

              

              
                Page 104 of 25

                
                  


              

              
                Revisado: 1 de mayo de 2017

                

                OB-GYN

                 

                  

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                          [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                          Límites]

                    


              	
                      Sedating Histamine1 Blocking Agents [Sedantes Bloqueadores Histamine1]

                    
	
                      promethazine hcl 12.5 mg  tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml syr

                    	
                      1

                    	
                      Preferred

                    	
                      PHENERGAN

                    	 
	
                      Sympathomimetic Bronchodilators [Broncodilatadores Simpatomiméticos]

                    
	
                      albuterol sulfate (2.5  mg/3ml) 0.083% inh neb soln, (5 mg/ml) 0.5% inh neb soln

                    	
                      1

                    	
                      Preferred

                    	
                      ALBUTEROL

                    	 
	
                      terbutaline sulfate 2.5 mg tab, 5 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      BRETHINE

                    	 
	
                      VENTOLIN HFA 108 (90 base) mcg/act inh aer

                    	
                      1

                    	
                      Preferred

                    	 	
                      QL = 1 pompa / 30 días, P

                    


              

              

              • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL –
                  Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] •
                  P – Preferred Contracted Product [Producto Contratado Preferido]

               

                

              
                Page 105 of 25

                
                  


              

              
                	
                        OB-GYN

                      	
                        

                      


              

              

              
                
                  	
                          A

                        	 
	 	 
	
                          acyclovir

                        	
                          17

                        
	
                          ADVAIR DISKUS

                        	
                           25, 26

                        
	
                          ADVAIR HFA

                        	
                           25, 26

                        
	
                          albuterol sulfate

                        	
                          26

                        
	
                          alendronate sodium

                        	
                          19

                        
	
                          alyacen 1/35

                        	
                          21

                        
	
                          amoxicillin

                        	
                          12

                        
	
                          amoxicillin-pot clavulanate

                        	
                           12, 13

                        
	
                           ampicillin

                        	
                          12

                        
	
                          atenolol

                        	
                          15

                        
	
                          atenolol-chlorthalidone

                        	
                          15

                        
	
                          azithromycin

                        	
                          11

                        
	 	 
	
                          B

                        	 
	 	 
	
                          betamethasone sod phos & acet

                        	
                          22

                        
	
                          BICILLIN L-A

                        	
                          13

                        
	
                          budesonide

                        	
                          25

                        
	 	 
	
                          C

                        	 
	 	 
	
                          CARAFATE

                        	
                          20

                        
	
                          carvedilol

                        	
                          16

                        
	
                          cefaclor

                        	
                          13

                        
	
                          cefdinir

                        	
                          13

                        
	
                          cefprozil

                        	
                          13

                        
	
                          cephalexin

                        	
                          11

                        
	
                          clindamycin hcl

                        	
                          12

                        
	
                          clindamycin phosphate

                        	
                          14

                        
	
                          clotrimazole

                        	
                          20

                        
	
                           CRYSELLE-28

                        	
                          21

                        
	
                          cyanocobalamin

                        	
                          18

                        
	 	 
	
                          D

                        	 
	 	 
	
                          dapsone

                        	
                          17

                        
	
                          dexamethasone

                        	
                          23

                        
	
                          dexamethasone sodium phosphate

                        	
                          23

                        
	
                          DEXFERRUM

                        	
                          19

                        
	 	 
	
                          E

                        	 


                

              

              
                
                  	
                          E.E.S. GRANULES

                        	
                          12

                        
	
                          ELINEST

                        	
                          21

                        
	
                          ERYPED 200

                        	
                          12

                        
	
                          ERYPED 400

                        	
                          12

                        
	
                          ERY-TAB

                        	
                          11

                        
	
                          ERYTHROCIN STEARATE

                        	
                          11

                        
	
                          erythromycin base

                        	
                          11

                        
	
                          erythromycin ethylsuccinate

                        	
                          11

                        
	
                          estradiol

                        	
                          21

                        
	
                          estradiol-norethindrone acet

                        	
                          22

                        
	
                          estropipate

                        	
                           21, 22

                        
	
                          ethambutol hcl

                        	
                          16

                        
	 	 
	
                          F

                        	 
	 	 
	
                          famotidine

                        	
                          20

                        
	
                          FLOVENT DISKUS

                        	
                          25

                        
	
                          FLOVENT HFA

                        	
                          25

                        
	
                          fludrocortisone acetate

                        	
                          22

                        
	
                          folic acid

                        	
                          18

                        
	 	 
	
                          H

                        	 
	 	 
	
                          heparin sodium (porcine)

                        	
                          18

                        
	
                          heparin sodium (porcine) pf

                        	
                          18

                        
	
                          HUMALOG

                        	
                          14

                        
	
                          HUMALOG MIX 50/50

                        	
                          14

                        
	
                          HUMALOG MIX 75/25

                        	
                          14

                        
	
                          HUMULIN 70/30

                        	
                          14

                        
	
                          HUMULIN N

                        	
                          14

                        
	
                          HUMULIN R

                        	
                          14

                        
	
                          hydralazine hcl

                        	
                          16

                        
	
                          hydrocortisone

                        	
                          24

                        
	
                          hydrocortisone ace-pramoxine

                        	
                          21

                        
	
                          hydroxyzine hcl

                        	
                          20

                        
	
                          hydroxyzine pamoate

                        	
                          11

                        
	 	 
	
                          I

                        	 
	 	 
	
                          INFED

                        	
                          19

                        
	
                          insulin syringe/needle

                        	
                          20

                        
	
                          ipratropium bromide

                        	
                          25

                        


                

              

               

                

               

                

               

              
                	
                         

                      


                
                  • PA – Prior Authorization
                      [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo
                      Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] 

                   

                    

                  
                    Page 106 of 25

                    
                      


                    
                      	
                               

                            		
                               

                            


                    

                  

                

                
                  
                    	
                            iron

                          	
                            19

                          
	
                            isoniazid

                          	
                            16

                          
	 	 
	
                            K

                          	 
	 	 
	
                            KENALOG

                          	
                             23, 24

                          
	 	 
	
                            L

                          	 
	 	 
	
                            LANTUS

                          	
                            14

                          
	
                            LANTUS SOLOSTAR

                          	
                            14

                          
	
                            leucovorin calcium

                          	
                            19

                          
	
                            levothyroxine sodium

                          	
                            22

                          
	
                            loratadine

                          	
                            26

                          
	
                            LOW-OGESTREL

                          	
                            21

                          
	
                            LUPRON DEPOT

                          	
                            19

                          
	 	 
	
                            M

                          	 
	 	 
	
                            MACRODANTIN

                          	
                            12

                          
	
                            MEDROL

                          	
                            23

                          
	
                            medroxyprogesterone acetate

                          	
                            21

                          
	
                            methyldopa

                          	
                            15

                          
	
                            methylprednisolone

                          	
                             23, 24

                          
	
                            methylprednisolone (pak)

                          	
                            24

                          
	
                            metoclopramide hcl

                          	
                            14

                          
	
                            metoprolol succinate er

                          	
                            15

                          
	
                            metoprolol tartrate

                          	
                            15

                          
	
                            metoprolol-hydrochlorothiazide

                          	
                            15

                          
	
                            metronidazole

                          	
                             12, 13

                          
	 	 
	
                            N

                          	 
	 	 
	
                            NEBUPENT

                          	
                            17

                          
	
                            nitrofurantoin macrocrystal

                          	
                            12

                          
	
                            nitrofurantoin monohyd macro

                          	
                            12

                          
	
                            nitrofurantoin oral suspension

                          	
                            12

                          
	
                            nystatin

                          	
                            20

                          
	 	 
	
                            O

                          	 
	 	 
	
                            oseltamivir phosphate

                          	
                            17

                          
	
                            oxycodone-acetaminophen

                          	
                            11

                          
	 	 
	
                            P

                          	 


                  

                

                
                  
                    	
                            penicillin g procaine

                          	
                            13

                          
	
                            penicillin v potassium

                          	
                            13

                          
	
                            pramcort

                          	
                            21

                          
	
                            prednisolone

                          	
                            24

                          
	
                            prednisone

                          	
                            24

                          
	
                            prednisone (pak)

                          	
                            24

                          
	
                            pre-natal formula

                          	
                            24

                          
	
                            prochlorperazine

                          	
                            15

                          
	
                            prochlorperazine edisylate

                          	
                            15

                          
	
                            prochlorperazine maleate

                          	
                            15

                          
	
                            promethazine hcl

                          	
                            26

                          
	
                            propranolol hcl

                          	
                            16

                          
	 	 
	
                            R

                          	 
	 	 
	
                            ranitidine hcl

                          	
                            21

                          
	
                            RELENZA DISKHALER

                          	
                            17

                          
	
                            RHOGAM ultra-filtered plus im soln 1500 unit

                          	
                            24

                          
	
                            rifabutin

                          	
                            16

                          
	
                            RIFAMATE

                          	
                            17

                          
	
                            rifampin

                          	
                            16

                          
	 	 
	
                            S

                          	 
	
                            sucralfate

                          	
                            20

                          
	
                            sulfamethoxazole-tmp ds

                          	
                            13

                          
	
                            sulfamethoxazole-trimethoprim

                          	
                            13

                          
	
                            SYNTHROID

                          	
                            23

                          
	 	 
	
                            T

                          	 
	 	 
	
                            TAMIFLU

                          	
                            18

                          
	
                            terbutaline sulfate

                          	
                            26

                          
	
                            terconazole

                          	
                            17

                          
	
                            TRECATOR

                          	
                            17

                          
	
                            trimethobenzamide hcl

                          	
                            14

                          
	 	 
	
                            V

                          	 
	 	 
	
                            VAGIFEM

                          	
                            23

                          
	
                            VENTOLIN HFA

                          	
                            26

                          


                  

                

                

                  

                  

                  	

                        	

                        


                  
                    

                    Page 107 of 25

                    
                      


                  

                  
                    	
                            OB-GYN

                          	
                            

                          


                  

                  

                  
                    
                      	
                              Z

                            	 
	
                              zidovudine

                            	
                              18

                            


                    

                  

                  
                    
                      	
                              ZOLADEX

                            	
                              20

                            


                    

                  

                

              

              

              
                	
                         

                      


              

              
                Page 108 of 25

                
                  


                
                  	
                           

                        		
                           

                        


                

              

              ASES

               

                

              Puerto Rico Healthcare Insurance Administration

              

              

              Oncology

               

                

              2017

               

                

              Formulary of Drugs Covered by

               

                

              the Government Healthcare Plan (GHP)

               

                

              Authorized by the P.R. Elections Commission CEE-SA-16-2732

                  

                

              
                

                Page 109 of 25

                
                  


              

              
                
                  	
                           

                          

                        
	
                          

                          

                        	 


                

                 

                

                	
                        

                      	 	
                        GOVERNMENT OF PUERTO RICO

                      	
                        Hon. Ricardo A. Rosselló Nevares

                      
	 	
                        Healthcare Insurance Administration

                      	Governor
	 	 	 	
                        Ms. Ángela M. Ávila Marrero

                        Executive Director

                      


                

              

              May 1, 2017

              

              

              TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

              

              

              Dear provider:

              

              

              I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its corresponding
                  sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

              

              

              The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and Sub-physical. Moreover, the
                  Mental Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health Sub-formulary will be used by
                  participating primary care physicians (PCPs) in Primary Care Medical Groups.

              

              

              The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare Insurance Administration
                  (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical aspects. The FDC is a dynamic
                  document that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

              

              

              I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

              

              

              Cordially,

              

              

              [signed]

              Ángela M. Ávila Marrero

              Executive Director

               

                	
                        

                      
	 

                      
	

                      
	
                        PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                      


                 

                

              

              
                Page 110 of 25

                
                  


                
                  	
                           

                        		
                           

                        


                

              

              GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

               

                

              OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

               

                

              
                
                  	1.	
                          Drug Formulary

                        


                

              

              

              

              The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and reviewing the Formulary
                  of Drugs Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee is constituted by healthcare
                  professionals, including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES for the drug formulary based on
                  scientific evidence, clinical aspects, and a cost-effectiveness analysis.

              

              

              The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the prescription drug coverage.
                  The purpose of the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

              

              

              ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator or PPA based on the most
                  recent clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

              

              

              Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain in point number 2.

              

              

              
                
                  	2.	
                          Exception Process

                        


                

              

              

              

              In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as applicable, insurance
                  companies must use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

              

              

              
                
                  	

                        	m.	
                          Contraindication to the drug(s) included in the FDC;

                        


                

              

              
                
                  	

                        	n.	
                          History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                        


                

              

              
                
                  	

                        	o.	
                          Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                        


                

              

              
                
                  	

                        	p.	
                          Lack of a therapeutic alternative in the FDC.

                        


                

              

              This exception process requires a clinical justification that is duly documented by the service provider with the clinical
                  reasons justifying the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

              

              

              
                	
                        3.

                      	
                        Other Aspects of the Prescription Drug Coverage

                      


              

              

              

              
                
                  	

                        	A.	
                          The prescription drug coverage of the GHP establishes that using generic bioequivalent products as
                                the first option is mandatory.

                        


                

              

              

              

              
                

                Page 111 of 25

                
                  


              

              
                
                  
                    Revisado: 5 de mayo de 2017

                     
                    

                    ONCOLOGIA 

                      

                    

                      

                  

                  	

                        	B.	
                          Insurance companies or the TPA (Third Party Administrator) and healthcare service providers will
                                only process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                        


                

              

              

              

              
                
                  	

                        	C.	
                          ASES has an active process to continually review the prescription drug coverage in accordance with
                                changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES may require
                                that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will safeguard adequate
                                access to services and maintain continuity of care.

                        


                

              

              

              

              
                
                  	

                        	D.	
                          No entity contracted by ASES or by healthcare companies or organizations (for example, primary care
                                medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES. Furthermore, they may not
                                limit the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be responsible for supervising their
                                providers and employees with regard to their compliance with these provisions.

                        


                

              

              

              

              
                
                  	

                        	E.	
                          The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The
                                treatment period may be extended, as applicable, when medically necessary.

                        


                

              

              

              

              
                
                  	

                        	F.	
                          The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty (30)
                                day therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating adherence and
                                tolerance. The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case of narcotics, which
                                will be dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms of adherence, tolerance,
                                and dosage within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                        


                

              

              

              

              
                
                  	

                        	G.	
                          ASES requires the use of generic bioequivalent drugs approved by the Food and Drug Administration
                                (FDA) coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                        


                

              

              

              

              
                
                  	

                        	H.	
                          The lack of appropriate bioequivalent drug inventories does not exempt providers from dispensing
                                the prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the corresponding brand-name
                                drug, unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception mechanism.

                        


                

              

              

              

              
                Page 112 of 25

                
                  


              

              
                
                  
                    Revisado: 5 de mayo de 2017

                    

                    ONCOLOGIA

                     

                      

                  

                  	

                        	I.	
                          Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized under
                                the law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                        


                

              

              

              

              
                
                  	

                        	J.	
                          The right to freedom of choice requires the availability of a pharmacy that is reasonably
                                accessible to each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                        


                

              

              

              

              Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or when an
                  electronic prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24 hours. If a drug
                  is not available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her physician to have the
                  prescription sent to another pharmacy of his or her choice.

              

              

              
                
                  	4.	
                          Emergency Rule

                        


                

              

              

              

              The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except as otherwise
                  specified.

              

              

              The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will also be
                  dispensed in amounts sufficient for five (5) business days.

              

              

              Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for continuity of
                  treatment, including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the IEF.

              

              

              
                If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES in your
                    region and/or the Pharmacy Benefit Manager (PBM) contracted by ASES.

                

                

              

              
                Page 113 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

                  

              

              GOVERNMENT HEALTHCARE PLAN

               

                

              FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

               

                

              2017

               

                

              TABLE OF CONTENTS

               

                

              
                	
                        GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE GOVERNMENT HEALTHCARE PLAN

                      	
                        3

                      
	 	 	 
	
                        DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                      	
                        9

                      
	 	 	 
	 	
                        MONTHLY NET COST RANGE

                      	
                        9

                      
	 	 	 
	 	
                        GENERIC DRUGS

                      	
                        10

                      
	 	 	 
	
                        THERAPEUTIC CATEGORY

                      	
                        11

                      
	
                        ANALGESICS

                      	
                        11

                      
	 	
                        Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

                      	
                        11

                      
	 	
                        Opioid Analgesics, Long-Acting

                      	
                        11

                      
	 	
                        Short-Acting Opioid Analgesics

                      	
                        12

                      
	
                        ANESTHETICS

                      	
                        13

                      
	 	
                        Local Anesthetics

                      	
                        13

                      
	
                        ANTIBACTERIALS

                      	
                        13

                      
	 	
                        Macrolides

                      	
                        13

                      
	 	
                        Penicillins

                      	
                        14

                      
	 	
                        Quinolones

                      	
                        15

                      
	 	
                        Sulfonamides

                      	
                        15

                      
	
                        ANTICONVULSANTS

                      	
                        15

                      
	 	
                        Anticonvulsants

                      	
                        15

                      
	
                        ANTIEMETICS

                      	
                        16

                      
	 	
                        5-Hydroxytryptamine 3 (5-HT3) Antagonists

                      	
                        16

                      
	 	
                        Miscellaneous Antiemetics

                      	
                        16

                      
	 	
                        Phenothiazines

                      	
                        16

                      
	
                        ANTIMYCOBACTERIALS

                      	
                        16

                      


                
                  

                  

                  
                    Page 114 of 25

                    
                      


                  

                  
                    
                      Revisado: 5 de mayo de 2017

                      

                       

                      

                      ONCOLOGIA

                       

                    

                    	 	
                            Miscellaneous Antimycobacterials

                          	
                            16

                          
	
                            ANTIMYCOTIC AGENTS

                          	
                            17

                          
	 	
                            Antifungals

                          	
                            17

                          
	
                            ANTIVIRALS

                          	
                            17

                          
	 	
                            Antiherpetic Agents

                          	
                            17

                          
	
                            BLOOD MODIFIERS

                          	
                            17

                          
	 	
                            Cobalamins

                          	
                            17

                          
	 	
                            Colony Stimulating Factors

                          	
                            17

                          
	 	
                            Erythropoiesis-Stimulating Agents

                          	
                            17

                          
	 	
                            Folates

                          	
                            18

                          
	 	
                            Iron

                          	
                            18

                          
	
                            CHEMOTHERAPIES

                          	
                            19

                          
	 	
                            Alkylating Agents

                          	
                            19

                          
	 	
                            Angiogenesis Inhibitors

                          	
                            19

                          
	 	
                            Antiandrogens

                          	
                            19

                          
	 	
                            Antiestrogens

                          	
                            19

                          
	 	
                            Antimetabolites

                          	
                            19

                          
	 	
                            Antineoplastic Enzyme Inhibitors

                          	
                            19

                          
	 	
                            Antineoplastic Progestins

                          	
                            20

                          
	 	
                            Aromatase Inhibitors

                          	
                            20

                          
	 	
                            Folic Acid Antagonists Rescue Agents

                          	
                            20

                          
	 	
                            Luteinizing Hormone-Releasing (Lhrh) Analogs

                          	
                            20

                          
	 	
                            Miscellaneous Antineoplastics

                          	
                            21

                          
	 	
                            Mitotic Inhibitors

                          	
                            21

                          
	
                            DENTAL AND ORAL AGENTS

                          	
                            21

                          
	 	
                            Antifungals

                          	
                            21

                          
	
                            DERMATOLOGICAL AGENTS

                          	
                            21

                          
	 	
                            Dermatological Skin Cancer Agents

                          	
                            21

                          
	
                            GASTROINTESTINAL AGENTS

                          	
                            21

                          


                  

                  

                

              

              
                Page 115 of 25

                
                  


              

              
                
                  Revisado: 5 de mayo de 2017

                  

                   

                  

                  ONCOLOGIA

                   

                

                	 	
                        Anti-Ulcer Agents

                      	
                        21

                      
	 	
                        Histamine2 (H2) Receptor Antagonists

                      	
                        21

                      
	 	
                        Proton Pump Inhibitors

                      	
                        22

                      
	
                        HORMONAL AGENTS

                      	
                        22

                      
	 	
                        Mineralocorticoids

                      	
                        22

                      
	
                        IMMUNOSUPPRESSANTS

                      	
                        22

                      
	 	
                        Cyclosporine Analogs

                      	
                        22

                      
	 	
                        Glucocorticosteroids

                      	
                        23

                      
	 	
                        Organ Transplant Agents

                      	
                        23

                      
	
                        MINERALS & ELECTROLYTES

                      	
                        24

                      
	 	
                        Calcium Regulating Agents

                      	
                        24

                      


                 

                

                
                  Page 116 of 25

                  
                    


                

                
                   Revisado: 5 de mayo de 2017

                  

                   

                  

                  ONCOLOGIA

                   

                

              

              DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

              

              

              The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their safety profile,
                  proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

              

              

              The example below illustrates the information provided for the drugs included in the FDC.

              

              

              	
                      Drug Name

                    	
                      Net Cost

                    	
                      Tier

                    	
                      Reference Name

                    	
                      Requirements/ Limits

                    
	
                      THERAPEUTIC CATEGORY

                    
	
                      Therapeutic Class

                    
	
                      ANALGESICS

                    
	
                      Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

                    
	
                      ibuprofen 400 mg tab, 600 mg tab, 800 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MOTRIN

                    	 
	
                      indomethacin 25 mg cap, 50 mg cap

                    	
                      1

                    	
                      Non-preferred

                    	
                      INDOCIN

                    	 
	
                      nabumetone 500 mg tab, 750 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      RELAFEN

                    	 
	
                      naproxen 250 mg tab, 375 mg tab, 500 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      NAPROSYN

                    	 
	
                      naproxen dr 375 mg tab dr, 500 mg tab dr

                    	
                      1

                    	
                      Preferred

                    	
                      NAPROSYN

                    	 
	
                      naproxen sodium 275 mg tab, 550 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      ANAPROX

                    	 
	
                      sulindac 150 mg tab, 200 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      CLINORIL

                    	 
	
                      celecoxib 50 mg cap

                    	
                      2

                    	
                      Non- preferred

                    	
                      CELEBREX

                    	
                      ST

                    


              For each drug included in the FDC, the First Column shows
                  the name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

              

              

              The Second Column shows the Monthly Net Cost Range per
                  Average Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

              

              

              
                Page 117 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

                MONTHLY NET COST RANGE

                

                

                The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly net cost of
                    the therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy for thirty (30)
                    days. The cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost and must be
                    interpreted as follows:

                 

                  

              

              	
                      1

                    	
                      less than $20

                    	
                      Least costly per month

                    
	
                      2

                    	
                      $20 - $49

                    	 
	
                      3

                    	
                      $50 - $99

                    	 
	
                      4

                    	
                      $100 - $199

                    	 
	
                      5

                    	
                      $200 - $349

                    	 
	
                      6

                    	
                      $350 - $549

                    	 
	
                      7

                    	
                      $550 - $799

                    	 
	
                      8

                    	
                      $800 - $1,099

                    	 
	
                      9

                    	
                      $1,100 - $1,499

                    	 
	
                      10

                    	
                      $1,500 - $1,999

                    	 
	
                      11

                    	
                      $2,000 - $2,499

                    	 
	
                      12

                    	
                      $2,500 - $2,999

                    	 
	
                      13

                    	
                      $3,000 - $3,499

                    	 
	
                      14

                    	
                      $3,500 - $3,999

                    	 
	
                      15

                    	
                      $4,000 - $4,499

                    	 
	
                      16

                    	
                      $4,500 - $4,999

                    	 
	
                      17

                    	
                      $5,000 - $5,499

                    	 
	
                      18

                    	
                      $5,500 - $5,999

                    	 
	
                      19

                    	
                      $6,000 - $6,499

                    	 
	
                      20

                    	
                      $6,500 - $6,999

                    	 
	
                      21

                    	
                      $7,000 - $7,499

                    	 
	
                      22

                    	
                      $7,500 - $7,999

                    	 
	
                      23

                    	
                      $8,000 - $8,499

                    	 
	
                      24

                    	
                      $8,500 - $9,000

                    	 
	
                      25

                    	
                      more than $9,000

                    	
                      Most costly per month

                    


              

              

              We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic category (the one
                  with the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

               

                

              The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of this edition of
                  the FDC.

               

                

              GENERIC DRUGS

               

                

              Generic bioequivalent drugs are identified with lower-case
                    letters. Certain generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the generic product, but not the
                  brand-name product. The products selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

               

                

              
                Page 118 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

                

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/ Límites]

                    


              	
                      THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                    
	
                      Therapeutic Class [Clase Terapéutica]

                    
	
                      ANALGESICS [ANALG ÉSICOS]

                    
	
                      Nonsteroidal Anti-Inflammatory Agents (NSAIDS) [Anti-Inflamatorios No Esteroidales]

                    
	
                      ibuprofen 400 mg tab, 600 mg tab, 800 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MOTRIN

                    	
                      QL=15 días  No refills

                    
	
                      nabumetone 500 mg tab, 750 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      RELAFEN

                    	 
	
                      naproxen 250 mg tab, 375 mg tab, 500 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      NAPROSYN

                    	
                      QL=15 días  No refills

                    
	
                      naproxen dr 375 mg tab dr, 500 mg tab dr

                    	
                      1

                    	
                      Preferred

                    	
                      NAPROSYN

                    	
                      QL=15 días  No refills

                    
	
                      sulindac 150 mg tab, 200 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      CLINORIL

                    	 
	
                      meloxicam7.5 mg tab, 15 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MOBIC

                    	
                      QL=15 días  No refills

                    
	
                      indomethacin 25 mg cap, 50 mg cap

                    	
                      1

                    	
                        

                      Non-Preferred

                    	
                        

                      INDOCIN

                    	 
	
                      Opioid Analgesics, Long-Acting [Analgésicos Opiodes, Larga Duración]

                    
	
                      fentanyl 25 mcg/hr td patch  72 hr

                    	
                      2

                    	
                      Preferred

                    	
                      DURAGESIC

                    	 
	
                      oxycodone hcl 10 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      DAZIDOX

                    	
                      QL=15 días

                         No refills

                    
	
                      fentanyl 50 mcg/hr td patch 72 hr, 75 mcg/hr td patch 72 hr

                    	
                      3

                    	
                      Preferred

                    	
                      DURAGESIC

                    	 
	
                      morphine sulfate er 15 mg tab er

                    	
                      3

                    	
                      Preferred

                    	
                      MORPHINE

                    	 
	
                      oxycodone hcl 20 mg tab

                    	
                      3

                    	
                      Preferred

                    	
                      DAZIDOX

                    	
                      QL=15 días

                        No refills

                    
	
                      fentanyl 100 mcg/hr td patch 72 hr

                    	
                      4

                    	
                      Preferred

                    	
                      DURAGESIC

                    	 


              

              

              
                Page 119 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      morphine sulfate er 30 mg tab er

                    	
                      4

                    	
                      Preferred

                    	
                      MORPHINE

                    	 
	
                      morphine sulfate er 60 mg tab er

                    	
                      5

                    	
                      Preferred

                    	
                      MORPHINE

                    	 
	
                      morphine sulfate er 100 mg tab er

                    	
                      6

                    	
                      Preferred

                    	
                      MORPHINE

                    	 
	
                      Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]

                    
	
                      acetaminophen          -codeine 120-12 mg/5ml soln, 300-15 mg tab, 300-30 mg tab, 300-

                      60 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      TYLENOL-

                      CODEINE

                    	
                      QL=15 días 

                      No refills

                    
	
                      acetaminophen-codeine #2 300-15 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      TYLENOL-

                      CODEINE

                    	
                      QL=15 días

                      No refills

                    
	
                      acetaminophen-codeine #3 300-30 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      TYLENOL-

                      CODEINE

                    	
                      QL=15 días

                         No refills

                    
	
                      acetaminophen-codeine #4 300-60 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      TYLENOL-

                      CODEINE

                    	
                      QL=15 días

                       No refills

                    
	
                      hydrocodoneacetaminophen 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab, 7.5-500 mg/15ml soln

                    	
                      1

                    	
                      Preferred

                    	
                      VICODIN

                    	
                      QL=15 días

                      No refills

                    
	
                      hydromorphone hcl 2 mg tab, 4 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      DILAUDID

                    	 
	
                      meperidine hcl 50 mg/ml inj soln

                    	
                      1

                    	
                      Preferred

                    	
                      DEMEROL

                    	 
	
                      morphine sulfate 15 mg tab, 30 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MORPHINE

                    	 
	
                      oxycodone-acetaminophen 5-325 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      PERCOCET

                    	
                      QL=15 días

                      No refills

                    
	
                      tramadol hcl 50 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      ULTRAM

                    	 
	
                      codeine sulfate 15 mg tab, 30 mg tab, 60 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      CODEINE

                    	 


              

              

              
                Page 120 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    
	
                      meperidine hcl 100 mg/ml inj soln

                    	
                      2

                    	
                      Preferred

                    	
                      DEMEROL

                    	 
	
                      morphine sulfate 10 mg/5ml soln

                    	
                      2

                    	
                      Preferred

                    	
                      MORPHINE

                    	 
	
                      morphine sulfate

                      (concentrate) 100 mg/5ml soln, 20 mg/ml soln

                    	
                      2

                    	
                      Preferred

                    	
                      MORPHINE

                    	 
	
                      hydromorphone hcl 8 mg tab

                    	
                      3

                    	
                      Preferred

                    	
                      DILAUDID

                    	 
	
                      oxycodone-acetaminophen 10-325 mg tab, 7.5-325 mg tab

                    	
                      3

                    	
                      Preferred

                    	
                      PERCOCET

                    	
                      QL=15 días

                       No refills

                    
	
                      hydromorphone hcl 1 mg/ml

                      oral liquid

                    	
                      4

                    	
                      Preferred

                    	
                      DILAUDID

                    	 
	
                      ANESTHETICS [ANESTÉSICOS]

                    
	
                      Local Anesthetics [Anestésicos Locales]

                    
	
                      lidocaine viscous 2 %  mouth/throat soln 1

                    	 	
                      Preferred

                    	
                      XYLOCAINE

                    	 
	
                      ANTIBACTERIALS [ANTIBACTERIANOS]

                    
	
                      Macrolides [Macrólidos]

                    
	
                      azithromycin 250 mg tab,  500 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      ZITHROMAX

                    	 
	
                      azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      ZITHROMAX

                    	 
	
                      clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      BIAXIN

                    	 
	
                      clarithromycin 250 mg/5ml susp

                    	
                      3

                    	
                      Preferred

                    	
                      BIAXIN

                    	 
	
                      ERY-TAB 500 mg tab dr

                    	
                      3

                    	
                      Preferred

                    	 	 
	
                      erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab

                    	
                      3

                    	
                      Preferred

                    	
                      ERY-TAB

                    	 


              

              

              
                Page 121 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    
	
                      erythromycin ethylsuccinate 400 mg tab

                    	
                      3

                    	
                      Preferred

                    	
                      E.E.S.

                    	 
	
                      ERYTHROCIN STEARATE

                      250 mg tab

                    	
                      4

                    	
                      Non-Preferred

                    	 	 
	
                      E.E.S. GRANULES 200 mg/5ml susp

                    	
                      5

                    	
                      Preferred

                    	 	 
	
                      ERYPED 200 200 mg/5ml susp

                    	
                      5

                    	
                      Preferred

                    	 	 
	
                      ERYPED 400 400 mg/5ml susp

                    	
                      6

                    	
                      Preferred

                    	 	 
	
                      Penicillins [Penicilinas]

                    
	
                      amoxicillin 125 mg/5ml susp,  200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml
                            susp, 500 mg cap, 500 mg tab, 875 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      AMOXIL

                    	 
	
                      amoxicillin-pot clavulanate, 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 875-125 mg
                          tab

                    	
                      1

                    	
                      Preferred

                    	
                      AUGMENTIN

                    	 
	
                      ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap

                    	
                      1

                    	
                      Preferred

                    	
                      PRINCIPEN

                    	 
	
                      penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      VEETIDS

                    	 
	
                      amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp

                    	
                      3

                    	
                      Preferred

                    	
                      AUGMENTIN

                    	 
	
                      BICILLIN L-A 600000 unit/ml im susp

                    	
                      3

                    	
                      Non-Preferred

                    	 	 
	
                      penicillin g procaine 600000 unit/ml im susp

                    	
                      3

                    	
                      Non-Preferred

                    	
                      BICILLIN LA

                    	 


              

              

              
                Page 122 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      BICILLIN L-A 1200000 unit/2ml im susp

                    	
                      4

                    	
                      Non-Preferred

                    	 	 
	
                      BICILLIN L-A 2400000 unit/4ml im susp

                    	
                      5

                    	
                      Non-Preferred

                    	 	 
	
                      Quinolones [Quinolonas]

                    	 
	
                      ciprofloxacin hcl 250 mg tab,  500 mg tab, 750 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      CIPRO

                    	 
	
                      levofloxacin 250 mg tab, 500 mg tab, 750 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      LEVAQUIN

                    	 
	
                      ciprofloxacin 500 mg/5ml (10%) susp

                    	
                      3

                    	
                      Preferred

                    	
                      CIPRO

                    	 
	
                      ciprofloxacin 250 mg/5ml (5%) susp

                    	
                      4

                    	
                      Preferred

                    	
                      CIPRO

                    	 
	
                      Sulfonamides [Sulfonamidas]

                    	 
	
                      sulfamethoxazole          -tmp ds 800-160 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      SEPTRA

                    	 
	
                      sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      SEPTRA

                    	 
	
                      sulfadiazine 500 mg tab

                    	
                      4

                    	
                      Preferred

                    	
                      SULFADIAZINE

                    	 
	
                      ANTICONVULSANTS [ANTICONVULSIVANTES]

                    	 
	
                       Anticonvulsants
                            [Anticonvulsivantes]

                    	 
	
                      gabapentin 100 mg cap, 300  mg cap, 400 mg cap, 600 mg tab, 800 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      NEURONTIN

                    	 
	
                      DILANTIN 30 mg cap

                    	
                      2

                    	
                      Preferred

                    	 	 
	
                      gabapentin 250 mg/5ml soln

                    	
                      2

                    	
                      Preferred

                    	
                      NEURONTIN

                    	 
	
                      phenytoin 125 mg/5ml susp, 50 mg tab chew

                    	
                      2

                    	
                      Preferred

                    	
                      DILANTIN

                    	 
	
                      phenytoin sodium extended 100 mg cap

                    	
                      2

                    	
                      Preferred

                    	
                      DILANTIN

                    	 


               

              

              
                Page 123 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      ANTIEMETICS [ANTIEMÉTICOS]

                    
	
                      5-Hydroxytryptamine 3 (5-HT3) Antagonists [Antagonistas De 5-HT3]

                    
	
                      ondansetron 4 mg odt, 8 mg  odt

                    	
                      1

                    	
                      Preferred

                    	
                      ZOFRAN ODT

                    	 
	
                      ondansetron hcl 24 mg tab, 4 mg tab, 8 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      ZOFRAN

                    	 
	
                      Miscellaneous Antiemetics [Antieméticos Misceláneos]

                    
	
                      metoclopramide hcl 10 mg  tab, 10 mg/10ml soln, 5 mg tab, 5 mg/5ml soln, 5 mg/ml inj soln

                    	
                      1

                    	
                      Preferred

                    	
                      REGLAN

                    	 
	
                      promethazine hcl 25 mg/ml inj soln, 50 mg/ml inj soln

                    	
                      1

                    	
                      Preferred

                    	
                      PHENERGAN

                    	 
	
                      promethazine hcl 12.5 mg tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml syr

                    	
                      1

                    	
                      Preferred

                    	
                      PHENERGAN

                    	 
	
                      trimethobenzamide hcl 300 mg cap

                    	
                      1

                    	
                      Preferred

                    	
                      TIGAN

                    	 
	
                      Phenothiazines [Fenotiazinas]

                    
	
                      prochlorperazine edisylate 5  mg/ml inj soln

                    	
                      1

                    	
                      Preferred

                    	
                      COMPAZINE

                    	 
	
                      prochlorperazine maleate 10 mg tab, 5 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      COMPAZINE

                    	 
	
                      prochlorperazine 25 mg rect supp

                    	
                      4

                    	
                      Non-Preferred

                    	
                      COMPAZINE

                    	 
	
                      ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]

                    
	
                       Miscellaneous Antimycobacterials
                            [Antimicobacterianos Misceláneos]

                    
	
                      dapsone 100 mg tab, 25 mg  tab

                    	
                      2

                    	
                      Preferred

                    	
                      DAPSONE

                    	 


              

              

              
                Page 124 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      ANTIMYCOTIC AGENTS [ANTIMICÓTICOS]

                    
	
                      Antifungals [Antifungales]

                    
	
                      fluconazole 10 mg/ml susp,  100 mg tab, 150 mg tab, 200 mg tab, 50 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      DIFLUCAN

                    	 
	
                      ketoconazole 200 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      NIZORAL

                    	 
	
                      terbinafine hcl 250 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      LAMISIL

                    	 
	
                      fluconazole 40 mg/ml susp

                    	
                      2

                    	
                      Preferred

                    	
                      DIFLUCAN

                    	 
	
                      ANTIVIRALS [ANTIVIRALES]

                    
	
                      Antiherpetic Agents [Agentes Antiherpéticos]

                    
	
                      acyclovir 200 mg cap, 400  mg tab, 800 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      ZOVIRAX

                    	 
	
                      acyclovir 200 mg/5ml susp

                    	
                      2

                    	
                      Preferred

                    	
                      ZOVIRAX

                    	 
	
                      BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]

                    
	
                      Cobalamins [Cobalaminas]

                    
	
                      cyanocobalamin 1000  mcg/ml inj soln

                    	
                      1

                    	
                      Preferred

                    	
                      VIT B-12

                    	 
	
                      Colony Stimulating Factors [Estimulantes Mieloides]

                    
	
                      NEUPOGEN 300 mcg/0.5ml 

                      inj soln, 300 mcg/ml inj soln, 480 mcg/1.6ml inj soln

                    	
                      10

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      NEULASTA 6 mg/0.6ml sc soln

                    	
                      12

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      NEUPOGEN 480 mcg/0.8ml

                      inj soln

                    	
                      12

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      Erythropoiesis-Stimulating Agents [Agentes Estimulantes De Eritropoiesis]

                    
	
                      ARANESP (ALBUMIN 

                      FREE) 100 mcg/0.5ml inj soln

                    	
                      1

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      PROCRIT 2000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln

                    	
                      5

                    	
                      Preferred

                    	 	
                      PA, P

                    


              

              

              
                Page 125 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      ARANESP (ALBUMIN

                      FREE) 25 mcg/0.42ml inj soln, 25 mcg/ml inj soln

                    	
                      6

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      PROCRIT 10000 unit/ml inj soln

                    	
                      6

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      ARANESP (ALBUMIN

                      FREE) 40 mcg/0.4ml inj soln

                    	
                      7

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      ARANESP (ALBUMIN

                      FREE) 40 mcg/ml inj soln, 60 mcg/ml inj soln

                    	
                      8

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      ARANESP (ALBUMIN

                      FREE) 150 mcg/0.3ml inj soln, 150 mcg/0.75ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj soln, 300
                          mcg/ml inj soln, 500 mcg/ml inj soln, 60 mcg/0.3ml inj soln

                    	
                      9

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      PROCRIT 20000 unit/ml inj soln

                    	
                      9

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      ARANESP (ALBUMIN

                      FREE) 100 mcg/ml inj soln

                    	
                      11

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      PROCRIT 40000 unit/ml inj soln

                    	
                      11

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      Folates [Folatos]

                    
	
                       folic acid 1 mg tab, 400 mcg  tab, 800 mcg tab

                    	
                      1

                    	
                      Preferred

                    	
                      FOLIC ACID

                    	
                      OTC

                    
	
                      Iron [Hierro]

                    
	
                      iron 325 (65 fe) mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      IRON

                    	 
	
                      DEXFERRUM 50 mg/ml inj soln

                    	
                      5

                    	
                      Non-Preferred

                    	 	 
	
                      INFED 50 mg/ml inj soln

                    	
                      5

                    	
                      Preferred

                    	 	 


              

              

              
                Page 126 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    


              	
                      CHEMOTHERAPIES [QUIMIOTERAPIAS]

                    
	
                      Alkylating Agents [Agentes Alquilantes]

                    
	
                      lomustine 10 mg cap

                    	
                      3

                    	
                      Non-Preferred

                    	
                      CEENU

                    	 
	
                      ALKERAN 2 mg tab

                    	
                      4

                    	
                      Non-Preferred

                    	 	 
	
                      temozolomide 5 mg cap

                    	
                      4

                    	
                      Non-Preferred

                    	
                      TEMODAR

                    	
                      PA

                    
	
                      lomustine 40 mg cap

                    	
                      5

                    	
                      Non-Preferred

                    	
                      CEENU

                    	 
	
                      LEUKERAN 2 mg tab

                    	
                      6

                    	
                      Non-Preferred

                    	 	 
	
                      lomustine 100 mg cap

                    	
                      6

                    	
                      Non-Preferred

                    	
                      CEENU

                    	 
	
                      MYLERAN 2 mg tab

                    	
                      7

                    	
                      Preferred

                    	 	 
	
                      temozolomide 20 mg cap

                    	
                      9

                    	
                      Non-Preferred

                    	
                      TEMODAR

                    	
                      PA

                    
	
                      temozolomide 250 mg cap

                    	
                      11

                    	
                      Non-Preferred

                    	
                      TEMODAR

                    	
                      PA

                    
	
                      temozolomide 140 mg cap

                    	
                      13

                    	
                      Non-Preferred

                    	
                      TEMODAR

                    	
                      PA

                    
	
                      temozolomide 100 mg cap, 180 mg cap

                    	
                      14

                    	
                      Non-Preferred

                    	
                      TEMODAR

                    	
                      PA

                    
	
                      Angiogenesis Inhibitors [Inhibidores de Angiogénesis]

                    
	
                      STIVARGA 40 mg tab

                    	
                      21

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      Antiandrogens [Antiandrógenos]

                    
	
                      bicalutamide 50 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      CASODEX

                    	 
	
                      flutamide 125 mg cap

                    	
                      4

                    	
                      Non-Preferred

                    	
                      EULEXIN

                    	
                      PA

                    
	
                      Antiestrogens [Antiestrógenos]

                    
	
                      tamoxifen citrate 10 mg tab,  20 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      NOLVADEX

                    	 
	
                      Antimetabolites [Antimetabolitos]

                    
	
                      hydroxyurea 500 mg cap          

                    	
                      2

                    	
                      Preferred

                    	
                      HYDREA

                    	 
	
                      mercaptopurine 50 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      PURINETHOL

                    	 
	
                      methotrexate 2.5 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      METHOTREXATE

                    	 
	
                      capecitabine 150 mg tab

                    	
                      7

                    	
                      Preferred

                    	
                      XELODA

                    	
                      PA

                    
	
                      capecitabine 500 mg tab

                    	
                      11

                    	
                      Preferred

                    	
                      XELODA

                    	
                      PA

                    
	
                      Antineoplastic Enzyme Inhibitors [Antineoplásicos Inhibidores De Enzimas]

                    
	
                      SPRYCEL 20 mg tab          

                    	
                      10

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      SPRYCEL 50 mg tab

                    	
                      13

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      imatinib 100 mg tab

                    	
                      13

                    	
                      Non-Preferred

                    	
                      GLEEVEC

                    	
                      PA

                    


              

              

              
                Page 127 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    
	
                      SPRYCEL 70 mg tab

                    	
                      14

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      TASIGNA 200 mg cap

                    	
                      15

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      SPRYCEL 80 mg tab

                    	
                      17

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      TASIGNA 150 mg cap

                    	
                      18

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      SPRYCEL 100 mg tab

                    	
                      19

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      AFINITOR 2.5 mg tab

                    	
                      20

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      NEXAVAR 200 mg tab

                    	
                      20

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      SPRYCEL 140 mg tab

                    	
                      20

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      AFINITOR 10 mg tab, 5 mg tab, 7.5 mg tab

                    	
                      21

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      imatinib 400 mg tab

                    	
                      23

                    	
                      Non-Preferred

                    	
                      GLEEVEC

                    	
                      PA

                    
	
                      Antineoplastic Progestins [Antineoplásicos De Progestina]

                    
	
                      megestrol acetate 20 mg  tab, 40 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MEGACE

                    	 
	
                      megestrol acetate 40 mg/ml susp, 400 mg/10ml susp

                    	
                      2

                    	
                      Preferred

                    	
                      MEGACE

                    	 
	
                      Aromatase Inhibitors [Inhibidores De La Aromatasa]

                    
	
                      anastrozole 1 mg tab          

                    	
                      1

                    	
                      Preferred

                    	
                      ARIMIDEX

                    	 
	
                      Folic Acid Antagonists Rescue Agents [Antagonistas De Ácido Fólico]

                    
	
                      leucovorin calcium 5 mg tab          

                    	
                      3

                    	
                      Preferred

                    	
                      LEUCOVORIN

                    	 
	
                      leucovorin calcium 10 mg tab, 15 mg tab

                    	
                      4

                    	
                      Preferred

                    	
                      LEUCOVORIN

                    	 
	
                      leucovorin calcium 25 mg tab

                    	
                      9

                    	
                      Preferred

                    	
                      LEUCOVORIN

                    	 
	
                      Luteinizing Hormone-Releasing (Lhrh) Analogs [Análogos De Lhrh]

                    
	
                      LUPRON DEPOT 11.25 mg 

                      im kit, 3.75 mg im kit

                    	
                      6

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      LUPRON DEPOT-PED

                      11.25 mg im kit, 15 mg im kit, 7.5 mg im kit

                    	
                      8

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      LUPRON DEPOT 22.5 mg

                      im kit, 30 mg im kit

                    	
                      9

                    	
                      Preferred

                    	 	
                      PA, P

                    


              

              

              
                Page 128 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/ 

                      Límites]

                    
	
                      leuprolide acetate 1 mg/ 0.2 ml inj kit

                    	 	
                      Non-preferred

                    	 	
                      PA

                    
	
                      ZOLADEX 3.6 mg, 10.8 mg subcutaneous implant

                    	
                      7

                    	
                      Non-preferred

                    	 	
                      PA

                    
	
                      Miscellaneous Antineoplastics [Antineoplásicos Misceláneos]

                    
	
                      MATULANE 50 mg cap          

                    	
                      10

                    	
                      Non-Preferred

                    	 	
                      PA

                    
	
                      ACTIMMUNE 2000000

                      unit/0.5ml sc soln

                    	
                      25

                    	
                      Non-Preferred

                    	 	
                      PA

                    
	
                      Mitotic Inhibitors [Inhibidores Mitóticos]

                    
	
                      etoposide 50 mg cap          

                    	
                      4

                    	
                      Non-Preferred

                    	
                      VEPESID

                    	 
	
                      DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]

                    
	
                      Antifungals [Antifungales]

                    
	
                      clotrimazole 10 mg  mouth/throat lozenge, 10 mg mouth/throat troche

                    	
                      1

                    	
                      Preferred

                    	
                      MYCELEX

                    	
                      OTC

                    
	
                      nystatin 100000 unit/ml mouth/throat susp

                    	
                      1

                    	
                      Preferred

                    	
                      MYCOSTATIN

                    	 
	
                      DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]

                    
	
                      Dermatological Skin Cancer Agents [Dermatológicos Para Cáncer De La Piel]

                    
	
                      fluorouracil 2 % soln, 5 %  soln

                    	
                      3

                    	
                      Preferred

                    	
                      EFUDEX

                    	 
	
                      fluorouracil 5 % crm

                    	
                      4

                    	
                      Non-Preferred

                    	
                      EFUDEX

                    	 
	
                      GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]

                    
	
                      Anti-Ulcer Agents [Agentes Anti-Ulceras]

                    
	
                      misoprostol 100 mcg tab,  200 mcg tab

                    	
                      1

                    	
                      Preferred

                    	
                      CYTOTEC

                    	 
	
                      sucralfate 1 gm tab

                    	
                      1

                    	
                      Preferred

                    	
                      CARAFATE

                    	 
	
                      CARAFATE 1 gm/10ml susp

                    	
                      3

                    	
                      Non-Preferred

                    	 	 
	
                      Histamine2 (H2) Receptor Antagonists [Antagonistas Del Receptor De H2]

                    
	
                      famotidine           20 mg tab, 40 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      PEPCID

                    	 


              

              

              
                Page 129 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    
	
                      ranitidine hcl 15 mg/ml syr,

                      150 mg/10ml syr, 300 mg

                      tab, 75 mg/5ml syr

                    	
                      1

                    	
                      Preferred

                    	
                      ZANTAC

                    	 
	
                      Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]

                    
	
                        

                      omeprazole 10 mg cap dr, 20 mg cap dr

                    	
                      1

                    	
                      Preferred

                    	
                      PRILOSEC

                    	
                      QL=180 caps/ 365 días

                    
	
                      omeprazole 40 mg cap dr

                    	
                      1

                    	
                      Preferred

                    	
                      PRILOSEC

                    	
                      QL=180 caps/ 365 días

                    
	
                      HORMONAL AGENTS [AGENTES HORMONALES]

                    
	
                      Mineralocorticoids [Mineralocorticoides]

                    
	
                      fludrocortisone acetate 0.1  mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      FLORINEF

                    	 
	
                      IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]

                    
	
                      Cyclosporine Analogs [Análogos De Ciclosporina]

                    
	
                      NEORAL  25 mg cap

                    	
                      3

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      cyclosporine modified 25 mg cap, 50 mg cap

                    	
                      3

                    	
                      Preferred

                    	
                      NEORAL

                    	
                      PA

                    
	
                      cyclosporine 25 mg cap

                    	
                      4

                    	
                      Preferred

                    	
                      SANDIMMUNE

                    	
                      PA

                    
	
                      cyclosporine modified 100 mg cap, 100 mg/ml soln

                    	
                      4

                    	
                      Preferred

                    	
                      NEORAL

                    	
                      PA

                    
	
                      cyclosporine 100 mg cap

                    	
                      5

                    	
                      Preferred

                    	
                      SANDIMMUNE

                    	
                      PA

                    
	
                      NEORAL 100 mg cap

                    	
                      5

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      cyclosporine 100 mg cap, 25 mg cap

                    	
                      6

                    	
                      Preferred

                    	
                      SANDIMMUNE

                    	
                      PA

                    
	
                      SANDIMMUNE 100 mg cap, 100 mg/ml soln, 25 mg cap

                    	
                      6

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      NEORAL 100 mg/ml soln

                    	
                      7

                    	
                      Preferred

                    	 	
                      PA, P

                    


              

              

              
                Page 130 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    
	
                      Glucocorticosteroids [Glucocorticoides]

                    
	
                      dexamethasone 0.5 mg tab,  0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg
                            tab, 4 mg tab, 6 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      DECADRON

                    	 
	
                      MEDROL 2 mg tab

                    	
                      1

                    	
                      Preferred

                    	 	 
	
                      methylprednisolone 32 mg tab, 4 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MEDROL

                    	 
	
                      methylprednisolone (pak) 4 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      MEDROL

                    	 
	
                      prednisolone 15 mg/5ml soln, 15 mg/5ml syr

                    	
                      1

                    	
                      Preferred

                    	
                      PRELONE

                    	 
	
                      prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      DELTASONE

                    	 
	
                      prednisone (pak) 10 mg tab, 5 mg tab

                    	
                      1

                    	
                      Preferred

                    	
                      DELTASONE

                    	 
	
                      hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      CORTEF

                    	 
	
                      methylprednisolone 16 mg tab, 8 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      MEDROL

                    	 
	
                      Organ Transplant Agents [Agentes Para Trasplantes]

                    
	
                      azathioprine 50 mg tab          

                    	
                      1

                    	
                      Preferred

                    	
                      IMURAN

                    	 
	
                      mycophenolate mofetil 200 mg/ml susp, 250 mg cap, 500 mg tab

                    	
                      2

                    	
                      Preferred

                    	
                      CELLCEPT

                    	
                      PA

                    
	
                      tacrolimus 0.5 mg cap

                    	
                      3

                    	
                      Non-Preferred

                    	
                      PROGRAF

                    	
                      PA

                    
	
                      MYFORTIC 180 mg tab dr

                    	
                      4

                    	
                      Preferred

                    	 	
                      PA, P

                    
	
                      tacrolimus 1 mg cap

                    	
                      4

                    	
                      Non-Preferred

                    	
                      PROGRAF

                    	
                      PA

                    
	
                      sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab

                    	
                      5

                    	
                      Non-Preferred

                    	
                      RAPAMUNE

                    	
                      PA

                    
	
                      MYFORTIC 360 mg tab dr

                    	
                      6

                    	
                      Preferred

                    	 	
                      PA, P

                    


              

              

              
                Page 131 of 25

                
                  


              

              
                Revisado: 5 de mayo de 2017

                

                 

                

                ONCOLOGIA

                 

              

              	
                      Drug Name [Nombre del

                      Medicamento]

                    	
                      Net

                      Cost

                      [Costo

                      Neto]

                    	
                      Tier [Tier]

                    	
                      Reference Name

                      [Nombre de

                      Referencia]

                    	
                      Requirements/

                      Limits

                      [Requerimientos/

                      Límites]

                    
	
                      tacrolimus 5 mg cap

                    	
                      6

                    	
                      Non-Preferred

                    	
                      PROGRAF

                    	
                      PA

                    
	
                      RAPAMUNE 1 mg/ml soln

                    	
                      8

                    	
                      Non-Preferred

                    	 	
                      PA

                    
	
                      MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]

                    
	
                      Calcium Regulating Agents [Agentes Reguladores De Calcio]

                    
	
                      calcitriol  0.25 mcg cap

                    	
                      1

                    	
                      Preferred

                    	
                      ROCALTROL

                    	 
	
                      calcitriol 0.5 mcg cap

                    	
                      2

                    	
                      Preferred

                    	
                      ROCALTROL

                    	 


              

            

            
              Page 132 of 25

              
                


              
                	
                         

                      		
                         

                      


              

            

            
              
                	
                        A

                      	 
	 	 
	
                        acetaminophen-codeine

                      	
                        12

                      
	
                        acetaminophen-codeine #2

                      	
                        12

                      
	
                        acetaminophen-codeine #3

                      	
                        12

                      
	
                        acetaminophen-codeine #4

                      	
                        13

                      
	
                        ACTIMMUNE

                      	
                        27

                      
	
                        acyclovir

                      	
                        20

                      
	
                        AFINITOR

                      	
                        25

                      
	
                        ALKERAN

                      	
                        23

                      
	
                        amoxicillin

                      	
                        16

                      
	
                        amoxicillin-pot clavulanate

                      	
                        16

                      
	
                        ampicillin

                      	
                        16

                      
	
                        anastrozole

                      	
                        26

                      
	
                        ARANESP (ALBUMIN FREE)

                      	
                         21, 22

                      
	
                        azathioprine

                      	
                        31

                      
	
                        azithromycin

                      	
                        14

                      
	 	 
	
                        B

                      	 
	 	 
	
                        bicalutamide

                      	
                        24

                      
	
                        BICILLIN L-A

                      	
                         16, 17

                      
	 	 
	
                        C

                      	 
	 	 
	
                        calcitriol

                      	
                         31, 32

                      
	
                        capecitabine

                      	
                        24

                      
	
                        CARAFATE

                      	
                        28

                      
	
                        ciprofloxacin

                      	
                        17

                      
	
                        ciprofloxacin hcl

                      	
                        17

                      
	
                        clarithromycin

                      	
                        15

                      
	
                        clotrimazole

                      	
                        27

                      
	
                        codeine sulfate

                      	
                        13

                      
	
                        cyanocobalamin

                      	
                        20

                      
	
                        cyclosporine

                      	
                        29

                      
	
                        cyclosporine modified

                      	
                        29

                      
	 	 
	
                        D

                      	 
	 	 
	
                        dapsone

                      	
                        19

                      
	
                        dexamethasone

                      	
                        30

                      
	
                        DEXFERRUM

                      	
                        22

                      
	
                        DILANTIN

                      	
                        18

                      
	 	 
	
                        E

                      	 
	 	 
	
                        E.E.S. GRANULES

                      	
                        15

                      
	
                        ERYPED 200

                      	
                        15

                      
	
                        ERYPED 400

                      	
                        15

                      


              

            

            
              
                	
                        ERY-TAB

                      	
                        15

                      
	
                        ERYTHROCIN STEARATE

                      	
                        15

                      
	
                        erythromycin base

                      	
                        15

                      
	
                        erythromycin ethylsuccinate

                      	
                        15

                      
	
                        etoposide

                      	
                        27

                      
	 	 
	
                        F

                      	 
	 	 
	
                        famotidine

                      	
                        28

                      
	
                        fentanyl

                      	
                         11, 12

                      
	
                        fluconazole

                      	
                         19, 20

                      
	
                        fludrocortisone acetate

                      	
                        28

                      
	
                        fluorouracil

                      	
                        27

                      
	
                        flutamide

                      	
                        24

                      
	
                        folic acid

                      	
                        22

                      
	 	 
	
                        G

                      	 
	 	 
	
                        gabapentin

                      	
                        18

                      
	
                        GLEEVEC

                      	
                        25

                      
	 	 
	
                        H

                      	 
	 	 
	
                        hydrocodone-acetaminophen

                      	
                        13

                      
	
                        hydrocortisone

                      	
                        30

                      
	
                        hydromorphone hcl

                      	
                         13, 14

                      
	
                        hydroxyurea

                      	
                        24

                      
	 	 
	
                        I

                      	 
	 	 
	
                        ibuprofen

                      	
                        11

                      
	
                        imatinib

                      	
                        25

                      
	
                        indomethacin

                      	
                        11

                      
	
                        INFED

                      	
                        22

                      
	
                        iron

                      	
                        22

                      
	 	 
	
                        K

                      	 
	 	 
	
                        ketoconazole

                      	
                        20

                      
	 	 
	
                        L

                      	 
	 	 
	
                        leucovorin calcium

                      	
                        26

                      
	
                        LEUKERAN

                      	
                        23

                      
	
                        leuprolide acetate

                      	
                        26

                      
	
                        levofloxacin

                      	
                        17

                      
	
                        lidocaine viscous

                      	
                        14

                      
	
                        lomustine

                      	
                        23

                      
	
                        LUPRON DEPOT

                      	
                        26

                      
	
                        LUPRON DEPOT-PED

                      	
                        26

                      


              

            

            

              	
                       

                    


              
                

                Page 133 of 25

                
                  


                
                  	
                           

                        		
                           

                        


                

              

              

                
                  
                    	
                            M

                          	 
	 	 
	
                            MATULANE

                          	
                            27

                          
	
                            MEDROL

                          	
                            30

                          
	
                            megestrol acetate

                          	
                             25, 26

                          
	
                            meloxicam

                          	
                            11

                          
	
                            meperidine hcl

                          	
                            13

                          
	
                            mercaptopurine

                          	
                            24

                          
	
                            methotrexate

                          	
                            24

                          
	
                            methylprednisolone

                          	
                             30, 31

                          
	
                            methylprednisolone (pak)

                          	
                            30

                          
	
                            metoclopramide hcl

                          	
                            18

                          
	
                            misoprostol

                          	
                            28

                          
	
                            morphine sulfate

                          	
                             13, 14

                          
	
                            morphine sulfate (concentrate)

                          	
                            14

                          
	
                            morphine sulfate er

                          	
                            12

                          
	
                            mycophenolate mofetil

                          	
                            31

                          
	
                            mycophenolic acid

                          	
                            31

                          
	
                            MYLERAN

                          	
                            23

                          
	 	 
	
                            N

                          	 
	 	 
	
                            nabumetone

                          	
                            11

                          
	
                            naproxen

                          	
                            11

                          
	
                            naproxen dr

                          	
                            11

                          
	
                            NEORAL

                          	
                            29

                          
	
                            NEULASTA

                          	
                            20

                          
	
                            NEUPOGEN

                          	
                            20

                          
	
                            NEXAVAR

                          	
                            25

                          
	
                            nystatin

                          	
                            27

                          
	 	 
	
                            O

                          	 
	 	 
	
                            omeprazole

                          	
                            28

                          
	
                            ondansetron

                          	
                            18

                          
	
                            ondansetron hcl

                          	
                            18

                          
	
                            oxycodone hcl

                          	
                             11, 12

                          
	
                            oxycodone-acetaminophen

                          	
                             13, 14

                          
	 	 
	
                            P

                          	 
	 	 
	
                            penicillin g procaine

                          	
                            16

                          
	
                            penicillin v potassium

                          	
                            16

                          


                  

                

                
                  
                    	
                            phenytoin

                          	
                            18

                          
	
                            phenytoin sodium extended

                          	
                            18

                          
	
                            prednisolone

                          	
                            30

                          
	
                            prednisone

                          	
                            30

                          
	
                            prednisone (pak)

                          	
                            30

                          
	
                            prochlorperazine

                          	
                            19

                          
	
                            prochlorperazine edisylate

                          	
                            19

                          
	
                            prochlorperazine maleate

                          	
                            19

                          
	
                            PROCRIT

                          	
                             21, 22

                          
	
                            promethazine hcl

                          	
                            19

                          
	 	 
	
                            R

                          	 
	 	 
	
                            ranitidine hcl

                          	
                            28

                          
	
                            RAPAMUNE

                          	
                            31

                          
	 	 
	
                            S

                          	 
	 	 
	
                            SANDIMMUNE

                          	
                            29

                          
	
                            sirolimus

                          	
                            31

                          
	
                             SPRYCEL

                          	
                            25

                          
	
                            STIVARGA

                          	
                            24

                          
	
                            sucralfate

                          	
                            28

                          
	
                            sulfadiazine

                          	
                            17

                          
	
                            sulfamethoxazole-tmp ds

                          	
                            17

                          
	
                             sulfamethoxazole-trimethoprim

                          	
                            17

                          
	
                            sulindac

                          	
                            11

                          
	 	 
	
                            T

                          	 
	 	 
	
                            tacrolimus

                          	
                            31

                          
	
                            tamoxifen citrate

                          	
                            24

                          
	
                            TASIGNA

                          	
                            25

                          
	
                            temozolomide

                          	
                            23

                          
	
                            terbinafine hcl

                          	
                            20

                          
	
                            tramadol hcl

                          	
                            13

                          
	
                            trimethobenzamide hcl

                          	
                            19

                          
	 	 
	
                            Z

                          	 
	 	 
	
                            ZOLADEX

                          	
                            27

                          


                  

                

                

                

                

                  

                  

                  

                

                

              

              

              	
                       

                    


              
                

                Page 134 of 25

                
                  


                
                  	
                           

                        		
                           

                        


                

              

               ASES

               

                  

              Puerto Rico Healthcare Insurance Administration

              

              

              Physical Health

               

                

              2017

               

                

              Formulary of Drugs Covered by

               

                

              the Government Healthcare Plan (GHP)

                  

                

              Authorized by the P.R. Elections Commission CEE-SA-16-2732

               

                

              
                

                Page 135 of 25

                
                  


                
                  	
                           

                        		
                           

                        


                

              

              
                	
                        

                      	 	
                        GOVERNMENT OF PUERTO RICO

                      	
                        Hon. Ricardo A. Rosselló Nevares

                      
	 	
                        Healthcare Insurance Administration

                      	Governor
	 	 	 	
                        Ms. Ángela M. Ávila Marrero

                        Executive Director

                      


              

               

              

              May 1, 2017

              

              

              TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

              

              

              Dear provider:

              

              

              I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its corresponding
                  sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

              

              

              The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and Sub-physical. Moreover, the
                  Mental Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health Sub-formulary will be used by
                  participating primary care physicians (PCPs) in Primary Care Medical Groups.

              

              

              The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare Insurance Administration
                  (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical aspects. The FDC is a dynamic
                  document that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

              

              

              I urge you to keep this guide for future reference. It is also available on our
                    webpage, www.asespr.org.

              

              

              Cordially,

              

              

              [signed]

              Ángela M. Ávila Marrero

              Executive Director

              

              

              

              

              
                	
                        

                      
	 

                      
	

                      
	
                        PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                      


              

              

              

              
                

                Page 136 of 25

                
                  


                
                  	
                           

                        		
                           

                        


                

              

              GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

               

                

              OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

              

              

              
                
                  	1.	
                          Drug Formulary

                        


                

              

              

              

              The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and reviewing the Formulary
                  of Drugs Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee is constituted by healthcare
                  professionals, including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES for the drug formulary based on
                  scientific evidence, clinical aspects, and a cost-effectiveness analysis.

              

              

              The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the prescription drug coverage.
                  The purpose of the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

              

              

              ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator or PPA based on the most
                  recent clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

              

              

              Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain in point number 2.

              

              

              
                
                  	2.	
                          Exception Process

                        


                

              

              

              

              In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as applicable, insurance
                  companies must use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

              

              

              
                
                  	

                        	q.	
                          Contraindication to the drug(s) included in the FDC;

                        


                

              

              
                
                  	

                        	r.	
                          History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                        


                

              

              
                
                  	

                        	s.	
                          Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                        


                

              

              
                
                  	

                        	t.	
                          Lack of a therapeutic alternative in the FDC.

                        


                

              

              

              

              This exception process requires a clinical justification that is duly documented by the service provider with the clinical
                  reasons justifying the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

              
                
                  	3.	
                          Other Aspects of the Prescription Drug Coverage

                        


                

              

              

              

              
                
                  	

                        	A.	
                          The prescription drug coverage of the GHP establishes that using generic bioequivalent products as
                                the first option is mandatory.

                        


                   

                  

                

              

              
                

                Page 137 of 25

                
                  


              

              
                
                   
                    

                    

                  

                  	

                        	B.	
                          Insurance companies or the TPA (Third Party Administrator) and healthcare service providers will
                                only process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                        


                

              

              

              

              
                
                  	

                        	C.	
                          ASES has an active process to continually review the prescription drug coverage in accordance with
                                changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES may require
                                that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will safeguard adequate
                                access to services and maintain continuity of care.

                        


                

              

              

              

              
                
                  	

                        	D.	
                          No entity contracted by ASES or by healthcare companies or organizations (for example, primary care
                                medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES. Furthermore, they may not
                                limit the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be responsible for supervising their
                                providers and employees with regard to their compliance with these provisions.

                        


                

              

              

              

              
                
                  	

                        	E.	
                          The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The
                                treatment period may be extended, as applicable, when medically necessary.

                        


                

              

              

              

              
                
                  	

                        	F.	
                          The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty (30)
                                day therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating adherence and
                                tolerance. The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case of narcotics, which
                                will be dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms of adherence, tolerance,
                                and dosage within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                        


                

              

              

              

              
                
                  	

                        	G.	
                          ASES requires the use of generic bioequivalent drugs approved by the Food and Drug Administration
                                (FDA) coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                        


                

              

              

              

              
                
                  	

                        	H.	
                          The lack of appropriate bioequivalent drug inventories does not exempt providers from dispensing
                                the prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the corresponding brand-name
                                drug, unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception mechanism.

                        


                

              

              

              

              
                
                  	

                        	I.	
                          Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized under
                                the law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                        


                

              

              

              

              
                Page 138 of 25

                
                  


              

              
                
                   

                   

                  

                  	

                        	J.	
                          The right to freedom of choice requires the availability of a pharmacy that is reasonably
                                accessible to each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                        


                

              

              

              

              Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or when an
                  electronic prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24 hours. If a drug
                  is not available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her physician to have the
                  prescription sent to another pharmacy of his or her choice.

              

              

              
                
                  	4.	
                          Emergency Rule

                        


                

              

              

              

              The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except as otherwise
                  specified. The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will also be dispensed in amounts sufficient for five (5) business days.

              

              

              Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for continuity of
                  treatment, including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the IEF.

              

              

              If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES in your region and/or the Pharmacy Benefit
                  Manager (PBM) contracted by ASES.

              

              
                
                  Page 139 of 25

                  
                    


                

                
                
                   

                  

                  PHYSICAL HEALTH

                   

                  

                

              

              ASES

              Puerto Rico Healthcare Insurance Administration

              

              

              Physical Health

               

                

              2017

               

                

              Formulary of Drugs Covered by

               

                

              the Government Healthcare Plan (GHP)

              

              
                Page 140 of 25

                
                  


              

              
                	 
                        SALUD FÍSICA

                      	
                        

                      
	

                      	 


              

              GOVERNMENT HEALTHCARE PLAN

               

                

              FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

               

                

              2017

                  

                

              TABLE OF CONTENTS

               

                	
                        GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE GOVERNMENT HEALTHCARE PLAN

                      	
                        3

                      
	
                        DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                      	
                        15

                      
	
                        THERAPEUTIC CATEGORY

                      	
                        17

                      
	
                        ANALGESICS

                      	
                        17

                      
	 	
                        Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

                      	
                        17

                      
	 	
                        Long-Acting Opioid Analgesics

                      	
                        17

                      
	 	
                        Short-Acting Opioid Analgesics

                      	
                        18

                      
	 	
                        test

                      	
                        18

                      
	
                        ANESTHETICS

                      	
                        19

                      
	 	
                        Local Anesthetics

                      	
                        19

                      
	
                        ANTIANXIETY AGENTS

                      	
                        19

                      
	 	
                        Benzodiazepines

                      	
                        19

                      
	 	
                        Miscellaneous Anxiolytics

                      	
                        19

                      
	
                        ANTIBACTERIALS

                      	
                        19

                      
	 	
                        Aminoglycosides

                      	
                        19

                      
	 	
                        First Generation Cephalosporins

                      	
                        20

                      
	 	
                        Macrolides

                      	
                        20

                      
	 	
                        Miscellaneous Antibacterials

                      	
                        20

                      
	 	
                        Quinolones

                      	
                        22

                      
	 	
                        Second Generation Cephalosporins

                      	
                        22

                      
	 	
                        Sulfonamides

                      	
                        22

                      
	 	
                        Tetracyclines

                      	
                        22

                      
	 	
                        Third Generation Cephalosporins

                      	
                        22

                      


                

                

                
                  Page 141 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        
	
                          

                          

                        	 


                

                 

                

                	 	
                        Vaginal Antibiotics

                      	
                        23

                      
	
                        ANTICONVULSANTS

                      	
                        23

                      
	 	
                        Anticonvulsants

                      	
                        23

                      
	
                        ANTIDEMENTIA AGENTS

                      	
                        25

                      
	 	
                        Antidementia Agents

                      	
                        25

                      
	 	
                        Cholinesterase Inhibitors

                      	
                        25

                      
	 	
                        NMDA Receptor Antagonists

                      	
                        25

                      
	
                        ANTIDEPRESSANTS

                      	
                        25

                      
	 	
                        Antidepressants

                      	
                        25

                      
	
                        ANTIDIABETIC AGENTS

                      	
                        26

                      
	 	
                        Alpha-Glucosidase Inhibitors

                      	
                        26

                      
	 	
                        Biguanides

                      	
                        26

                      
	 	
                        Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

                      	
                        26

                      
	 	
                        Glycemic Agents

                      	
                        26

                      
	 	
                        Insulin Mixtures

                      	
                        26

                      
	 	
                        Insulin Sensitizing Agents

                      	
                        26

                      
	 	
                        Intermediate-Acting Insulins

                      	
                        26

                      
	 	
                        Long-Acting Insulins

                      	
                        26

                      
	 	
                        Rapid-Acting Insulins

                      	
                        27

                      
	 	
                        Short-Acting Insulins

                      	
                        27

                      
	 	
                        Sulfonylureas

                      	
                        27

                      
	
                        DIABETES SUPPLIES

                      	
                        27

                      
	 	
                        Needles & Syringes

                      	
                        27

                      
	
                        ANTIEMETICS

                      	
                        27

                      
	 	
                        5-Hydroxytryptamine 3 (5-HT3) Antagonists

                      	
                        27

                      


                

                

                
                  Page 142 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        


                

                 

                

                	 	
                        Miscellaneous Antiemetics

                      	
                        27

                      
	 	
                        Phenothiazines

                      	
                        27

                      
	
                        ANTIGOUT AGENTS

                      	
                        28

                      
	 	
                        Antigout Agents

                      	
                        28

                      
	 	
                        Uricosurics

                      	
                        28

                      
	
                        ANTIHYPERTENSIVES

                      	
                        28

                      
	 	
                        Alpha-Adrenergic Agonists

                      	
                        28

                      
	 	
                        Alpha-Adrenergic Blocking Agents

                      	
                        28

                      
	 	
                        Angiotensin II Receptor Blockers (ARB)

                      	
                        28

                      
	 	
                        Angiotensin-Converting Enzyme (ACE) Inhibitors

                      	
                        28

                      
	 	
                        Calcium Channel Blocking Agents

                      	
                        29

                      
	 	
                        Carbonic Anhydrase Inhibitors Diuretics

                      	
                        30

                      
	 	
                        Cardioselective Beta Blocking Agents

                      	
                        30

                      
	 	
                        Cardioselective Beta-Adrenergic Blocking Agents

                      	
                        30

                      
	 	
                        Loop Diuretics

                      	
                        30

                      
	 	
                        Nonselective Beta Blocking Agents

                      	
                        31

                      
	 	
                        Potassium-Sparing Diuretics

                      	
                        31

                      
	 	
                        Thiazide Diuretics

                      	
                        31

                      
	 	
                        Vasodilator Beta Blockers

                      	
                        31

                      
	 	
                        Vasodilators

                      	
                        31

                      
	
                        ANTIMIGRAINE AGENTS

                      	
                        32

                      
	 	
                        Beta-Adrenergic Blocking Agents

                      	
                        32

                      
	 	
                        Serotonin (5-HT) Receptor Agonists

                      	
                        32

                      
	
                        ANTIMYASTHENIC AGENTS

                      	
                        32

                      
	 	
                        Parasympathomimetics

                      	
                        32

                      


                

                

                
                  Page 143 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        


                

                 

                

                	
                        ANTIMYCOBACTERIALS

                      	
                        32

                      
	 	
                        Antituberculars

                      	
                        32

                      
	 	
                        Miscellaneous Antimycobacterials

                      	
                        32

                      
	
                        ANTIMYCOTIC AGENTS

                      	
                        33

                      
	 	
                        Antifungals

                      	
                        33

                      
	 	
                        Vaginal Antifungals

                      	
                        33

                      
	 	
                        Antimalarials

                      	
                        33

                      
	 	
                        Antiprotozoals - Non-Antimalarials

                      	
                        33

                      
	
                        ANTIPARASITICS

                      	
                        33

                      
	 	
                        Anthelmintics

                      	
                        33

                      
	
                        ANTIPARKINSON AGENTS

                      	
                        33

                      
	 	
                        Anticholinergics

                      	
                        33

                      
	 	
                        Antiparkinson Dopaminergics

                      	
                        33

                      
	 	
                        Dopamine Precursors

                      	
                        34

                      
	 	
                        Monoamine Oxidase B (MAO-B) Inhibitors

                      	
                        34

                      
	 	
                        Anti-Influenza Agents

                      	
                        34

                      
	 	
                        Anti-Cytomegalovirus (CMV) Agents

                      	
                        35

                      
	 	
                        Antiherpetic Agents

                      	
                        35

                      
	 	
                        Antiretroviral Combinations

                      	
                        35

                      
	 	
                        Integrase Inhibitors

                      	
                        35

                      
	 	
                        Miscellaneous Anti-HIV Agents

                      	
                        35

                      
	 	
                        Non-Nucleoside Reverse Transcriptase Inhibitors

                      	
                        35

                      
	 	
                        Nucleoside/Nucleotide Reverse Transcriptase Inhibitors

                      	
                        36

                      
	
                        BENIGN PROSTATIC HYPERTROPHY AGENTS

                      	
                        36

                      
	 	
                        5-Alpha Reductase Inhibitors

                      	
                        36

                      


                

                

                
                  Page 144 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        


                

                 

                

                	 	
                        Alpha-Adrenergic Blocking Agents

                      	
                        37

                      
	
                        BLOOD MODIFIERS

                      	
                        37

                      
	 	
                        Anticoagulants

                      	
                        37

                      
	 	
                        Cobalamins

                      	
                        37

                      
	 	
                        Colony Stimulating Factors

                      	
                        37

                      
	 	
                        Erythropoiesis-Stimulating Agents

                      	
                        38

                      
	 	
                        Factor Xa Inhibitors

                      	
                        38

                      
	 	
                        Folates

                      	
                        39

                      
	 	
                        Iron

                      	
                        39

                      
	 	
                        Low Molecular Weight Heparins

                      	
                        39

                      
	 	
                        Platelet Modifying Agents

                      	
                        39

                      
	
                        BONE DENSITY REGULATORS

                      	
                        39

                      
	 	
                        Bisphosphonates

                      	
                        39

                      
	
                        CARDIOVASCULAR AGENTS

                      	
                        40

                      
	 	
                        Antiarrhythmics Class II

                      	
                        40

                      
	 	
                        Antiarrhythmics Type I-A

                      	
                        40

                      
	 	
                        Antiarrhythmics Type I-B

                      	
                        40

                      
	 	
                        Antiarrhythmics Type I-C

                      	
                        40

                      
	 	
                        Antiarrhythmics Type III

                      	
                        40

                      
	 	
                        Intermittent Claudication Agents

                      	
                        40

                      
	 	
                        Miscellaneous Cardiovascular Agents

                      	
                        40

                      
	 	
                        Pulmonary Hypertension Agents

                      	
                        41

                      
	 	
                        Vasodilators

                      	
                        41

                      
	
                        CENTRAL NERVOUS SYSTEM AGENTS

                      	
                        41

                      
	 	
                        Multiple Sclerosis Agents

                      	
                        41

                      


                

                

                
                  Page 145 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        


                

                 

                

                	
                        CHEMOTHERAPIES

                      	
                        42

                      
	 	
                        Alkylating Agents

                      	
                        42

                      
	 	
                        Angiogenesis Inhibitors

                      	
                        42

                      
	 	
                        Antiandrogens

                      	
                        42

                      
	 	
                        Antiestrogens

                      	
                        42

                      
	 	
                        Vaginal Estrogens

                      	
                        42

                      
	 	
                        Antimetabolites

                      	
                        42

                      
	 	
                        Antineoplastic Enzyme Inhibitors

                      	
                        43

                      
	 	
                        Appetite Stimulants

                      	
                        43

                      
	 	
                        Aromatase Inhibitors

                      	
                        43

                      
	 	
                        Folic Acid Antagonists Rescue Agents

                      	
                        43

                      
	 	
                        Luteinizing Hormone-Releasing (LHRH) Analogs

                      	
                        43

                      
	 	
                        Miscellaneous Antineoplastics

                      	
                        44

                      
	 	
                        Mitotic Inhibitors

                      	
                        44

                      
	
                        DENTAL AND ORAL AGENTS

                      	
                        44

                      
	 	
                        Antifungals

                      	
                        44

                      
	 	
                        Oral Antiseptics

                      	
                        44

                      
	 	
                        Xerostomia

                      	
                        44

                      
	
                        DERMATOLOGICAL AGENTS

                      	
                        45

                      
	 	
                        Acne Antibiotics

                      	
                        45

                      
	 	
                        Acne Products

                      	
                        45

                      
	 	
                        Antihistamines

                      	
                        45

                      
	 	
                        Antiseborrheic Products

                      	
                        45

                      
	 	
                        Dermatological Skin Cancer Agents

                      	
                        45

                      
	 	
                        Very High Potency Topical Glucocorticoids

                      	
                        45

                      


                

                

                
                  Page 146 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        


                

                 

                

                	 	
                        High Potency Topical Glucocorticoids

                      	
                        45

                      
	 	
                        Medium Potency Topical Glucocorticoids

                      	
                        46

                      
	 	
                        Low Potency Topical Glucocorticoids

                      	
                        46

                      
	 	
                        Pediculicides and Scabicides

                      	
                        46

                      
	 	
                        Topical Skin Antibiotics

                      	
                        46

                      
	 	
                        Topical Antifungals

                      	
                        46

                      
	 	
                        Topical Antipsoriatics

                      	
                        46

                      
	
                        DYSLIPIDEMICS

                      	
                        46

                      
	 	
                        Bile Acid Sequestrants

                      	
                        46

                      
	 	
                        Fibric Acid Derivatives

                      	
                        46

                      
	 	
                        HMG-CoA Reductase Inhibitors

                      	
                        46

                      
	
                        GASTROINTESTINAL AGENTS

                      	
                        47

                      
	 	
                        Antispasmodics

                      	
                        47

                      
	 	
                        Anti-Ulcer Agents

                      	
                        47

                      
	 	
                        Digestive Enzymes

                      	
                        47

                      
	 	
                        Histamine2 (H2) Receptor Antagonists

                      	
                        47

                      
	 	
                        Miscellaneous Gastrointestinal Agents

                      	
                        47

                      
	 	
                        Proton Pump Inhibitors

                      	
                        48

                      
	 	
                        Rectal Anti-Inflammatories

                      	
                        48

                      
	
                        GENITOURINARY AGENTS

                      	
                        48

                      
	 	
                        Miscellaneous Genitourinary Agents

                      	
                        48

                      
	 	
                        Phosphate Binder Agents

                      	
                        48

                      
	 	
                        Urinary Antibiotics

                      	
                        48

                      
	 	
                        Urinary Antispasmodics

                      	
                        48

                      
	
                        HEMATOLOGICAL AGENTS

                      	
                        48

                      


                

                

                
                  Page 147 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        


                

                 

                

                	 	
                        Antihemophilic Products

                      	
                        48

                      
	 	
                        Hemostatics

                      	
                        49

                      
	
                        HORMONAL AGENTS

                      	
                        50

                      
	 	
                        Androgens

                      	
                        50

                      
	 	
                        Antithyroid Agents

                      	
                        50

                      
	 	
                        Calcimimetics

                      	
                        50

                      
	 	
                        Dopamine Agonists

                      	
                        50

                      
	 	
                        Dysmenorrhea Agents

                      	
                        50

                      
	 	
                        Estrogens

                      	
                        50

                      
	 	
                        Estrogens and Progestins

                      	
                        51

                      
	 	
                        Growth Hormones Analogs

                      	
                        51

                      
	 	
                        Mineralocorticoids

                      	
                        51

                      
	 	
                        Prostaglandins

                      	
                        51

                      
	 	
                        Somatostatic Analogs

                      	
                        51

                      
	 	
                        Thyroid Hormones

                      	
                        52

                      
	 	
                        Vasopressin Analogs

                      	
                        52

                      
	
                        IMMUNOLOGICAL AGENTS

                      	
                        52

                      
	 	
                        Immunomodulators (TNF and Non-TNF)

                      	
                        52

                      
	
                        IMMUNOSUPPRESSANTS

                      	
                        53

                      
	 	
                        Glucocorticosteroids

                      	
                        53

                      
	 	
                        Organ Transplant Agents

                      	
                        54

                      
	
                        INFLAMMATORY BOWEL DISEASE

                      	
                        55

                      
	 	
                        Aminosalicylates

                      	
                        55

                      
	 	
                        Immunomodulators (TNF and Non-TNF)

                      	
                        55

                      
	 	
                        Intrarectal Low Potency Glucocorticoids

                      	
                        55

                      


                

                

                
                  Page 148 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        


                

                 

                

                	 	
                        Sulfonamides

                      	
                        55

                      
	
                        MINERALS & ELECTROLYTES

                      	
                        55

                      
	 	
                        Calcium Regulating Agents

                      	
                        55

                      
	 	
                        Carnitine Deficiency

                      	
                        56

                      
	 	
                        Chelating Agents

                      	
                        56

                      
	 	
                        Electrolytes/Minerals Replacement

                      	
                        56

                      
	 	
                        Potassium Removing Resins

                      	
                        56

                      
	 	
                        Prenatal Vitamins

                      	
                        56

                      
	 	
                        Vitamin K

                      	
                        57

                      
	
                        MUSCLE RELAXANTS

                      	
                        57

                      
	 	
                        Antispasticity Agents

                      	
                        57

                      
	 	
                        Skeletal Muscle Relaxants

                      	
                        57

                      
	
                        NASAL AGENTS

                      	
                        57

                      
	 	
                        Nasal Anticholinergics

                      	
                        57

                      
	 	
                        Nasal Mast Cell Stabilizers

                      	
                        57

                      
	 	
                        Nasal Steroids

                      	
                        57

                      
	
                        OPHTHALMIC AGENTS

                      	
                        57

                      
	 	
                        Antiglaucoma Agents

                      	
                        57

                      
	 	
                        Miotics

                      	
                        58

                      
	 	
                        Mydriatics

                      	
                        58

                      
	 	
                        Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

                      	
                        58

                      
	 	
                        Ophthalmic Antibiotics

                      	
                        58

                      
	 	
                        Ophthalmic Antivirals

                      	
                        58

                      
	 	
                        Ophthalmic Prostaglandins

                      	
                        58

                      
	 	
                        Ophthalmic Steroids

                      	
                        59

                      


                

                

                
                  Page 149 of 25

                  
                    


                

                
                  	 
                          SALUD FÍSICA

                        	
                          

                        


                

                 

                

                	
                        OTIC AGENTS

                      	
                        59

                      
	 	
                        Miscellaneous Otic Agents

                      	
                        59

                      
	 	
                        Otic Antibiotics

                      	
                        59

                      
	
                        RESPIRATORY AGENTS

                      	
                        59

                      
	 	
                        Anticholinergic Bronchodilators

                      	
                        59

                      
	 	
                        Antileukotrienes

                      	
                        59

                      
	 	
                        Antitussive-Expectorant

                      	
                        59

                      
	 	
                        Bronchiolitis Agents

                      	
                        59

                      
	 	
                        Inhaled Corticosteroids

                      	
                        60

                      
	 	
                        Nonsedating Histamine1 Blocking Agents

                      	
                        60

                      
	 	
                        Phosphodiesterase Inhibitors

                      	
                        60

                      
	 	
                        Sympathomimetic Bronchodilators

                      	
                        61

                      
	
                        RHEUMATOID ARTHRITIS AGENTS

                      	
                        61

                      
	 	
                        Immunomodulators (TNF and Non-TNF)

                      	
                        61

                      
	 	
                        Non-Biologic Agents

                      	
                        61

                      


              

              
                 

                

                
                  Page 150 of 25

                  
                    


                

                	 SALUD FÍSICA	
                        
                          

                        

                      


                 

                

                DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                 

                

                The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their safety
                    profile, proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

                 

                  

                The example below illustrates the information provided for the drugs included in the FDC.

                 

                  

                	 	
                        Drug Name

                      	
                        Net

                        Cost

                      	
                        Tier

                      	
                        Reference

                        Name

                      	
                        Requirements/

                        Limits

                      
	 	
                        THERAPEUTIC CATEGORY

                      
	 	
                        Therapeutic Class

                      
	 	
                        ANALGESICS

                      
	 	
                        Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

                      
	 	
                        ibuprofen 400 mg tab, 600 mg tab, 800 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MOTRIN

                      	 
	 	
                        indomethacin 25 mg cap, 50 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        INDOCIN

                      	 
	 	
                        nabumetone 500 mg tab, 750 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        RELAFEN

                      	 
	 	
                        naproxen 250 mg tab, 375 mg tab, 500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        NAPROSYN

                      	 
	 	
                        naproxen dr 375 mg tab dr, 500 mg tab dr

                      	
                        1

                      	
                        Preferred

                      	
                        NAPROSYN

                      	 
	 	
                        naproxen sodium 275 mg tab, 550 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ANAPROX

                      	 
	 	
                        salsalate 500 mg tab, 750 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        DISALCID

                      	 
	 	
                        sulindac 150 mg tab, 200 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        CLINORIL

                      	 
	 	
                        celecoxib 50 mg cap

                      	
                        2

                      	
                        Non- preferred

                      	
                        CELEBREX

                      	
                        ST

                      


                 

                  

                For each drug included in the FDC, the First Column
                    shows the name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

                 

                  

                The Second Column shows the Monthly Net Cost Range per
                    Average Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

                 

                  

                The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly net cost of
                    the therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy for thirty (30)
                    days. The cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost and must be
                    interpreted as follows:

                 

                  

                
                  Page 151 of 25

                  
                    


                

                
                  	
                          SALUD FÍSICA

                        	
                          
                            

                          

                        


                

                 

                      

                MONTHLY NET COST RANGE

                 

                      

                	
                        1

                      	
                        less than $20

                      	
                        Least costly per month

                      
	
                        2

                      	
                        $20 - $49

                      	 
	
                        3

                      	
                        $50 - $99

                      	 
	
                        4

                      	
                        $100 - $199

                      	 
	
                        5

                      	
                        $200 - $349

                      	 
	
                        6

                      	
                        $350 - $549

                      	 
	
                        7

                      	
                        $550 - $799

                      	 
	
                        8

                      	
                        $800 - $1,099

                      	 
	
                        9

                      	
                        $1,100 - $1,499

                      	 
	
                        10

                      	
                        $1,500 - $1,999

                      	 
	
                        11

                      	
                        $2,000 - $2,499

                      	 
	
                        12

                      	
                        $2,500 - $2,999

                      	 
	
                        13

                      	
                        $3,000 - $3,499

                      	 
	
                        14

                      	
                        $3,500 - $3,999

                      	 
	
                        15

                      	
                        $4,000 - $4,499

                      	 
	
                        16

                      	
                        $4,500 - $4,999

                      	 
	
                        17

                      	
                        $5,000 - $5,499

                      	 
	
                        18

                      	
                        $5,500 - $5,999

                      	 
	
                        19

                      	
                        $6,000 - $6,499

                      	 
	
                        20

                      	
                        $6,500 - $6,999

                      	 
	
                        21

                      	
                        $7,000 - $7,499

                      	 
	
                        22

                      	
                        $7,500 - $7,999

                      	 
	
                        23

                      	
                        $8,000 - $8,499

                      	 
	
                        24

                      	
                        $8,500 - $9,000

                      	 
	
                        25

                      	
                        more than $9,000

                      	
                        Most costly per month

                      


                

                

                We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic category (the one
                    with the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

                 

                  

                
                  Page 152 of 25

                  
                    


                

                
                  	
                          SALUD FÍSICA

                        	
                          
                            

                          

                        


                

                 

                  

                The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of this edition
                    of the FDC.

                    

                  

                Generic bioequivalent drugs are identified with lower-case
                      letters. Certain generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the generic product, but not the
                    brand-name product. The products selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

                 

                  

                
                  Page 153 of 25

                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                         Drug







                              Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                      
	
                        Therapeutic Class [Clase Terapéutica]

                      
	
                        ANALGESICS [ANA LGÉSICOS]

                      
	
                        Nonsteroidal Anti-Inflammatory Agents (NSAIDs) [Anti-Inflamatorios No Esteroidales]

                      
	
                        ibuprofen 400 mg tab, 600 mg tab, 800 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MOTRIN

                      	
                        QL=15 días No refills

                      
	
                        indomethacin 25 mg cap, 50 mg cap

                      	
                        1

                      	
                        Non-Preferred

                      	
                        INDOCIN

                      	 
	
                        nabumetone 500 mg tab, 750 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        RELAFEN

                      	 
	
                        naproxen 250 mg tab, 375 mg tab, 500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        NAPROSYN

                      	
                        QL=15 días No refills

                      
	
                        naproxen dr 375 mg tab dr, 500 mg tab dr

                      	
                        1

                      	
                        Preferred

                      	
                        NAPROSYN

                      	
                        QL=15 días No refills

                      
	
                        salsalate 500 mg tab, 750 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        DISALCID

                      	 
	
                        sulindac 150 mg tab, 200 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        CLINORIL

                      	 
	
                        meloxicam7.5 mg tab, 15 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MOBIC

                      	
                        QL=15 días

                         No refills

                      
	
                        Long-Acting Opioid Analgesics [Analgésicos Opiodes de Larga Duración]

                      
	
                        fentanyl 25 mcg/hr td patch  72 hr

                      	
                        2

                      	
                        Preferred

                      	
                        DURAGESIC

                      	 
	
                        fentanyl 50 mcg/hr td patch

                        72 hr, 75 mcg/hr td patch

                        72 hr

                      	
                        3

                      	
                        Preferred

                      	
                        DURAGESIC

                      	 
	
                        morphine sulfate er 15 mg tab er

                      	
                        3

                      	
                        Preferred

                      	
                        MORPHINE

                      	 
	
                        fentanyl 100 mcg/hr td patch 72 hr

                      	
                        4

                      	
                        Preferred

                      	
                        DURAGESIC

                      	 
	
                        morphine sulfate er 30 mg tab er

                      	
                        4

                      	
                        Preferred

                      	
                        MORPHINE

                      	 
	
                        morphine sulfate er 60 mg tab er

                      	
                        5

                      	
                        Preferred

                      	
                        MORPHINE

                      	 
	
                        morphine sulfate er 100 mg tab er

                      	
                        6

                      	
                        Preferred

                      	
                        MORPHINE

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        methadone hcl oral tablet 10 mg

                      	 	
                        Preferred

                      	
                        METHADONE

                      	
                        ASSMCA

                      
	
                        methadone hcl oral solution 10 mg/ 5ml

                      	 	
                        Preferred

                      	
                        METHADONE

                      	
                        ASSMCA

                      
	
                        Short-Acting Opioid Analgesics [Analgésicos Opiodes de Corta Duración]

                      
	
                        test 

                      
	
                        acetaminophen-codeine 120-12 mg/5ml soln, 30015 mg tab, 300-30 mg tab,

                        300-60 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TYLENOL-CODEINE

                      	
                          

                        QL=15 días No refills

                      
	
                        hydrocodoneacetaminophen 10-325 mg tab, 5-325 mg tab, 7.5-325 mg tab, 7.5-500 mg/15ml soln

                      	
                        1

                      	
                        Preferred

                      	
                        VICODIN

                      	
                                    QL=15 días No refills

                      
	
                        hydromorphone hcl 2 mg tab, 4 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        DILAUDID

                      	 
	
                        meperidine hcl 50 mg/ml inj soln

                      	
                        1

                      	
                        Preferred

                      	
                        DEMEROL

                      	 
	
                        morphine sulfate 15 mg tab, 30 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MORPHINE

                      	 
	
                        oxycodone-acetaminophen 5-325 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        OXYCODONE APAP

                      	
                        QL=15 días No refills

                      
	
                        tramadol hcl 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ULTRAM

                      	 
	
                        butalbital-apap-caffeine 50325-40 mg cap, 50-325-40 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        FIORICET

                      	
                        QL=15 días No refills

                      
	
                        codeine sulfate 15 mg tab, 30 mg tab, 60 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        CODEINE

                      	 
	
                        meperidine hcl 100 mg/ml inj soln

                      	
                        2

                      	
                        Preferred

                      	
                        DEMEROL

                      	 
	
                        morphine sulfate 10 mg/5ml soln

                      	
                        2

                      	
                        Preferred

                      	
                        MORPHINE

                      	 
	
                        morphine sulfate

                        (concentrate) 100 mg/5ml soln, 20 mg/ml soln

                      	
                        2

                      	
                        Preferred

                      	
                        MORPHINE

                      	 
	
                        hydromorphone hcl 8 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        DILAUDID

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        oxycodone-acetaminophen 10-325 mg tab, 7.5-325 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        OXYCODONE APAP

                      	
                        QL=15 días 

                        No refills

                      
	
                        hydromorphone hcl 1 mg/ml oral liquid

                      	
                        4

                      	
                        Preferred

                      	
                        DILAUDID

                      	 
	
                        ANESTHETICS [ANESTÉSICOS]

                      
	
                        Local Anesthetics [Anestésicos Locales]

                      
	
                        lidocaine viscous 2 % mouth/throat soln

                      	
                        1

                      	
                          Preferred

                      	
                        XYLOCAINE

                      	 
	
                        ANTIANXIETY AGENTS [AGENTES PARA LA ANSIEDAD]

                      
	
                        Benzodiazepines [Ben zodiazepinas]

                      
	
                        clonazepam 0.5 mg tab, 1 mg tab, 2mg tab

                      	
                        1

                      	
                          Preferred

                      	
                        KLONOPIN

                      	 
	
                        diazepam 1 mg/ml soln, 10 mg
                              tab, 2 mg tab, 5 mg tab, 5 mg/ml oral conc

                      	
                        1

                      	
                        Preferred

                      	
                        VALIUM

                      	
                        MENTAL/

                        SUB

                        MENTAL QL=

                        5días

                      
	
                        flurazepam hcl 15 mg cap, 30 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        DALMANE

                      	
                        MENTAL/

                        SUB

                        MENTAL QL=

                        5días

                      
	
                        lorazepam 0.5 mg tab, 1 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ATIVAN

                      	
                        MENTAL/

                        SUB

                        MENTAL QL=

                        5días

                      
	
                        midazolam hcl 10 mg/10ml inj soln, 2 mg/2ml inj soln, 5 mg/5ml inj soln, 5 mg/ml inj soln

                      	
                        1

                      	
                        Preferred

                      	
                        VERSED

                      	
                        QL 5ml / 30días

                      
	
                        Miscellaneous Anxiolytics [Ansiolíticos Misceláneos]

                      
	
                        hydroxyzine pamoate 100  mg cap, 25 mg cap, 50 mg
                              cap

                      	
                        1

                      	
                        Preferred

                      	
                        VISTARIL

                      	 
	
                        ANTIBACTERIALS [ANTIBACTERIANOS]

                      
	
                        Aminoglycosides [Aminoglucósidos]

                      
	
                        tobramycin 300 mg/5ml inh neb soln

                      	
                        18

                      	
                        Non-Preferred

                      	
                        TOBI

                      	
                        PA

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página 57 de 67 para
                      rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        First Generation Cephalosporins [Cefalosporinas de Primera Generación]

                      
	
                        cephalexin 125 mg/5ml  susp, 250 mg cap, 500 mg
                              cap

                      	
                        1

                      	
                        Preferred

                      	
                        KEFLEX

                      	 
	
                        cefadroxil 250 mg/5ml susp

                      	
                        2

                      	
                        Non-Preferred

                      	
                        DURICEF

                      	
                        AL ≤ 12 años

                      
	
                        cephalexin 250 mg/5ml susp

                      	
                        2

                      	
                        Preferred

                      	
                        KEFLEX

                      	 
	
                        cefadroxil 500 mg/5ml susp

                      	
                        3

                      	
                        Non-Preferred

                      	
                        DURICEF

                      	
                        AL ≤ 12 años

                      
	
                        Macrolides [Macrólidos]

                      
	
                        azithromycin 250 mg tab,  500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ZITHROMAX

                      	 
	
                        azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        ZITHROMAX

                      	 
	
                        clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        BIAXIN

                      	 
	
                        clarithromycin 250 mg/5ml susp

                      	
                        3

                      	
                        Preferred

                      	
                        BIAXIN

                      	 
	
                        erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        ERY-TAB

                      	 
	
                        erythromycin

                        ethylsuccinate 400 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        E.E.S.

                      	 
	
                        ERYTHROCIN

                        STEARATE 250 mg tab

                      	
                        4

                      	
                        Non-Preferred

                      	 	 
	
                        Miscellaneous Antibacterials [Antibacterianos Misceláneos]

                      
	
                        clindamycin hcl 150 mg  cap, 300 mg cap, 75 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        CLEOCIN

                      	 
	
                        MACRODANTIN 25 mg cap

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        metronidazole 250 mg tab, 500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        FLAGYL

                      	 
	
                        nitrofurantoin macrocrystal 50 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        MACRODANTIN

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        nitrofurantoin macrocrystal 100 mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        MACRODANTIN

                      	 
	
                        nitrofurantoin monohyd macro 100 mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        MACROBID

                      	 
	
                        nitrofurantoin oral

                        suspension 25 MG/5ML

                      	
                        6

                      	
                        Non-Preferred

                      	
                        FURADANTIN

                      	 
	
                        vancomycin hcl 125 mg cap

                      	
                        9

                      	
                        Non-Preferred

                      	
                        VANCOCIN

                      	 
	
                        vancomycin hcl 250 mg cap

                      	
                        10

                      	
                        Non-Preferred

                      	
                        VANCOCIN

                      	 
	
                        Penincillinis [Penicilinas]

                      
	
                        amoxicillin 125 mg/5ml susp, 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab,

                        875 mg tab

                      	
                        1

                      	
                          

                        Preferred

                      	
                        AMOXIL

                      	 
	
                        amoxicillin-pot clavulanate 200-28.5 mg/5ml susp,

                        400-57 mg/5ml susp, 500125 mg tab, 600-42.9 mg/5ml susp, 875-125 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        AUGMENTIN

                      	 
	
                        ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        PRINCIPEN

                      	 
	
                        penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        VEETIDS

                      	 
	
                        amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp

                      	
                        3

                      	
                        Preferred

                      	
                        AUGMENTIN

                      	 
	
                        BICILLIN L-A 600000 unit/ml im susp

                      	
                        3

                      	
                        Non-Preferred

                      	 	 
	
                        penicillin g procaine 600000 unit/ml im susp

                      	
                        3

                      	
                        Non-Preferred

                      	
                        BICILLIN LA

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        BICILLIN L-A 1200000 unit/2ml im susp

                      	
                        4

                      	
                        Non-Preferred

                      	 	 
	
                        BICILLIN L-A 2400000 unit/4ml im susp

                      	
                        5

                      	
                        Non-Preferred

                      	 	 
	
                        Quinolones [Quinolonas]

                      
	
                        ciprofloxacin hcl 250 mg  tab, 500 mg tab, 750 mg
                              tab

                      	
                        1

                      	
                        Preferred

                      	
                        CIPRO

                      	 
	
                        levofloxacin 250 mg tab, 500 mg tab, 750 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        LEVAQUIN

                      	 
	
                        ciprofloxacin 500 mg/5ml (10%) susp

                      	
                        3

                      	
                        Preferred

                      	
                        CIPRO

                      	 
	
                        ciprofloxacin 250 mg/5ml (5%) susp

                      	
                        4

                      	
                        Preferred

                      	
                        CIPRO

                      	 
	
                        Second Generation Cephalosporins [Cefalosporinas de Segunda Generación]

                      
	
                        cefaclor 250 mg cap, 500  mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        CECLOR

                      	 
	
                        cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        CEFZIL

                      	 
	
                        Sulfonamides [Sulfonamidas]

                      
	
                        sulfamethoxazole -tmp ds 800-160 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        SEPTRA

                      	 
	
                        sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg

                        tab

                      	
                        1

                      	
                        Preferred

                      	
                        SEPTRA

                      	 
	
                        sulfadiazine 500 mg tab

                      	
                        4

                      	
                        Preferred

                      	
                        SULFADIAZINE

                      	 
	
                        Tetracyclines [Tetraciclinas]

                      
	
                        minocycline hcl 100 mg  cap, 50 mg cap, 75 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        MINOCIN

                      	 
	
                        doxycycline monohydrate 50  mg cap, 100 mg cap

                      	
                        2

                      	
                        Non-Preferred

                      	
                        MONODOX

                      	 
	
                        Third Generation Cephalosporins [Cefalosporinas de Tercera Generación]

                      
	
                        cefdinir 125 mg/5ml susp,  300 mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        OMNICEF

                      	 
	
                        cefdinir 250 mg/5ml susp

                      	
                        3

                      	
                        Preferred

                      	
                        OMNICEF

                      	 


                

                

                
                  
                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                        Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                        Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                  

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Vaginal Antibiotics [Antibióticos Vaginales]

                      
	
                        metronidazole 0.75 % vag  gel

                      	
                        2

                      	
                        Preferred

                      	
                        VANDAZOLE

                      	 
	
                        clindamycin phosphate 2 % vag crm

                      	
                        3

                      	
                        Non-Preferred

                      	
                        CLEOCIN

                      	 
	
                        ANTICONVULSANTS [ANTICONVULSIVANTES]

                      
	
                        Anticonvulsants [Anticonvulsivantes]

                      
	
                        carbamazepine 100 mg tab  chew, 200 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TEGRETOL

                      	 
	
                        clonazepam 0.5 mg tab, 1 mg tab, 2 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        KLONOPIN

                      	 
	
                        divalproex sodium 125 mg tab dr, 250 mg tab dr, 500 mg tab dr

                      	
                        1

                      	
                        Preferred

                      	
                        DEPAKOTE

                      	 
	
                        gabapentin 100 mg cap, 300 mg cap, 400 mg cap,

                        600 mg tab, 800 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        NEURONTIN

                      	 
	
                        lamotrigine 100 mg tab, 150 mg tab, 200 mg tab,

                        25 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        LAMICTAL

                      	 
	
                        lamotrigine chew tab 5 mg, 25 mg

                      	
                        3

                      	
                        Non-Preferred

                      	
                        LAMICTAL

                      	 
	
                        levetiracetam 250 mg tab, 500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        KEPPRA

                      	 
	
                        levetiracetam er 24 hrs 500 mg tab, 750 mg

                      	
                        3

                      	
                        Non-Preferred

                      	
                        KEPPRA XR

                      	 
	
                        oxcarbazepine 150 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TRILEPTAL

                      	 
	
                        phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab,
                            97.2 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PHENOBARBITAL

                      	 
	
                        primidone 250 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MYSOLINE

                      	 
	
                        topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TOPAMAX

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                    

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        valproic acid 250 mg cap, 250 mg/5ml syr

                      	
                        1

                      	
                        Preferred

                      	
                        DEPAKENE

                      	 
	
                        zonisamide 50 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        ZONEGRAN

                      	 
	
                        DILANTIN 30 mg cap

                      	
                        2

                      	
                        Preferred

                      	 	 
	
                        gabapentin 250 mg/5ml soln

                      	
                        2

                      	
                        Preferred

                      	
                        NEURONTIN

                      	 
	
                        levetiracetam 100 mg/ml soln, 1000 mg tab, 750 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        KEPPRA

                      	 
	
                        oxcarbazepine 300 mg tab, 600 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        TRILEPTAL

                      	 
	
                        phenytoin 125 mg/5ml susp, 50 mg tab chew

                      	
                        2

                      	
                        Preferred

                      	
                        DILANTIN

                      	 
	
                        phenytoin sodium extended 100 mg cap, 200 mg cap, 300 mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        DILANTIN

                      	 
	
                        zonisamide 100 mg cap, 25 mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        ZONEGRAN

                      	 
	
                        carbamazepine er 200 mg tab er 12 hr

                      	
                        3

                      	
                        Preferred

                      	
                        TEGRETOL

                      	 
	
                        ethosuximide 250 mg cap, 250 mg/5ml soln

                      	
                        3

                      	
                        Preferred

                      	
                        ZARONTIN

                      	 
	
                        phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln

                      	
                        3

                      	
                        Preferred

                      	
                        PHENOBARBITAL

                      	 
	
                        carbamazepine 100 mg/5ml susp

                      	
                        4

                      	
                        Preferred

                      	
                        TEGRETOL

                      	 
	
                        carbamazepine er 400 mg tab er 12 hr

                      	
                        4

                      	
                        Preferred

                      	
                        TEGRETOL

                      	 
	
                        oxcarbazepine 300 mg/5ml susp

                      	
                        4

                      	
                        Preferred

                      	
                        TRILEPTAL

                      	 
	
                        VIMPAT 10 mg/ml soln,

                        100 mg tab, 150 mg tab,

                        50 mg tab

                      	
                        5

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        VIMPAT 200 mg tab, 200 mg/20ml iv soln

                      	
                        6

                      	
                        Preferred

                      	 	
                        PA, C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        ANTIDEMENTIA AGENTS [AGENTES ANTIDEMENCIA]

                      
	
                        Antidementia Agents [Agen tes








                            Antidemencia]

                      
	
                        ergoloid mesylates 1 mg  tab

                      	
                        6

                      	
                        Non-Preferred

                      	
                        HYDERGINE

                      	 
	
                        Cholinesterase Inhibitors [Inhibidores de Colinesterasa]

                      
	
                        donepezil hcl 10 mg tab,  10 mg odt, 5 mg tab, 5 mg
                              odt

                      	
                        1

                      	
                        Preferred

                      	
                        ARICEPT

                      	 
	
                        rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap

                      	
                        3

                      	
                        Preferred

                      	
                        EXELON

                      	 
	
                        NMDA Receptor Antagonists [Antagonista del Receptor NMDA]

                      
	
                        memantine 10 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        NAMENDA

                      	 
	
                        memantine TITRATION

                        PAK 5 (28)-10 (21) mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        NAMENDA

                      	 
	
                        ANTIDEPRESSANTS [ANTIDEPRESIVOS]

                      
	
                        Antidepressants [Antidepresivos]

                      
	
                        amitriptyline hcl 10 mg tab,  100 mg tab, 150 mg tab, 25
                              mg tab, 50 mg tab, 75 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ELAVIL

                      	
                        MENTAL, SUB MENTAL

                      
	
                        doxepin hcl 10 mg cap, 10 mg/ml oral conc, 25 mg cap, 50 mg cap, 75 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        SINEQUAN

                      	
                        MENTAL, SUB MENTAL

                      
	
                        imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TOFRANIL

                      	
                        MENTAL, SUB MENTAL

                      
	
                        nortriptyline hcl 10 mg cap, 10 mg/5ml soln, 25 mg cap, 50 mg cap, 75 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        PAMELOR

                      	
                        MENTAL, SUB MENTAL

                      
	
                        doxepin hcl 100 mg cap, 150 mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        SINEQUAN

                      	
                        MENTAL, SUB MENTAL

                      
	
                        duloxetine 20 mg cap, 30 mg cap, 60 mg cap

                      	
                        2

                      	
                        Non-Preferred

                      	
                        CYMBALTA

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                    

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]

                      
	
                        Alpha-Glucosidase Inhibitors [Inhibidores de Alfa Glucosidasa]

                      
	
                        acarbose 100 mg tab, 25  mg tab, 50 mg
                              tab

                      	
                        2

                      	
                        Preferred

                      	
                        PRECOSE

                      	 
	
                        Biguanides [Biguanidas]

                      
	
                        metformin hcl 1000 mg tab, 500 mg tab, 850 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        GLUCOPHAGE

                      	 
	
                        metformin hcl er 500 mg tab er 24 hr, 750 mg tab er 24 hr

                      	
                        1

                      	
                        Preferred

                      	
                        GLUCOPHAGE XR

                      	 
	
                        Dipeptidyl Peptidase-4 (DPP-4) Inhibitors [Inhibidores de DPP-4]

                      
	
                         KOMBIGL YZE







                            XR 2.51000 mg tab er 24 hr, 5-

                        1000 mg tab er 24 hr, 5-500 mg tab er 24 hr

                      	
                        3

                      	
                        Preferred

                      	 	
                        ST, C

                      
	
                        ONGLYZA 2.5 mg tab, 5 mg tab

                      	
                        3

                      	
                        Preferred

                      	 	
                        ST, C

                      
	
                        Glycemic Agents [Agentes Glicémicos]

                      
	
                        GLUCAGON 

                        EMERGENCY 1 mg inj kit

                      	
                        4

                      	
                        Preferred

                      	 	 
	
                        Insulin Mixtures [Mezclas de Insulinas]

                      
	
                        HUMULIN 70/30 (70 -30) 100 unit/ml sc susp

                      	
                        3

                      	
                        Preferred

                      	 	
                        C

                      
	
                        HUMALOG MIX 75/25 (7525) 100 unit/ml sc susp

                      	
                        4

                      	
                        Preferred

                      	 	
                        C

                      
	
                        HUMALOG MIX 50/50 (5050) 100 unit/ml sc susp

                      	
                        4

                      	
                        Preferred

                      	 	
                        C

                      
	
                        Insulin Sensitizing Agents [Agentes Sensibilizantes de Insulin]

                      
	
                        pioglitazone hcl 15 mg tab,  30 mg tab, 45 mg
                              tab

                      	
                        1

                      	
                        Preferred

                      	
                        ACTOS

                      	 
	
                        Intermediate-Acting Insulins [Insulinas de Duración Intermedia]

                      
	
                        HUMULIN N 100 unit/ml sc susp

                      	
                        2

                      	
                        Preferred

                      	 	
                        C

                      
	
                        Long-Acting Insulins [Insulinas de Larga Duración]

                      
	
                        LANTUS SOLOSTAR 100  unit/ml subcutaneous solution pen-injector

                      	
                        2

                      	
                        Preferred

                      	 	
                        C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        LANTUS 100 unit/ml sc soln

                      	
                        3

                      	
                        Preferred

                      	 	
                        C

                      
	
                        Rapid-Acting Insulins [Insulinas de Rápida Duración]

                      
	
                        HUMALOG 100 unit/ml sc  soln

                      	
                        3

                      	
                        Preferred

                      	 	
                        C

                      
	
                        Short-Acting Insulins [Insulinas de Corta Duración]

                      
	
                        HUMULIN R 100 unit/ml inj soln

                          

                      	2	Preferred 

                        	 	C
	
                        Sulfonylureas [Sulfonilureas]

                      
	
                        glimepiride 1 mg tab, 2 mg  tab, 4 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        AMARYL

                      	 
	
                        glipizide 10 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        GLUCOTROL

                      	 
	
                        DIABETES SUPPLIES [SUMINISTROS PARA DIABETES]

                      
	
                        Needles & Syringes [Agujas y Jeringuillas]

                      
	
                        insulin syringe/needle

                        

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        ANTIEMETICS [ANTIEMÉTICOS]

                      
	
                        5-Hydroxytryptamine 3 (5-HT3) Antagonists [Antagonistas de 5-HT3]

                      
	
                        ondansetron 4 mg odt, 8  mg odt

                      	
                        1

                      	
                        Preferred

                      	
                        ZOFRAN ODT

                      	 
	
                        ondansetron hcl 24 mg tab, 4 mg tab, 8 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ZOFRAN

                      	 
	
                        Miscellaneous Antiemetics [Antieméticos Misceláneos]

                      
	
                        metoclopramide hcl 10 mg  tab, 10 mg/10ml soln, 5 mg
                              tab, 5 mg/5ml soln, 5 mg/ml inj soln

                      	
                        1

                      	
                        Preferred

                      	
                        REGLAN

                      	 
	
                        promethazine hcl 12.5 mg tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml syr, 25 mg/ml 
                            inj soln, 50 mg/ml inj soln

                      	
                        1

                      	
                        Preferred

                      	
                        PHENERGAN

                      	 
	
                        trimethobenzamide hcl 300 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        TIGAN

                      	 
	
                        Phenothiazines [Fenotiazinas]

                      
	
                        prochlorperazine edisylate  5 mg/ml inj soln

                      	
                        1

                      	
                        Preferred

                      	
                        COMPAZINE

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                    

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        prochlorperazine maleate 10 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        COMPAZINE

                      	 
	
                        prochlorperazine 25 mg rect supp

                      	
                        4

                      	
                        Non-Preferred

                      	
                        COMPAZINE

                      	 
	
                        ANTIGOUT AGENTS [AGENTES ANTIGOTA]

                      
	
                        Antigout Agents [Agentes Antigota]

                      
	
                        allopurinol 100 mg tab, 300  mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ZYLOPRIM

                      	 
	
                        colchicine 0.6 mg cap

                      	
                        3

                      	
                        Preferred

                      	
                        MITIGARE

                      	
                        PA

                      
	
                        colchicine 0.6 mg tab

                      	
                        3

                      	
                        Non-Preferred

                      	
                        COLCRYS

                      	
                        QL= 3 tab, 15días

                      
	
                        Uricosurics [Uricosúricos]

                      
	
                        probenecid 500 mg tab

                        

                      	
                        1

                      	
                        Preferred

                      	
                        BENEMID

                      	 
	
                        ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]

                      
	
                        Alpha-Adrenergic Agonists [Agonistas Alfa Adrenérgicos]

                      
	
                        clonidine hcl 0.1 mg tab, 

                        0.2 mg tab, 0.3 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        CATAPRESS

                      	 
	
                        methyldopa 250 mg tab, 500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ALDOMET

                      	 
	
                        Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]

                      
	
                        terazosin hcl 1 mg cap, 10  mg cap, 2 mg cap, 5 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        HYTRIN

                      	 
	
                        Angiotensin II Receptor Blockers (ARB) [Antagonistas Del Receptor Angiotensina II]

                      
	
                        losartan potassium 100 mg tab, 25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        COZAAR

                      	 
	
                        losartan potassium-hctz 100-12.5 mg tab, 100-25 mg tab, 50-12.5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        HYZAAR

                      	 
	
                        Angiotensin-Converting Enzyme (ACE) Inhibitors [Inhibidores de la Enzima Convertidora de Angiotensin] 

                      
	
                        fosinopril sodium 10 mg  tab, 20 mg tab, 40 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MONOPRIL

                      	 
	
                        lisinopril 10 mg tab, 2.5 mg tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ZESTRIL

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        lisinopril-

                        hydrochlorothiazide 1012.5 mg tab, 20-12.5 mg tab, 20-25 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ZESTORETIC

                      	 
	
                        Calcium Channel Blocking Agents [Bloqueadores de Canales de Calcio]

                      
	
                        amlodipine besylate 10 mg  tab, 2.5 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        NORVASC

                      	 
	
                        diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        CARDIZEM

                      	 
	
                        diltiazem hcl er 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr

                      	
                        1

                      	
                        Preferred

                      	
                        DILACOR XR

                      	 
	
                        diltiazem hcl er beads 120 mg cap er 24 hr

                      	
                        1

                      	
                        Preferred

                      	
                        TIAZAC

                      	 
	
                        diltiazem hcl er coated beads 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr

                      	
                        1

                      	
                        Preferred

                      	
                        CARDIZEM CD

                      	 
	
                        dilt-xr 120 mg cap er 24 hr, 180 mg cap er 24 hr, 240 mg cap er 24 hr

                      	
                        1

                      	
                        Preferred

                      	
                        DILACOR XR

                      	 
	
                        nifedipine er osmotic 30 mg tab er 24 hr

                      	
                        1

                      	
                        Preferred

                      	
                        PROCARDIA XL

                      	 
	
                        verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        CALAN

                      	 
	
                        verapamil hcl er 120 mg tab er, 180 mg tab er, 240 mg tab er

                      	
                        1

                      	
                        Preferred

                      	
                        CALAN SR

                      	 
	
                        diltiazem hcl er beads 180 mg cap er 24 hr, 240 mg cap er 24 hr, 300 mg cap er 24 hr, 360 mg er
                            24 hr

                      	
                        2

                      	
                        Preferred

                      	
                        TIAZAC

                      	 
	
                        diltiazem hcl er coated beads 300 mg cap er 24 hr

                      	
                        2

                      	
                        Preferred

                      	
                        CARDIZEM CD

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                    

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        nifedipine er osmotic 60 mg tab er 24 hr, 90 mg tab er 24 hr

                      	
                        2

                      	
                        Preferred

                      	
                        PROCARDIA XL

                      	 
	
                        Carbonic Anhydrase Inhibitors Diuretics [Diuréticos Inhibidores de Anhidrasa Carbónica]

                      
	
                        acetazolamide 125 mg tab,  250 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        DIAMOX

                      	 
	
                        Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]

                      
	
                        atenolol 100 mg tab, 25 mg  tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TENORMIN

                      	 
	
                        metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr

                      	
                        1

                      	
                        Preferred

                      	
                        TOPROL XL

                      	 
	
                        metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        LOPRESSOR

                      	 
	
                        metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr

                      	
                        2

                      	
                        Non-Preferred

                      	
                        TOPROL XL

                      	 
	
                        Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos Cardioselectivos] 

                      
	
                        atenolol -chlorthalidone

                        100-25 mg tab, 50-25 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TENORETIC

                      	 
	
                        metoprolol-

                        hydrochlorothiazide 50-25 mg tab

                      	
                        2

                      	
                        Non-Preferred

                      	
                        LOPRESSOR HCT

                      	 
	
                        metoprolol-

                        hydrochlorothiazide 100-25 mg tab, 100-50 mg tab

                      	
                        3

                      	
                        Non-Preferred

                      	
                        LOPRESSOR HCT

                      	 
	
                        Loop Diuretics [Diuréticos del Asa]

                      
	
                        bumetanide 0.5 mg tab, 1  mg tab, 2 mg tab

                      	
                        1

                      	
                        Non-Preferred

                      	
                        BUMEX

                      	 
	
                        furosemide 10 mg/ml soln, 20 mg tab, 40 mg tab, 80 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        LASIX

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]

                      
	
                        propranolol hcl 10 mg tab,  20 mg tab, 20 mg/5ml soln,

                        40 mg tab, 40 mg/5ml soln,

                        80 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        INDERAL

                      	 
	
                        propranolol hcl 60 mg tab

                      	
                        2

                      	
                        Non-Preferred

                      	
                        INDERAL

                      	 
	
                        Potassium-Sparing Diuretics [Diuréticos Conservadores de Potasio]

                      
	
                        spironolactone 100 mg tab,  25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ALDACTONE

                      	 
	
                        triamterene-hctz 37.5-25 mg cap, 37.5-25 mg tab, 75-50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MAXZIDE

                      	 
	
                        Thiazide Diuretics [Diuréticos Tiazidas]

                      
	
                        chlorothiazide 250 mg tab,  500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        DIURIL

                      	 
	
                        chlorthalidone 25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Non-Preferred

                      	
                        HYGROTON

                      	 
	
                        DIURIL 250 mg/5ml susp

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        hydrochlorothiazide 12.5 mg tab, 25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MICROZIDE

                      	 
	
                        indapamide 1.25 mg tab,

                        2.5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        LOZOL

                      	 
	
                        metolazone 2.5 mg tab, 5 mg tab

                      	
                        1

                      	
                        Non-Preferred

                      	
                        ZAROXOLYN

                      	 
	
                        chlorthalidone 100 mg tab

                      	
                        2

                      	
                        Non-Preferred

                      	
                        HYGROTON

                      	 
	
                        metolazone 10 mg tab

                      	
                        2

                      	
                        Non-Preferred

                      	
                        ZAROXOLYN

                      	 
	
                        Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]

                      
	
                        carvedilol 12.5 mg tab, 25  mg tab, 3.125 mg tab, 6.25
                              mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        COREG

                      	 
	
                        Vasodilators [Vasodilatadores]

                      
	
                        hydralazine hcl 10 mg tab,  100 mg tab, 25 mg tab, 50
                              mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        APRESOLINE

                      	 
	
                        minoxidil 10 mg tab, 2.5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        LONITEN

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                    

                   

                    

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]

                      
	
                        Beta-Adrenergic Blocking Agents [Bloqueadores Beta Adrenérgicos]

                      
	
                        divalproex sodium 125 mg  tab dr, 250 mg tab dr, 500
                              mg tab dr

                      	
                        1

                      	
                        Preferred

                      	
                        DEPAKOTE

                      	 
	
                        topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TOPAMAX

                      	 
	
                        Serotonin (5-HT) Receptor Agonists [Agonistas Del Receptor De Serotonina]

                      
	
                        sumatriptan succinate 100  mg tab, 25 mg tab, 50 mg
                              tab

                      	
                        1

                      	
                        Preferred

                      	
                        IMITREX

                      	
                        QL= 6 tab

                      
	
                        ANTIMYASTHENIC AGENTS [AGENTES ANTIMIASTÉNICOS]

                      
	
                        Parasympathomimetics [Parasimpatomiméticos]

                      
	
                        pyridostigmine  bromide 60 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        MESTINON

                      	 
	
                        MESTINON 60 mg/5ml syr

                      	
                        4

                      	
                        Non-Preferred

                      	 	 
	
                        pyridostigmine bromide
                            180 mg tab er

                      	
                        6

                      	
                        Non-Preferred

                      	
                        MESTINON

                      	 
	
                        ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]

                      
	
                        Antituberculars [Antituberculosos]

                      
	
                        isoniazid 100 mg tab, 300  mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ISONIAZID

                      	 
	
                        rifampin 150 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        RIFADIN

                      	 
	
                        ethambutol hcl 100 mg tab

                      	
                        2

                      	
                        Non-Preferred

                      	
                        MYAMBUTOL

                      	 
	
                        pyrazinamide 500 mg tab

                      	
                        2

                      	
                        Non-Preferred

                      	
                        PYRAZINAMIDE

                      	 
	
                        rifampin 300 mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        RIFADIN

                      	 
	
                        ethambutol hcl 400 mg tab

                      	
                        3

                      	
                        Non-Preferred

                      	
                        MYAMBUTOL

                      	 
	
                        isoniazid 50 mg/5ml syr

                      	
                        5

                      	
                        Non-Preferred

                      	
                        ISONIAZID

                      	 
	
                        rifabutin 150 mg cap

                      	 	 	
                        MYCOBUTIN

                      	
                        Puerto Rico Health

                        Department

                        Tuberculosis

                        Control Program

                      
	
                        cycloserine 250 mg cap

                      	 	 	
                        SEROMYCIN

                      
	
                        RIFAMATE 50-300 mg cap

                      	 	 	 
	
                        TRECATOR 250 mg tab

                      	 	 	 
	
                        CAPASTAT 1 gm inj

                      	 	 	 
	
                        Miscellaneous Antimycobacterials [Antimicobacterianos Misceláneos]

                      
	
                        dapsone 100 mg tab, 25  mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        DAPSONE

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        ANTIMYCOTIC AGENTS [ANTIMICÓTICOS]

                      
	
                        Antifungals [Antifungales]

                      
	
                        fluconazole 10 mg/ml susp, 

                        100 mg tab, 150 mg tab,

                        200 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        DIFLUCAN

                      	 
	
                        ketoconazole 200 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        NIZORAL

                      	 
	
                        nystatin 100000 unit/gm crm

                      	
                        1

                      	
                        Preferred

                      	
                        MYCOSTATIN

                      	 
	
                        terbinafine hcl 250 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        LAMISIL

                      	 
	
                        fluconazole 40 mg/ml susp

                      	
                        2

                      	
                        Preferred

                      	
                        DIFLUCAN

                      	 
	
                        itraconazole 100 mg cap

                      	 	
                        Preferred

                      	
                        SPORANOX

                      	
                        SIDA

                      
	
                        Vaginal Antifungals [Antifungales Vaginales]

                      
	
                        terconazole 0.4 % vag crm, 

                        0.8 % vag crm

                      	
                        2

                      	
                        Preferred

                      	
                        TERAZOL

                      	 
	
                        Antimalarials [Antimaláricos]

                      
	
                        chloroquine phosphate 250  mg tab, 500 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ARALEN

                      	 
	
                        hydroxychloroquine sulfate 200 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PLAQUENIL

                      	 
	
                        DARAPRIM 25 mg tab

                      	
                        19

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        Antiprotozoals - Non-Antimalarials [Antiprotozoarios No-Antimalaráricos]

                      
	
                        NEBUPENT 300 mg inh  soln

                      	
                        4

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        ANTIPARASITICS [ANTIPARASITARIOS]

                      
	
                        Anthelmintics [Antihelmínticos]

                      
	
                        PIN-X 720.5 mg chew tab

                      	
                        1

                      	
                        Preferred

                      	 	
                              OTC

                      
	
                        REESES PINWORM

                        MEDICINE 144 mg/ml Susp

                      	
                        1

                      	
                        Preferred

                      	 	
                               OTC

                      
	
                        BILTRICIDE 600 mg tab

                      	
                        7

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]

                      
	
                        Anticholinergics [Anticolinérgicos]

                      
	
                        benztropine mesylate 0.5  mg tab, 1 mg tab, 2 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        COGENTIN

                      	 
	
                        Antiparkinson Dopaminergics [Dopaminérgicos Antiparkinson]

                      
	
                        amantadine hcl 50 mg/5ml  syr

                      	
                        1

                      	
                        Preferred

                      	
                        SYMMETREL

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        pramipexole

                        dihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab,

                        1.5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MIRAPEX

                      	 
	
                        ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 3 mg tab, 4 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        REQUIP

                      	 
	
                        ropinirole hcl 2 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        REQUIP

                      	 
	
                        amantadine hcl 100 mg cap

                      	
                        3

                      	
                        Preferred

                      	
                        SYMMETREL

                      	 
	
                        bromocriptine mesylate 2.5 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        PARLODEL

                      	 
	
                        carbidopa-levodopaentacapone 18.75-75-200 mg tab

                      	
                        4

                      	
                        Non-Preferred

                      	
                        STALEVO

                      	 
	
                        carbidopa-levodopaentacapone 12.5-50-200 mg tab, 25-100-200 mg tab, 31.25-125-200 mg tab,

                        37.5-150-200 mg tab, 50200-200 mg tab

                      	
                        5

                      	
                        Non-Preferred

                      	
                        STALEVO

                      	 
	
                        Dopamine Precursors [Precursores de Dopamina]

                      
	
                        carbidopa -levodopa 10-

                        100 mg tab, 25-100 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        SINEMET

                      	 
	
                        carbidopa-levodopa 25250 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        SINEMET

                      	 
	
                        carbidopa-levodopa er 25100 mg tab er, 50-200 mg tab er

                      	
                        2

                      	
                        Preferred

                      	
                        SINEMET CR

                      	 
	
                        Monoamine Oxidase B (MAO-B) Inhibitors [Inhibidores de MAO-B]

                      
	
                        selegiline hcl 5 mg tab

                        

                      	
                        3

                      	
                        Non-Preferred

                      	
                        CARBEX

                      	 
	
                        ANTIVIRALS [ANTIVIRALES]

                      
	
                        Anti-Influenza Agents [Age ntes








                            Anti-Infuenza]

                      
	
                        oseltamivir phosphate 30 mg cap, 45 mg cap, 75 mg cap

                      	
                        4

                      	
                        Preferred

                      	
                        TAMIFLU

                      	 
	
                        TAMIFLU 6 mg/ ml susp

                      	
                        13

                      	
                        Non-Preferred

                      	 	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Anti-Cytomegalovirus (CMV) Agents [Agentes Anti-Citomegalovirus]

                      
	
                        valganciclovir hcl 450 mg  tab

                      	
                        13

                      	
                        Non-Preferred

                      	
                        VALCYTE

                      	
                        PA

                      
	
                        Antiherpetic Agents [Agentes Antiherpéticos]

                      
	
                        acyclovir 200 mg cap, 400  mg tab, 800 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ZOVIRAX

                      	 
	
                        acyclovir 200 mg/5ml susp

                      	
                        2

                      	
                        Preferred

                      	
                        ZOVIRAX

                      	 
	
                        Antiretroviral Combinations [Combinaciones Antiretrovirales]

                      
	
                        EPZICOM 600-300 mg tab

                      	 	 	 	
                        CENTROS DE

                        PREVENCIÓN Y

                        TRATAMIENTO

                        - CLÍNICAS DE

                        IMMUNOLOGÍA

                      
	
                        ATRIPLA 600-200-300 mg

                        tab

                      	 	 	 
	
                        Integrase Inhibitors [Inhibidores de la Integrasa]

                      
	
                        ISENTRESS potassium 400 mg tab

                      	 	 	 	
                        CENTROS DE

                        PREVENCIÓN Y

                        TRATAMIENTO

                        - CLÍNICAS DE

                        IMMUNOLOGÍA

                      
	
                        Miscellaneous Anti-HIV Agents [Agentes Anti-VIH Misceláneos]

                      
	
                        SELZENTRY 300 mg tab

                      	 	 	 	
                        CENTROS DE

                        PREVENCIÓN Y

                        TRATAMIENTO

                        - CLÍNICAS DE

                        IMMUNOLOGÍA

                      
	
                        FUZEON subcutaneous kit 90 mg

                      	 	 	 
	
                        Non-Nucleoside Reverse Transcriptase Inhibitors [Inhibidores No Nucleósidos de la Transciptasa Reversa]

                      
	
                        nevirapine 200 mg tab

                        

                      	
                        1

                      	
                        Preferred

                      	
                        VIRAMUNE

                      	 
	
                        nevirapine 50 mg/5ml susp

                      	
                        5

                      	
                        Non-Preferred

                      	
                        VIRAMUNE

                      	 
	
                        RESCRIPTOR 200 mg tab

                      	
                        6

                      	
                        Non-Preferred

                      	 	 
	
                        SUSTIVA 50 mg cap, 200 mg cap

                      	
                        6

                      	
                        Preferred

                      	 	
                        C 

                      
	
                        nevirapine er, 100 mg tab er 24 hr, 400 mg tab er 24 hr

                      	
                        7

                      	
                        Non-Preferred

                      	
                        VIRAMUNE XR

                      	 
	
                        SUSTIVA 600 mg tab

                      	
                        7

                      	
                        Preferred

                      	 	
                        C 

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        INTELENCE 200 mg tab

                      	 	 	 	
                        CENTROS DE

                        PREVENCIÓN Y

                        TRATAMIENTO

                        - CLÍNICAS DE

                        IMMUNOLOGÍA

                      
	
                        Nucleoside/Nucleotide Reverse Transcriptase Inhibitors [Inhibidores Nucleósidos/Nucleótidos de la Transcriptasa Reversa]

                      
	
                        zidovudine 300 mg tab

                        

                      	
                        2

                      	
                        Non-Preferred

                      	
                        RETROVIR

                      	 
	
                        stavudine 1 mg/ml soln, 15 mg cap, 20 mg cap, 30 mg cap, 40 mg cap

                      	
                        3

                      	
                        Preferred

                      	
                        ZERIT

                      	 
	
                        didanosine 125 mg cap dr, 200 mg cap dr, 250 mg cap dr

                      	
                        4

                      	
                        Non-Preferred

                      	
                        ZIAGEN

                      	 
	
                        lamivudine 10 mg/ml soln

                      	
                        5

                      	
                        Preferred

                      	
                        EPIVIR

                      	 
	
                        lamivudine 150 mg tab

                      	
                        4

                      	
                        Preferred

                      	
                        EPIVIR

                      	 
	
                        zidovudine 100 mg cap, 50 mg/5ml syr

                      	
                        4

                      	
                        Non-Preferred

                      	
                        RETROVIR

                      	 
	
                        abacavir sulfate 300 mg tab

                      	
                        5

                      	
                        Preferred

                      	
                        ZIAGEN

                      	 
	
                        didanosine 400 mg cap dr

                      	
                        5

                      	
                        Non-Preferred

                      	
                        ZIAGEN

                      	 
	
                        lamivudine 300 mg tab

                      	
                        5

                      	
                        Preferred

                      	
                        EPIVIR

                      	 
	
                        VIDEX 2 gm soln

                      	
                        5

                      	
                        Non-Preferred

                      	 	 
	
                        lamivudine 100 mg tab

                      	
                        6

                      	
                        Preferred

                      	
                        EPIVIR

                      	
                        PA

                      
	
                        lamivudine-zidovudine 150-300 mg tab

                      	
                        6

                      	
                        Preferred

                      	
                        COMBIVIR

                      	 
	
                        abacavir-lamivudinezidovudine 300-150-300 mg tab

                      	
                        10

                      	
                        Non-Preferred

                      	
                        TRIZIVIR

                      	 
	
                        EMTRIVA 200 mg cap

                      	 	 	 	
                        CENTROS DE

                        PREVENCIÓN Y

                        TRATAMIENTO

                        - CLÍNICAS DE

                        IMMUNOLOGÍA

                      
	
                        VIREAD 300 mg tab

                      	 	 	 
	
                        TRUVADA 200-300 mg tab

                      	 	 	
                        TRUVADA

                      
	
                        BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA PROSTÁTICA BENIGNA]

                      
	
                        5-Alpha Reductase Inhibitors [Inhibidores de 5-Alfa Reductasa]

                      
	
                        finasteride 5 mg tab 

                      	
                        1

                      	
                        Preferred

                      	
                        PROSCAR

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]

                      
	
                        tamsulosin hcl 0.4 mg cap 

                      	
                        1

                      	
                        Preferred

                      	
                        FLOMAX

                      	 
	
                        terazosin hcl 1 mg cap, 10 mg cap, 2 mg cap, 5 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        HYTRIN

                      	 
	
                        BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]

                      
	
                        Anticoagulants [Anticoagulantes]

                      
	
                        warfarin sodium 1 mg tab,  10 mg tab, 2 mg tab, 2.5
                              mg tab, 3 mg tab, 4 mg tab, 5 mg tab, 6 mg tab,

                        7.5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        COUMADIN

                      	 
	
                        heparin sodium (porcine) 1000 unit/ml inj soln

                      	
                        2

                      	
                        Preferred

                      	
                        HEPARIN

                      	 
	
                        heparin sodium (porcine)

                        10000 unit/ml inj soln,

                        5000 unit/ml inj soln

                      	
                        3

                      	
                        Preferred

                      	
                        HEPARIN

                      	 
	
                        heparin sodium (porcine) pf 5000 unit/0.5ml inj soln

                      	
                        3

                      	
                        Preferred

                      	
                        HEPARIN

                      	 
	
                        heparin sodium (porcine) 2000 unit/ml iv soln

                      	
                        8

                      	
                        Preferred

                      	
                        HEPARIN

                      	 
	
                        Cobalamins [Cobalaminas]

                      
	
                        cyanocobalamin 1000  mcg/ml inj soln

                      	
                        1

                      	
                        Preferred

                      	
                        VIT B-12

                      	 
	
                        Colony Stimulating Factors [Estimulantes Mieloides]

                      
	
                        NEUPOGEN 300 

                        mcg/0.5ml inj soln, 300 mcg/ml inj soln, 480 mcg/1.6ml inj soln

                      	
                        10

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        NEULASTA 6 mg/0.6ml sc soln

                      	
                        15

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        NEULASTA DELIVERY

                        KIT

                        6 mg/0.6ml sc soln

                      	
                        15

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        NEUPOGEN 480

                        mcg/0.8ml inj soln

                      	
                        12

                      	
                        Preferred

                      	 	
                        PA, C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Erythropoiesis-Stimulating Agents [Agentes Estimulantes de Eritropoiesis]

                      
	
                        ARANESP (ALBUMIN 

                        FREE) 100 mcg/0.5ml inj soln

                      	
                        1

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        PROCRIT 2000 unit/ml inj soln, 3000 unit/ml inj soln, 4000 unit/ml inj soln

                      	
                        6

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ARANESP (ALBUMIN

                        FREE) 25 mcg/0.42ml inj soln, 25 mcg/ml inj soln

                      	
                        6

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        PROCRIT 10000 unit/ml inj soln

                      	
                        7

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ARANESP (ALBUMIN

                        FREE) 40 mcg/0.4ml inj soln

                      	
                        7

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ARANESP (ALBUMIN

                        FREE) 40 mcg/ml inj soln, 60 mcg/ml inj soln

                      	
                        8

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ARANESP (ALBUMIN

                        FREE) 150 mcg/0.3ml inj soln, 150 mcg/0.75ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj
                            soln, 300 mcg/ml inj soln, 500 mcg/ml inj soln, 60 mcg/0.3ml inj soln

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        PROCRIT 20000 unit/ml inj soln

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ARANESP (ALBUMIN

                        FREE) 100 mcg/ml inj soln

                      	
                        11

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        PROCRIT 40000 unit/ml inj soln

                      	
                        10

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        Factor Xa Inhibitors [Inhibidores Del Factor Xa]

                      
	
                        ELIQUIS 2.5 mg tab

                        

                      	
                        4

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ELIQUIS 5 mg tab

                      	
                        4

                      	
                        Preferred

                      	 	
                        PA, C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Folates [Folatos]

                      
	
                        folic acid 1 mg tab, 400  mcg tab, 800 mcg tab

                      	
                        1

                      	
                        Preferred

                      	
                        FOLIC ACID

                      	
                        OTC

                      
	
                        Iron [Hierro]

                      
	
                        ferrous sulfate 325 (65 fe)  mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        IRON

                      	
                        OTC

                      
	
                        INFED 50 mg/ml inj soln

                      	
                        5

                      	
                        Non-Preferred

                      	 	 
	
                        Low Molecular Weight Heparins [Heparinas de Bajo Peso Molecular]

                      
	
                        enoxaparin sodium 30  mg/0.3ml sc soln, 40
                              mg/0.4ml sc soln

                      	
                        5

                      	
                        Non-Preferred

                      	
                        LOVENOX

                      	
                        PA

                      
	
                        enoxaparin sodium 300 mg/3ml inj soln, 60 mg/0.6ml sc soln, 80 mg/0.8ml sc soln

                      	
                        7

                      	
                        Non-Preferred

                      	
                        LOVENOX

                      	
                        PA

                      
	
                        enoxaparin sodium 100 mg/ml sc soln

                      	
                        9

                      	
                        Non-Preferred

                      	
                        LOVENOX

                      	
                        PA

                      
	
                        enoxaparin sodium 120 mg/0.8ml sc soln

                      	
                        10

                      	
                        Non-Preferred

                      	
                        LOVENOX

                      	
                        PA

                      
	
                        enoxaparin sodium 150 mg/ml sc soln

                      	
                        14

                      	
                        Non-Preferred

                      	
                        LOVENOX

                      	
                        PA

                      
	
                        Platelet Modifying Agents [Modificadores de Plaquetas]

                      
	
                        aspirin 325 mg tab, 325 mg  tab dr, 81 mg tab dr

                      	
                        1

                      	
                        Preferred

                      	
                        ASPIRIN

                      	
                        OTC

                      
	
                        aspirin low dose 81 mg tab, 81 mg tab dr

                      	
                        1

                      	
                        Preferred

                      	
                        ASPIRIN

                      	
                        OTC

                      
	
                        cilostazol 100 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PLETAL

                      	 
	
                        clopidogrel bisulfate 75 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PLAVIX

                      	 
	
                        BONE DENSITY REGULATORS [REGULADORES DE DENSIDAD ÓSEA]

                      
	
                        Bisphosphonates [Bifosfonatos]

                      
	
                        alendronate sodium 10 mg  tab, 35 mg tab, 5 mg tab,
                              70 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        FOSAMAX

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                    

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        CARDIOVASCULAR AGENTS [AGENTES CARDIOVASCULARES]

                      
	
                        Antiarrhythmics Class II [Antiarrítmicos Clase II]

                      
	
                        propranolol hcl 10 mg tab,  20 mg tab, 40 mg tab, 80
                              mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        INDERAL

                      	 
	
                        sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        BETAPACE

                      	 
	
                        propranolol hcl 60 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        INDERAL

                      	 
	
                        Antiarrhythmics Type I-A [Antiarrítmicos Tipo I-A]

                      
	
                        quinidine sulfate 200 mg  tab, 300 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        QUINIDINE SULFATE

                      	 
	
                        quinidine gluconate er 324 mg tab er

                      	
                        2

                      	
                        Preferred

                      	
                        QUINAGLUTE

                      	 
	
                        quinidine sulfate er 300 mg tab er

                      	
                        2

                      	
                        Preferred

                      	
                        QUINIDINE SULFATE

                      	 
	
                        Antiarrhythmics Type I-B [Antiarrítmicos Tipo I-B]

                      
	
                        mexiletine hcl 150 mg cap

                        

                      	
                        2

                      	
                        Preferred

                      	
                        MEXITIL

                      	 
	
                        mexiletine hcl 200 mg cap

                      	
                        3

                      	
                        Preferred

                      	
                        MEXITIL

                      	 
	
                        Antiarrhythmics Type I-C [Antiarrítmicos Tipo I-C]

                      
	
                        flecainide acetate 100 mg  tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TAMBOCOR

                      	 
	
                        propafenone hcl 150 mg tab, 225 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        RYTHMOL

                      	 
	
                        flecainide acetate 150 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        TAMBOCOR

                      	 
	
                        propafenone hcl 300 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        RYTHMOL

                      	 
	
                        Antiarrhythmics Type III [Antiarrítmicos Tipo III]

                      
	
                        amiodarone hcl 200 mg tab

                        

                      	
                        1

                      	
                        Preferred

                      	
                        CORDARONE

                      	 
	
                        Intermittent Claudication Agents [Agentes Para La Claudicación Intermitente]

                      
	
                        pentoxifylline er 400 mg  tab er

                      	
                        1

                      	
                        Preferred

                      	
                        TRENTAL

                      	 
	
                        Miscellaneous Cardiovascular Agents [Agentes Cardiovasculares Misceláneos]

                      
	
                        digox 125 mcg tab, 250  mcg tab

                      	
                        2

                      	
                        Preferred

                      	
                        LANOXIN

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        digoxin 0.05 mg/ml soln, 125 mcg tab, 250 mcg tab

                      	
                        2

                      	
                        Preferred

                      	
                        LANOXIN

                      	 
	
                        Pulmonary Hypertension Agents [Agentes Para Hipertensión Pulmonar]

                      
	
                        sildenafil citrate 20 mg tab 

                      	
                        3

                      	
                        Preferred

                      	
                        REVATIO

                      	
                        PA

                      
	
                        ADEMPAS 0.5 mg tab

                      	
                        15

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ADEMPAS 1 mg tab, 1.5 mg tab, 2 mg tab

                      	
                        18

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ADEMPAS 2.5 mg tab

                      	
                        20

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        Vasodilators [Vasodilatadores]

                      
	
                        isosorbide mononitrate 10  mg tab, 20 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        IMDUR

                      	 
	
                        isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr

                      	
                        1

                      	
                        Preferred

                      	
                        IMDUR

                      	 
	
                        nitroglycerin 0.2 mg/hr td patch 24hr

                      	
                        1

                      	
                        Preferred

                      	
                        NITRODUR

                      	 
	
                        NITROSTAT 0.3 mg tab

                        subl, 0.4 mg tab subl, 0.6

                        mg tab subl

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        nitroglycerin 0.1 mg/hr td patch 24hr, 0.4 mg/hr td patch 24hr, 0.6 mg/hr td patch 24hr

                      	
                        2

                      	
                        Non-Preferred

                      	
                        NITRODUR

                      	 
	
                        CENTRAL NERVOUS SYSTEM AGENTS [AGENTES SISTEMA NERVIOSO CENTRAL]

                      
	
                        Multiple Sclerosis Agents [Agentes para Esclerosis Múltiple]

                      
	
                        AMPYRA  10 tab er
                            12hr

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        COPAXONE 20 mg/ml sc kit

                      	
                        17

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        COPAXONE 40 mg/ml subcutaneous solution prefilled syringe

                      	
                        14

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        AVONEX 30 mcg im kit

                      	
                        13

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        AVONEX PEN 30

                        mcg/0.5ml im kit

                      	
                        13

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        AVONEX PREFILLED 30

                        mcg/0.5ml im kit

                      	
                        13

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        GILENYA 0.5 mg cap

                      	
                        15

                      	
                        Preferred

                      	 	
                        PA, C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        TYSABRI intravenous concentrate 300 mg/15ml

                      	
                        15

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        TECFIDERA 120 mg cap dr

                      	
                        14

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        TECFIDERA 240 mg cap dr

                      	
                        14

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        TECFIDERA 120-240 MG misc

                      	
                        14

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        BETASERON 0.3 mg sc kit

                      	
                        13

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        CHEMOTHERAPIES [QUIMIOTERAPIAS]

                      
	
                        Alkylating Agents [Agentes Alquilantes]

                      
	
                        lomustine 10 mg cap

                        

                      	
                        3

                      	
                        Non-Preferred

                      	
                        CEENU

                      	 
	
                        ALKERAN 2 mg tab

                      	
                        4

                      	
                        Non-Preferred

                      	 	 
	
                        temozolomide 5 mg cap

                      	
                        4

                      	
                        Non-Preferred

                      	
                        TEMODAR

                      	
                        PA

                      
	
                        lomustine 40 mg cap

                      	
                        5

                      	
                        Non-Preferred

                      	
                        CEENU

                      	 
	
                        LEUKERAN 2 mg tab

                      	
                        6

                      	
                        Non-Preferred

                      	 	 
	
                        lomustine 100 mg cap

                      	
                        6

                      	
                        Non-Preferred

                      	
                        CEENU

                      	 
	
                        MYLERAN 2 mg tab

                      	
                        7

                      	
                        Non-Preferred

                      	 	 
	
                        temozolomide 20 mg cap

                      	
                        9

                      	
                        Non-Preferred

                      	
                        TEMODAR

                      	
                        PA

                      
	
                        temozolomide 250 mg cap

                      	
                        11

                      	
                        Non-Preferred

                      	
                        TEMODAR

                      	
                        PA

                      
	
                        temozolomide 140 mg cap

                      	
                        13

                      	
                        Non-Preferred

                      	
                        TEMODAR

                      	
                        PA

                      
	
                        temozolomide 100 mg cap, 180 mg cap

                      	
                        14

                      	
                        Non-Preferred

                      	
                        TEMODAR

                      	
                        PA

                      
	
                        Angiogenesis Inhibitors [Inhibidores de Angiogénesis]

                      
	
                        STIVARGA 40 mg tab

                        

                      	
                        15

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        Antiandrogens [Antiandrógenos]

                      
	
                        bicalutamide 50 mg tab

                        

                      	
                        2

                      	
                        Preferred

                      	
                        CASODEX

                      	 
	
                        flutamide 125 mg cap

                      	
                        4

                      	
                        Non-Preferred

                      	
                        EULEXIN

                      	 
	
                        Antiestrogens [Antiestrógenos]

                      
	
                        tamoxifen  citrate 10 mg tab, 20 mg
                              tab

                      	
                        1

                      	
                        Preferred

                      	
                        NOLVADEX

                      	 
	
                        Vaginal Estrogens [Estrógenos Vaginal]

                      
	
                        VAGIFEM 10 mcg vag tab 

                      	
                        3

                      	
                        Non-Preferred

                      	 	 
	
                        Antimetabolites [Antimetabolitos]

                      
	
                        hydroxyurea 500 mg cap 

                      	
                        2

                      	
                        Preferred

                      	
                        HYDREA

                      	 
	
                        mercaptopurine 50 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        PURINETHOL

                      	 
	
                        methotrexate 2.5 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        METHOTREXATE

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        capecitabine 150 mg tab

                      	
                        7

                      	
                        Non-Preferred

                      	
                        XELODA

                      	
                        PA

                      
	
                        capecitabine 500 mg tab

                      	
                        11

                      	
                        Non-Preferred

                      	
                        XELODA

                      	
                        PA

                      
	
                        Antineoplastic Enzyme Inhibitors [Antineoplásicos Inhibidores de Enzimas]

                      
	
                        SPRYCEL 20 mg tab 

                      	
                        14

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        SPRYCEL 50 mg tab

                      	
                        21

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        imatinib 100 mg tab

                      	
                        18

                      	
                        Non-Preferred

                      	
                        GLEEVEC

                      	
                        PA

                      
	
                        SPRYCEL 70 mg tab

                      	
                        17

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        SPRYCEL 80 mg tab

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        TASIGNA 150 mg cap

                      	
                        22

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        SPRYCEL 100 mg tab

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        AFINITOR 2.5 mg tab

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        NEXAVAR 200 mg tab

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        SPRYCEL 140 mg tab

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        AFINITOR 10 mg tab, 5 mg tab, 7.5 mg tab

                      	
                        23

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        TASIGNA 200 mg cap

                      	
                        19

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        imatinib 400 mg tab

                      	
                        25

                      	
                        Non-Preferred

                      	
                        GLEEVEC

                      	
                        PA

                      
	
                        Apetite Stimulants [Estimulantes de Apetito]

                      
	
                        megestrol acetate 20 mg  tab, 40 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MEGACE

                      	 
	
                        megestrol acetate 40 mg/ml susp, 400 mg/10ml susp

                      	
                        2

                      	
                        Preferred

                      	
                        MEGACE

                      	 
	
                        Aromatase Inhibitors [Inhibidores de la Aromatasa]

                      
	
                        anastrozole 1 mg tab

                      	1	Preferred	ARIMIDEX	 
	
                        Folic Acid Antagonists Rescue Agents [Antagonistas de Ácido Fólico]

                      
	
                        leucovorin calcium 5 mg  tab

                      	
                        3

                      	
                        Preferred

                      	
                        LEUCOVORIN

                      	 
	
                        leucovorin calcium 10 mg tab, 15 mg tab

                      	
                        4

                      	
                        Preferred

                      	
                        LEUCOVORIN

                      	 
	
                        leucovorin calcium 25 mg tab

                      	
                        9

                      	
                        Preferred

                      	
                        LEUCOVORIN

                      	 
	
                        Luteinizing Hormone-Releasing (LHRH) Analogs [Análogos De LHRH]

                      
	
                        LUPRON DEPOT 45 mg 

                        im kit

                      	
                        2

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        LUPRON DEPOT 11.25 mg im kit, 3.75 mg im kit

                      	
                        6

                      	
                        Preferred

                      	 	
                        PA, C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        LUPRON DEPOT-PED

                        11.25 mg im kit, 15 mg im kit, 7.5 mg im kit

                      	
                        8

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        LUPRON DEPOT 22.5 mg

                        im kit, 30 mg im kit

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        LUPRON DEPOT-PED

                        11.25 mg (ped) im kit

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        LUPRON DEPOT-PED 30

                        mg (ped) im kit

                      	
                        10

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        leuprolide acetate 1 mg/

                        0.2 ml inj kit

                      	
                        7

                      	
                        Non-preferred

                      	 	
                        PA

                      
	
                        ZOLADEX 3.6 mg, 10.8 mg subcutaneous implant

                      	
                        7

                      	
                        Non-preferred

                      	 	
                        PA

                      
	
                        Miscellaneous Antineoplastics [Antineoplásicos Misceláneos]

                      
	
                        MATULANE 50 mg cap

                        

                      	
                        10

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        ACTIMMUNE 2000000

                        unit/0.5ml sc soln

                      	
                        25

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        INTRON A  6000000

                        unit/ml, 10000000 unit, 18000000 unit, 50000000

                        unit

                      	 	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        Mitotic Inhibitors [Inhibidores Mitóticos]

                      
	
                        etoposide 50 mg cap

                      	4	Non-Preferred	VEPESID	

                      
	
                        DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]

                      
	
                        Antifungals [Antifungales]

                      
	
                        clotrimazole 10 mg  mouth/throat lozenge, 10 mg mouth/throat troche

                      	
                        1

                      	
                        Preferred

                      	
                        MYCELEX

                      	 
	
                        nystatin 100000 unit/ml mouth/throat susp

                      	
                        1

                      	
                        Preferred

                      	
                        MYCOSTATIN

                      	 
	
                        Oral Antiseptics [Antisépticos Orales]

                      
	
                        chlorhexidine gluconate 

                        0.12 % mouth/throat soln 1
                            Preferred PERIDEX

                      
	
                        Xerostomia [Xerostomía]

                      
	
                        pilocarpine 5 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        SALAGEN

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                            Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]

                      
	
                        Acne Antibiotics [Antibióticos para Acné]

                      
	
                        sulfacetamide sodium sulfur 10-5 % external emulsion

                      	
                        1

                      	
                        Preferred

                      	
                        SULFACET R

                      	 
	
                        clindamycin phosphate 1 % soln

                      	
                        2

                      	
                        Preferred

                      	
                        CLEOCIN T

                      	 
	
                        erythromycin 2 % gel, 2 % soln

                      	
                        2

                      	
                        Preferred

                      	
                        ERYGEL

                      	 
	
                        Acne Products [Productos para el Acné]

                      
	
                        tretinoin 0.05 % crm,           

                      	
                        2

                      	
                        Preferred

                      	
                        RETIN A

                      	
                        AL < 21 años

                      
	
                        isotretinoin 10 mg cap, 20 mg cap, 30 mg cap

                      	
                        6

                      	
                        Preferred

                      	
                        Zenatane

                      	 
	
                        Antihistamines [Antihistamínicos]

                      
	
                        hydroxyzine hcl 10 mg tab,  10 mg/5ml soln, 10 mg/5ml
                              syr, 25 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ATARAX

                      	 
	
                        Antipsoriatics [Antipsoriáticos]

                      
	
                        methoxsalen 10 m cap

                      	 	
                        Preferred

                      	
                        Oxsoralen

                      	 
	
                        Antiseborrheic Products [Productos Antiseborrea]

                      
	
                        selenium sulfide 2.5 % lot

                        

                      	
                        1

                      	
                        Preferred

                      	
                        SELSUN

                      	 
	
                        nystatin 100000 unit/gm oint, crm

                      	
                        1

                      	
                        Preferred

                      	
                        MYCOSTATIN

                      	 
	
                        Dermatological Skin Cancer Agents [Dermatológicos para Cáncer de la Piel]

                      
	
                        fluorouracil 2 % soln, 5 %  soln

                      	
                        3

                      	
                        Preferred

                      	
                        EFUDEX

                      	 
	
                        fluorouracil 5 % crm

                      	
                        4

                      	
                        Non-Preferred

                      	
                        EFUDEX

                      	 
	
                        Very High Potency Topical Glucocorticoids [Glucocorticoides Tópicos de Muy Alta Potencia]

                      
	
                        betamethasone dipropionate aug 0.05 % crm

                      	
                        3

                      	
                          Non-Preferred

                      	
                        DIPROLENE

                      	 
	
                        betamethasone dipropionate aug 0.05 % oint

                      	
                        4

                      	
                        Non-Preferred

                      	
                        DIPROLENE

                      	 
	
                        High Potency Topical Glucocorticoids [Glucocorticoides Tópicos de Alta Potencia]

                      
	
                        mometasone furoate 0.1 % oint, 0.1% crm, 0.1% soln

                      	
                        1

                      	
                        Preferred

                      	
                        ELOCON

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                    

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Medium Potency Topical Glucocorticoids [Glucocorticoides Tópicos de Mediana Potencia]

                      
	
                        triamcinolone acetonide  0.1 % crm, 0.1 % oint, 0.5

                        % crm, 0.5 % oint

                      	
                        1

                      	
                        Preferred

                      	
                        KENALOG

                      	 
	
                        betamethasone valerate 0.1 % crm, 0.1 % lot, 0.1 % oint

                      	
                        1

                      	
                        Preferred

                      	
                        DIPROLENE

                      	 
	
                        Low Potency Topical Glucocorticoids [Glucocorticoides Tópicos de Baja Potencia]

                      
	
                        hydrocortisone 2.5 % crm, 

                        2.5 % lot, 2.5 % oint

                      	
                        1

                      	
                        Preferred

                      	
                        HYDROCORTISONE

                      	 
	
                        Pediculicides and Scabicides [Pediculicidas y Escabicidas]

                      
	
                        permethrin 5 % crm 

                      	
                        3

                      	
                        Preferred

                      	
                        ELIMITE

                      	
                        QL= 60 gm.

                      
	
                        lindane 1 % lot

                      	
                        4

                      	
                        Non-Preferred

                      	
                        LINDANE

                      	
                        QL = 60 cc, 30días,  ST

                      
	
                        Topical Skin Antibiotics [Antibióticos Tópicos para la piel]

                      
	
                        mupirocin 2 % oint

                        

                      	
                        1

                      	
                        Preferred

                      	
                        BACTROBAN

                      	 
	
                        silver sulfadiazine 1 % crm

                      	
                        1

                      	
                        Preferred

                      	
                        SILVADENE

                      	 
	
                        metronidazole 0.75 % crm,

                        0.75 % gel, 0.75 % lot

                      	
                        4

                      	
                        Non-Preferred

                      	
                        METROLOTION

                      	 
	
                        Topical Antifungals [Antifungales Tópicos]

                      
	
                        clotrimazole 1 % crm

                        

                      	
                        1

                      	
                        Preferred

                      	
                        LOTRIMIN

                      	
                        OTC (crm)

                      
	
                        nystatin 100000 unit/gm oint, crm

                      	
                        1

                      	
                        Preferred

                      	
                        MYCOSTATIN

                      	 
	
                        Topical Antipsoriatics [Antipsoriáticos Tópicos]

                      
	
                        calcipotriene 0.005 % crm

                        

                      	
                        6

                      	
                        Non-Preferred

                      	
                        DOVONEX

                      	 
	
                        acitretin 10 mg cap, 17.5 mg cap, 25 mg cap

                      	
                        7

                      	
                        Non-Preferred

                      	
                        SORIATANE

                      	 
	
                        DYSLIPIDEMICS [DISLIPIDÉMICOS]

                      
	
                        Bile Acid Sequestrants [Secuestradores de Acidos Biliares]

                      
	
                        cholestyramine 4 gm pckt,  4 gm/dose oral pwdr

                      	
                        3

                      	
                        Preferred

                      	
                        QUESTRAN

                      	 
	
                        Fibric Acid Derivatives [Derivados de Ácido Fíbrico]

                      
	
                        gemfibrozil 600 mg tab

                        

                      	
                        1

                      	
                        Preferred

                      	
                        LOPID

                      	 
	
                        HMG-CoA Reductase Inhibitors [Inhibidores de la Reductasa De HMG-CoA]

                      
	
                        atorvastatin calcium 10 mg  tab, 20 mg tab, 40 mg tab,
                              80 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        LIPITOR

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        pravastatin sodium 10 mg tab, 20 mg tab, 80 mg tab

                      	
                        1

                      	
                        Non-Preferred

                      	
                        PRAVACHOL

                      	 
	
                        simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab, 80 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ZOCOR

                      	 
	
                        pravastatin sodium 40 mg tab

                      	
                        2

                      	
                        Non-Preferred

                      	
                        PRAVACHOL

                      	 
	
                        GASTROINTESTINAL AGENTS [AGENTESGASTROINTESTINALES]

                      
	
                        Antispasmodics [Antiespasmódicos]

                      
	
                        dicyclomine hcl 10 mg cap,  20 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        BENTYL

                      	 
	
                        dicyclomine hcl 10 mg/5ml soln

                      	
                        2

                      	
                        Preferred

                      	
                        BENTYL

                      	 
	
                        Anti-Ulcer Agents [Agentes Anti-Ulceras]

                      
	
                        misoprostol 100 mcg tab,  200 mcg tab

                      	
                        1

                      	
                        Preferred

                      	
                        CYTOTEC

                      	 
	
                        sucralfate 1 gm tab

                      	
                        1

                      	
                        Preferred

                      	
                        CARAFATE

                      	 
	
                         1 gm/10ml susp

                      	
                        3

                      	
                        Non-Preferred

                      	 	 
	
                        Digestive Enzymes [Enzimas Digestivas]

                      
	
                        CREON 12000 unit cap dr  prt,







                            6000 unit cap dr prt

                      	
                        3

                      	
                        Preferred

                      	 	
                        C

                      
	
                        CREON 24000 unit cap dr prt, 36000 unit cap dr prt, 3000-9500 unit cap dr prt

                      	
                        5

                      	
                        Preferred

                      	 	
                        C

                      
	
                        Histamine2 (H2) Receptor Antagonists [Antagonistas del Receptor de H2]

                      
	
                        famotidine  20 mg tab, 40 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PEPCID

                      	 
	
                        ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr

                      	
                        1

                      	
                        Preferred

                      	
                        ZANTAC

                      	 
	
                        Miscellaneous Gastrointestinal Agents [Agentes Gastrointestinales Misceláneos]

                      
	
                        ursodiol 300 mg cap 

                      	
                        4

                      	
                        Preferred

                      	
                        ACTIGALL

                      	
                        PA

                      
	
                        cromolyn sodium 100 mg/5ml oral conc

                      	
                        6

                      	
                        Non-Preferred

                      	
                        GASTROCROM

                      	
                        PA

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Proton Pump Inhibitors [Inhibidores de la Bomba de Protones]

                      
	
                        omeprazole 10 mg cap dr, 20 mg cap dr,40 mg cap dr

                      	
                        1

                      	
                        Preferred

                      	
                        PRILOSEC

                      	
                        QL=180 caps/ 365 días

                      
	
                        Rectal Anti-Inflammatories [Anti-Inflamatorios Rectales]

                      
	
                        hydrocortisone ace pramoxine 1-1 % rect crm,

                        2.5-1 % rect crm

                      	
                        2

                      	
                        Preferred

                      	
                        ANALPRAM-HC

                      	 
	
                        GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]

                      
	
                        Miscellaneous Genitourinary Agents [Agentes Genitourinarios Misceláneos]

                      
	
                        phenazopyridine hcl 100  mg tab, 200 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PYRIDIUM

                      	
                        QL= 6 tab.

                      
	
                        Phosphate Binder Agents [Enlazadores de Fosfato]

                      
	
                        RENVELA  0.8 gm
                            pckt

                      	
                        8

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        RENVELA 2.4 gm pckt, 800 mg tab

                      	
                        8

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        calcium acetate 667 mg cap.

                      	
                        3

                      	
                        Non-Preferred

                      	
                        PHOSLO

                      	 
	
                        Urinary Antibiotics [Antibióticos Urinarios]

                      
	
                        ur n -c 81.6 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        URIN D/S

                      	 
	
                        URETRON D/S tab

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        URIMAR-T 120 mg tab

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        urin ds tab

                      	
                        1

                      	
                        Preferred

                      	
                        URIN D/S

                      	 
	
                        Urinary Antispasmodics [Antiespasmódicos Urinarios]

                      
	
                        oxybutynin chloride 5 mg  tab, 5 mg/5ml syr

                      	
                        1

                      	
                        Preferred

                      	
                        DITROPAN

                      	 
	
                        HEMATOLOGICAL AGENTS [AGENTES HEMATOLÓGICOS]

                      
	
                        Antihemophilic Products [Productos Antithemofílicos]

                      
	
                        ADVATE 250 unit iv soln,  500







                            unit iv soln, 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln, 3000 unit iv soln, 4000 unit iv soln

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        ALPHANATE/VWF COMPLEX/HUMAN 250

                        unit iv soln, 500 unit iv soln, 1000 unit iv soln, 1500 unit iv soln, 2000 unit iv soln

                      	
                        25

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        KOGENATE FS 1000 unit

                        intravenous kit, 2000 unit intravenous kit, 250 unit intravenous kit, 3000 unit intravenous kit, 500 unit intravenous kit

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        KOGENATE FS BIO-SET

                        1000 unit intravenous kit, 2000 unit intravenous kit,

                        250 unit intravenous kit,

                        3000 unit intravenous kit,

                        500 unit intravenous kit

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        BENEFIX 250 unit intravenous kit, 500 unit intravenous kit, 1000 unit intravenous kit, 2000 unit intravenous kit, 3000 unit intravenous
                            kit

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ANTIINHIBITOR

                        COAGULANT COMPLEX for inj

                      	
                        25

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        ANTIHEMOPHILIC

                        FACTOR VIII for inj.

                      	
                        25

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        Hemostatics [Hemostáticos]

                      
	
                        tranexamic acid  650 mg tab, 1000 mg/ ml IV soln

                      	
                          4

                      	
                          Non-Preferred

                      	
                          LYSTEDA

                      	
                          PA

                      
	
                        AMICAR 500 mg tab, 0.25 gm/ml oral soln 

                      	
                          5

                      	
                          Non-Preferred

                      	 	
                          PA

                      
	
                        AMICAR 0.25 gm/ml oral soln

                      	
                          8

                      	
                          Non-Preferred

                      	 	
                          PA

                      
	
                        tranexamic acid  100
                            mg/ml IV soln

                      	 	
                          Non-Preferred

                      	
                          CYKLOKAPRON

                      	
                          PA

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        HORMONAL AGENTS [AGENTES HORMONALES]

                      
	
                        Androgens [Andrógenos]

                      
	
                        testosterone cypionate 100  mg/ml im soln, 200 mg/ml
                              im soln

                      	
                        2

                      	
                        Preferred

                      	
                        DEPO-

                        TESTOSTERONE

                      	 
	
                        Antithyroid Agents [Agentes Antitiroide]

                      
	
                        methimazole 10 mg tab, 5  mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        TAPAZOLE

                      	 
	
                        propylthiouracil 50 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        PROPYLTHIOURACIL

                      	 
	
                        Calcimimetics [Calcimiméticos]

                      
	
                        SENSIPAR 30 mg tab

                      	
                        7

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        SENSIPAR 60 mg tab

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        SENSIPAR 90 mg tab

                      	
                        10

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        Dopamine Agonists [Agonistas de Dopamina]

                      
	
                        bromocriptine mesylate 2.5  mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        PARLODEL

                      	 
	
                        cabergoline 0.5 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        DOSTINEX

                      	 
	
                        Dysmenorrhea Agents [Agentes para la Dismenorrea]

                      
	
                        medroxyprogesterone  acetate 10 mg tab, 2.5 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PROVERA

                      	 
	
                        alyacen 1/35 1-35 mg-mcg tab

                      	
                        2

                      	
                        Preferred

                      	
                        ARANELLE

                      	
                        PA

                      
	
                        CRYSELLE-28 0.3-30 mgmcg tab

                      	
                        2

                      	
                        Preferred

                      	 	
                        PA

                      
	
                        LOW-OGESTREL 0.3-30 mg-mcg tab

                      	
                        2

                      	
                        Preferred

                      	 	
                        PA

                      
	
                        medroxyprogesterone acetate 150mg/ml susp

                      	
                        5

                      	
                        Preferred

                      	
                        DEPO-PROVERA

                      	
                        PA

                      
	
                        Estrogens [Estrógenos]

                      
	
                        estradiol 0.5 mg tab, 1 mg  tab, 2 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ESTRACE

                      	 
	
                        estropipate 0.75 mg tab,

                        1.5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        ESTROPIPATE

                      	 
	
                        estropipate 3 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        ESTROPIPATE

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Estrogens and Progestins [Estrógenos y Progestinas]

                      
	
                        estradiol -norethindrone acet 1-0.5
                              mg tab

                      	
                        4

                      	
                        Non-Preferred

                      	
                        ACTIVELLA

                      	 
	
                        Growth Hormones Analogs [Análogos de Hormona de Crecimiento]

                      
	
                        NORDITROPIN FLEXPRO           

                        5 mg/1.5ml sc soln

                      	
                        5

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        NORDITROPIN FLEXPRO

                        30 mg/3ml sc soln

                      	
                        8

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        NORDITROPIN

                        NORDIFLEX

                        30 mg/3ml sc soln

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        NORDITROPIN FLEXPRO

                        10 mg/1.5ml sc soln, 15 mg/1.5ml sc soln

                      	
                        8

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        Mineralocorticoids [Mineralocorticoides]

                      
	
                        fludrocortisone acetate 0.1  mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        FLORINEF

                      	 
	
                        Prostaglandins [Prostaglandinas]

                      
	
                        misoprostol 100 mcg tab,  200 mcg tab

                      	
                        1

                      	
                        Preferred

                      	
                        CYTOTEC

                      	 
	
                        Somatostatic Analogs [Análogos de Somastatina]

                      
	
                        octreotide acetate 50  mcg/ml inj soln

                      	
                        3

                      	
                        Preferred

                      	
                        SANDOSTATIN

                      	
                        PA

                      
	
                        octreotide acetate 100 mcg/ml inj soln, 1000 mcg/5ml inj soln, 200 mcg/ml inj soln, 500 mcg/ml
                            inj soln

                      	
                        6

                      	
                        Preferred

                      	
                        SANDOSTATIN

                      	
                        PA

                      
	
                        octreotide acetate 1000 mcg/ml inj soln

                      	
                        8

                      	
                        Preferred

                      	
                        SANDOSTATIN

                      	
                        PA

                      
	
                        SANDOSTATIN LAR DEPOT 10 mg im kit

                      	
                        11

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        SANDOSTATIN LAR DEPOT 30 mg im kit

                      	
                        14

                      	
                        Non-Preferred

                      	 	
                        PA

                      
	
                        SANDOSTATIN LAR DEPOT 20 mg im kit

                      	
                        16

                      	
                        Non-Preferred

                      	 	
                        PA

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                  

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Thyroid Hormones [Hormona Tiroidea]

                      
	
                        levothyroxine sodium 100  mcg tab, 112 mcg tab, 125
                              mcg tab, 137 mcg tab, 150 mcg tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

                      	
                        1

                      	
                        Preferred

                      	
                        SYNTHROID

                      	 
	
                        SYNTHROID 100 mcg tab,

                        112 mcg tab, 125 mcg tab,

                        137 mcg tab, 150 mcg tab,

                        175 mcg tab, 200 mcg tab,

                        25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

                      	
                        1

                      	
                        Preferred

                      	 	
                        C

                      
	
                        Vasopressin Analogs [Análogos de Vasopresina]

                      
	
                        desmopressin  acetate 4 mcg/ml inj soln

                      	
                        2

                      	
                        Non-Preferred

                      	
                        DDAVP

                      	 
	
                        desmopressin acetate 0.2 mg tab

                      	
                        3

                      	
                        Non-Preferred

                      	
                        DDAVP

                      	 
	
                        desmopressin ace rhinal tube 0.01 % nasal soln

                      	
                        4

                      	
                        Non-Preferred

                      	
                        DDAVP

                      	 
	
                        desmopressin ace spray refrig 0.01 % nasal soln

                      	
                        4

                      	
                        Non-Preferred

                      	
                        DDAVP

                      	 
	
                        desmopressin acetate 0.1 mg tab

                      	
                        4

                      	
                        Non-Preferred

                      	
                        DDAVP

                      	 
	
                        desmopressin acetate spray 0.01 % nasal soln

                      	
                        4

                      	
                        Non-Preferred

                      	
                        DDAVP

                      	 
	
                        STIMATE 1.5 mg/ml nasal soln

                      	
                        7

                      	
                        Non-Preferred

                      	 	 
	
                        IMMUNOLOGICAL AGENTS [AGENTES INMUNOLÓGICOS]

                      
	
                        Immunomodulators (TNF and Non-TNF) [Inmunomoduladores (TNF y No-TNF)]

                      
	
                        ENBREL  25 mg sc
                            kit, 25mg/0.5ml sc sol

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ENBREL 50mg/ml sc soldermat

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        HUMIRA 10 mg/0.2ml sc

                        kit, 20 mg/0.4ml sc kit, 40 mg/0.8ml sc kit

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        REMICADE 100 mg iv soln

                      	
                        16

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]

                      
	
                        Organ Transplant Agents

                      
	
                        cyclosporine modified 25  mg cap, 50 mg cap

                      	
                        3

                      	
                        Preferred

                      	
                        NEORAL

                      	
                        aPA

                      
	
                        cyclosporine modified 25 mg cap, 50 mg cap

                      	
                        3

                      	
                        Preferred

                      	
                        NEORAL

                      	
                        aPA

                      
	
                        NEORAL 25 mg cap

                      	
                        4

                      	
                        Preferred

                      	 	
                        aPA, C

                      
	
                        cyclosporine 25 mg cap

                      	
                        4

                      	
                        Preferred

                      	
                        SANDIMMUNE

                      	
                        aPA

                      
	
                        cyclosporine modified 100 mg cap, 100 mg/ml soln

                      	
                        4

                      	
                        Preferred

                      	
                        NEORAL

                      	
                        aPA

                      
	
                        cyclosporine 100 mg cap

                      	
                        5

                      	
                        Preferred

                      	
                        SANDIMMUNE

                      	
                        aPA

                      
	
                        cyclosporine modified 100 mg cap

                      	
                        5

                      	
                        Preferred

                      	
                        NEORAL

                      	
                        aPA

                      
	
                        NEORAL 100 mg cap

                      	
                        5

                      	
                        Preferred

                      	 	
                        aPA, C

                      
	
                        cyclosporine 100 mg cap, 25 mg cap

                      	
                        6

                      	
                        Preferred

                      	
                        SANDIMMUNE

                      	
                        aPA

                      
	
                        SANDIMMUNE 100 mg

                        cap, 100 mg/ml soln, 25 mg cap

                      	
                        6

                      	
                        Preferred

                      	 	
                        aPA, C

                      
	
                        cyclosporine modified 100 mg/ml soln

                      	
                        7

                      	
                        Preferred

                      	
                        NEORAL

                      	
                        aPA

                      
	
                        NEORAL 100 mg/ml soln

                      	
                        8

                      	
                        Preferred

                      	 	
                        aPA, C

                      
	
                        Glucocorticosteroids [Glucocorticoides]

                      
	
                        dexamethasone 0.5 mg  tab, 0.5 mg/5ml oral elix,
                              0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        DECADRON

                      	 
	
                        dexamethasone sodium phosphate 120 mg/30ml inj soln, 20 mg/5ml inj soln, 4 mg/ml inj soln

                      	
                        1

                      	
                        Preferred

                      	
                        DECADRON

                      	
                        OB-GYN

                      


                 

                

                 • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización   Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age              Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16   Página 1 de 67
                    para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]               Revisado 5/18/2017

                    

                 

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        KENALOG 10 mg/ml inj susp

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        MEDROL 2 mg tab

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        methylprednisolone 32 mg tab, 4 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MEDROL

                      	 
	
                        methylprednisolone (pak) 4 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        MEDROL

                      	 
	
                        prednisolone 15 mg/5ml soln, 15 mg/5ml syr

                      	
                        1

                      	
                        Preferred

                      	
                        PRELONE

                      	 
	
                        prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        DELTASONE

                      	 
	
                        prednisone (pak) 10 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        DELTASONE

                      	 
	
                        hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        CORTEF

                      	 
	
                        methylprednisolone 16 mg tab, 8 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        MEDROL

                      	 
	
                        cortisone acetate 25 mg tab

                      	
                        3

                      	
                        Non-Preferred

                      	
                        CORTISONE

                      	 
	
                        KENALOG 40 mg/ml inj susp

                      	
                        5

                      	
                        Non-Preferred

                      	 	 
	
                        betamethasone sod phos & acet 6
                              mg/ml inj susp

                      	
                        2

                      	
                        Preferred

                      	
                        CELESTONE SOLUSPAN

                      	
                        OB-GYN

                      
	
                        Organ Transplant Agents [Agentes para Trasplantes]

                      
	
                        azathioprine 50 mg tab

                        

                      	
                        1

                      	
                        Preferred

                      	
                        IMURAN

                      	 
	
                        AZASAN 75 mg, 100 mg

                      	 	
                        Non-Preferred

                      	 	 
	
                        mycophenolate mofetil 200 mg/ml susp, 250 mg cap, 500 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        CELLCEPT

                      	
                        aPA

                      
	
                        tacrolimus 0.5 mg cap

                      	
                        3

                      	
                        Non-Preferred

                      	
                        PROGRAF

                      	
                        aPA

                      
	
                         MYFORTIC 180 mg tab dr

                      	
                        4

                      	
                        Preferred

                      	 	
                        aPA, C

                      
	
                        tacrolimus 1 mg cap

                      	
                        4

                      	
                        Non-Preferred

                      	
                        PROGRAF

                      	
                        aPA

                      
	
                        sirolimus 0.5 mg tab, 1 mg tab, 2 mg tab

                      	
                        5

                      	
                        Non-Preferred

                      	
                        RAPAMUNE

                      	
                        aPA

                      
	
                        MYFORTIC 360 mg tab dr

                      	
                        6

                      	
                        Preferred

                      	 	
                        aPA, C

                      
	
                        tacrolimus 5 mg cap

                      	
                        6

                      	
                        Non-Preferred

                      	
                        PROGRAF

                      	
                        aPA

                      
	
                        RAPAMUNE 1 mg/ml soln

                      	
                        8

                      	
                        Non-Preferred

                      	 	
                        aPA

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                    

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        INFLAMMATORY BOWEL DISEASE [ENFERMEDAD INFLAMATORIA INTESTINAL]

                      
	
                        Aminosalicylates [Aminosalicilatos]

                      
	
                        mesalamine  rectal enema 4 gm

                      	
                        4

                      	
                        Preferred

                      	
                        ROWASA

                      	 
	
                        DELZICOL 400 mg cap dr

                      	
                        5

                      	
                        Preferred

                      	 	
                        C

                      
	
                        ASACOL HD 800 mg tab dr

                      	
                        6

                      	
                        Preferred

                      	 	
                        C

                      
	
                        Immunomodulators (TNF and Non-TNF) [Inmunomoduladores (TNF y No-TNF)]

                      
	
                        ENBREL  25 mg sc
                            kit, 25mg/0.5ml sc sol

                      	
                        8

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ENBREL 50mg/ml sc sol

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        HUMIRA 10 mg/0.2 ml sc kit, 20 mg/0.4ml sc kit, 40 mg/0.8ml sc kit

                      	
                        11

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        HUMIRA PEDIATRIC CROHNS START 40

                        mg/0.8ml sc kit

                      	
                        11

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        HUMIRA PEN 40 mg/0.8ml sc kit

                      	
                        11

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        HUMIRA PEN-CROHNS STARTER 40 mg/0.8ml sc kit

                      	
                        11

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        HUMIRA PEN-PSORIASIS STARTER 40 mg/0.8ml sc kit

                      	
                        11

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        REMICADE 100 mg iv soln

                      	
                        13

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        Intrarectal Low Potency Glucocorticoids [Glucocorticoides Intrarectales de Baja Potencia]

                      
	
                        hydrocortisone 100  mg/60ml rect enema

                      	
                        2

                      	
                        Preferred

                      	
                        COLOCORT

                      	 
	
                        Sulfonamides [Sulfonamidas]

                      
	
                        sulfasalazine 500 mg tab,  500 mg tab dr

                      	
                        1

                      	
                        Preferred

                      	
                        AZULFIDINE

                      	 
	
                        MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]

                      
	
                        Calcium Regulating Agents [Agentes Reguladores de Calcio]

                      
	
                        calcitriol 0.25 mcg cap 

                      	
                        1

                      	
                        Preferred

                      	
                        ROCALTROL

                      	 
	
                        calcitriol 0.5 mcg cap

                      	
                        2

                      	
                        Preferred

                      	
                        ROCALTROL

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Carnitine Deficiency [Deficiencia de Carnitina]

                      
	
                        levocarnitine 1 gm/10ml soln, 330 mg tab

                      	
                        3

                      	
                        Preferred

                      	
                        CARNITOR

                      	 
	
                        Chelating Agents [Agentes Quelantes]

                      
	
                        DEPEN TITRATABS  250 mg tab

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA

                      
	
                        Electrolytes/Minerals Replacement [Reemplazo de Electrolitos/Minerales]

                      
	
                        potassium chloride 20  meq/15ml (10%) oral
                              liquid, 20 meq/15ml (10%) soln

                      	
                        1

                      	
                        Preferred

                      	
                        KAY-CIEL

                      	 
	
                        potassium chloride crys er 10 meq tab er, 20 meq tab er

                      	
                        1

                      	
                        Preferred

                      	
                        KLOR-CON

                      	 
	
                        potassium chloride er 10 meq cap er, 8 meq cap er

                      	
                        2

                      	
                        Preferred

                      	
                        MICRO-K

                      	 
	
                        potassium chloride 40 meq/15ml (20%) oral solution

                      	
                        4

                      	
                        Preferred

                      	
                        KAON CL

                      	 
	
                        Potassium Removing Resins [Resinas Removedoras de Potasio]

                      
	
                        sodium polystyrene  sulfonate 15 gm/60ml susp

                      	
                        3

                      	
                        Preferred

                      	
                        KAYEXALATE

                      	 
	
                        Prenatal Vitamins [Vitaminas Prenatales]

                      
	
                        classic  prenatal 28-0.8 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PRENATAL VITAMINS

                      	
                        OB-GYN

                      
	
                        prenatal 27-0.8 mg tab, 271 mg tab, 28-0.8 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PREPLUS

                      	
                        OB-GYN

                      
	
                        prenatal 19 tab chew, tab, 29-1 mg tab chew, 29-1 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PRENATAL VITAMINS

                      	
                        OB-GYN

                      
	
                        prenatal formula 28-0.8 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PRENATAL VITAMINS

                      	
                        OB-GYN

                      
	
                        prenatal low iron 27-0.8 mg tab, 27-1 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PREPLUS

                      	
                        OB-GYN

                      
	
                        prenatal plus iron 29-1 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PRENATABS

                      	
                        OB-GYN

                      
	
                        prenatal vitamins 0.8 mg tab, 28-0.8 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        PRENATAL VITAMINS

                      	
                        OB-GYN

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Vitamin K [Vitamina K]

                      
	
                        MEPHYTOIN 5 mg tab

                        

                      	
                        6

                      	
                        Non-Preferred

                      	 	 
	
                        MUSCLE RELAXANTS [RELAJANTES MUSCULARES]

                      
	
                        Antispasticity Agents [Agentes Antiespasticidad]

                      
	
                        baclofen 10 mg tab, 20 mg  tab

                      	
                        1

                      	
                        Preferred

                      	
                        LIORESAL

                      	 
	
                        dantrolene sodium 25 mg cap, 50 mg cap

                      	
                        2

                      	
                        Preferred

                      	
                        DANTRIUM

                      	 
	
                        dantrolene sodium 100 mg cap

                      	
                        3

                      	
                        Preferred

                      	
                        DANTRIUM

                      	 
	
                        Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]

                      
	
                        cyclobenzaprine hcl 10 mg  tab

                      	
                        1

                      	
                        Preferred

                      	
                        FLEXERIL

                      	 
	
                        NASAL AGENTS [AGENTES NASALES]

                      
	
                        Nasal Anticholinergics [Anticolinérgicos Nasales]

                      
	
                        ipratropium bromide 0.03  % nasal soln

                      	
                        2

                      	
                        Non-Preferred

                      	
                        ATROVENT

                      	 
	
                        Nasal Mast Cell Stabilizers [Estabilizadores Nasales de Mastocitos]

                      
	
                        cromolyn sodium  5.2 mg/act nasal aerosol sol

                      	
                        1

                      	
                        Preferred

                      	
                        NASALCROM

                      	 
	
                        Nasal Steroids [Esteroides Nasales]

                      
	
                        fluticasone propionate 50  mcg/act nasal susp

                      	
                        1

                      	
                        Preferred

                      	
                        FLONASE

                      	
                        QL = 1 pompa / 30 días

                      
	
                        OPHTHALMIC AGENTS [AGENTES OFTÁLMICOS]

                      
	
                        Antiglaucoma Agents [Agentes Antiglaucoma]

                      
	
                        brimonidine tartrate 0.2 %  ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        ALPHAGAN

                      	 
	
                        dorzolamide hcl 2 % ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        TRUSOPT

                      	 
	
                        levobunolol hcl 0.25 % ophth soln, 0.5 % ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        BETAGAN

                      	 
	
                        timolol maleate 0.25 % ophth soln, 0.5 % ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        TIMOPTIC

                      	 
	
                        dorzolamide hcl-timolol mal ophth sol 22.3-6.8 mg/ml

                      	
                        1

                      	
                        Preferred

                      	
                        COSOPT

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        betaxolol hcl 0.5 % ophth soln

                      	
                        2

                      	
                        Non-Preferred

                      	
                        BETOPTIC

                      	 
	
                        Miotics [Mióticos]

                      
	
                        pilocarpine hcl 1 % ophth  soln, 2 % ophth soln, 4 %
                              ophth soln

                      	
                        3

                      	
                        Preferred

                      	
                        ISOPTOCARPINE

                      	 
	
                        Mydriatics [Midriáticos]

                      
	
                        atropine sulfate 1 % ophth  oint, 1 % ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        ISO-ATROPINE

                      	 
	
                        Nonsteroidal Anti-Inflammatory Agents (NSAIDs) [Anti-Inflamatorios No Esteroidales]

                      
	
                        diclofenac sodium 0.1 %  ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        VOLTAREN

                      	
                        QL = max 30 días / 365 días

                      
	
                        ketorolac tromethamine 0.5 % ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        ACULAR

                      	
                        QL = max 30 días / 365 días

                      
	
                        Ophthalmic Antibiotics [Antibióticos Oftálmicos]

                      
	
                        ciprofloxacin hcl 0.3 %  ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        CILOXAN

                      	 
	
                        gentamicin sulfate 0.3 % ophth oint, 0.3 % ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        GARAMYCIN

                      	 
	
                        ofloxacin 0.3 % ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        OCUFLOX

                      	 
	
                        polymyxin b-trimethoprim 10000-0.1 unit/ml-% ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        POLYTRIM

                      	 
	
                        tobramycin 0.3 % ophth soln

                      	
                        1

                      	
                        Preferred

                      	
                        TOBREX

                      	 
	
                        bacitracin 500 unit/gm ophth oint

                      	
                        3

                      	
                        Non-Preferred

                      	
                        BACITRACIN

                      	 
	
                        Ophthalmic Antivirals [Antivirales Oftálmicos]

                      
	
                        trifluridine 1 % ophth soln

                        

                      	
                        4

                      	
                        Non-Preferred

                      	
                        VIROPTIC

                      	
                        PA

                      
	
                        Ophthalmic Prostaglandins [Prostaglandinas Oftálmicas]

                      
	
                        latanoprost 0.005 % ophth  soln

                      	
                        1

                      	
                        Preferred

                      	
                        XALATAN

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                   

                    

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Ophthalmic Steroids [Esteroides Oftálmicos]

                      
	
                        neomycin -polymyxindexamethasone 3.5-

                        10000-0.1 ophth oint, 3.5-

                        10000-0.1 ophth susp

                      	
                        1

                      	
                        Preferred

                      	
                        MAXITROL

                      	 
	
                        prednisolone acetate 1 % ophth susp

                      	
                        2

                      	
                        Preferred

                      	
                        PRED FORTE

                      	 
	
                        prednisolone sodium phosphate 1 % ophth soln

                      	
                        2

                      	
                        Preferred

                      	
                        INFLAMASE

                      	 
	
                        fluorometholone 0.1 % ophth susp

                      	
                        3

                      	
                        Preferred

                      	
                        FML LIQUIFILM

                      	 
	
                        OTIC AGENTS [AGENTES OTICOS]

                      
	
                        Miscellaneous Otic Agents [Agentes Oticos Misceláneos]

                      
	
                        acetic acid 2 % otic soln

                        

                      	
                        2

                      	
                        Preferred

                      	
                        VOSOL

                      	 
	
                        Otic Antibiotics [Antibióticos Oticos]

                      
	
                        neomycin -polymyxin-hc 1 % otic soln, 3.5-10000-1 otic soln,
                              3.5-10000-1 otic susp

                      	
                        2

                      	
                        Preferred

                      	
                        CORTISPORIN

                      	 
	
                        cipro hc  0.2-1 % otic susp

                      	
                        1

                      	
                        Preferred

                      	 	 
	
                        RESPIRATORY AGENTS [AGENTES RESPIRATORIOS]

                      
	
                        Anticholinergic Bronchodilators [Broncodilatadores Anticolinérgicos]

                      
	
                        ipratropium bromide 0.02  % inh soln

                      	
                        1

                      	
                        Preferred

                      	
                        ATROVENT

                      	 
	
                        Antileukotrienes [Antileukotrienos]

                      
	
                        montelukast sodium 10 mg  tab, 4 mg tab chew, 5 mg
                              tab chew

                      	
                        1

                      	
                        Preferred

                      	
                        SINGULAIR

                      	 
	
                        Antitussive-Expectorant [Expectorantes Antitusivos]

                      
	
                        benzonatate  100 mg cap

                      	
                        1

                      	
                        Preferred

                      	
                        TESSALON

                      	 
	
                        guaifenesin-codeine 10010 mg/5ml soln

                      	
                        1

                      	
                        Preferred

                      	
                        CHERATUSSIN

                      	 
	
                        Bronchiolitis Agents [Agentes para Bronquiolitis]

                      
	
                        SYNAGIS 50 mg/0.5ml im  soln

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        SYNAGIS 100 mg/ml im soln

                      	
                        11

                      	
                        Preferred

                      	 	
                        PA, C

                      


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Inhaled Corticosteroids [Corticosteroides Inhalados]

                      
	
                        FLOVENT DISKUS 100 

                        mcg/blist inh aer pwdr, 250 mcg/blist inh aer pwdr, 50 mcg/blist inh aer pwdr

                      	
                        3

                      	
                        Preferred

                      	 	
                        QL = 1 pompa / 30 días, C

                      
	
                        FLOVENT HFA 110

                        mcg/act inh aer, 44 mcg/act inh aer

                      	
                        3

                      	
                        Preferred

                      	 	
                        QL = 1 pompa / 30 días, C

                      
	
                        ADVAIR DISKUS 100-50 mcg/dose inh aer pwdr, 250-50 mcg/dose inh aer pwdr

                      	
                        4

                      	
                        Preferred

                      	 	
                        QL= 1 pompa / 30 días, ST, C

                      
	
                        ADVAIR HFA 115-21

                        mcg/act inh aer, 45-21 mcg/act inh aer

                      	
                        4

                      	
                        Preferred

                      	 	
                        QL= 1 pompa / 30 días, ST, C

                      
	
                        budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp

                      	
                        4

                      	
                        Non-Preferred

                      	
                        PULMICORT

                      	
                        AL ≤ 12 años

                      
	
                        budesonide 1mg/2ml inh susp

                      	
                        8

                      	
                        Non-Preferred

                      	
                        PULMICORT

                      	
                        AL ≤ 12 años

                      
	
                        FLOVENT HFA 220

                        mcg/act inh aer

                      	
                        4

                      	
                        Preferred

                      	 	
                        QL= 1 pompa / 30 días, C

                      
	
                        ADVAIR DISKUS 500-50 mcg/dose inh aer pwdr

                      	
                        5

                      	
                        Preferred

                      	 	
                        QL= 1 pompa / 30 días, ST, C

                      
	
                        ADVAIR HFA 230-21 mcg/act inh aer

                      	
                        5

                      	
                        Preferred

                      	 	
                        QL= 1 pompa / 30 días, ST, C

                      
	
                        Nonsedating Histamine1 Blocking Agents [Bloqueadores de Histamina1 No-Sedantes]

                      
	
                        cetirizine HCl oral soln 1

                        MG/ML (5 MG/5ML)

                      	
                        1

                      	
                        Preferred

                      	
                        ZYRTEC

                      	
                        OTC

                      
	
                        loratadine 5 mg/5ml soln, 5 mg/5ml syr

                      	
                        1

                      	
                        Preferred

                      	
                        CLARITIN

                      	
                        OTC

                      
	
                        loratadine 10 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        CLARITIN

                      	
                        OTC

                      
	
                        Phosphodiesterase Inhibitors [Inhibidores de la Fosfodiesterasa]

                      
	
                        theophylline er 100 mg tab  er 12 hr, 200 mg tab er 12
                              hr, 300 mg tab er 12 hr, 450 mg tab er 12 hr

                      	
                        1

                      	
                        Preferred

                      	
                        THEO-DUR

                      	 


                

                

                
                  • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                      Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                

                

                

                
                  
                    


                

                
                  
                    	
                            SALUD FÍSICA

                          	
                            
                              

                            

                          


                  

                

                 

                

                	
                        Drug Name [Nombre del

                        Medicamento]

                      	
                        Net

                        Cost

                        [Costo

                        Neto]

                      	
                        Tier [Tier]

                      	
                        Reference Name

                        [Nombre de

                        Referencia]

                      	
                        Requirements/

                        Limits

                        [Requerimientos

                        /Límites]

                      
	
                        Sympathomimetic Bronchodilators [Broncodilatadores Simpatomiméticos]

                      
	
                        albuterol sulfate (2.5  mg/3ml) 0.083% inh neb
                              soln, (5 mg/ml) 0.5% inh neb soln, 2 mg/5ml syr

                      	
                        1

                      	
                        Preferred

                      	
                        ALBUTEROL

                      	 
	
                        terbutaline sulfate 2.5 mg tab, 5 mg tab

                      	
                        1

                      	
                        Preferred

                      	
                        BRETHINE

                      	 
	
                        VENTOLIN HFA 108 (90 base) mcg/act inh aer

                      	
                        2

                      	
                        Preferred

                      	 	
                        QL = 1 pompa / 30 días, C

                      
	
                        RHEUMATOID ARTHRITIS AGENTS [AGENTES PARA ARTRITIS REUMATOIDE]

                      
	
                        Immunomodulators (TNF And Non-TNF) [Inmunomoduladores (TNF Y No-TNF)]

                      
	
                        ENBREL  25 mg sc
                            kit, 25mg/0.5ml sc sol

                      	
                        8

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ENBREL 50mg/ml sc sol

                      	
                        9

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        ORENCIA 125 mg/ml subcutaneous solution prefilled syringe, 125 mg/ml ClickJect sc sol Autoinjector

                      	
                        10

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        HUMIRA 10 mg/ 0.2ml sc kit, 20 mg/0.4ml sc kit, 40 mg/0.8ml sc kit

                      	
                        11

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        REMICADE 100 mg iv soln

                      	
                        13

                      	
                        Preferred

                      	 	
                        PA, C

                      
	
                        Non-Biologic Agents [Agentes No-Biológicos]

                      
	
                        methotrexate 2.5 mg tab

                      	
                        2

                      	
                        Preferred

                      	
                        METHOTREXATE

                      	 
	
                        leflunomide 10 mg tab, 20 mg tab

                      	
                        4

                      	
                        Non-Preferred

                      	
                        ARAVA

                      	
                        PA

                      
	
                        DEPEN TITRATABS 250 mg tab

                      	
                        25

                      	
                        Preferred

                      	 	
                        PA

                      


                

                

                • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre
                    Autorización           Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age           Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 16 for monthly net cost range [Ver página 16 Página  de 67 para rangos de costo neto mensual] • P –
                    Preferred Contracted Product [Producto Contratado Preferido] Revisado 5/18/2017

                 

                  

                
                  
                    


                

                
                  ASES

                   

                  

                  Puerto Rico Healthcare Insurance Administration

                  

                  

                  Mental Health

                   

                    

                  2017

                   

                    

                  Formulary of Drugs Covered by

                   

                    

                  the Government Healthcare Plan (GHP)

                  

                  

                  Authorized by the P.R. Elections Commission CEE-SA-16-2732

                   

                    

                  
                    
                      


                  

                  	
                          

                        	 	
                          GOVERNMENT OF PUERTO RICO

                        	 	
                          Hon. Ricardo A. Rosselló Nevares

                          Governor

                           

                          Ms. Ángela M. Ávila Marrero

                          Executive Director

                        
	 	
                          Healthcare Insurance Administration

                        


                  

                  

                  May 1, 2017

                   

                    

                  TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

                  

                  

                  Dear provider:

                   

                    

                  I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its
                      corresponding sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

                   

                    

                  The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and Sub-physical.
                      Moreover, the Mental Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health Sub-formulary
                      will be used by participating primary care physicians (PCPs) in Primary Care Medical Groups.

                   

                    

                  The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare Insurance
                      Administration (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical aspects. The FDC
                      is a dynamic document that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

                   

                    

                  I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

                  

                  

                  Cordially,

                  

                  

                  [signed]

                  Ángela M. Ávila Marrero

                  Executive Director

                  

                  
                    

                      


                    

                    

                  

                  PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                  

                  

                  
                    
                      


                  

                  GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE GOVERNMENT HEALTHCARE PLAN (GHP) 

                  

                  

                  
                    
                      	1.	
                              Drug Formulary

                            


                    

                  

                  

                  

                  The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and
                      reviewing the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee is
                      constituted by healthcare professionals, including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES for the
                      drug formulary based on scientific evidence, clinical aspects, and a cost-effectiveness analysis.

                  

                  

                  The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the prescription
                      drug coverage. The purpose of the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

                  

                  

                  ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator or PPA based
                      on the most recent clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

                  

                  

                  Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain in point
                      number 2.

                  

                  

                  
                    
                      	2.	
                              Exception Process

                            


                    

                  

                  

                  

                  In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as applicable,
                      insurance companies must use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

                  

                  

                  
                    
                      	

                            	a.	
                              Contraindication to the drug(s) included in the FDC;

                            


                    

                  

                  
                    
                      	

                            	b.	
                              History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                            


                    

                  

                  
                    
                      	

                            	c.	
                              Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                            


                    

                  

                  
                    
                      	

                            	d.	
                              Lack of a therapeutic alternative in the FDC.

                            


                    

                  

                  

                  

                  This exception process requires a clinical justification that is duly documented by the service provider with the clinical
                      reasons justifying the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

                   

                    

                  
                    
                      	3.	
                              Other Aspects of the Prescription Drug Coverage

                            


                    

                  

                  

                  

                  
                    
                      	

                            	A.	
                              The prescription drug coverage of the GHP establishes that using generic bioequivalent products
                                    as the first option is mandatory.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	B.	
                              Insurance companies or the TPA (Third Party Administrator) and healthcare service providers
                                    will only process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                            


                    

                  

                  

                  

                  
                    
                      


                  

                  
                    
                      	

                            	C.	
                              ASES has an active process to continually review the prescription drug coverage in accordance
                                    with changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES
                                    may require that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will
                                    safeguard adequate access to services and maintain continuity of care.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	D.	
                              No entity contracted by ASES or by healthcare companies or organizations (for example, primary
                                    care medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES. Furthermore, they may
                                    not limit the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be responsible for supervising
                                    their providers and employees with regard to their compliance with these provisions.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	E.	
                              The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The
                                    treatment period may be extended, as applicable, when medically necessary.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	F.	
                              The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty
                                    (30) day therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating adherence
                                    and tolerance. The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case of narcotics,
                                    which will be dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms of adherence,
                                    tolerance, and dosage within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	G.	
                              ASES requires the use of generic bioequivalent drugs approved by the Food and Drug
                                    Administration (FDA) coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	H.	
                              The lack of appropriate bioequivalent drug inventories does not exempt providers from
                                    dispensing the prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the corresponding
                                    brand-name drug, unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception mechanism.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	I.	
                              Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized
                                    under the law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	J.	
                              The right to freedom of choice requires the availability of a pharmacy that is reasonably
                                    accessible to each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                            


                    

                  

                  

                  

                  
                    
                      


                  

                  
                  Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or when an
                      electronic prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24 hours. If a
                      drug is not available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her physician to
                      have the prescription sent to another pharmacy of his or her choice.

                  

                  

                  
                    
                      	4.	
                              Emergency Rule

                            


                    

                  

                  

                  

                  The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except
                      as otherwise specified.

                  

                  

                  The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will
                      also be dispensed in amounts sufficient for five (5) business days.

                  

                  

                  Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for
                      continuity of treatment, including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the
                      IEF.

                  

                  

                  If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES
                      in your region and/or the Pharmacy Benefit Manager (PBM) contracted by ASES.

                  

                  

                   

                  
                     

                  

                  
                    
                      	
                               Page 3 of 83

                            


                    

                    
                      


                  

                  
                    	
                            
                              SALUD MENTAL

                            

                          	


                    

                  

                  GOVERNMENT HEALTHCARE PLAN

                   

                    

                  FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

                   

                    

                  2017

                  

                  

                  TABLE OF CONTENTS

                   

                    

                  	
                          GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE GOVERNMENT HEALTHCARE PLAN

                        	
                          3

                        
	 	 
	
                          DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                        	5
	 	 
	
                          MONTHLY NET COST RANGE

                        	5
	 	 
	
                          GENERIC DRUGS

                        	6
	 	 
	
                          ANTI-ADDICTION AGENTS

                        	8
	 	 
	
                          Opioid Antagonist

                        	8
	 	 
	
                          Detox Treatment

                        	8
	 	 
	
                          ANTIANXIETY AGENTS

                        	8
	 	 
	
                          Benzodiazepines

                        	8
	 	 
	
                          Sedating Histamine 1 Blocking Agents

                        	8
	 	 
	
                          ANTIDEPRESSANTS

                        	9
	 	 
	
                          Miscellaneous Antidepressants

                        	9
	 	 
	
                          Serotonin and/or Norepinephrine Modulators

                        	9
	 	 
	
                          Tricyclic Agents

                        	10
	 	 
	
                          ANTIPARKINSON AGENTS

                        	10
	 	 
	
                          ANTIPSYCHOTICS

                        	10
	 	 
	
                          Atypical - Second Generation

                        	10
	 	 
	
                          Typical - First Generation

                        	11
	 	 
	
                          MOOD STABILIZERS

                        	12
	 	 
	
                          Bipolar Agents

                        	12
	 	 
	
                          PSYCHOSTIMULANTS

                        	13
	 	 
	
                          ADHD Amphetamines

                        	13
	 	 
	
                          ADHD Non-Amphetamines

                        	14
	 	 
	
                          SLEEP DISORDER AGENTS

                        	14
	 	 
	
                          Benzodiazepines

                        	14
	 	 
	
                          Miscellaneous Sleep Disorder Agents

                        	14


                  

                  

                   

                  
                    
                      	
                               Page 4 of 83

                            


                    

                    
                      


                  

                  
                    	
                            
                              SALUD MENTAL

                            

                          	


                  

                   

                    

                  DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                  

                  

                  The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their
                      safety profile, proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

                  

                  

                  The example below illustrates the information provided for the drugs included in the FDC.

                  

                  

                  	 	
                          Drug Name

                        	
                          Net

                          Cost

                        	
                          Tier

                        	
                          Reference

                          Name

                        	
                          Requirements/

                          Limits

                        
	 	
                          THERAPEUTIC CATEGORY

                        
	 	
                          Therapeutic Class

                        
	 	
                          ANTI-ADDICTION AGENTS

                        
	 	
                          Opioid Antagonist

                        
	 	
                          buprenorphine hcl 2 mg tab subl, 8 mg tab subl

                        	
                          3

                        	
                          Preferred

                        	
                          SUBUTEX

                        	
                          PA

                        
	 	
                          SUBOXONE subl film 2-0.5 mg, 8-2 mg, 4-1 mg, 12-3 mg

                        	
                          4

                        	
                          Preferred

                        	 	
                          PA, C

                        
	 	
                          Detox Treatment

                        
	 	
                          b-1 100 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          THIAMINE

                        	
                          QL

                        
	 	
                          clonidine hcl 0.1 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          CATAPRESS

                        	 
	 	
                          folic acid 1 mg tab, 400 mcg tab, 800 mcg tab

                        	
                          1

                        	
                          Preferred

                        	
                          FOLIC ACID

                        	
                          QL, OTC

                        
	 	
                          ibuprofen 800 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MOTRIN

                        	
                          QL

                        
	 	
                          loperamide hcl 2 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          IMODIUM

                        	
                          QL

                        


                  

                  

                  For each drug included in the FDC, the First

                        Column shows the name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

                  

                  

                  The Second Column shows the
                      Monthly Net Cost Range per Average Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or
                      Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed
                      if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

                   

                    

                  
                    
                      	
                               Page 5 of 83

                            


                    

                    
                      


                  

                  
                    	
                            
                              SALUD MENTAL

                            

                          	


                  

                  
                     

                      

                    MONTHLY NET COST RANGE

                        

                      

                    The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly
                        net cost of the therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy
                        for thirty (30) days. The cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost
                        and must be interpreted as follows:

                  

                  

                  	
                          1

                        	
                          less than $20

                        	
                          Least costly per month

                        
	
                          2

                        	
                          $20 - $49

                        	 
	
                          3

                        	
                          $50 - $99

                        	 
	
                          4

                        	
                          $100 - $199

                        	 
	
                          5

                        	
                          $200 - $349

                        	 
	
                          6

                        	
                          $350 - $549

                        	 
	
                          7

                        	
                          $550 - $799

                        	 
	
                          8

                        	
                          $800 - $1,099

                        	 
	
                          9

                        	
                          $1,100 - $1,499

                        	 
	
                          10

                        	
                          $1,500 - $1,999

                        	 
	
                          11

                        	
                          $2,000 - $2,499

                        	 
	
                          12

                        	
                          $2,500 - $2,999

                        	 
	
                          13

                        	
                          $3,000 - $3,499

                        	 
	
                          14

                        	
                          $3,500 - $3,999

                        	 
	
                          15

                        	
                          $4,000 - $4,499

                        	 
	
                          16

                        	
                          $4,500 - $4,999

                        	 
	
                          17

                        	
                          $5,000 - $5,499

                        	 
	
                          18

                        	
                          $5,500 - $5,999

                        	 
	
                          19

                        	
                          $6,000 - $6,499

                        	 
	
                          20

                        	
                          $6,500 - $6,999

                        	 
	
                          21

                        	
                          $7,000 - $7,499

                        	 
	
                          22

                        	
                          $7,500 - $7,999

                        	 
	
                          23

                        	
                          $8,000 - $8,499

                        	 
	
                          24

                        	
                          $8,500 - $9,000

                        	 
	
                          25

                        	
                          more than $9,000

                        	
                          Most costly per month

                        


                  

                  

                  We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic
                      category (the one with the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

                  

                  

                  The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of
                      this edition of the FDC.

                  

                  

                  GENERIC DRUGS

                  

                  

                  Generic bioequivalent drugs are identified
                        with lower-case letters. Certain generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the generic
                      product, but not the brand-name product. The products selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

                  

                  

                  
                    
                      	
                               Page 6 of 83

                            


                    

                    
                      


                  

                  
                    	
                            
                              SALUD MENTAL

                            

                          	


                     

                    

                  

                  
                    
                      	
                               Page 7 of 83

                            


                    

                    
                      


                  

                  
                    Revisado: 1 de mayo de 2017

                    
                      

                      

                    

                    SALUD MENTAL

                  

                   

                  

                  	 	
                           Drug Name [Nombre del

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                          Límites]

                        
	 	
                          THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                        
	 	
                          Therapeutic Class [Clase 
                                Terapéutica]

                        
	 	
                          ANTI-ADDICTION AGENTS [AGENTES  CONTRA LA ADDICIÓN]

                        
	 	
                          Opioid Antagonist [Antagonistas De Opioides]

                        
	 	
                          buprenorphine hcl 2 mg tab  subl,

                              8 mg tab subl

                        	
                          3

                        	
                          Preferred

                        	
                          SUBUTEX

                        	
                          PA

                        
	 	
                          SUBOXONE subl film 2-0.5 mg, 8-2 mg, 4-1 mg, 12-3 mg

                        	
                          4

                        	
                          Preferred

                        	 	
                          PA, C

                        
	 	
                          Detox Treatment [Tratamiento De Detox]

                        
	 	
                          b-1 100 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          THIAMINE

                        	
                          QL

                        
	 	
                          clonidine hcl 0.1 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          CATAPRESS

                        	 
	 	
                          folic acid 1 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          FOLIC ACID

                        	
                          QL

                        
	 	
                          ibuprofen 800 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MOTRIN

                        	
                          QL

                        
	 	
                          loperamide hcl 2 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          IMODIUM

                        	
                          QL

                        
	 	
                          ANTIANXIETY AGENTS [AGENTES PARA LA ANXIEDAD]

                        
	 	
                          Benzodiazepines [Benzodiazepinas]

                        
	 	
                          clonazepam 0.5 mg tab, 1  mg tab, 2mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          KLONOPIN

                        	 
	 	
                          diazepam 10 mg tab, 2 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          VALIUM

                        	 
	 	
                          lorazepam 0.5 mg tab, 1 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ATIVAN

                        	 
	 	
                          diazepam 1 mg/ml soln

                        	
                          2

                        	
                          Non-Preferred

                        	
                          VALIUM

                        	 
	 	
                          DIAZEPAM INTENSOL 5 mg/ml oral conc

                        	
                          2

                        	
                          Non-Preferred

                        	 	 
	 	
                          lorazepam 2 mg/ml oral conc

                        	
                          2

                        	
                          Non-Preferred

                        	
                          ATIVAN

                        	 
	 	
                          Sedating Histamine 1 Blocking Agents [Sedantes Bloqueadores Histamine 1]

                        
	 	
                          hydroxyzine pamoate 100  mg cap, 25 mg cap, 50 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          VISTARIL

                        	 


                  

                  

                  
                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity
                      Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido]

                  

                  

                  

                  
                    
                      	
                               Page 8 of 83

                            


                    

                    
                      


                  

                  
                    Revisado: 1 de mayo de 2017

                    

                     

                    

                    SALUD MENTAL

                  

                   

                  

                  	 	
                          Drug Name [Nombre del

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                          Límites]

                        
	 	
                          ANTIDEPRESSANTS [ANTIDEPRESIVOS]

                        
	 	
                          

                            

                        	Miscellaneous Antidepressants

                        
	 	[Antidepresivos Misceláneos]
	 	
                          bupropion hcl 75 mg tab          

                        	
                          1

                        	
                          Preferred

                        	
                          WELLBUTRIN

                        	 
	 	
                          bupropion hcl er (sr) 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr

                        	
                          1

                        	
                          Preferred

                        	
                          WELLBUTRIN SR

                        	 
	 	
                          escitalopram oxalate 5mg tab, 10 mg tab, 20 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          LEXAPRO

                        	 
	 	
                          mirtazapine 15 mg tab, 30 mg tab, 45 mg tab, 7.5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          REMERON

                        	 
	 	
                          trazodone hcl 100 mg tab, 150 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          DESYREL

                        	 
	 	
                          bupropion hcl 100 mg tab

                        	
                          2

                        	
                          Non-Preferred

                        	
                          WELLBUTRIN

                        	 
	 	
                          bupropion hcl er (xl) 150 mg tab er 24 hr, 300 mg tab er 24 hr

                        	
                          2

                        	
                          Non-Preferred

                        	
                          WELLBUTRIN XL

                        	 
	 	
                          mirtazapine 15 mg odt, 30 mg odt, 45 mg odt

                        	
                          3

                        	
                          Non-Preferred

                        	
                          REMERON

                        	 
	 	
                          Serotonin and/or Norepinephrine Modulators [Moduladores De Serotonina y/o Norepinefrina]

                        
	 	 
	 	
                          citalopram hydrobromide
                              10 mg tab, 20 mg tab, 40 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          CELEXA

                        	 
	 	
                          fluoxetine hcl 10 mg cap, 20 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          PROZAC

                        	 
	 	
                          paroxetine hcl 10 mg tab, 20 mg tab, 30 mg tab, 40 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          PAXIL

                        	 
	 	
                          sertraline hcl 100 mg tab, 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZOLOFT

                        	 
	 	
                          sertraline hcl oral concentrate 20 mg/ml

                        	
                          2

                        	
                          Non-Preferred

                        	
                          ZOLOFT

                        	 


                  

                  

                  
                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity
                      Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido]

                     

                    

                  

                  
                    
                      	
                               Page 9 of 83

                            


                    

                    
                      


                  

                  Revisado: 1 de mayo de 2017

                  

                   

                  

                  SALUD MENTAL

                   

                  

                  	 	
                          Drug Name [Nombre del

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                          Límites]

                        
	 	
                          venlafaxine hcl 100mg tab, 25mg tab, 37.5mg tab, 50mg tab, 75mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          EFFEXOR

                        	 
	 	
                          venlafaxine hcl er 150 mg cap er 24 hr, 37.5 mg cap er 24 hr, 75 mg cap er 24 hr

                        	
                          1

                        	
                          Preferred

                        	
                          EFFEXOR XR

                        	 
	 	
                          duloxetine 20 mg cap, 30 mg cap, 60 mg cap

                        	
                          2

                        	
                          Non-Preferred

                        	
                          CYMBALTA

                        	 
	 	
                          Tricyclic Agents [Tricíclicos]

                        
	 	
                          amitriptyline hcl 10 mg tab,  100 mg tab, 150 mg tab, 25 mg tab, 50
                                mg tab, 75 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ELAVIL

                        	 
	 	
                          doxepin hcl 10 mg cap, 10 mg/ml oral conc, 25 mg cap, 50 mg cap, 75 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          SINEQUAN

                        	 
	 	
                          imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TOFRANIL

                        	 
	 	
                          nortriptyline hcl 10 mg cap, 10 mg/5ml soln, 25 mg cap, 50 mg cap, 75 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          PAMELOR

                        	 
	 	
                          doxepin hcl 100 mg cap, 150 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          SINEQUAN

                        	 
	 	
                          ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]

                        
	 	
                          Anticholinergics [Anticolinérgicos]

                        
	 	
                          benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab

                        	
                          1

                        	
                            

                          Preferred

                        	
                          COGENTIN

                        	 
	 	
                          ANTIPSYCHOTICS [ANTIPSICÓTICOS]

                        
	 	
                          Atypical - Second Generation [Atípicos - Segunda Generación]

                        
	 	 	 	 	 	 
	 	
                          olanzapine 10 mg tab, 15 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZYPREXA

                        	 
	 	
                          quetiapine fumarate 25 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 


                  

                  

                  
                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity
                      Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido]

                  

                  

                  

                  
                    
                      	
                               Page 10 of 83

                            


                    

                    
                      


                  

                  
                    Revisado: 1 de mayo de 2017

                    

                     

                    

                    SALUD MENTAL

                  

                  

                  

                  	 	
                          Drug Name [Nombre del

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                          Límites]

                        
	 	
                          risperidone 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          RISPERDAL

                        	 
	 	
                          quetiapine fumarate 50 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          risperidone 1 mg/ml soln

                        	
                          2

                        	
                          Preferred

                        	
                          RISPERDAL

                        	 
	 	
                          quetiapine fumarate 100 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          LATUDA 120 mg tab, 20 mg tab, 40 mg tab, 60 mg tab, 80 mg tab

                        	
                          4

                        	
                          Preferred

                        	
                          PA

                        	
                          PA, P

                        
	 	
                          quetiapine fumarate 200 mg tab

                        	
                          4

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          quetiapine fumarate 300 mg tab

                        	
                          5

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          quetiapine fumarate 400 mg tab

                        	
                          6

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          aripriprazole 2 mg tab, 5 mg tab, 10 mg tab, 15 mg tab, 20 mg tab, 30 mg tab

                        	
                          7

                        	
                          Non-Preferred

                        	
                          ABILIFY

                        	
                          PA

                        
	 	
                          aripiprazole 1 mg/ml soln

                        	
                          10

                        	
                          Non-Preferred

                        	
                          ABILIFY

                        	
                          PA

                        
	 	
                          Typical - First Generation [Típicos - Primera Generación]

                        
	 	
                          fluphenazine hcl 1 mg tab,  10 mg tab, 2.5 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          PROLIXIN

                        	 
	 	
                          haloperidol 0.5 mg tab, 1 mg tab, 2 mg tab, 2 mg/ml oral conc

                        	
                          1

                        	
                          Preferred

                        	
                          HALDOL

                        	 
	 	
                          thioridazine hcl 10 mg tab, 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MELLARIL

                        	 
	 	
                          thiothixene 1 mg cap, 2 mg cap, 5 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          NAVANE

                        	 
	 	
                          trifluoperazine hcl mg tab, 2 mg tab, 5 mg tab, 10 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          STELAZINE

                        	 


                  

                  

                  
                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity
                      Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido]

                  

                  

                  

                  
                    
                      	
                               Page 11 of 83

                            


                    

                    
                      


                  

                  Revisado: 1 de mayo de 2017

                  

                   

                  

                  SALUD MENTAL

                  

                  

                  	 	
                          Drug Name [Nombre del

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                          Límites]

                        
	 	
                          chlorpromazine hcl 25 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          THORAZINE

                        	 
	 	
                          haloperidol 5 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          HALDOL

                        	 
	 	
                          haloperidol decanoate 50 mg/ml im soln

                        	
                          2

                        	
                          Preferred

                        	
                          HALDOL DECANOATE

                        	 
	 	
                          thioridazine hcl 100 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          MELLARIL

                        	 
	 	
                          thiothixene 10 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          NAVANE

                        	 
	 	
                          chlorpromazine hcl 100 mg tab, 50 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          THORAZINE

                        	 
	 	
                          haloperidol 10 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          HALDOL

                        	 
	 	
                          haloperidol decanoate 100 mg/ml im soln

                        	
                          3

                        	
                          Preferred

                        	
                          HALDOL DECANOATE

                        	 
	 	
                          chlorpromazine hcl 200 mg tab

                        	
                          4

                        	
                          Preferred

                        	
                          THORAZINE

                        	 
	 	
                          haloperidol 20 mg tab

                        	
                          4

                        	
                          Preferred

                        	
                          HALDOL

                        	 
	 	
                          MOOD STABILIZERS [ESTABILIZADORES DEL ÁNIMO]

                        
	 	
                           Bipolar Agents [Agentes Para Bipolaridad]

                        
	 	
                          divalproex sodium 125 mg  tab dr, 250 mg tab dr, 500 mg tab dr

                        	
                          1

                        	
                          Preferred

                        	
                          DEPAKOTE

                        	 
	 	
                          lamotrigine 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          LAMICTAL

                        	 
	 	
                          lamotrigine chew tab 5 mg, 25 mg

                        	
                          3

                        	
                          Non-Preferred

                        	
                          LAMICTAL

                        	 
	 	
                          lithium carbonate 150 mg cap, 300 mg cap, 300 mg tab, 600 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          LITHIUM

                        	 
	 	
                          lithium carbonate er 300 mg tab er, 450 mg tab er

                        	
                          1

                        	
                          Preferred

                        	
                          LITHIUM

                        	 
	 	
                          olanzapine 10 mg tab, 15 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZYPREXA

                        	 
	 	
                          quetiapine fumarate 25 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 


                  

                  

                  
                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity
                      Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido]

                  

                  

                  

                  
                    
                      	
                               Page 12 of 83

                            


                    

                    
                      


                  

                  
                    Revisado: 1 de mayo de 2017

                    

                     

                    

                    SALUD MENTAL

                  

                  

                  

                  	 	
                          Drug Name [Nombre del

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                          Límites]

                        
	 	
                          risperidone 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          RISPERDAL

                        	 
	 	
                          valproic acid 250 mg cap, 250 mg/5ml soln, 250 mg/5ml syr

                        	
                          1

                        	
                          Preferred

                        	
                          DEPAKENE

                        	 
	 	
                          quetiapine fumarate 50 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          risperidone 1 mg/ml soln

                        	
                          2

                        	
                          Preferred

                        	
                          RISPERDAL

                        	 
	 	
                          quetiapine fumarate 100 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          quetiapine fumarate 200 mg tab

                        	
                          4

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          quetiapine fumarate 300 mg tab

                        	
                          5

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          quetiapine fumarate 400 mg tab

                        	
                          6

                        	
                          Preferred

                        	
                          SEROQUEL

                        	 
	 	
                          aripriprazole 10 mg tab, 15 mg tab, 2 mg tab, 5 mg tab, 20 mg tab, 30 mg tab

                        	
                          7

                        	
                          Non-Preferred

                        	
                          ABILIFY

                        	
                          PA

                        
	 	
                          aripiprazole 1 mg/ml soln

                        	
                          10

                        	
                          Non-Preferred

                        	
                          ABILIFY

                        	
                          PA

                        
	 	
                          PSYCHOSTIMULANTS [PSICOESTIMULANTES]

                        
	 	
                           ADHD Amphetamines [Anfetaminas ADHD]

                        
	 	
                          amphetamine - dextroamphetamine 15 mg tab,
                              30 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          ADDERALL

                        	
                          AL 4-20años

                        
	 	
                          amphetamine- dextroamphetamine 10 mg tab, 12.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          ADDERALL

                        	
                          AL 4-20 años

                        
	 	
                          dextroamphetamine sulfate 10 mg tab, 5 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          DEXEDRINE

                        	
                          AL 4-20 años

                        
	 	
                          dextroamphetamine sulfate er 5 mg cap er 24 hr, 10 mg cap er 24 hr

                        	
                          4

                        	
                          Non-Preferred

                        	
                          DEXEDRINE SR

                        	
                          AL 4-20 años

                        


                  

                  

                  
                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity
                      Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido]

                     

                    

                  

                  
                    
                      	
                               Page 13 of 83

                            


                    

                    
                      


                  

                  
                    Revisado: 1 de mayo de 2017

                    

                     

                    

                    SALUD MENTAL

                  

                  

                  

                  	 	
                          Drug Name [Nombre del

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                          Límites]

                        
	 	
                          dextroamphetamine sulfate er 15 mg cap er 24 hr

                        	
                          5

                        	
                          Non-Preferred

                        	
                          DEXEDRINE SR

                        	
                          AL 4-20 años

                        
	 	
                          DYANAVEL XR oral susp. er 2.5 mg/ mL

                        	
                          4

                        	
                          Non-Preferred

                        	
                          DYANAVEL XR

                        	
                          PA, AL 6-20 años

                        
	 	
                          ADHD Non-Amphetamines [No-Anfetaminas ADHD]

                        
	 	
                          clonidine hcl 0.1 mg tab          

                        	
                          1

                        	
                          Preferred

                        	
                          CATAPRESS

                        	 
	 	
                          dexmethylphenidate hcl 2.5 mg tab, 5 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          FOCALIN

                        	
                          AL 6-20 años

                        
	 	
                          methylphenidate hcl 5 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          RITALIN

                        	
                          AL 6-20 años

                        
	 	
                          dexmethylphenidate hcl 10 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          FOCALIN

                        	
                          AL 6-20 años

                        
	 	
                          methylphenidate hcl 10 mg tab, 20 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          RITALIN

                        	
                          AL 6-20 años

                        
	 	
                          methylphenidate soln 5mg/5ml, 10 mg/5ml

                        	 	
                          Non-Preferred

                        	
                          METHYLIN

                        	 
	 	
                          STRATTERA 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap

                        	
                          4

                        	
                          Preferred

                        	 	
                          PA, AL 6-20 años, P

                        
	 	
                          SLEEP DISORDER AGENTS [DESORDENES DEL SUEÑO]

                        
	 	
                          

                          

                        	
                          Benzodiazepines [Benzodiazepinas]

                        
	 	
                          flurazepam hcl 15 mg cap,  30 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          DALMANE

                        	 
	 	
                          temazepam 15 mg cap, 30 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          RESTORIL

                        	 
	 	
                          Miscellaneous Sleep Disorder Agents [Agentes Misceláneos Desordenes Del Sueño]

                        
	 	
                          doxepin hcl 10 mg cap, 10  mg/ml oral
                                conc, 25 mg cap, 50 mg cap, 75 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          SINEQUAN

                        	 
	 	
                          zolpidem tartrate 10 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          AMBIEN

                        	 


                  

                  

                  
                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity
                      Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P –
                      Preferred Contracted Product [Producto Contratado Preferido]

                     

                    

                  

                  
                    
                      	
                               Page 14 of 83

                            


                    

                    
                      


                  

                  
                    
                      	
                              A

                            	 
	
                              ABILIFY

                            	
                              14, 17

                            
	
                              amitriptyline hcl

                            	
                              12

                            
	
                              amphetamine-dextroamphetamine

                            	
                              17

                            
	 	 
	
                              B

                            	 
	
                              b-1

                            	
                              9

                            
	
                              benztropine mesylate

                            	
                              13

                            
	
                              buprenorphine hcl

                            	
                              9

                            
	
                              bupropion hcl

                            	
                              10, 11

                            
	
                              bupropion hcl er (sr)

                            	
                              10

                            
	
                              bupropion hcl er (xl)

                            	
                              11

                            
	 	 
	
                              C

                            	 
	
                              chlorpromazine hcl 

                                  

                            	
                              14, 15

                            
	
                              citalopram hydrobromide

                            	
                              11

                            
	
                              clonazepam

                            	
                               9

                            
	
                              clonidine hcl

                            	
                              9, 18

                            
	 	 
	
                              D

                            	 
	
                              dexmethylphenidate hcl

                            	
                              18

                            
	
                              dextroamphetamine sulfate

                            	
                              18

                            
	
                              dextroamphetamine sulfate er

                            	
                              18

                            
	
                              diazepam

                            	
                              9, 10

                            
	
                              DIAZEPAM INTENSOL

                            	
                              10

                            
	
                              divalproex sodium

                            	
                              15

                            
	
                              doxepin hcl.

                            	
                              12, 19

                            
	
                              DYANAVEL XR

                            	
                              18

                            
	 	 
	
                              E

                            	 
	
                              escitalopram 

                                  

                            	
                              10

                            
	
                               

                            	 
	
                              F

                            	 
	
                              fluoxetine hcl

                            	
                              11

                            
	
                              fluphenazine hcl

                            	
                              14

                            
	
                              flurazepam hcl

                            	
                              19

                            
	
                              folic acid

                            	
                               9

                            
	 	 
	
                              H

                            	 
	
                              haloperidol

                            	
                              14, 15

                            
	
                              haloperidol decanoate

                            	
                              15

                            
	
                              hydroxyzine pamoate

                            	
                              10

                            


                    

                  

                  
                    
                      	
                              I

                            	 
	
                              Ibuprofen

                            	
                              9

                            
	
                              imipramine hcl

                            	
                              12

                            
	 	 
	
                              L

                            	 
	
                              lamotrigine

                            	
                              16

                            
	
                              lamotrigine chew tab

                            	
                              16

                            
	
                              LATUDA

                            	
                              13

                            
	
                              lithium carbonate

                            	
                              16

                            
	
                              lithium carbonate er

                            	
                              16

                            
	
                              loperamide hcl 

                                  

                            	
                              9

                            
	
                              lorazepam

                            	
                              10

                            
	 	 
	
                              M

                            	 
	
                              methylphenidate hcl

                            	
                              18

                            
	
                              methylphenidate soln

                            	
                              18

                            
	
                              mirtazapine 

                                  

                            	
                              10, 11

                            
	 	 
	
                              N

                            	 
	 	 
	
                              nortriptyline hcl

                            	
                              12

                            
	 	 
	
                              O

                            	 
	
                              olanzapine

                            	
                               13, 16

                            
	 	 
	
                              P

                            	 
	
                              paroxetine hcl

                            	
                              11

                            
	 	 
	
                              Q

                            	 
	
                              quetiapine fumarate

                            	
                               13, 14, 16, 17

                            
	 	 
	
                              R

                            	 
	
                              risperidone

                            	
                              13, 16, 17

                            
	 	 
	
                              S

                            	 
	
                              sertraline hcl

                            	
                              11

                            
	
                              sertraline hcl oral concentrate .

                            	
                              11

                            
	
                              STRATTERA 

                                  

                            	
                              19

                            
	
                              SUBOXONE

                            	
                               9

                            


                    

                  

                  

                  	
                           

                        


                  
                    
                      	
                               Page 15 of 83

                            


                    

                    
                      


                  

                  
                    
                      	
                              T

                            	 
	
                              temazepam

                            	
                              19

                            
	
                              thioridazine hcl

                            	
                               14, 15

                            
	
                              thiothixene 

                                  

                            	
                               14, 15

                            
	
                              trazodone hcl 

                                  

                            	
                              11

                            
	 	 
	
                              V

                            	 
	
                              valproic acid

                            	
                              16

                            
	
                               venlafaxine hcl 

                                  

                            	
                              12

                            
	
                              venlafaxine hcl er

                            	
                              12

                            
	 	 
	
                              Z

                            	 
	
                              zolpidem tartrate

                            	
                              19

                            


                    

                  

                  
                     

                  

                  
                    	
                             

                          


                  

                  
                    
                      	
                               Page 16 of 83

                            


                    

                    
                      


                  

                  ASES

                   

                    

                  Puerto Rico Healthcare Insurance Administration

                  

                  

                  Sub-formulary of

                   

                    

                  Physical Health

                   

                    

                  2017

                   

                    

                  Formulary of Drugs Covered by

                   

                    

                  the Government Healthcare Plan (GHP)

                  

                  

                  Authorized by the P.R. Elections Commission CEE-SA-16-2732

                   

                  

                  
                    
                      


                  

                  	
                          

                        	 	
                          GOVERNMENT OF PUERTO RICO

                        	 	
                          Hon. Ricardo A. Rosselló Nevares

                          Governor

                           

                          Ms. Ángela M. Ávila Marrero

                          Executive Director

                        
	 	
                          Healthcare Insurance Administration

                        
	 	
                          

                          

                        


                  

                  

                  May 1, 2017

                  

                  

                  TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

                  

                  

                  Dear provider:

                   

                    

                  I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its corresponding
                      sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

                   

                    

                  The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and Sub-physical. Moreover,
                      the Mental Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health Sub-formulary will be used
                      by participating primary care physicians (PCPs) in Primary Care Medical Groups.

                   

                    

                  The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare Insurance
                      Administration (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical aspects. The FDC
                      is a dynamic document that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

                   

                    

                  I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

                  

                  

                  Cordially,

                   

                    

                  [signed]

                  Ángela M. Ávila Marrero

                  Executive Director

                  

                  

                  
                    

                    

                  

                  
                    


                  

                  

                  PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                   

                  

                  
                    
                      


                  

                  GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

                   

                    

                  OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

                  

                  

                  
                    
                      	1.	
                              Drug Formulary

                            


                    

                  

                  

                  

                  The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and reviewing
                      the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee is
                      constituted by healthcare professionals, including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES for the
                      drug formulary based on scientific evidence, clinical aspects, and a cost-effectiveness analysis.

                  

                  

                  The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the prescription
                      drug coverage. The purpose of the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

                  

                  

                  ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator or PPA based
                      on the most recent clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

                  

                  

                  Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain in point
                      number 2.

                  

                  

                  
                    
                      	2.	
                              Exception Process

                            


                    

                  

                  

                  

                  In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as applicable,
                      insurance companies must use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

                  

                  

                  
                    
                      	

                            	a.	
                              Contraindication to the drug(s) included in the FDC;

                            


                    

                  

                  
                    
                      	

                            	b.	
                              History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                            


                    

                  

                  
                    
                      	

                            	c.	
                              Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                            


                    

                  

                  
                    
                      	

                            	d.	
                              Lack of a therapeutic alternative in the FDC.

                            


                    

                  

                  

                  

                  This exception process requires a clinical justification that is duly documented by the service provider with the clinical
                      reasons justifying the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

                   

                    

                  
                    
                      	3.	
                              Other Aspects of the Prescription Drug Coverage

                            


                    

                  

                  

                  

                  
                    
                      	

                            	A.	
                              The prescription drug coverage of the GHP establishes that using generic bioequivalent products
                                    as the first option is mandatory.

                            


                       

                      

                       

                       

                    

                  

                  
                    
                      	
                               Page 3 of 83

                            


                    

                    
                      


                  

                  
                    
                      	

                            	B.	
                              Insurance companies or the TPA (Third Party Administrator) and healthcare service providers
                                    will only process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	C.	
                              ASES has an active process to continually review the prescription drug coverage in accordnce
                                    with changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES
                                    may require that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will
                                    safeguard adequate access to services and maintain continuity of care.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	D.	
                              No entity contracted by ASES or by healthcare companies or organizations (for example, primary
                                    care medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES. Furthermore, they may
                                    not limit the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be responsible for supervising
                                    their providers and employees with regard to their compliance with these provisions.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	E.	
                              The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The
                                    treatment period may be extended, as applicable, when medically necessary.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	F.	
                              The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty
                                    (30) day therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating adherence
                                    and tolerance. The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case of narcotics,
                                    which will be dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms of adherence,
                                    tolerance, and dosage within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	G.	
                              ASES requires the use of generic bioequivalent drugs approved by the Food and Drug
                                    Adminitration (FDA) coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	H.	
                              The lack of appropriate bioequivalent drug inventories does not exempt providers from
                                    dispensing the prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the corresponding
                                    brand-name drug, unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception mechanism.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	I.	
                              Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized
                                    under the law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	J.	
                              The right to freedom of choice requires the availability of a pharmacy that is reasonably
                                    accessible to each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                            


                       

                      

                    

                  

                  
                    
                      	
                               Page 4 of 83

                            


                    

                    
                      


                  

                  Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or
                      when an electronic prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24
                      hours. If a drug is not available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her
                      physician to have the prescription sent to another pharmacy of his or her choice.

                  

                  

                  
                    
                      	K.	
                              Emergency Rule

                            


                    

                  

                  

                  

                  The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except
                      as otherwise specified.

                  

                  

                  The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will
                      also be dispensed in amounts sufficient for five (5) business days.

                  

                  

                  Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for
                      continuity of treatment, including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the
                      IEF.

                  

                  

                  

                  If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES
                      in your region and/or the Pharmacy Benefit Manager (PBM) contracted by ASES.

                   

                    

                  
                    
                      	
                               Page 5 of 83

                            


                    

                    
                      


                  

                   
                    	SUB FÍSICA	
                            

                            

                            

                          


                  

                   

                    

                  GOVERNMENT HEALTHCARE PLAN

                   

                    

                  FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

                   

                    

                  2017

                  

                  

                  TABLE OF CONTENTS

                  

                  

                  	
                          
                            GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE OF THE
                                GOVERNMENT HEALTHCARE PLAN

                          

                        	
                          3

                        
	
                          
                            DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                          

                        	11
	
                          MONTHLY NET COST RANGE

                        	12
	
                          GENERIC DRUGS

                        	
                          12

                        
	
                          ANALGESICS

                        	
                          13

                        
	
                          Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

                        	
                          13

                        
	
                          Short-Acting Opioid Analgesics

                        	
                          13

                        
	
                          ANESTHETICS

                        	
                          14

                        
	
                          Local Anesthetics

                        	
                          14

                        
	
                          ANTIBACTERIALS

                        	
                          14

                        
	
                          First Generation Cephalosporins

                        	
                          14

                        
	
                          Macrolides

                        	
                          14

                        
	
                          Miscellaneous Antibacterials

                        	
                          14

                        
	
                          Penicillins

                        	
                          15

                        
	
                          Quinolones

                        	
                          15

                        
	
                          Second Generation Cephalosporins

                        	
                          16

                        
	
                          Sulfonamides

                        	
                          16

                        
	
                          Third Generation Cephalosporins

                        	
                          16

                        
	
                          ANTICONVULSANTS

                        	
                          16

                        


                  

                  

                  
                    
                      	
                               Page 6 of 83

                            


                    

                    
                      


                  

                  
                    	SUB FÍSICA	
                            

                          


                  

                   

                  

                  	
                          Anticonvulsants

                        	
                          16

                        
	
                          ANTIDEMENTIA AGENTS

                        	
                          17

                        
	
                          Cholinesterase Inhibitors

                        	
                          17

                        
	
                          ANTIDEPRESSANTS

                        	
                          17

                        
	
                          Monoamine Oxidase (Mao) Inhibitors

                        	
                          17

                        
	
                          ANTIDIABETIC AGENTS

                        	
                          17

                        
	
                          Alpha-Glucosidase Inhibitors

                        	
                          17

                        
	
                          Biguanides

                        	
                          17

                        
	
                          Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors

                        	
                          18

                        
	
                          Insulin Mixtures

                        	
                          18

                        
	
                          Insulin Sensitizing Agents

                        	
                          18

                        
	
                          Intermediate-Acting Insulins

                        	
                          18

                        
	
                          Short-Acting Insulins

                        	
                          18

                        
	
                          Sulfonylureas

                        	
                          18

                        
	
                          ANTIEMETICS

                        	
                          18

                        
	
                          Miscellaneous Antiemetics

                        	
                          18

                        
	
                          Phenothiazines

                        	
                          18

                        
	
                          ANTIGOUT AGENTS

                        	
                          19

                        
	
                          Antigout Agents

                        	
                          19

                        
	
                          Uricosurics

                        	
                          19

                        
	
                          ANTIHYPERTENSIVES

                        	
                          19

                        
	
                          Alpha-Adrenergic Agonists

                        	
                          19

                        
	
                          Alpha-Adrenergic Blocking Agents

                        	
                          19

                        
	
                          Angiotensin II Receptor Blockers (Arb)

                        	
                          19

                        
	
                          Angiotensin-Converting Enzyme (Ace) Inhibitors

                        	
                          19

                        
	
                          Calcium Channel Blocking Agents

                        	
                          19

                        
	
                          Carbonic Anhydrase Inhibitors Diuretics

                        	
                          20

                        
	
                          Cardioselective Beta Blocking Agents

                        	
                          20

                        
	
                          Cardioselective Beta-Adrenergic Blocking Agents

                        	
                          20

                        
	
                          Loop Diuretics

                        	
                          20

                        
	
                          Nonselective Beta Blocking Agents

                        	
                          20

                        


                  

                  

                  
                    
                      	
                               Page 7 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                    

                    

                    

                    

                  

                  	
                          Potassium-Sparing Diuretics

                        	
                          21

                        
	
                          Thiazide Diuretics

                        	
                          21

                        
	
                          Vasodilator Beta Blockers

                        	
                          21

                        
	
                          Vasodilators

                        	
                          21

                        
	
                          ANTIMIGRAINE AGENTS

                        	
                          21

                        
	
                          Beta-Adrenergic Blocking Agents

                        	
                          21

                        
	
                          ANTIMYASTHENIC AGENTS

                        	
                          21

                        
	
                          Parasympathomimetics

                        	
                          21

                        
	
                          ANTIMYCOBACTERIALS

                        	
                          22

                        
	
                          Antituberculars

                        	
                          22

                        
	
                          ANTIPARASITICS

                        	
                          22

                        
	
                          Antimalarials

                        	
                          22

                        
	
                          ANTIPARKINSON AGENTS

                        	
                          22

                        
	
                          Antiparkinson Dopaminergics

                        	
                          22

                        
	
                          Dopamine Precursors

                        	
                          23

                        
	
                          Monoamine Oxidase B (Mao-B) Inhibitors

                        	
                          23

                        
	
                          ANTIVIRALS

                        	
                          23

                        
	
                          Anti-Cytomegalovirus (Cmv) Agents

                        	
                          23

                        
	
                          Antiherpetic Agents

                        	
                          23

                        
	
                          Anti-Influenza Agents

                        	
                          23

                        
	
                          BENIGN PROSTATIC HYPERTROPHY AGENTS

                        	
                          24

                        
	
                          Alpha-Adrenergic Blocking Agents

                        	
                          24

                        
	
                          BLOOD MODIFIERS

                        	
                          24

                        
	
                          Anticoagulants

                        	
                          24

                        
	
                          Colony Stimulating Factors

                        	
                          24

                        
	
                          Platelet Modifying Agents

                        	
                          24

                        
	
                          CARDIOVASCULAR AGENTS

                        	
                          24

                        
	
                          Antiarrhythmics Class II

                        	
                          24

                        
	
                          Antiarrhythmics Type I-A

                        	
                          25

                        
	
                          Antiarrhythmics Type I-B

                        	
                          25

                        
	
                          Antiarrhythmics Type I-C

                        	
                          25

                        


                  

                  

                  
                    
                      	
                               Page 8 of 83

                            


                    

                    
                      


                  

                  
                    	SUB FÍSICA	
                            

                          


                    

                  

                  	
                          Antiarrhythmics Type III

                        	
                          25

                        
	
                          Miscellaneous Cardiovascular Agents

                        	
                          25

                        
	
                          Vasodilators

                        	
                          25

                        
	
                          DENTAL AND ORAL AGENTS

                        	
                          26

                        
	
                          Antifungals

                        	
                          26

                        
	
                          DERMATOLOGICAL AGENTS

                        	
                          26

                        
	
                          Topical Antibiotics

                        	
                          26

                        
	
                          DYSLIPIDEMICS

                        	
                          26

                        
	
                          Bile Acid Sequestrants

                        	
                          26

                        
	
                          Fibric Acid Derivatives

                        	
                          26

                        
	
                          Hmg-Coa Reductase Inhibitors

                        	
                          26

                        
	
                          GASTROINTESTINAL AGENTS

                        	
                          27

                        
	
                          Histamine2 (H2) Receptor Antagonists

                        	
                          27

                        
	
                          Miscellaneous Gastrointestinal Agents

                        	
                          27

                        
	
                          Proton Pump Inhibitors

                        	
                          27

                        
	
                          GENITOURINARY AGENTS

                        	
                          27

                        
	
                          Miscellaneous Genitourinary Agents

                        	
                          27

                        
	
                          HORMONAL AGENTS

                        	
                          27

                        
	
                          Antithyroid Agents

                        	
                          27

                        
	
                          Calcimimetic Agents

                        	
                          27

                        
	
                          Dopamine Agonists

                        	
                          27

                        
	
                          Thyroid Hormones

                        	
                          27

                        
	
                          IMMUNOSUPPRESSANTS

                        	
                          28

                        
	
                          Glucocorticosteroids

                        	
                          28

                        
	
                          INFLAMMATORY BOWEL DISEASE

                        	
                          28

                        
	
                          Aminosalicylates

                        	
                          28

                        
	
                          Sulfonamides

                        	
                          28

                        
	
                          MINERALS & ELECTROLYTES

                        	
                          28

                        
	
                          MUSCLE RELAXANTS

                        	
                          28

                        
	
                          Antispasticity Agents

                        	
                          28

                        
	
                          Skeletal Muscle Relaxants

                        	
                          29

                        


                  

                  

                  
                    
                      	
                               Page 9 of 83

                            


                    

                    
                      


                  

                  
                    	SUB FÍSICA	
                            

                          


                    

                  

                  	
                          OPHTHALMIC AGENTS

                        	
                          29

                        
	
                          Antiglaucoma Agents

                        	
                          29

                        
	
                          Ophthalmic Antibiotics

                        	
                          29

                        
	
                          Ophthalmic Prostaglandins

                        	
                          29

                        
	
                          Ophthalmic Steroids

                        	
                          29

                        
	
                          OTIC AGENTS

                        	
                          30

                        
	
                          Miscellaneous Otic Agents

                        	
                          30

                        
	
                          Otic Antibiotics

                        	
                          30

                        
	
                          RESPIRATORY AGENTS

                        	
                          30

                        
	
                          Anticholinergic Bronchodilators

                        	
                          30

                        
	
                          Antileukotrienes

                        	
                          30

                        
	
                          Antitussive-Expectorant

                        	
                          30

                        
	
                          Inhaled Corticosteroids

                        	
                          30

                        
	
                          Sedating Histamine1 Blocking Agents

                        	
                          31

                        
	
                          Sympathomimetic Bronchodilators

                        	
                          31

                        


                   

                  

                  
                    
                      	
                               Page 10 of 83

                            


                    

                    
                      


                  

                  
                    	SUB FÍSICA	
                            

                          


                  

                   

                    

                  DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                  

                  

                  The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their safety
                      profile, proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

                   

                    

                  The example below illustrates the information provided for the drugs included in the FDC.

                   

                    

                  	 	
                          Drug Name

                        	
                          Net 

                          Cost

                        	
                          Tier

                        	
                          Reference Name

                        	
                          Requirements/ 

                          Limits

                        
	 	
                          THERAPEUTIC CATEGORY

                        
	 	
                          Therapeutic Class

                        
	

                        	
                          ANALGESICS

                        
	 	
                          Nonsteroidal Anti-Inflammatory Agents (NSAIDs)

                        
	 	
                          ibuprofen 400 mg tab, 600 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MOTRIN

                        	
                          QL = 5 days

                        
	 	
                          indomethacin 25 mg cap, 50 mg cap

                        	
                          1

                        	
                          Non-preferred

                        	
                          INDOCIN

                        	
                          QL = 5 days

                        
	 	
                          nabumetone 500 mg tab, 750 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          RELAFEN

                        	
                          QL = 5 days

                        
	 	
                          naproxen 250 mg tab, 375 mg tab, 500 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          NAPROSYN

                        	
                          QL = 5 days

                        
	 	
                          naproxen sodium 275 mg tab, 550 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ANAPROX

                        	
                          QL = 5 days

                        
	 	
                          salsalate 500 mg tab, 750 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          DISALCID

                        	
                          QL = 5 days

                        
	 	
                          indomethacin er 75 mg cap er

                        	
                          2

                        	
                          Non- preferred

                        	
                          INDOCIN

                        	
                          QL = 5 days

                        


                  

                  

                  For each drug included in the FDC, the First Column
                      shows the name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

                   

                    

                  The Second Column shows the Monthly Net Cost Range per
                      Average Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

                   

                    

                  
                    
                      	
                               Page 11 of 83

                            


                    

                    
                      


                  

                  
                    	SUB FÍSICA	
                            

                          


                  

                   

                    

                  MONTHLY NET COST RANGE

                   

                    

                  The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly net cost of
                      the therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy for thirty (30)
                      days. The cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost and must be
                      interpreted as follows:

                   

                    

                  	
                          1

                        	
                          less than $20

                        	
                          Least costly per month

                        
	
                          2

                        	
                          $20 - $49

                        	 
	
                          3

                        	
                          $50 - $99

                        	 
	
                          4

                        	
                          $100 - $199

                        	 
	
                          5

                        	
                          $200 - $349

                        	 
	
                          6

                        	
                          $350 - $549

                        	 
	
                          7

                        	
                          $550 - $799

                        	 
	
                          8

                        	
                          $800 - $1,099

                        	 
	
                          9

                        	
                          $1,100 - $1,499

                        	 
	
                          10

                        	
                          $1,500 - $1,999

                        	 
	
                          11

                        	
                          $2,000 - $2,499

                        	 
	
                          12

                        	
                          $2,500 - $2,999

                        	 
	
                          13

                        	
                          $3,000 - $3,499

                        	 
	
                          14

                        	
                          $3,500 - $3,999

                        	 
	
                          15

                        	
                          $4,000 - $4,499

                        	 
	
                          16

                        	
                          $4,500 - $4,999

                        	 
	
                          17

                        	
                          $5,000 - $5,499

                        	 
	
                          18

                        	
                          $5,500 - $5,999

                        	 
	
                          19

                        	
                          $6,000 - $6,499

                        	 
	
                          20

                        	
                          $6,500 - $6,999

                        	 
	
                          21

                        	
                          $7,000 - $7,499

                        	 
	
                          22

                        	
                          $7,500 - $7,999

                        	 
	
                          23

                        	
                          $8,000 - $8,499

                        	 
	
                          24

                        	
                          $8,500 - $9,000

                        	 
	
                          25

                        	
                          more than $9,000

                        	
                          Most costly per month

                        


                  

                  

                  We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic category (the
                      one with the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

                  

                  

                  The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of this edition
                      of the FDC.

                  

                  

                  GENERIC DRUGS

                  

                  Generic bioequivalent drugs are identified with lower-case
                        letters. Certain generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the generic product, but not the
                      brand-name product. The products selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

                   

                    

                  
                    
                      	
                               Page 12 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                          Límites]

                        
	 	
                          THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                        
	 	
                                    Therapeutic Class [Clase Terapéutica]

                        
	 	
                          ANALGESICS [ANALG ÉSICOS]

                        
	 	
                                    Nonsteroidal Anti-Inflammatory Agents (NSAIDs) [Anti-Inflamatorios No Esteroidales]

                        
	 	
                          ibuprofen 400 mg tab, 600  mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MOTRIN

                        	
                          QL=5 días

                        
	 	
                          nabumetone 500 mg tab, 750 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          RELAFEN

                        	
                          QL=5 días

                        
	 	
                          naproxen 250 mg tab, 375 mg tab, 500 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          NAPROSYN

                        	
                          QL=15 días No repeticiones 

                        
	 	
                          salsalate 500 mg tab, 750 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          DISALCID

                        	
                          QL=5 días

                        
	 	
                          indomethacin 25 mg cap, 50 mg cap

                        	
                          1

                        	
                          Non-Preferred

                        	
                          INDOCIN

                        	 
	 	
                          Short-Acting Opioid Analgesics [Analgésicos Opiodes De Corta Duración]

                        
	 	
                          acetaminophen -codeine 120-12 mg/5ml soln, 300-15 mg tab, 300-30 mg tab, 300-

                          60 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TYLENOL-

                          CODEINE

                        	
                          QL=5 días

                        
	 	
                          acetaminophen-codeine #2 300-15 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TYLENOL-

                          CODEINE

                        	
                          QL=5 días

                        
	 	
                          acetaminophen-codeine #3 300-30 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TYLENOL-

                          CODEINE

                        	
                          QL=5 días

                        
	 	
                          acetaminophen-codeine #4 300-60 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TYLENOL-

                          CODEINE

                        	
                          QL=5 días

                        
	 	
                          butalbital-apap-caffeine 50325-40 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          FIORICET

                        	
                          QL=5 días

                        
	 	
                          tramadol hcl 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ULTRAM

                        	
                          QL=5 días

                        
	 	
                          butalbital-apap-caffeine 50325-40 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          FIORICET

                        	
                          QL=5 días

                        
	 	
                          margesic 50-325-40 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          FIORICET

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 13 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          ANESTHETICS [ANESTÉSICOS]

                        
	 	
                           Local Anesthetics
                              [Anestésicos Locales]

                        
	 	
                           lidocaine viscous 2 % mouth/throat soln

                           

                        	
                          1

                           

                           

                           

                        	
                          Preferred

                           

                           

                           

                        	
                           

                          XYLOCAINE

                        	
                          QL=5 días

                            

                        
	 	
                          ANTIBACTERIALS [ANTIBACTERIANOS]

                        
	 	
                          First Generation Cephalosporins [Cefalosporinas De Primera Generación]

                        
	 	
                          cephalexin 125 mg/5ml  susp, 250 mg cap, 500 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          KEFLEX

                        	
                          QL=5 días

                        
	 	
                          cefadroxil 250 mg/5ml susp

                        	
                          2

                        	
                          Non-Preferred

                        	
                          DURICEF

                        	
                          QL=5 días, AL 012 años

                        
	 	
                          cephalexin 250 mg/5ml susp

                        	
                          2

                        	
                          Preferred

                        	
                          KEFLEX

                        	
                          QL=5 días

                        
	 	
                          cefadroxil 500 mg/5ml susp

                        	
                          3

                        	
                          Non-Preferred

                        	
                          DURICEF

                        	
                          QL=5 días, AL 0-12 años

                        
	 	
                          Macrolides [Macrólidos]

                        
	 	
                          azithromycin 250 mg tab,  500 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZITHROMAX

                        	
                          QL=5 días

                        
	 	
                          azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          ZITHROMAX

                        	
                          QL=5 días

                        
	 	
                          clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          BIAXIN

                        	
                          QL=5 días

                        
	 	
                          clarithromycin 250 mg/5ml susp

                        	
                          3

                        	
                          Preferred

                        	
                          BIAXIN

                        	
                          QL=5 días

                        
	 	
                          erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          ERY-TAB

                        	
                          QL=5 días

                        
	 	
                          erythromycin ethylsuccinate 400 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          E.E.S.

                        	
                          QL=5 días

                        
	 	
                          ERYTHROCIN STEARATE

                          250 mg tab

                        	
                          4

                        	
                          Non-Preferred

                        	 	
                          QL=5 días

                        
	 	
                          Miscellaneous Antibacterials [Antibacterianos Misceláneos]

                        
	 	
                          clindamycin hcl 150 mg cap,  300 mg cap, 75 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          CLEOCIN

                        	
                          QL=5 días

                        
	 	
                          MACRODANTIN 25 mg cap

                        	
                          1

                        	
                          Preferred

                        	 	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite
                          de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                    

                  

                  
                    
                      	
                               Page 14 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Cost

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          metronidazole 250 mg tab, 500 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          FLAGYL

                        	
                          QL=5 días

                        
	 	
                          nitrofurantoin macrocrystal 50 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          MACRODANTIN

                        	
                          QL=5 días

                        
	 	
                          nitrofurantoin macrocrystal 100 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          MACRODANTIN

                        	
                          QL=5 días

                        
	 	
                          nitrofurantoin monohyd macro 100 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          MACROBID

                        	
                          QL=5 días

                        
	 	 	
                          Penicillins [Penicilinas]

                        
	 	
                          amoxicillin 125 mg/5ml susp,  200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml
                                susp, 500 mg cap, 500 mg tab, 875 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          AMOXIL

                        	
                          QL=5 días

                        
	 	
                          amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp,
                              500-125 mg tab, 600-42.9 mg/5ml susp, 875-125 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          AUGMENTIN

                        	
                          QL=5 días

                        
	 	
                          ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          PRINCIPEN

                        	
                          QL=5 días

                        
	 	
                          penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg
                              tab

                        	
                          1

                        	
                          Preferred

                        	
                          VEETIDS

                        	
                          QL=5 días

                        
	 	
                          amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp

                        	
                          3

                        	
                          Preferred

                        	
                          AUGMENTIN

                        	
                          QL=5 días

                        
	 	 	
                          Quinolones [Quinolonas]

                        
	 	
                          ciprofloxacin hcl 250 mg tab,  500 mg tab, 750 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          CIPRO

                        	
                          QL=5 días

                        
	 	
                          levofloxacin 250 mg tab, 500 mg tab, 750 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          LEVAQUIN

                        	
                          QL=5 días

                        
	 	
                          ciprofloxacin 500 mg/5ml (10%) susp

                        	
                          3

                        	
                          Preferred

                        	
                          CIPRO

                        	
                          QL=5 días

                        
	 	
                          ciprofloxacin 250 mg/5ml (5%) susp

                        	
                          4

                        	
                          Preferred

                        	
                          CIPRO

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 15 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          Second Generation Cephalosporins [Cefalosporinas De Segunda Generación]

                        
	 	
                          cefaclor 250 mg cap, 500  mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          CECLOR

                        	
                          QL=5 días

                        
	 	
                          cefprozil 125 mg/5ml susp, 250 mg tab, 250 mg/5ml susp, 500 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          CEFZIL

                        	
                          QL=5 días

                        
	 	
                          Sulfonamides [Sulfonamidas]

                        
	 	
                          sulfamethoxazole-tmp ds 800-160 mg tab

                        	
                          1

                        	
                            

                          Preferred

                        	
                          SEPTRA

                        	
                          QL=5 días

                        
	 	
                          sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          SEPTRA

                        	
                          QL=5 días

                        
	 	
                          Third Generation Cephalosporins [Cefalosporinas De Tercera Generación]

                        
	 	
                          cefdinir 125 mg/5ml susp,  300 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          OMNICEF

                        	
                          QL=5 días

                        
	 	
                          cefdinir 250 mg/5ml susp

                        	
                          3

                        	
                          Preferred

                        	
                          OMNICEF

                        	
                          QL=5 días

                        
	 	
                          ANTICONVULSANTS [ANTICONVULSIVANTES]

                        
	 	
                           Anticonvulsants
                              [Anticonvulsivantes]

                        
	 	
                          carbamazepine 100 mg tab  chew, 200 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TEGRETOL

                        	
                          QL=5 días

                        
	 	
                          gabapentin 100 mg cap, 300 mg cap, 400 mg cap, 600 mg tab, 800 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          NEURONTIN

                        	
                          QL=5 días

                        
	 	
                          levetiracetam 250 mg tab, 500 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          KEPPRA

                        	
                          QL=5 días

                        
	 	
                          oxcarbazepine 150 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TRILEPTAL

                        	
                          QL=5 días

                        
	 	
                          phenobarbital 100 mg tab, 15 mg tab, 16.2 mg tab, 30 mg tab, 32.4 mg tab, 60 mg tab, 64.8 mg tab, 97.2 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          PHENOBARBITAL

                        	
                          QL=5 días

                        
	 	
                          primidone 250 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MYSOLINE

                        	
                          QL=5 días

                        
	 	
                          topiramate 100 mg tab, 200 mg tab, 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TOPAMAX

                        	
                          QL=5 días

                        
	 	
                          DILANTIN 30 mg cap

                        	
                          2

                        	
                          Preferred

                        	 	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                    

                  

                  
                    
                      	
                               Page 16 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/

                           Límites]

                        
	 	
                          levetiracetam 1000 mg tab, 750 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          KEPPRA

                        	
                          QL=5 días

                        
	 	
                          oxcarbazepine 300 mg tab, 600 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          TRILEPTAL

                        	
                          QL=5 días

                        
	 	
                          phenytoin 125 mg/5ml susp, 50 mg tab chew

                        	
                          2

                        	
                          Preferred

                        	
                          DILANTIN

                        	
                          QL=5 días

                        
	 	
                          phenytoin sodium extended

                          100 mg cap, 200 mg cap,

                          300 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          DILANTIN

                        	
                          QL=5 días

                        
	 	
                          phenytoin sodium extended

                          100 mg cap, 200 mg cap,

                          300 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          DILANTIN

                        	
                          QL=5 días

                        
	 	
                          ethosuximide 250 mg cap, 250 mg/5ml soln

                        	
                          3

                        	
                          Preferred

                        	
                          ZARONTIN

                        	
                          QL=5 días

                        
	 	
                          phenobarbital 20 mg/5ml oral elix, 20 mg/5ml soln

                        	
                          3

                        	
                          Preferred

                        	
                          PHENOBARBITAL

                        	
                          QL=5 días

                        
	 	
                          ANTIDEMENTIA AGENTS [AGENTES ANTIDEMENCIA]

                        
	 	
                           Cholinesterase
                              Inhibitors [Inhibidores De Colinesterasa]

                        
	 	
                          donepezil hcl 10 mg tab, 5  mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ARICEPT

                        	
                          QL=5 días

                        
	 	
                          rivastigmine tartrate 1.5 mg cap, 3 mg cap, 4.5 mg cap, 6 mg cap

                        	
                          3

                        	
                          Preferred

                        	
                          EXELON

                        	
                          QL=5 días

                        
	 	
                          ANTIDEPRESSANTS [ANTIDEPRESIVOS]

                        
	 	
                           Monoamine Oxidase (Mao)
                              Inhibitors [Inhibidores De Mao]

                        
	 	
                          selegiline  hcl 5 mg tab

                        	
                          3

                        	
                          Non-Preferred

                        	
                          CARBEX

                        	
                          QL=5 días

                        
	 	
                          ANTIDIABETIC AGENTS [AGENTES ANTIDIABÉTICOS]

                        
	 	
                                    Alpha-Glucosidase Inhibitors [Inhibidores De Alfa Glucosidasa]

                        
	 	
                          acarbose 100 mg tab, 25 mg  tab, 50 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          PRECOSE

                        	
                          QL=5 días

                        
	 	
                          Biguanides [Biguanidas]

                        
	 	
                          metformin hcl 1000 mg tab,  500 mg tab, 850 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          GLUCOPHAGE

                        	
                          QL=5 días

                        


                  
                     

                      

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative
                        Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL –
                        Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto
                        mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] 

                     

                      

                  

                  
                    
                      	
                               Page 17 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors [Inhibidores De Dpp-4]

                        
	 	
                          KOMBIGLYZE XR 2.5          -1000 mg tab er 24 hr, 5-1000 mg tab er
                              24 hr, 5-500 mg tab er 24 hr

                        	
                          3

                        	
                          Preferred

                        	 	
                          QL=5 días, ST, P

                        
	 	
                          ONGLYZA 2.5 mg tab, 5 mg tab

                        	
                          3

                        	
                          Preferred

                        	 	
                          QL=5 días, ST, P

                        
	 	
                          Insulin Mixtures [Mezclas De Insulinas]

                        
	 	
                          HUMULIN 70/30 (70          -30) 100 unit/ml sc susp

                        	
                          2

                        	
                          Preferred

                        	 	
                          QL= 1 vial / 30 días, P

                        
	 	
                          Insulin Sensitizing Agents [Agentes Sensibilizantes De Insulin]

                        
	 	
                          pioglitazone hcl 15 mg tab,  30 mg tab, 45 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ACTOS

                        	
                          QL=5 días

                        
	 	
                          Intermediate-Acting Insulins [Insulinas De Duración Intermedia]

                        
	 	
                          HUMULIN N 100 unit/ml sc  QL= 1 vial / susp
                              2 Preferred  30 días, P

                        
	 	
                          Short-Acting Insulins [Insulinas De Corta Duración]

                        
	 	
                          HUMULIN R 100 unit/ml inj  soln

                        	
                          2

                        	
                          Preferred

                        	 	
                          QL= 1 vial / 30 días, P

                        
	 	
                          Sulfonylureas [Sulfonilureas]

                        
	 	
                          glimepiride 1 mg tab, 2 mg  tab, 4 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          AMARYL

                        	
                          QL=5 días

                        
	 	
                          glipizide 10 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          GLUCOTROL

                        	
                          QL=5 días

                        
	 	
                          ANTIEMETICS [ANTIEMÉTICOS]

                        
	 	
                           Miscellaneous
                              Antiemetics [Antieméticos Misceláneos]

                        
	 	
                          metoclopramide hcl 10 mg  tab, 5 mg tab, 5 mg/ml inj soln

                        	
                          1

                        	
                          Preferred

                        	
                          REGLAN

                        	
                          QL=5 días

                        
	 	
                          trimethobenzamide hcl 300 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          TIGAN

                        	
                          QL=5 días

                        
	 	
                          Phenothiazines [Fenotiazinas]

                        
	 	
                          prochlorperazine maleate 10  mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          COMPAZINE

                        	
                          QL=5 días

                        
	 	
                          prochlorperazine 25 mg rect supp

                        	
                          4

                        	
                          Non-Preferred

                        	
                          COMPAZINE

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 18 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          ANTIGOUT AGENTS [AGENTES ANTIGOTA]

                        
	 	
                           Antigout Agents [Agentes
                              Antigota]

                        
	 	
                          allopurinol 100 mg tab, 300  mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZYLOPRIM

                        	
                          QL=5 días

                        
	 	
                          colchicine 0.6 mg cap

                        	
                          3

                        	
                          Preferred

                        	
                          MITIGARE

                        	
                          PA

                        
	 	
                          colchicine 0.6 mg tab

                        	
                          3

                        	
                          Non-Preferred

                        	
                          COLCRYS

                        	
                          QL= 3 tab, 15días

                        
	 	
                          Uricosurics [Uricosúricos]

                        
	 	
                          probenecid 500 mg tab          

                        	
                          1

                        	
                          Preferred

                        	
                          BENEMID

                        	
                          QL=5 días

                        
	 	
                          ANTIHYPERTENSIVES [ANTIHIPERTENSIVOS]

                        
	 	
                           Alpha-Adrenergic
                              Agonists [Agonistas Alfa Adrenérgicos]

                        
	 	
                          clonidine hcl 0.2 mg tab, 0.3  mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          CATAPRESS

                        	
                          QL=5 días

                        
	 	
                          methyldopa 250 mg tab, 500 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ALDOMET

                        	
                          QL=5 días

                        
	 	
                          Alpha-Adrenergic Blocking Agents [Bloqueadores Alfa Adrenérgicos]

                        
	 	
                          terazosin hcl 1 mg cap, 10  mg cap, 2 mg cap, 5 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          HYTRIN

                        	
                          QL=5 días

                        
	 	
                          Angiotensin II Receptor Blockers (Arb) [Antagonistas Del Receptor Angiotensina II]

                        
	 	
                          losartan potassium           100 mg tab, 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          COZAAR

                        	
                          QL=5 días

                        
	 	
                          losartan potassium-hctz 100-12.5 mg tab, 100-25 mg

                          tab, 50-12.5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          HYZAAR

                        	
                          QL=5 días

                        
	 	
                          Angiotensin-Converting Enzyme (Ace) Inhibitors [Inhibidores De La Enzima Convertidora De

                          Angiotensin]

                        
	 	
                          lisinopril 10 mg tab, 2.5 mg  tab, 20 mg tab, 30 mg tab, 40 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZESTRIL

                        	
                          QL=5 días

                        
	 	
                          lisinopril-hydrochlorothiazide 10-12.5 mg tab, 20-12.5 mg tab, 20-25 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZESTORETIC

                        	
                          QL=5 días

                        
	 	
                          Calcium Channel Blocking Agents [Bloqueadores De Canales De Calcio]

                        
	 	
                          amlodipine besylate 10 mg  tab, 2.5 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          NORVASC

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 19 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          diltiazem hcl 120 mg tab, 30 mg tab, 60 mg tab, 90 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          CARDIZEM

                        	
                          QL=5 días

                        
	 	
                          verapamil hcl 120 mg tab, 40 mg tab, 80 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          CALAN

                        	
                          QL=5 días

                        
	 	
                          Carbonic Anhydrase Inhibitors Diuretics [Diuréticos Inhibidores De Anhidrasa Carbónica]

                        
	 	
                          acetazolamide 125 mg tab,  250 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          DIAMOX

                        	
                          QL=5 días

                        
	 	
                          Cardioselective Beta Blocking Agents [Bloqueadores Beta Cardioselectivos]

                        
	 	
                          atenolol 100 mg tab,           25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TENORMIN

                        	
                          QL=5 días

                        
	 	
                          metoprolol succinate er 25 mg tab er 24 hr, 50 mg tab er 24 hr

                        	
                          1

                        	
                          Preferred

                        	
                          LOPRESSOR

                        	
                          QL=5 días

                        
	 	
                          metoprolol tartrate 100 mg tab, 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          LOPRESSOR

                        	
                          QL=5 días

                        
	 	
                          metoprolol succinate er 100 mg tab er 24 hr, 200 mg tab er 24 hr

                        	
                          2

                        	
                          Preferred

                        	
                          LOPRESSOR

                        	
                          QL=5 días

                        
	 	
                          Cardioselective Beta-Adrenergic Blocking Agents [Bloqueadores Beta-Adrenérgicos

                          Cardioselectivos]

                        
	 	
                          atenolol          -chlorthalidone 10025 mg tab, 50-25 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TENORETIC

                        	
                          QL=5 días

                        
	 	
                          metoprolol-

                          hydrochlorothiazide 50-25 mg tab

                        	
                          2

                        	
                          Non-Preferred

                        	
                          LOPRESSOR HCT

                        	
                          QL=5 días

                        
	 	
                          metoprolol-

                          hydrochlorothiazide 100-25 mg tab, 100-50 mg tab

                        	
                          3

                        	
                          Non-Preferred

                        	
                          LOPRESSOR HCT

                        	
                          QL=5 días

                        
	 	
                          Loop Diuretics [Diuréticos Del Asa]

                        
	 	
                          furosemide 10 mg/ml soln,  20 mg tab, 40 mg tab, 80 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          LASIX

                        	
                          QL=5 días

                        
	 	
                          Nonselective Beta Blocking Agents [Bloqueadores Beta No-Selectivos]

                        
	 	
                          propranolol hcl 10 mg tab,  20 mg tab, 40 mg tab, 80 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          INDERAL

                        	
                          QL=5 días

                        
	 	
                          propranolol hcl 60 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          INDERAL

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                          

                        

                  

                  
                    
                      	
                               Page 20 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          Potassium-Sparing Diuretics [Diuréticos Conservadores De Potasio]

                        
	 	
                          spironolactone 100 mg tab,  25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ALDACTONE

                        	
                          QL=5 días

                        
	 	
                          triamterene-hctz 37.5-25 mg cap, 37.5-25 mg tab, 75-50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MAXZIDE

                        	
                          QL=5 días

                        
	 	
                          Thiazide Diuretics [Diuréticos Tiazidas]

                        
	 	
                          chlorothiazide 250 mg tab,  500 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          DIURIL

                        	
                          QL=5 días

                        
	 	
                          chlorthalidone 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          HYGROTON

                        	
                          QL=5 días

                        
	 	
                          DIURIL 250 mg/5ml susp

                        	
                          1

                        	
                          Preferred

                        	 	
                          QL=5 días

                        
	 	
                          hydrochlorothiazide 12.5 mg tab, 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MICROZIDE

                        	
                          QL=5 días

                        
	 	
                          indapamide 1.25 mg tab, 2.5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          LOZOL

                        	
                          QL=5 días

                        
	 	
                          metolazone 2.5 mg tab, 5 mg tab

                        	
                          1

                        	
                          Non-Preferred

                        	
                          ZAROXOLYN

                        	
                          QL=5 días

                        
	 	
                          chlorthalidone 100 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          HYGROTON

                        	
                          QL=5 días

                        
	 	
                          metolazone 10 mg tab

                        	
                          2

                        	
                          Non-Preferred

                        	
                          ZAROXOLYN

                        	
                          QL=5 días

                        
	 	
                          Vasodilator Beta Blockers [Bloqueadores Beta Vasodilatadores]

                        
	 	
                          carvedilol 12.5 mg tab, 25  mg tab, 3.125 mg tab, 6.25 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          COREG

                        	
                          QL=5 días

                        
	 	
                          Vasodilators [Vasodilatadores]

                        
	 	
                          hydralazine hcl 10 mg tab,  100 mg tab, 25 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          APRESOLINE

                        	
                          QL=5 días

                        
	 	
                          ANTIMIGRAINE AGENTS [AGENTES ANTIMIGRAÑA]

                        
	 	
                           Beta-Adrenergic Blocking
                              Agents [Bloqueadores Beta Adrenérgicos]

                        
	 	
                          topiramate 100 mg tab, 200  mg tab, 25 mg tab, 50 mg

                          tab 1 Preferred TOPAMAX QL=5 días

                        
	 	
                          ANTIMYASTHENIC AGENTS [AGENTES ANTIMIASTÉNICOS]

                        
	 	
                           Parasympathomimetics
                              [Parasimpatomiméticos]

                        
	 	
                          pyridostigmine bromide 60  mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          MESTINON

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 21 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          pyridostigmine bromide 180 mg tab er

                        	
                          6

                        	
                          Non-Preferred

                        	
                          MESTINON

                        	 
	 	
                          ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]

                        
	 	
                           Antituberculars
                              [Antituberculosos]

                        
	 	
                          isoniazid 100 mg tab, 300  mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ISONIAZID

                        	
                          QL=5 días

                        
	 	
                          rifampin 150 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          RIFADIN

                        	
                          QL=5 días

                        
	 	
                          pyrazinamide 500 mg tab

                        	
                          2

                        	
                          Non-Preferred

                        	
                          PYRAZINAMIDE

                        	
                          QL=5 días

                        
	 	
                          rifampin 300 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          RIFADIN

                        	
                          QL=5 días

                        
	 	
                          isoniazid 50 mg/5ml syr

                        	
                          5

                        	
                          Non-Preferred

                        	
                          ISONIAZID

                        	
                          QL=5 días

                        
	 	
                          rifabutin 150 mg cap

                        	 	 	
                          MYCOBUTIN

                        	
                          Puerto Rico Health

                          Department

                          Tuberculosis Program

                        
	 	
                          cycloserine 250 mg cap

                        	 	 	
                          SEROMYCIN

                        
	 	
                          CAPASTAT SULFATE 1 gm inj

                        	 	 	 
	 	
                          RIFAMATE 150-300 mg cap

                        	 	 	 
	 	
                          TRECATOR 250 mg tab

                        	 	 	 
	 	
                          ANTIPARASITICS [ANTIPARASITARIOS]

                        
	 	
                           Antimalarials
                              [Antimaláricos]

                        
	 	
                          chloroquine phosphate 250  mg tab, 500 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ARALEN

                        	
                          QL=5 días

                        
	 	
                          hydroxychloroquine sulfate 200 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          PLAQUENIL

                        	
                          QL=5 días

                        
	 	
                          DARAPRIM 25 mg tab

                        	
                          7

                        	
                          Non-Preferred

                        	 	
                          QL=5 días

                        
	 	
                          ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]

                        
	 	
                           Antiparkinson
                              Dopaminergics [Dopaminérgicos Antiparkinson]

                        
	 	
                          amantadine hcl 50 mg/5ml  syr

                        	
                          1

                        	
                          Preferred

                        	
                          SYMMETREL

                        	
                          QL=5 días

                        
	 	
                          pramipexole dihydrochloride 0.125 mg tab, 0.25 mg tab, 0.5 mg tab, 0.75 mg tab, 1 mg tab, 1.5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MIRAPEX

                        	
                          QL=5 días

                        
	 	
                          ropinirole hcl 0.25 mg tab, 0.5 mg tab, 1 mg tab, 3 mg tab, 4 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          REQUIP

                        	
                          QL=5 días

                        
	 	
                          ropinirole hcl 2 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          REQUIP

                        	
                          QL=5 días

                        
	 	
                          amantadine hcl 100 mg cap

                        	
                          3

                        	
                          Preferred

                        	
                          SYMMETREL

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9  para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 22 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          bromocriptine mesylate 2.5 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          PARLODEL

                        	
                          QL=5 días

                        
	 	
                          carbidopa-levodopaentacapone 18.75-75-200 mg tab

                        	
                          4

                        	
                          Non-Preferred

                        	
                          STALEVO

                        	
                          QL=5 días

                        
	 	
                          carbidopa-levodopaentacapone 12.5-50-200 mg tab, 25-100-200 mg tab, 31.25-125-200 mg tab, 37.5150-200 mg tab,
                              50-200-200 mg tab

                        	
                          5

                        	
                          Non-Preferred

                        	
                          STALEVO

                        	
                          QL=5 días

                        
	 	
                          Dopamine Precursors [Precursores De Dopamina]

                        
	 	
                          carbidopa          -levodopa 10-100 mg tab, 25-100 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          SINEMET

                        	
                          QL=5 días

                        
	 	
                          carbidopa-levodopa 25-250 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          SINEMET

                        	
                          QL=5 días

                        
	 	
                          carbidopa-levodopa er 25100 mg tab er, 50-200 mg tab er

                        	
                          2

                        	
                          Preferred

                        	
                          SINEMET CR

                        	
                          QL=5 días

                        
	 	
                          Monoamine Oxidase B (Mao-B) Inhibitors [Inhibidores De Mao-B]

                        
	 	
                          selegiline hcl 5 mg tab          

                        	
                          3

                        	
                          Preferred

                        	
                          CARBEX

                        	
                          QL=5 días

                        
	 	
                          ANTIVIRALS [ANTIVIRALES]

                        
	 	
                           Anti-Cytomegalovirus
                              (Cmv) Agents [Agentes Anti-Citomegalovirus]

                        
	 	
                          valganciclovir hcl 450 mg  tab

                        	
                          13

                        	
                          Non-Preferred

                        	
                          VALCYTE

                        	
                          PA, QL=5 días

                        
	 	
                          Antiherpetic Agents [Agentes Antiherpéticos]

                        
	 	
                          acyclovir 200 mg cap, 400  mg tab, 800 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZOVIRAX

                        	
                          QL=5 días

                        
	 	
                          acyclovir 200 mg/5ml susp

                        	
                          2

                        	
                          Preferred

                        	
                          ZOVIRAX

                        	
                          QL=5 días

                        
	 	
                          Anti-Influenza Agents [Agentes Antiinfluenza]

                        
	 	
                          amantadine hcl 50 mg/5ml  syr

                        	
                          1

                        	
                          Preferred

                        	
                          SYMMETREL

                        	
                          QL=5 días

                        
	 	
                          amantadine hcl 100 mg cap

                        	
                          3

                        	
                          Preferred

                        	
                          SYMMETREL

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net
                          Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product
                          [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 23 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          BENIGN PROSTATIC HYPERTROPHY AGENTS [AGENTES PARA HIPERTROFIA

                          PROSTÁTICA BENIGNA]

                        
	 	
                           Alpha-Adrenergic
                              Blocking Agents [Bloqueadores Alfa Adrenérgicos]

                        
	 	
                          terazosin hcl 1 mg cap, 10  mg cap, 2 mg cap, 5 mg cap

                        	
                          1

                        	
                          Preferred

                        	
                          HYTRIN

                        	
                          QL=5 días

                        
	 	
                          BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]

                        
	 	
                           Anticoagulants
                              [Anticoagulantes]

                        
	 	
                          warfarin sodium 1 mg tab,  10 mg tab, 2 mg tab, 2.5 mg tab, 3 mg tab, 4 mg tab, 5 mg
                                tab, 6 mg tab, 7.5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          COUMADIN

                        	
                          QL=5 días

                        
	 	
                          heparin sodium (porcine) 1000 unit/ml inj soln

                        	
                          2

                        	
                          Preferred

                        	
                          HEPARIN

                        	
                          QL=5 días

                        
	 	
                          heparin sodium (porcine) 10000 unit/ml inj soln, 5000 unit/ml inj soln

                        	
                          3

                        	
                          Preferred

                        	
                          HEPARIN

                        	
                          QL=5 días

                        
	 	
                          heparin sodium (porcine) pf 5000 unit/0.5ml inj soln

                        	
                          3

                        	
                          Preferred

                        	
                          HEPARIN

                        	
                          QL=5 días

                        
	 	
                          heparin sodium (porcine) 2000 unit/ml iv soln

                        	
                          8

                        	
                          Preferred

                        	
                          HEPARIN

                        	
                          QL=5 días

                        
	 	
                          Colony Stimulating Factors [Estimulantes Mieloides]

                        
	 	
                          NEULASTA 6 mg/0.6ml sc  soln

                        	
                          12

                        	
                          Preferred

                        	 	
                          PA, QL=5 días, P

                        
	 	
                          NEULASTA DELIVERY KIT

                          6 mg/0.6ml sc soln

                        	
                          12

                        	
                          Preferred

                        	 	
                          PA, QL=5 días, P

                        
	 	
                          Platelet Modifying Agents [Modificadores De Plaquetas]

                        
	 	
                          cilostazol 100           mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          PLETAL

                        	
                          QL=5 días

                        
	 	
                          clopidogrel bisulfate 75 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          PLAVIX

                        	
                          QL=5 días

                        
	 	
                          CARDIOVASCULAR AGENTS [AGENTES CARDIOVASCULARES]

                        
	 	
                           Antiarrhythmics Class II
                              [Antiarrítmicos Clase II]

                        
	 	
                          propranolol hcl 10 mg tab,  20 mg tab, 40 mg tab, 80 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          INDERAL

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de
                          costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

                     

                    

                  

                  
                    
                      	
                               Page 24 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          sotalol hcl 120 mg tab, 160 mg tab, 240 mg tab, 80 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          BETAPACE

                        	
                          QL=5 días

                        
	 	
                          sotalol hcl (af) 120 mg tab, 160 mg tab, 80 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          BETAPACE

                        	
                          QL=5 días

                        
	 	
                          propranolol hcl 60 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          INDERAL

                        	
                          QL=5 días

                        
	 	
                          Antiarrhythmics Type I-A [Antiarrítmicos Tipo I-A]

                        
	 	
                          quinidine sulfate 200           mg tab, 300 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          QUINIDINE SULFATE

                        	
                          QL=5 días

                        
	 	
                          quinidine gluconate er 324 mg tab er

                        	
                          2

                        	
                          Preferred

                        	
                          QUINAGLUTE

                        	
                          QL=5 días

                        
	 	
                          quinidine sulfate er 300 mg tab er

                        	
                          2

                        	
                          Preferred

                        	
                          QUINIDINE SULFATE

                        	
                          QL=5 días

                        
	 	
                          Antiarrhythmics Type I-B [Antiarrítmicos Tipo I-B]

                        
	 	
                          mexiletine hcl 150 mg cap          

                        	
                          2

                        	
                          Preferred

                        	
                          MEXITIL

                        	
                          QL=5 días

                        
	 	
                          mexiletine hcl 200 mg cap

                        	
                          3

                        	
                          Preferred

                        	
                          MEXITIL

                        	
                          QL=5 días

                        
	 	
                          Antiarrhythmics Type I-C [Antiarrítmicos Tipo I-C]

                        
	 	
                          flecainide acetate 100 mg  tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TAMBOCOR

                        	
                          QL=5 días

                        
	 	
                          propafenone hcl 150 mg tab, 225 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          RYTHMOL

                        	
                          QL=5 días

                        
	 	
                          flecainide acetate 150 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          TAMBOCOR

                        	
                          QL=5 días

                        
	 	
                          propafenone hcl 300 mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          RYTHMOL

                        	
                          QL=5 días

                        
	 	
                          Antiarrhythmics Type III [Antiarrítmicos Tipo III]

                        
	 	
                          amiodarone hcl 200 mg tab          

                        	
                          1

                        	
                          Preferred

                        	
                          CORDARONE

                        	
                          QL=5 días

                        
	 	
                          Miscellaneous Cardiovascular Agents [Agentes Cardiovasculares Misceláneos]

                        
	 	
                          digox 125 mcg tab, 250 mcg  tab

                        	
                          2

                        	
                          Preferred

                        	
                          LANOXIN

                        	
                          QL=5 días

                        
	 	
                          digoxin 125 mcg tab, 250 mcg tab

                        	
                          2

                        	
                          Preferred

                        	
                          LANOXIN

                        	
                          QL=5 días

                        
	 	
                          Vasodilators [Vasodilatadores]

                        
	 	
                          isosorbide mononitrate 10  mg tab, 20 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ISORDIL

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 25 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          isosorbide mononitrate er 120 mg tab er 24 hr, 30 mg tab er 24 hr, 60 mg tab er 24 hr

                        	
                          1

                        	
                          Preferred

                        	
                          IMDUR

                        	
                          QL=5 días

                        
	 	
                          NITROSTAT 0.3 mg tab

                          subl, 0.4 mg tab subl, 0.6

                          mg tab subl

                        	
                          1

                        	
                          Preferred

                        	 	
                          QL=5 días

                        
	 	
                          DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]

                        
	 	
                           Antifungals
                              [Antifungales]

                        
	 	
                          clotrimazole 10 mg  mouth/throat lozenge, 10 mg mouth/throat troche

                        	
                          1

                        	
                          Preferred

                        	
                          MYCELEX

                        	
                          QL=5 días, OTC

                        
	 	
                          nystatin 100000 unit/ml mouth/throat susp, 100000 unit/ml crm

                        	
                          1

                        	
                          Preferred

                        	
                          NYSTATIN

                        	
                          QL=5 días

                        
	 	
                          DERMATOLOGICAL AGENTS [AGENTES DERMATOLÓGICOS]

                        
	 	
                           Topical Antibiotics
                              [Antibióticos Tópicos]

                        
	 	
                          mupirocin 2 % oint          

                        	
                          1

                        	
                          Preferred

                        	
                          BACTROBAN

                        	
                          QL=5 días

                        
	 	
                          silver sulfadiazine 1 % crm

                        	
                          1

                        	
                          Preferred

                        	
                          SILVADENE

                        	
                          QL=5 días

                        
	 	
                          gentamicin sulfate 0.1 % crm

                        	
                          2

                        	
                          Preferred

                        	
                          GARAMYCIN

                        	
                          QL=1 frasco / 5 días

                        
	 	
                          gentamicin sulfate 0.1 % oint

                        	
                          2

                        	
                          Preferred

                        	
                          GARAMYCIN

                        	
                          QL=1 tubo / 5 días

                        
	 	
                          DYSLIPIDEMICS [DISLIPIDÉMICOS]

                        
	 	
                           Bile Acid Sequestrants
                              [Secuestradores De Acidos Biliares]

                        
	 	
                          cholestyramine 4 gm pckt, 4  gm/dose oral pwdr

                        	
                          3

                        	
                          Preferred

                        	
                          QUESTRAN

                        	
                          QL=5 días

                        
	 	
                          cholestyramine light 4 gm pckt, 4 gm/dose oral pwdr

                        	
                          3

                        	
                          Preferred

                        	
                          QUESTRAN

                        	
                          QL=5 días

                        
	 	
                          Fibric Acid Derivatives [Derivados De Ácido Fíbrico]

                        
	 	
                          gemfibrozil 600 mg tab          

                        	
                          1

                        	
                          Preferred

                        	
                          LOPID

                        	
                          QL=5 días

                        
	 	
                          Hmg-Coa Reductase Inhibitors [Inhibidores De La Hmg-Coa Reductasa]

                        
	 	
                          atorvastatin calcium 10 mg  tab, 20 mg tab, 40 mg tab, 80 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          LIPITOR

                        	
                          QL=5 días

                        
	 	
                          simvastatin 10 mg tab, 20 mg tab, 40 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          ZOCOR

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 26 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          GASTROINTESTINAL AGENTS [AGENTES GASTROINTESTINALES]

                        
	 	
                           Histamine2 (H2) Receptor
                              Antagonists [Antagonistas Del Receptor De H2]

                        
	 	
                          famotidine           20 mg tab, 40 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          PEPCID

                        	
                          QL=5 días

                        
	 	
                          ranitidine hcl 15 mg/ml syr, 150 mg/10ml syr, 300 mg tab, 75 mg/5ml syr

                        	
                          1

                        	
                          Preferred

                        	
                          ZANTAC

                        	
                          QL=5 días

                        
	 	
                          Miscellaneous Gastrointestinal Agents [Agentes Gastrointestinales Misceláneos]

                        
	 	
                          ursodiol 300 mg cap          

                        	
                          2

                        	
                          Preferred

                        	
                          ACTIGALL

                        	
                          PA, QL=5 días

                        
	 	
                          Proton Pump Inhibitors [Inhibidores De La Bomba De Protones]

                        
	 	
                          omeprazole 10 mg cap dr,  20 mg cap dr

                        	
                          1

                        	
                          Preferred

                        	
                          PRILOSEC

                        	
                          QL=5 días

                        
	 	
                          GENITOURINARY AGENTS [AGENTES GENITOURINARIOS]

                        
	 	
                           Miscellaneous
                              Genitourinary Agents [Agentes Genitourinarios Misceláneos]

                        
	 	
                          phenazopyridine hcl 100 mg  tab, 200 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          PYRIDIUM

                        	
                          QL=3 días

                        
	 	
                          HORMONAL AGENTS [AGENTES HORMONALES]

                        
	 	
                           Antithyroid Agents
                              [Agentes Antitiroide]

                        
	 	
                          methimazole 10 mg tab, 5  mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          TAPAZOLE

                        	
                          QL=5 días

                        
	 	
                          propylthiouracil 50 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          PROPYLTHIOURA

                          CIL

                        	
                          QL=5 días

                        
	 	
                          Calcimimetic Agents [Agentes Calcimiméticos]

                        
	 	
                          SENSIPAR 30 mg tab          

                        	
                          7

                        	 	 	
                          PA, QL=5 días

                        
	 	
                          SENSIPAR 60 mg tab

                        	
                          9

                        	 	 	
                          PA, QL=5 días

                        
	 	
                          SENSIPAR 90 mg tab

                        	
                          10

                        	 	 	
                          PA, QL=5 días

                        
	 	
                          Dopamine Agonists [Agonistas De Dopamina]

                        
	 	
                          bromocriptine mesylate 2.5  mg tab

                        	
                          3

                        	
                          Preferred

                        	
                          PARLODEL

                        	
                          QL=5 días

                        
	 	
                          Thyroid Hormones [Hormona Tiroidea]

                        
	 	
                          levothyroxine sodium 100  mcg tab, 112 mcg tab, 125 mcg tab, 137 mcg tab, 150 mcg
                                tab, 175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

                        	
                          1

                        	
                          Preferred

                        	
                          SYNTHROID

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 27 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          SYNTHROID 100 mcg tab,

                          112 mcg tab, 125 mcg tab,

                          137 mcg tab, 150 mcg tab,

                          175 mcg tab, 200 mcg tab, 25 mcg tab, 300 mcg tab, 50 mcg tab, 75 mcg tab, 88 mcg tab

                        	
                          1

                        	
                          Preferred

                        	 	
                          QL=5 días

                        
	 	
                          IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]

                        
	 	
                           Glucocorticosteroids
                              [Glucocorticoides]

                        
	 	
                          dexamethasone 0.5 mg tab,  0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg
                                tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          DECADRON

                        	
                          QL=5 días

                        
	 	
                          methylprednisolone 32 mg tab, 4 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          MEDROL

                        	
                          QL=5 días

                        
	 	
                          prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          DELTASONE

                        	
                          QL=5 días

                        
	 	
                          prednisone (pak) 10 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          DELTASONE

                        	
                          QL=5 días

                        
	 	
                          methylprednisolone 16 mg tab, 8 mg tab

                        	
                          2

                        	
                          Preferred

                        	
                          MEDROL

                        	
                          QL=5 días

                        
	 	
                          INFLAMMATORY BOWEL DISEASE [ENFERMEDAD INFLAMATORIA INTESTINAL]

                        
	 	
                           Aminosalicylates
                              [Aminosalicilatos]

                        
	 	
                          DELZICOL 400 mg cap dr          

                        	
                          5

                        	
                          Preferred

                        	 	
                          QL=5 días, P

                        
	 	
                          ASACOL HD 800 mg tab dr

                        	
                          6

                        	
                          Preferred

                        	 	
                          QL=5 días, P

                        
	 	
                          Sulfonamides [Sulfonamidas]

                        
	 	
                          sulfasalazine 500 mg tab,  500 mg tab dr

                        	
                          1

                        	
                          Preferred

                        	
                          AZULFIDINE

                        	
                          QL=5 días

                        
	 	
                          MINERALS & ELECTROLYTES [MINERALES Y ELECTROLITOS]

                        
	 	
                           MUSCLE RELAXANTS
                              [RELAJANTES MUSCULARES]

                        
	 	
                           Antispasticity Agents
                              [Agentes Antiespasticidad]

                        
	 	
                          baclofen 10 mg tab, 20 mg  tab

                        	
                          1

                        	
                          Preferred

                        	
                          LIORESAL

                        	
                          QL=5 días

                        
	 	
                          dantrolene sodium 25 mg cap, 50 mg cap

                        	
                          2

                        	
                          Preferred

                        	
                          DANTRIUM

                        	
                          QL=5 días

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                    

                  

                  
                    
                      	
                               Page 28 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                           	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          dantrolene sodium 100 mg cap

                        	
                          3

                        	
                          Preferred

                        	
                          DANTRIUM

                        	
                          QL=5 días

                        
	 	
                          Skeletal Muscle Relaxants [Relajantes Musculoesqueletales]

                        	 
	 	
                          cyclobenzaprine hcl 10 mg  tab

                        	
                          1

                        	
                          Preferred

                        	
                          FLEXERIL

                        	
                          QL=5 días

                        
	 	
                          OPHTHALMIC AGENTS [AGENTES OFTÁLMICOS]

                        	 
	 	
                                    Antiglaucoma Agents [Agentes Antiglaucoma]

                        	 
	 	
                          brimonidine tartrate 0.2 %  ophth soln

                        	
                          1

                        	
                          Preferred

                        	
                          ALPHAGAN

                        	
                          QL=1 frasco 5 ml / 15 días

                        
	 	
                          dorzolamide hcl 2 % ophth soln

                        	
                          1

                        	
                          Preferred

                        	
                          TRUSOPT

                        	
                          QL=1 frasco / 30 días

                        
	 	
                          levobunolol hcl 0.5 % ophth soln

                        	
                          1

                        	
                          Preferred

                        	
                          BETAGAN

                        	
                          QL=1 frasco / 15 días

                        
	 	
                          levobunolol hcl 0.25 % ophth soln

                        	
                          1

                        	
                          Preferred

                        	
                          BETAGAN

                        	
                          QL=1 frasco / 15 días

                        
	 	
                          timolol maleate 0.5 % ophth soln

                        	
                          1

                        	
                          Preferred

                        	
                          TIMOPTIC

                        	
                          QL=1 frasco / 30 días

                        
	 	
                          timolol maleate 0.25 % ophth soln

                        	
                          1

                        	
                          Preferred

                        	
                          TIMOPTIC

                        	
                          QL=1 frasco / 25 días

                        
	 	
                          dorzolamide hcl-timolol mal ophth sol 22.3-6.8 mg/ml

                        	
                          1

                        	
                          Preferred

                        	
                          COSOPT

                        	
                          QL=1 frasco / 30 días

                        
	 	
                          betaxolol hcl 0.5 % ophth soln

                        	
                          2

                        	
                          Non-Preferred

                        	
                          BETOPTIC

                        	
                          QL=1 frasco / 15 días

                        
	 	
                          Ophthalmic Antibiotics [Antibióticos Oftálmicos]

                        	 
	 	
                          gentamicin sulfate 0.3 %  ophth oint

                        	
                          1

                        	
                          Preferred

                        	
                          GARAMYCIN

                        	
                          QL=5 días

                        
	 	
                          gentamicin sulfate 0.3 % ophth soln

                        	
                          1

                        	
                          Preferred

                        	
                          GARAMYCIN

                        	
                          QL=5 días

                        
	 	
                          tobramycin 0.3 % ophth soln

                        	
                          1

                        	
                          Preferred

                        	
                          TOBREX

                        	
                          QL=1 frasco / 5 días

                        
	 	
                          Ophthalmic Prostaglandins [Prostaglandinas Oftálmicas]

                        	 
	 	
                          latanoprost 0.005 % ophth  soln

                        	
                          1

                        	
                          Preferred

                        	
                          XALATAN

                        	
                          QL=1 frasco / 25 días

                        
	 	
                          Ophthalmic Steroids [Esteroides Oftálmicos]

                        	 
	 	
                          neomycin -polymyxindexamethasone 3.5-100000.1 ophth oint,
                                3.5-100000.1 ophth susp

                        	
                          1

                        	
                          Preferred

                        	
                          MAXITROL

                        	 


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age  Limit [Límite
                          de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                    

                  

                  
                    
                      	
                               Page 29 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          prednisolone acetate 1 % ophth susp

                        	
                          2

                        	
                          Preferred

                        	
                          PRED FORTE

                        	
                          QL=1 frasco 5ml / 25 días

                        
	 	
                          OTIC AGENTS [AGENTES OTICOS]

                        
	 	
                           Miscellaneous Otic
                              Agents [Agentes Oticos Misceláneos]

                        
	 	
                            

                          acetic acid 2 % otic soln

                        	
                          2

                        	
                          Preferred

                        	
                          VOSOL

                        	
                          QL= 1 frasco / 10 días

                        
	 	
                          Otic Antibiotics [Antibióticos Oticos]

                        
	 	
                          neomycin          -polymyxin-hc 1 % otic soln, 3.5-10000-1 otic soln, 3.5-10000-1 otic susp

                        	
                          2

                        	
                          Preferred

                        	
                          CORTISPORIN

                        	
                          QL=1 frasco / 10 días

                        
	 	
                          RESPIRATORY AGENTS [AGENTES RESPIRATORIOS]

                        
	 	
                           Anticholinergic
                              Bronchodilators [Broncodilatadores Anticolinérgicos]

                        
	 	
                          ipratropium bromide 0.02 %  inh soln

                        	
                          1

                        	
                          Non-Preferred

                        	
                          ATROVENT

                        	
                          QL=5 días

                        
	 	
                          Antileukotrienes [Antileukotrienos]

                        
	 	
                          montelukast sodium           10 mg tab, 4 mg tab chew, 5 mg tab chew

                        	
                          1

                        	
                          Preferred

                        	
                          SINGULAIR

                        	
                          QL=5 días

                        
	 	
                          Antitussive-Expectorant [Expectorantes Antitusivos]

                        
	 	
                          guaifenesin          -codeine 100-10 mg/5ml soln

                        	
                          1

                        	
                          Preferred

                        	
                          CHERATUSSIN

                        	
                          QL=5 días

                        
	 	
                          Inhaled Corticosteroids [Corticosteroides Inhalados]

                        
	 	
                          FLOVENT DISKUS 100 

                          mcg/blist inh aer pwdr, 250 mcg/blist inh aer pwdr, 50 mcg/blist inh aer pwdr

                        	
                          3

                        	
                          Preferred

                        	 	
                          QL=1 pompa / 30 días, P

                        
	 	
                          FLOVENT HFA 110 mcg/act

                          inh aer

                        	
                          3

                        	
                          Preferred

                        	 	
                          QL=1 pompa / 30 días, P

                        
	 	
                          FLOVENT HFA 44 mcg/act

                          inh aer

                        	
                          3

                        	
                          Preferred

                        	 	
                          QL=1 pompa / 30 días, P

                        
	 	
                          budesonide 0.25 mg/2ml inh susp, 0.5 mg/2ml inh susp,

                        	
                          4

                        	
                          Non-Preferred

                        	
                          PULMICORT

                        	
                          QL=5 días, AL 012 años

                        
	 	
                          budesonide 1mg/2ml inh susp

                        	
                          8

                        	
                          Non-Preferred

                        	
                          PULMICORT

                        	
                          AL 0-12 años

                        
	 	
                          FLOVENT HFA 220 mcg/act

                          inh aer

                        	
                          4

                        	
                          Preferred

                        	 	
                          QL=1 pompa / 30 días, P

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de
                          Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted
                          Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 30 of 83

                            


                    

                    
                      


                  

                  
                    
                      	SUB FÍSICA	
                              

                            


                       

                      

                    

                  

                  	 	
                          Drug Name [Nombre del 

                          Medicamento]

                        	
                          Net

                          Cost

                          [Costo

                          Neto]

                        	
                          Tier [Tier]

                        	
                          Reference Name 

                          [Nombre de

                          Referencia]

                        	
                          Requirements/

                          Limits

                          [Requerimientos/ 

                          Límites]

                        
	 	
                          Sedating Histamine1 Blocking Agents [Sedantes Bloqueadores Histamine1]

                        
	 	
                          promethazine hcl 12.5 mg  tab, 25 mg tab, 50 mg tab, 6.25 mg/5ml soln, 6.25 mg/5ml
                                syr

                        	
                          1

                        	
                          Preferred

                        	
                          PHENERGAN

                        	
                          QL=5 días

                        
	 	
                          Sympathomimetic Bronchodilators [Broncodilatadores Simpatomiméticos]

                        
	 	
                          albuterol sulfate (2.5  mg/3ml) 0.083% inh neb soln, (5 mg/ml) 0.5% inh neb soln,
                                2 mg/5ml syr

                        	
                          1

                        	
                          Preferred

                        	
                          PROVENTIL

                        	
                          QL=5 días

                        
	 	
                          terbutaline sulfate 2.5 mg tab, 5 mg tab

                        	
                          1

                        	
                          Preferred

                        	
                          BRETHINE

                        	
                          QL=5 días

                        
	 	
                          VENTOLIN HFA 108 (90 base) mcg/act inh aer

                        	
                          1

                        	
                          Preferred

                        	 	
                          QL=1 frasco / 30 días, P

                        


                  
                     

                    

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite
                          de Edad] • Net Cost [Costo Neto] – Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred
                          Contracted Product [Producto Contratado Preferido]

                     

                        

                  

                  
                    
                      	
                               Page 31 of 83

                            


                    

                    
                      


                  

                  
                    	
                            A

                          	 
	
                            acarbose 

                                

                          	
                            19

                          
	
                            acetaminophen-codeine

                          	
                            13

                          
	
                            acetaminophen-codeine #2 

                                

                          	
                            13

                          
	
                            acetaminophen-codeine #3 

                                

                          	
                            13

                          
	
                            acetaminophen-codeine #4 

                                

                          	
                            13

                          
	
                            acetazolamide 

                                

                          	
                            22

                          
	
                            acetic acid 

                                

                          	
                            37

                          
	
                            acyclovir 

                                

                          	
                            28

                          
	
                            albuterol sulfate

                          	
                            38

                          
	
                            allopurinol 

                                

                          	
                            21

                          
	
                            amantadine hcl 

                                

                          	
                            26, 27, 28

                          
	
                            amiodarone hcl 

                                

                          	
                            30

                          
	
                            amlodipine besylate 

                                

                          	
                            22

                          
	
                            amoxicillin 

                                

                          	
                            16

                          
	
                            amoxicillin-pot clavulanate 

                                

                          	
                            16

                          
	
                            ampicillin 

                                

                          	
                            16

                          
	
                            ASACOL HD 

                                

                          	
                            35

                          
	
                            atenolol .

                          	
                            22

                          
	
                            atenolol-chlorthalidone 

                                

                          	
                            23

                          
	
                             atorvastatin calcium 

                                

                          	
                            32

                          
	
                            azithromycin

                          	
                            14

                          
	 	 
	
                            B

                          	 
	
                            baclofen 

                                

                          	
                            35

                          
	
                            betaxolol hcl 

                                

                          	
                            36

                          
	
                            brimonidine tartrate 

                                

                          	
                            35

                          
	
                            bromocriptine mesylate

                          	
                             27, 33

                          
	
                            budesonide

                          	
                            38

                          
	
                            butalbital-apap-caffeine

                          	
                            14

                          
	 	 
	
                            C

                          	 
	
                            CAPASTAT SULFATE

                          	
                            26

                          
	
                            carbamazepine ..

                          	
                            17

                          
	
                            carbidopa-levodopa

                          	
                            27

                          
	
                            carbidopa-levodopa er 

                                

                          	
                            27

                          
	
                            carbidopa-levodopa-entacapone

                          	
                            27

                          
	
                            carvedilol 

                                

                          	
                            24

                          
	
                            cefaclor 

                                

                          	
                            17

                          
	
                            cefadroxil

                          	
                            14

                          
	
                            cefdinir

                          	
                            17

                          
	
                            cefprozil

                          	
                            17

                          


                  

                  
                    
                      	
                              cephalexin

                            	
                              14

                            
	
                              chloroquine phosphate 

                                  

                            	
                              26

                            
	
                              chlorothiazide

                            	
                              24

                            
	
                              chlorthalidone

                            	
                              24

                            
	
                              cholestyramine 

                                  

                            	
                              32

                            
	
                              cholestyramine light

                            	
                              32

                            
	
                              cilostazol 

                                  

                            	
                              29

                            
	
                              ciprofloxacin 

                                  

                            	
                              16, 17

                            
	
                              ciprofloxacin hcl

                            	
                              16

                            
	
                              clarithromycin

                            	
                              15

                            
	
                              clindamycin hcl

                            	
                              15

                            
	
                              clonidine hcl 

                                  

                            	
                              21

                            
	
                              clopidogrel bisulfate

                            	
                              29

                            
	
                              clotrimazole

                            	
                              31

                            
	
                              colchicine

                            	
                              21

                            
	
                              COLCRYS

                            	
                              .21

                            
	
                              cyclobenzaprine hcl 

                                  

                            	
                              35

                            
	
                              cycloserine

                            	
                              25

                            
	 	 
	
                              D

                            	 
	
                              dantrolene sodium

                            	
                              35

                            
	
                              DARAPRIM 

                                  

                            	
                              26

                            
	
                              DELZICOL

                            	
                              34

                            
	
                              dexamethasone .

                            	
                              34

                            
	
                              digox

                            	
                              30

                            
	
                              digoxin

                            	
                              31

                            
	
                              DILANTIN

                            	
                              18

                            
	
                              diltiazem hcl

                            	
                              22

                            
	
                              DIURIL

                            	
                              4

                            
	
                              donepezil hcl

                            	
                              19

                            
	
                              dorzolamide hcl 

                                  

                            	
                              35

                            
	 	 
	
                              E

                            	 
	
                              ERYTHROCIN STEARATE

                            	
                              15

                            
	
                              erythromycin base 

                                  

                            	
                              15

                            
	
                              erythromycin ethylsuccinate .

                            	
                              15

                            
	
                              ethosuximide

                            	
                              18

                            
	 	 
	
                              F

                            	 
	
                              famotidine

                            	
                              32

                            
	
                              flecainide acetate 

                                  

                            	
                              30

                            
	
                              FLOVENT DISKUS

                            	
                              37

                            


                    

                  

                  
                    	
                             

                          


                  

                  
                    
                      	
                               Page 32 of 83

                            


                    

                    
                      


                  

                  
                    
                      
                        	
                                FLOVENT HFA 

                                    

                              	
                                37, 38

                              
	
                                furosemide

                              	
                                23

                              
	 	 
	
                                G

                              	 
	
                                gabapentin 

                                    

                              	
                                17

                              
	
                                gemfibrozil

                              	
                                32

                              
	
                                gentamicin sulfate .

                              	
                                31, 36

                              
	
                                glimepiride

                              	
                                20

                              
	
                                glipizide

                              	
                                20

                              
	
                                guaifenesin-codeine

                              	
                                37

                              
	 	 
	
                                H

                              	 
	
                                heparin sodium (porcine) 

                                    

                              	
                                28, 29

                              
	
                                heparin sodium (porcine) pf 

                                    

                              	
                                29

                              
	
                                HUMULIN 70/30

                              	
                                20

                              
	
                                HUMULIN N

                              	
                                20

                              
	
                                HUMULIN R

                              	
                                20

                              
	
                                 hydralazine hcl

                              	
                                25

                              
	
                                hydrochlorothiazide

                              	
                                24

                              
	
                                hydroxychloroquine sulfate 

                                    

                              	
                                26

                              
	 	 
	
                                I

                              	 
	
                                ibuprofen

                              	
                                13

                              
	
                                indapamide

                              	
                                24

                              
	
                                indomethacin

                              	
                                13

                              
	
                                ipratropium bromide

                              	
                                37

                              
	
                                isoniazid

                              	
                                25

                              
	
                                isosorbide mononitrate 

                                    

                              	
                                31

                              
	
                                isosorbide mononitrate er

                              	
                                31

                              
	 	 
	
                                K

                              	 
	
                                KOMBIGLYZE XR

                              	
                                19

                              
	 	 
	
                                L

                              	 
	
                                latanoprost

                              	
                                36

                              
	
                                levetiracetam 

                                    

                              	
                                17, 18

                              
	
                                levobunolol hcl 

                                    

                              	
                                35

                              
	
                                levofloxacin 

                                    

                              	
                                16

                              
	
                                levothyroxine sodium .

                              	
                                33

                              
	
                                lidocaine viscous

                              	
                                14

                              
	
                                 lisinopril 

                                    

                              	
                                22

                              
	
                                lisinopril-hydrochlorothiazide

                              	
                                22

                              


                      

                    

                    
                      
                        	
                                losartan potassium 

                                    

                              	
                                21

                              
	
                                losartan potassium-hctz 

                                    

                              	
                                21

                              
	 	 
	
                                M

                              	 
	
                                MACRODANTIN .

                              	
                                15

                              
	
                                margesic 

                                    

                              	
                                14

                              
	
                                MESTINON

                              	
                                25

                              
	
                                metformin hcl 

                                    

                              	
                                19

                              
	
                                 methimazole

                              	
                                .33

                              
	
                                methyldopa

                              	
                                21

                              
	
                                methylprednisolone

                              	
                                34

                              
	
                                metoclopramide hcl

                              	
                                20

                              
	
                                metolazone 

                                    

                              	
                                24

                              
	
                                metoprolol succinate er

                              	
                                22, 23

                              
	
                                metoprolol tartrate

                              	
                                23

                              
	
                                metoprolol-hydrochlorothiazide

                              	
                                23

                              
	
                                metronidazole 

                                    

                              	
                                15

                              
	
                                mexiletine hcl

                              	
                                30

                              
	
                                montelukast sodium

                              	
                                37

                              
	
                                mupirocin

                              	
                                31

                              
	 	 
	
                                N

                              	 
	
                                nabumetone 

                                    

                              	
                                13

                              
	
                                naproxen 

                                    

                              	
                                13

                              
	
                                neomycin-polymyxin-dexamethasone .

                              	
                                36

                              
	
                                neomycin-polymyxin-hc

                                    

                              	
                                37

                              
	
                                NEULASTA

                              	
                                29

                              
	
                                NEULASTA DELIVERY KIT

                              	
                                29

                              
	
                                nitrofurantoin macrocrystal

                              	
                                15

                              
	
                                nitrofurantoin monohyd macro .

                              	
                                15

                              
	
                                NITROSTAT

                              	
                                31

                              
	
                                nystatin 

                                    

                              	
                                31

                              
	 	 
	
                                O

                              	 
	
                                omeprazole

                              	
                                .32

                              
	
                                ONGLYZA

                              	
                                19

                              
	
                                oxcarbazepine

                              	
                                18

                              
	 	 
	
                                P

                              	 
	
                                penicillin v potassium .

                              	
                                16

                              
	
                                phenazopyridine hcl

                              	
                                33

                              
	
                                 phenobarbital

                              	
                                18, 19

                              
	
                                phenytoin

                              	
                                18

                              
	
                                phenytoin sodium extended 

                                    

                              	
                                18

                              


                      

                    

                    

                    	
                             

                          


                    

                  

                  
                    
                      	
                               Page 33 of 83

                            


                    

                    
                      


                  

                  
                    	
                            pioglitazone hcl 

                                

                          	
                            20

                          
	
                            pramipexole dihydrochloride

                          	
                            26

                          
	
                            prednisolone acetate

                          	
                            36

                          
	
                            prednisone 

                                

                          	
                            34

                          
	
                            prednisone (pak)

                          	
                            34

                          
	
                            primidone

                          	
                            18

                          
	
                            probenecid 

                                

                          	
                            21

                          
	
                            prochlorperazine

                          	
                            20

                          
	
                            prochlorperazine maleate

                          	
                            20

                          
	
                            promethazine hcl 

                                

                          	
                            38

                          
	
                            propafenone hcl

                          	
                            30

                          
	
                            propranolol hcl 

                                

                          	
                            23, 29

                          
	
                            propylthiouracil

                          	
                            33

                          
	
                            pyrazinamide

                          	
                            25

                          
	
                            pyridostigmine

                          	
                            25

                          
	
                            pyridostigmine bromide

                          	
                            25

                          
	 	 
	
                            Q

                          	 
	
                            quinidine gluconate er

                          	
                            30

                          
	
                            quinidine sulfate

                          	
                            30

                          
	
                            quinidine sulfate er

                          	
                            30

                          
	 	 
	
                            R

                          	 
	
                            ranitidine hcl

                          	
                            32

                          
	
                            rifabutin

                          	
                            25

                          
	
                            RIFAMATE

                          	
                            26

                          
	
                            rifampin

                          	
                            25

                          
	
                            rivastigmine tartrate

                          	
                            19

                          
	
                            ropinirole hcl

                          	
                            26

                          
	
                            S

                          	 
	
                            salsalate

                          	
                            13

                          
	
                            selegiline hcl 

                                

                          	
                            19, 27

                          
	
                            SENSIPAR

                          	
                            33

                          
	
                            silver sulfadiazine

                          	
                            31

                          
	
                            simvastatin

                          	
                            32

                          
	
                            sotalol hcl

                          	
                            29

                          
	
                            sotalol hcl (af)

                          	
                            29

                          
	
                            spironolactone 

                                

                          	
                            24

                          
	
                            sulfamethoxazole-tmp ds

                          	
                            17

                          


                  

                  
                    	
                            sulfamethoxazole-trimethoprim 

                                

                          	
                            17

                          
	
                            sulfasalazine

                          	
                            35

                          
	
                            SYNTHROID 

                                

                          	
                            34

                          
	 	 
	
                            T

                          	 
	
                            terazosin hcl

                          	
                             21, 28

                          
	
                            terbutaline sulfate

                          	
                            38

                          
	
                            timolol maleate 

                                

                          	
                            36

                          
	
                            tobramycin 

                                

                          	
                            36

                          
	
                            topiramate 

                                

                          	
                             18, 25

                          
	
                            tramadol hcl 

                                

                          	
                            14

                          
	
                            TRECATOR

                          	
                            26

                          
	
                            triamterene-hctz 

                                

                          	
                            24

                          
	
                            trimethobenzamide hcl

                          	
                            20

                          
	 	 
	
                            U

                          	 
	
                            ursodiol

                          	
                            32

                          
	 	 
	
                            V

                          	 
	
                            valganciclovir hcl 

                                

                          	
                            27

                          
	
                            VENTOLIN HFA 

                                

                          	
                            38

                          
	
                            verapamil hcl

                          	
                            22

                          
	 	 
	
                            W

                          	 
	
                            warfarin sodium

                          	
                            28

                          


                  

                  
                    	
                             

                          


                  

                  
                    
                      	
                               Page 34 of 83

                            


                    

                    
                      


                  

                  
                    ASES

                     

                    Puerto Rico Healthcare Insurance Administration

                     

                    Sub-formulary of

                     

                    Mental Health

                     

                    2017

                     

                    Formulary of Drugs Covered by

                     

                    the Government Healthcare Plan (GHP)

                     

                    Authorized by the P.R. Elections Commission CEE-SA-16-2732

                     

                    
                      
                        	
                                 Page 35 of 83

                              


                      

                      
                        


                    

                    
                      
                        	
                                

                              	 	
                                GOVERNMENT OF PUERTO RICO

                              	 	
                                Hon. Ricardo A. Rosselló Nevares

                                Governor

                                 

                                Ms. Ángela M. Ávila Marrero

                                Executive Director

                              
	 	
                                Healthcare Insurance Administration

                              


                      

                      

                      

                    

                    May 1, 2017

                     

                    TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

                     

                    Dear provider:

                     

                    I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its
                        corresponding sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

                     

                    The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and
                        Sub-physical. Moreover, the Mental Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health
                        Sub-formulary will be used by participating primary care physicians (PCPs) in Primary Care Medical Groups.

                     

                    The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare
                        Insurance Administration (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical
                        aspects. The FDC is a dynamic document that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

                     

                    I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

                     

                    Cordially,

                     

                    [signed]

                     

                    Ángela M. Ávila Marrero

                     

                    Executive Director

                     

                    
                      	
                               

                            	
                              
                                

                              

                            
	 
	
                              
                                PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                              

                            


                    

                     

                    
                      
                        	
                                 Page 36 of 83

                              


                      

                      
                        


                    

                    GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

                     

                      

                    OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

                     

                    
                      
                        	1.	
                                Drug Formulary

                              


                      

                    

                     

                    The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and
                        reviewing the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee
                        is constituted by healthcare professionals, including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES
                        for the drug formulary based on scientific evidence, clinical aspects, and a cost-effectiveness analysis.

                    

                    

                    The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the
                        prescription drug coverage. The purpose of the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

                    

                    

                    ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator
                        or PPA based on the most recent clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

                    

                    

                    Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain
                        in point number 2.

                    

                    

                    
                      
                        	2.	
                                Exception Process

                              


                      

                    

                     

                    In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as
                        applicable, insurance companies must use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

                    

                    

                    
                      
                        	

                              	a.	
                                Contraindication to the drug(s) included in the FDC;

                              


                      

                    

                    
                      
                        	

                              	b.	
                                History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                              


                      

                    

                    
                      
                        	

                              	c.	
                                Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                              


                      

                    

                    
                      
                        	

                              	d.	
                                Lack of a therapeutic alternative in the FDC.

                              


                      

                    

                     

                    This exception process requires a clinical justification that is duly documented by the service provider with the
                        clinical reasons justifying the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

                     

                    
                      
                        	3.	
                                Other Aspects of the Prescription Drug Coverage

                              


                      

                    

                     

                    
                      
                        	

                              	A.	
                                The prescription drug coverage of the GHP establishes that using generic bioequivalent
                                      products as the first option is mandatory.

                              


                      

                    

                     

                    
                      
                        	
                                 Page 37 of 83

                              


                      

                      
                        


                    

                    
                      
                        	

                              	B.	
                                Insurance companies or the TPA (Third Party Administrator) and healthcare service providers
                                      will only process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                              


                      

                    

                     

                    
                      
                        	

                              	C.	
                                ASES has an active process to continually review the prescription drug coverage in accordance
                                      with changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES
                                      may require that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will
                                      safeguard adequate access to services and maintain continuity of care.

                              


                      

                    

                     

                    
                      
                        	

                              	D.	
                                No entity contracted by ASES or by healthcare companies or organizations (for example,
                                      primary care medical groups, independent providers, specialists, among others) may use a formulary other than the FDC or create an internal drug formulary different than the formularies established by ASES.
                                      Furthermore, they may not limit the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be
                                      responsible for supervising their providers and employees with regard to their compliance with these provisions.

                              


                      

                    

                     

                    
                      
                        	

                              	E.	
                                The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The
                                      treatment period may be extended, as applicable, when medically necessary.

                              


                      

                    

                     

                    
                      
                        	

                              	F.	
                                The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty
                                      (30) day therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating
                                      adherence and tolerance. The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case
                                      of narcotics, which will be dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms
                                      of adherence, tolerance, and dosage within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                              


                      

                    

                     

                    
                      
                        	

                              	G.	
                                ASES requires the use of generic bioequivalent drugs approved by the Food and Drug
                                      Administration (FDA) coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                              


                      

                    

                     

                    
                      
                        	

                              	H.	
                                The lack of appropriate bioequivalent drug inventories does not exempt providers from
                                      dispensing the prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the
                                      corresponding brand-name drug, unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception
                                      mechanism.

                              


                      

                    

                     

                    
                      
                        	
                                 Page 38 of 83

                              


                      

                      
                        


                    

                    
                      
                        	

                              	I.	
                                Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized
                                      under the law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                              


                      

                    

                     

                    
                      
                        	

                              	J.	
                                The right to freedom of choice requires the availability of a pharmacy that is reasonably
                                      accessible to each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                              


                      

                    

                     

                    Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or
                        when an electronic prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24
                        hours. If a drug is not available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her
                        physician to have the prescription sent to another pharmacy of his or her choice.

                    

                    

                    
                      
                        	4.	
                                Emergency Rule

                              


                      

                    

                     

                    The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except as
                        otherwise specified.

                    

                    

                    The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will also be
                        dispensed in amounts sufficient for five (5) business days.

                    

                    

                    Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for continuity of
                        treatment, including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the IEF.

                    

                    

                    If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES in your
                        region and/or the Pharmacy Benefit Manager (PBM) contracted by ASES.

                     

                      

                    
                      
                        	
                                 Page 39 of 83

                              


                      

                      
                        


                    

                    
                      	SUB MENTAL	


                      

                          GOVERNMENT HEALTHCARE PLAN

                    

                     

                      

                    FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

                     

                      

                    2017

                     

                      

                    TABLE OF CONTENTS

                     

                    	
                            GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

                          	 
	
                            OF THE GOVERNMENT HEALTHCARE PLAN

                          	
                            3

                          
	
                            DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND

                          	 
	
                            REFERENCE GUIDES

                          	
                            7

                          
	
                            MONTHLY NET COST RANGE

                          	
                            7

                          
	
                            GENERIC DRUGS

                          	
                            8

                          
	
                            ANTIANXIETY AGENTS

                          	
                            9

                          
	
                            Benzodiazepines

                          	
                            9

                          
	
                            Sedating Histamine 1 Blocking Agents

                          	
                            9

                          
	
                            ANTIDEPRESSANTS

                          	
                            9

                          
	
                            Miscellaneous Antidepressants

                          	
                            9

                          
	
                            Serotonin and/or Norepinephrine Modulators

                          	
                            9

                          
	
                            Tricyclic Agents

                          	
                            10

                          
	
                            ANTIPARKINSON AGENTS

                          	
                            10

                          
	
                            Anticholinergics

                          	
                            10

                          
	
                            ANTIPSYCHOTICS

                          	
                            10

                          
	
                            Atypical - Second Generation

                          	
                            10

                          
	
                            Typical - First Generation

                          	
                            10

                          
	
                            DETOX TREATMENT

                          	
                            11

                          
	
                            Detox Treatment

                          	
                            11

                          
	
                            MOOD STABILIZERS

                          	
                            11

                          
	
                            Bipolar Agents

                          	
                            11

                          
	
                            PSYCHOSTIMULANTS

                          	
                            11

                          
	
                            ADHD Amphetamines

                          	
                            11

                          
	
                            ADHD Non-Amphetamines

                          	
                            12

                          
	
                            SLEEP DISORDER AGENTS

                          	
                            12

                          
	
                            Benzodiazepines

                          	
                            12

                          
	
                            Miscellaneous Sleep Disorder Agents

                          	
                            12

                          


                    

                    

                    
                      
                        	
                                 Page 40 of 83

                              


                      

                      
                        


                    

                    
                      	SUB MENTAL	


                    

                    

                        DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                     

                    The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their
                        safety profile, proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

                     

                    The example below illustrates the information provided for the drugs included in the FDC.

                     

                    	 	
                            Drug Name

                          	
                            Net

                            Cost

                          	
                            Tier

                          	
                            Reference Name

                          	
                            Requirements/

                            Limits

                          
	 	
                            THERAPEUTIC CATEGORY

                          
	 	
                            Therapeutic Class

                          
	 	
                            ANTIANXIETY AGENTS

                          
	 	
                            Benzodiazepines

                          
	 	
                            diazepam 10 mg tab, 2 mg tab, 5 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            VALIUM

                          	
                            QL=5 days

                          
	 	
                            lorazepam 0.5 mg tab, 1 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            ATIVAN

                          	
                            QL=5 days

                          
	 	
                            Sedating Histamine 1 Blocking Agents

                          
	 	
                            hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap

                          	
                            1

                          	
                            Preferred

                          	
                            VISTARIL

                          	
                            QL=30 days

                          
	 	
                            ANTIDEPRESSANTS

                          
	 	
                            Miscellaneous Antidepressants

                          
	 	
                            bupropion hcl 75 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            WELLBUTRIN

                          	
                            QL=30 days

                          
	 	
                            bupropion hcl er (sr) 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr

                          	
                            1

                          	
                            Preferred

                          	
                            WELLBUTRIN SR

                          	
                            QL=30 days

                          


                    

                    

                    For each drug included in the FDC, the First

                          Column shows the name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

                    

                    

                    The Second Column shows the
                        Monthly Net Cost Range per Average Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or
                        Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed
                        if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

                    

                    

                    MONTHLY NET COST RANGE

                    

                    

                    The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly
                        net cost of the therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy
                        for thirty (30) days. The cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost
                        and must be interpreted as follows:

                    

                    

                    
                      
                        	
                                 Page 41 of 83

                              


                      

                      
                        


                    

                    
                      	SUB MENTAL	


                      

                    

                    	
                            1

                          	
                            less than $20

                          	
                            Least costly per month

                          
	
                            2

                          	
                            $20 - $49

                          	 
	
                            3

                          	
                            $50 - $99

                          	 
	
                            4

                          	
                            $100 - $199

                          	 
	
                            5

                          	
                            $200 - $349

                          	 
	
                            6

                          	
                            $350 - $549

                          	 
	
                            7

                          	
                            $550 - $799

                          	 
	
                            8

                          	
                            $800 - $1,099

                          	 
	
                            9

                          	
                            $1,100 - $1,499

                          	 
	
                            10

                          	
                            $1,500 - $1,999

                          	 
	
                            11

                          	
                            $2,000 - $2,499

                          	 
	
                            12

                          	
                            $2,500 - $2,999

                          	 
	
                            13

                          	
                            $3,000 - $3,499

                          	 
	
                            14

                          	
                            $3,500 - $3,999

                          	 
	
                            15

                          	
                            $4,000 - $4,499

                          	 
	
                            16

                          	
                            $4,500 - $4,999

                          	 
	
                            17

                          	
                            $5,000 - $5,499

                          	 
	
                            18

                          	
                            $5,500 - $5,999

                          	 
	
                            19

                          	
                            $6,000 - $6,499

                          	 
	
                            20

                          	
                            $6,500 - $6,999

                          	 
	
                            21

                          	
                            $7,000 - $7,499

                          	 
	
                            22

                          	
                            $7,500 - $7,999

                          	 
	
                            23

                          	
                            $8,000 - $8,499

                          	 
	
                            24

                          	
                            $8,500 - $9,000

                          	 
	
                            25

                          	
                            more than $9,000

                          	
                            Most costly per month

                          


                    

                    

                    We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic
                        category (the one with the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

                     

                    The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of
                        this edition of the FDC.

                     

                    GENERIC DRUGS

                     

                    Generic bioequivalent drugs are
                          identified with lower-case letters. Certain generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the
                        generic product, but not the brand-name product. The products selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

                     

                      

                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización

                    Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL –

                    Age Limit [Límite de Edad] • Net Cost [Costo Neto] –
                          Please refer to page 7 for monthly net cost range [Ver  de 14 página 7 para rangos de costo neto mensual] • P – Preferred Contracted Product
                          [Producto Contratado Preferido] Revisado 5/12/2017

                     

                     
                    
                      
                        	
                                 Page 42 of 83

                              


                      

                      
                        


                    

                    
                      	SUB MENTAL	


                      

                    

                    	 	
                            Drug Name [Nombre del

                             Medicamento]

                          	
                            Net

                            Cost

                            [Costo

                            Neto]

                          	
                            Tier [Tier]

                          	
                            Reference Name 

                            [Nombre de

                            Referencia]

                          	
                            Requirements/

                            Limits

                            [Requerimientos/

                             Límites]

                          
	 	
                            THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                          
	 	
                            Therapeutic Class [Clase Terapéutica]

                          
	 	
                            ANTIANXIETY AGENTS [AGENTES  PARA

                                LA ANXIEDAD]

                          
	 	
                            Benzodiazepines [Benzodiazepinas]

                          
	 	
                            diazepam 10 mg tab, 2 mg  tab, 5 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            VALIUM

                          	
                            QL=5 días

                          
	 	
                            lorazepam 0.5 mg tab, 1 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            ATIVAN

                          	
                            QL=5 días

                          
	 	
                            Sedating Histamine 1 Blocking Agents [Sedantes Bloqueadores Histamine 1]

                          
	 	
                            hydroxyzine pamoate 100 mg cap, 25 mg cap, 50 mg cap

                          	
                            1

                          	
                              

                            Preferred

                          	
                            VISTARIL

                          	
                            QL=30 días

                          
	 	
                            ANTIDEPRESSANTS [ANTIDEPRESIVOS]

                          
	 	
                                      Miscellaneous Antidepressants [Antidepresivos Misceláneos]

                          
	 	
                            bupropion hcl 75 mg tab

                          	
                            1

                          	
                            Preferred   

                          	
                            WELLBUTRIN

                          	
                            QL=30 días

                          
	 	
                            bupropion hcl er (sr) 100 mg tab er 12 hr, 150 mg tab er 12 hr, 200 mg tab er 12 hr

                          	
                            1

                          	
                            Preferred

                          	
                            WELLBUTRIN SR

                          	
                            QL=30 días

                          
	 	
                            mirtazapine 15 mg tab, 30 mg tab, 45 mg tab, 7.5 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            REMERON

                          	
                            QL=30 días

                          
	 	
                            trazodone hcl 100 mg tab, 150 mg tab, 50 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            DESYREL

                          	
                            QL=30 días

                          
	 	
                            bupropion hcl 100 mg tab

                          	
                            2

                          	
                            Non-Preferred

                          	
                            WELLBUTRIN

                          	
                            QL=30 días

                          
	 	
                            bupropion hcl er (xl) 150 mg tab er 24 hr, 300 mg tab er 24 hr

                          	
                            2

                          	
                            Non-Preferred

                          	
                            WELLBUTRIN XL

                          	
                            QL=30 días

                          
	 	
                            mirtazapine 15 mg odt, 30 mg odt, 45 mg odt

                          	
                            3

                          	
                            Non-Preferred

                          	
                            REMERON

                          	
                            QL=30 días

                          
	 	
                            Serotonin and/or Norepinephrine Modulators [Moduladores De Serotonina y/o

                            Norepinefrina]

                          
	 	
                            citalopram hydrobromide 10 mg tab, 20 mg tab, 40 mg tab

                          	
                            1

                          	
                              

                            Preferred

                          	
                            CELEXA

                          	
                            QL=30 días

                          
	 	
                            fluoxetine hcl 10 mg cap, 20 mg cap

                          	
                            1

                          	
                            Preferred

                          	
                            PROZAC

                          	
                            QL=30 días

                          


                     

                    

                    
                      
                        	
                                 Page 43 of 83

                              


                      

                      
                        


                    

                    
                      	 	
                              Drug Name [Nombre del

                               Medicamento]

                            	
                              Net

                              Cost

                              [Costo

                              Neto]

                            	
                              Tier [Tier]

                            	
                              Reference Name

                               [Nombre de

                              Referencia]

                            	
                              Requirements/

                              Limits

                              [Requerimientos/

                               Límites]

                            
	 	
                              paroxetine hcl 20 mg tab, 30 mg tab, 40 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              PAXIL

                            	
                              QL=30 días

                            
	 	
                              sertraline hcl 100 mg tab, 25 mg tab, 50 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              ZOLOFT

                            	
                              QL=30 días

                            
	 	
                              venlafaxine hcl 100 mg tab, 25 mg tab, 37.5 mg tab, 50 mg tab, 75 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              EFFEXOR

                            	
                              QL=30 días

                            
	 	
                              Tricyclic Agents [Tricíclicos]

                            
	 	
                              amitriptyline hcl 10 mg tab, 100 mg tab, 150 mg tab, 25 mg tab, 50 mg tab, 75 mg tab

                            	
                              1

                            	
                                

                              Preferred

                            	
                              ELAVIL

                            	
                              QL=30 días

                            
	 	
                              doxepin hcl 10 mg cap, 25 mg cap, 50 mg cap, 75 mg cap

                            	
                              1

                            	
                              Preferred

                            	
                              SINEQUAN

                            	
                              QL=30 días

                            
	 	
                              imipramine hcl 10 mg tab, 25 mg tab, 50 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              TOFRANIL

                            	
                              QL=30 días

                            
	 	
                              nortriptyline hcl 10 mg cap, 25 mg cap, 50 mg cap, 75

                              mg cap

                            	
                              1

                            	
                              Preferred

                            	
                              PAMELOR

                            	
                              QL=30 días

                            
	 	
                              doxepin hcl 100 mg cap, 150 mg cap

                            	
                              2

                            	
                              Preferred

                            	
                              SINEQUAN

                            	
                              QL=30 días

                            
	 	
                              ANTIPARKINSON AGENTS [AGENTES ANTIPARKINSON]

                            
	 	
                               Anticholinergics [Anticolinérgicos]

                            
	 	
                              benztropine mesylate 0.5 mg tab, 1 mg tab, 2 mg tab

                            	
                              1

                            	
                                

                              Preferred

                            	
                              COGENTIN

                            	
                              QL=30 días

                            
	 	
                              ANTIPSYCHOTICS [ANTIPSICÓTICOS]

                            
	 	
                               Atypical - Second Generation [Atípicos - Segunda Generación]

                            
	 	
                              risperidone 0.25 mg tab, 0.5 mg tab, 1 mg tab, 2 mg tab, 3 mg tab, 4 mg tab

                            	
                              1

                            	
                                

                              Preferred

                            	
                              RISPERDAL

                            	
                              QL=5 días

                            
	 	
                              Typical - First Generation [Típicos - Primera Generación]

                            
	 	
                              haloperidol 0.5 mg tab, 1 mg tab, 2 mg tab

                            	
                              1

                            	
                                

                              Preferred

                            	
                              HALDOL

                            	
                              QL=5 días

                            
	 	
                              haloperidol 5 mg tab

                            	
                              2

                            	
                              Preferred

                            	
                              HALDOL

                            	
                              QL=5 días

                            
	 	
                              haloperidol 10 mg tab

                            	
                              3

                            	
                              Preferred

                            	
                              HALDOL

                            	
                              QL=5 días

                            
	 	
                              haloperidol 20 mg tab

                            	
                              4

                            	
                              Preferred

                            	
                              HALDOL

                            	
                              QL=5 días

                            


                      

                      

                      
                        
                          	
                                   Page 44 of 83

                                


                        

                        
                          


                      

                      	 	
                              Drug Name [Nombre del

                               Medicamento]

                            	
                              Net

                              Cost

                              [Costo

                              Neto]

                            	
                              Tier [Tier]

                            	
                              Reference Name

                               [Nombre de

                              Referencia]

                            	
                              Requirements/

                              Limits

                              [Requerimientos/

                               Límites]

                            
	 	
                              DETOX TREATMENT [TRATAMIENTO DE DETOX]

                            
	 	
                               Detox Treatment [Tratamiento De Detox]

                            
	 	
                              clonidine hcl 0.1 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              CATAPRESS

                            	
                              QL=7 días

                            
	 	
                              folic acid 1 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              FOLIC ACID

                            	
                              QL=7 días

                            
	 	
                              ibuprofen 800 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              MOTRIN

                            	
                              QL=7 días

                            
	 	
                              loperamide hcl 2 mg cap

                            	
                              1

                            	
                              Preferred

                            	
                              IMODIUM

                            	
                              QL=7 días

                            
	 	
                              vitamin b-1 100 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              THIAMINE

                            	
                              QL=7 días

                            
	 	
                              MOOD STABILIZERS [ESTABILIZADORES DEL ÁNIMO]

                            
	 	
                               Bipolar Agents [Agentes Para Bipolaridad]

                            
	 	
                              divalproex sodium 125 mg tab dr, 250 mg tab dr, 500 mg tab dr

                            	
                              1

                            	
                                

                              Preferred

                            	
                              DEPAKOTE

                            	
                              QL=30 días

                            
	 	
                              lamotrigine 100 mg tab, 150 mg tab, 200 mg tab, 25 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              LAMICTAL

                            	
                              QL=30 días

                            
	 	
                              valproic acid 250 mg cap, 250 mg/5ml soln, 250 mg/5ml syr

                            	
                              1

                            	
                              Preferred

                            	
                              DEPAKENE

                            	
                              QL=30 días

                            
	 	
                              PSYCHOSTIMULANTS [PSICOESTIMULANTES]

                            
	 	
                              ADHD Amphetamines [Anfetaminas ADHD]

                            
	 	
                              amphetamine-

                              dextroamphetamine 15 mg tab, 30 mg tab

                            	
                              2

                            	
                               

                              Preferred

                            	
                              ADDERALL

                            	
                              QL=30 días,

                              AL 4-20 años,

                              PA ≥ 21 años

                            
	 	
                              amphetaminedextroamphetamine 10 mg tab, 12.5 mg tab, 20 mg tab, 5 mg tab, 7.5 mg tab

                            	
                              3

                            	
                              Preferred

                            	
                              ADDERALL

                            	
                              QL=30 días,

                              AL 4-20 años,

                              PA ≥ 21 años

                            
	 	
                              dextroamphetamine sulfate 10 mg tab, 5 mg tab

                            	
                              3

                            	
                              Preferred

                            	
                              DEXEDRINE

                            	
                              QL=30 días,

                              AL 4-20 años,

                              PA ≥ 21 años

                            
	 	
                              dextroamphetamine sulfate er 5 mg cap er 24 hr, 10 mg cap er 24 hr

                            	
                              4

                            	
                              Non-Preferred

                            	
                              DEXEDRINE SR

                            	
                              QL=30 días,

                              AL 4-20 años,

                              PA ≥ 21 años

                            
	 	
                              dextroamphetamine sulfate er 15 mg cap er 24 hr

                            	
                              5

                            	
                              Non-Preferred

                            	
                              DEXEDRINE SR

                            	
                              QL=30 días,

                              AL 4-20 años,

                              PA ≥ 21 años

                            
	 	
                              DYANAVEL XR oral susp. er

                              2.5 mg/ mL

                            	
                              4

                            	
                              Non-Preferred

                            	
                              DYANAVEL XR

                            	
                              PA, AL 6-20 años

                            


                      

                      

                      
                        
                          	
                                   Page 45 of 83

                                


                        

                        
                          


                      

                      	 	
                              Drug Name [Nombre del

                              Medicamento]

                            	
                              Net

                              Cost

                              [Costo

                              Neto]

                            	
                              Tier [Tier]

                            	
                              Reference Name

                              [Nombre de

                              Referencia]

                            	
                              Requirements/

                              Limits

                              [Requerimientos/

                              Límites]

                            
	 	
                              ADHD Non-Amphetamines [No-Anfetaminas ADHD]

                            
	 	
                              clonidine hcl 0.1 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              CATAPRESS

                            	
                              QL=7 días

                            
	 	
                              dexmethylphenidate hcl 2.5 mg tab, 5 mg tab

                            	
                              2

                            	
                              Preferred

                            	
                              FOCALIN

                            	
                              QL=30 días,

                              AL 6-20 años,

                              PA ≥ 21 años

                            
	 	
                              methylphenidate hcl 5 mg tab

                            	
                              2

                            	
                              Preferred

                            	
                              RITALIN

                            	
                              QL=30 días,

                              AL 6-20 años,

                              PA ≥ 21 años

                            
	 	
                              dexmethylphenidate hcl 10 mg tab

                            	
                              3

                            	
                              Preferred

                            	
                              FOCALIN

                            	
                              QL=30 días,

                              AL 6-20 años,

                              PA ≥ 21 años

                            
	 	
                              methylphenidate hcl 10 mg tab, 20 mg tab

                            	
                              3

                            	
                              Preferred

                            	
                              RITALIN

                            	
                              QL=30 días,

                              AL 6-20 años,

                              PA ≥ 21 años

                            
	 	
                              STRATTERA 10 mg cap, 100 mg cap, 18 mg cap, 25 mg cap, 40 mg cap, 60 mg cap, 80 mg cap

                            	
                              4

                            	
                              Preferred

                            	 	
                              PA, QL=30 días, AL 6-20

                              años, PA ≥ 21 años, P

                            
	 	
                              SLEEP DISORDER AGENTS [DESORDENES DEL SUEÑO]

                            
	 	
                              Benzodiazepines [Benzodiazepinas]

                            
	 	
                              flurazepam hcl 15 mg cap, 30 mg cap

                            	
                              1

                            	
                                

                              Preferred

                            	
                              DALMANE

                            	
                              QL=5 días

                            
	 	
                              temazepam 15 mg cap, 30 mg cap

                            	
                              1

                            	
                              Preferred

                            	
                              RESTORIL

                            	
                              QL=5 días

                            
	 	
                              Miscellaneous Sleep Disorder Agents [Agentes Misceláneos Desordenes Del Sueño]

                            
	 	
                              zolpidem tartrate 10 mg tab, 5 mg tab

                            	
                              1

                            	
                              Preferred

                            	
                              AMBIEN

                            	
                              QL=5 días

                            


                       

                      

                      
                        
                          	
                                   Page 46 of 83

                                


                        

                        
                          


                      

                      
                        
                          	
                                  A

                                	 
	
                                  amitriptyline hcl

                                	10
	
                                  amphetamine-dextroamphetamine

                                	11
	 	 
	
                                  B

                                	 
	
                                  benztropine mesylate

                                	10
	bupropion hcl 	9
	
                                  bupropion hcl er (sr)

                                	9
	
                                  bupropion hcl er (xl)

                                	9
	 	

                                
	
                                  C

                                	 
	
                                  citalopram hydrobromide

                                	9
	
                                  clonidine hcl

                                	11, 12

                                
	 	 
	
                                  D

                                	 
	
                                  dexmethylphenidate hcl

                                	12
	
                                  dextroamphetamine sulfate

                                	12
	
                                  dextroamphetamine sulfate er

                                	12
	
                                  diazepam

                                	9
	
                                  divalproex sodium

                                	11
	
                                  doxepin hcl

                                	10
	
                                  DYANAVEL XR

                                	12
	 	 
	
                                  F

                                	 
	
                                  fluoxetine hcl

                                	10
	
                                  flurazepam hcl

                                	12
	
                                  folic acid

                                	11
	 	 
	
                                  H

                                	 
	
                                  haloperidol

                                	11
	
                                  hydroxyzine pamoate

                                	9
	 	 
	
                                  I

                                	 
	
                                  ibuprofen

                                	11
	
                                  imipramine hcl

                                	10
	 	 
	
                                  L

                                	 
	
                                  lamotrigine

                                	11
	
                                  loperamide hcl

                                	11
	
                                  lorazepam

                                	9


                        

                        
                          
                            	
                                    M

                                  	 
	
                                    methylphenidate hcl

                                  	12
	
                                    mirtazapine

                                  	9
	 	 
	
                                    N

                                  	 
	
                                    nortriptyline hcl

                                  	10
	 	 
	
                                    P

                                  	 
	
                                    paroxetine hcl

                                  	10
	 	 
	
                                    R

                                  	 
	
                                    risperidone

                                  	10
	 	 
	
                                    
                                      S

                                    

                                  	

                                  
	
                                    sertraline hcl

                                  	10
	
                                    STRATTERA

                                  	12
	 	 
	
                                    T

                                  	 
	
                                    temazepam

                                  	12
	
                                    trazodone hcl

                                  	9
	 	 
	
                                    V

                                  	 
	
                                    valproic acid

                                  	11
	
                                    venlafaxine hcl

                                  	10
	
                                    vitamin b-1

                                  	11
	 	 
	
                                    Z

                                  	 
	
                                    zolpidem tartrate

                                  	13


                          

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        

                        	 


                        

                        

                      

                    

                    
                      
                        	
                                 Page 47 of 83

                              


                      

                      
                        


                    

                    ASES

                     

                    Puerto Rico Healthcare Insurance Administration

                     

                    HIV-AIDS

                     

                    2017

                     

                    Formulary of Drugs Covered by

                     

                    the Government Healthcare Plan (GHP)

                     

                    Authorized by the P.R. Elections Commission CEE-SA-16-2732

                     

                    
                      
                        	
                                 Page 48 of 83

                              


                      

                      
                        


                    

                    	
                            

                          	 	
                            GOVERNMENT OF PUERTO RICO

                          	 	
                            
                              Hon. Ricardo A. Rosselló Nevares

                              Governor

                            

                          
	 	
                            Healthcare Insurance Administration

                          	 	
                            Ms. Ángela M. Ávila Marrero

                            Executive Director

                          


                    

                    

                    May 1, 2017

                     

                    TO ALL GOVERNMENT HEALTHCARE PLAN (GHP) PROVIDERS

                     

                    Dear provider:

                     

                    I am pleased to submit to you the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health, as well as its
                        corresponding sub-formularies. The FDC supports healthcare under the new integrated services model of the Government Healthcare Plan, which has been in effect since April 1, 2015.

                     

                    The Physical Health FDC includes: Dental, Nephrology, Ob-gyn, Oncology, Integrated Emergency Formulary, HIV-AIDS, and
                        Sub-physical. Moreover, the Mental Health FDC also has a Sub-formulary. The Mental Health FDC will be used by contracted psychiatrists and by physicians contracted by facilities devoted to Mental Health treatment. The Mental Health
                        Sub-formulary will be used by participating primary care physicians (PCPs) in Primary Care Medical Groups.

                     

                    The drugs included in the FDC have been evaluated and approved by the Pharmacy and Therapeutics Committee of the Healthcare
                        Insurance Administration (ASES, Spanish acronym) constituted by primary care physicians and clinical pharmacists. This committee meets periodically to evaluate the therapeutic classes and make recommendations based on clinical
                        aspects. The FDC is a dynamic document that can undergo changes, of which you will be informed periodically by means of Regulatory Letters.

                     

                    I urge you to keep this guide for future reference. It is also available on our webpage, www.asespr.org.

                     

                    Cordially,

                     

                    [signed]

                     

                    Ángela M. Ávila Marrero

                     

                    Executive Director

                     

                    
                      	
                               

                            	
                              

                            
	 	 
	 
	
                              
                                PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                              

                            


                    

                     

                    

                     

                    
                      
                        	
                                 Page 49 of 83

                              


                      

                      
                        


                    

                    GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

                     

                    OF THE GOVERNMENT HEALTHCARE PLAN (GHP)

                     

                    
                      
                        	1.	
                                Drug Formulary

                              


                      

                    

                     

                    The Healthcare Insurance Administration (ASES, Spanish acronym) is the agency responsible for establishing and
                        reviewing the Formulary of Drugs Covered by the GHP (FDC) for Physical and Mental Health. For these purposes, ASES has established a Pharmacy and Therapeutics Committee that evaluates physical and mental health drugs. The Committee
                        is constituted by healthcare professionals, including primary care physicians, psychiatrists, and licensed pharmacists. The Committee meets periodically to evaluate the various therapeutic classes and make recommendations to ASES
                        for the drug formulary based on scientific evidence, clinical aspects, and a cost-effectiveness analysis.

                    

                    

                    The Formulary of Drugs Covered by the GHP (FDC) will serve as a guide in the provision of drugs under the
                        prescription drug coverage. The purpose of the FDC is to improve, update, and procure a cost-effective use of drugs under the GHP coverage.

                    

                    

                    ASES designs and updates the Formulary of Drugs Covered by the GHP through its Pharmacy Program Administrator
                        or PPA based on the most recent clinical evidence. Said formulary is the official formulary of the program from which drugs must be prescribed to GHP beneficiaries.

                    

                    

                    Non-formulary drugs may only be used in exceptional cases through the Exception Process that we will explain
                        in point number 2.

                    

                    

                    
                      
                        	2.	
                                Exception Process

                              


                      

                    

                     

                    In the case of patients who need a drug that is not included in the FDC, healthcare service providers and, as
                        applicable, insurance companies must use the process described below to obtain approval of the drug by exception. This procedure will consider the particular merits of each case, which may include:

                    

                    

                    
                      
                        	

                              	a.	
                                Contraindication to the drug(s) included in the FDC;

                              


                      

                    

                    
                      
                        	

                              	b.	
                                History of a clinically significant adverse reaction to the drug(s) included in the FDC;

                              


                      

                    

                    
                      
                        	

                              	c.	
                                Evidence of therapeutic failure of all alternatives available in the FDC; and/or

                              


                      

                    

                    
                      
                        	

                              	d.	
                                Lack of a therapeutic alternative in the FDC.

                              


                      

                    

                     

                    This exception process requires a clinical justification that is duly documented by the service provider with the
                        clinical reasons justifying the use of a non-formulary drug, which will be evaluated on a case-by-case basis by a clinical team at the insurance company(ies) contracted by ASES.

                     

                    
                      
                        	3.	
                                Other Aspects of the Prescription Drug Coverage

                              


                      

                    

                     

                    
                      
                        
                          	

                                	
                                  A.

                                	
                                  
                                    The prescription drug coverage of the GHP establishes that using generic bioequivalent products as the first option is mandatory.

                                  

                                


                        

                      

                    

                     

                    

                    
                      
                        	
                                 Page 50 of 83

                              


                      

                      
                        


                    

                    
                      
                        	

                              	B.	
                                Insurance companies or the TPA (Third Party Administrator) and healthcare service providers
                                      will only process their prescription drug claims through the Pharmacy Benefit Manager or PBM contracted by ASES.

                              


                      

                    

                     

                    
                      
                        	

                              	C.	
                                ASES has an active process to continually review the prescription drug coverage in accordance
                                      with changes or advances in medical practice standards in relation to an illness or treatment area. It also evaluates new drugs to decide if they should be included. Because of the dynamic nature of this process, ASES
                                      may require that drugs be included in or excluded from the FDC at any time, taking the necessary measures to inform beneficiaries and medical providers about the changes to guarantee a transition process that will
                                      safeguard adequate access to services and maintain continuity of care.

                              


                      

                    

                     

                    
                      
                        	

                              	D.	
                                No entity contracted by ASES or by healthcare companies or organizations (for example,
                                      primary care medical groups, independent providers, specialists, among others) may use a formulary other than the PDL or create an internal drug formulary different than the formularies established by ASES.
                                      Furthermore, they may not limit the drugs included in the ASES FDC in any way contrary to the provisions in the contract between ASES and the contracted entities or in this coverage. Insurance companies will be
                                      responsible for supervising their providers and employees with regard to their compliance with these provisions.

                              


                      

                    

                     

                    
                      
                        	

                              	E.	
                                The maximum supply dispensed for acute conditions will cover a fifteen (15) day therapy. The
                                      treatment period may be extended, as applicable, when medically necessary.

                              


                      

                    

                     

                    
                      
                        	

                              	F.	
                                The maximum supply dispensed for chronic conditions (maintenance drugs) will cover a thirty
                                      (30) day therapy with three refills or ninety (90) days, except at the start of the therapy when, at the physician’s discretion, a minimum of fifteen (15) days may be prescribed with the purpose of reevaluating
                                      adherence and tolerance. The Government Healthcare Plan has decided that one prescription and a maximum of five (5) refills will be covered. Drug prescriptions will be valid for twelve (12) months, except in the case
                                      of narcotics, which will be dispensed only one (1) time, without refills. Drugs requiring preauthorization (PA) will be approved for a maximum of six (6) months. Physicians must reevaluate the pharmacotherapy in terms
                                      of adherence, tolerance, and dosage within ninety (90) days after the maintenance drug has been prescribed. Changes in dosage will not require preauthorization. Changes in the drug(s) used may require preauthorization.

                              


                      

                    

                     

                    
                      
                        	

                              	G.	
                                ASES requires the use of generic bioequivalent drugs approved by the Food and Drug
                                      Administration (FDA) coded as “AB” and those authorized under applicable local regulations in Puerto Rico.

                              


                      

                    

                     

                    
                      
                        	

                              	H.	
                                The lack of appropriate bioequivalent drug inventories does not exempt providers from
                                      dispensing the prescribed drug or entail any additional payment by the beneficiary. As a general rule, generic bioequivalent drugs must be dispensed only as long as there is a generic bioequivalent for the
                                      corresponding brand-name drug, unless, in spite of the fact that there is a generic bioequivalent, ASES decides to cover the brand-name drug or both, in which case it will usually be managed by means of the exception
                                      mechanism.

                              


                      

                    

                     

                    
                      
                        	
                                 Page 51 of 83

                              


                      

                      
                        


                    

                    
                      
                        	

                              	I.	
                                Drug prescriptions will be filled by a pharmacy contracted by the PBM that is duly authorized
                                      under the law of the Commonwealth of Puerto Rico and has been freely chosen by the beneficiary.

                              


                      

                    

                     

                    
                      
                        	

                              	J.	
                                The right to freedom of choice requires the availability of a pharmacy that is reasonably
                                      accessible to each insured. The PBM is the entity in charge of contracting the pharmacy network according to the terms specified by ASES.

                              


                      

                    

                     

                    Prescription drugs must be delivered after the date and time when the beneficiary presents the prescription or when an
                        electronic prescription is received at the pharmacy. Drugs must be dispensed within no more than 72 hours. Drugs requiring a PA must be approved within 72 hours, except for expedited PAs, which must be processed within 24 hours. If
                        a drug is not available at the pharmacy, the insured must have the option of requesting the prescription to have it filled at another pharmacy; in the case of electronic prescriptions, the insured must contact his or her physician
                        to have the prescription sent to another pharmacy of his or her choice.

                    

                    

                    
                      
                        	4.	
                                Emergency Rule

                              


                      

                    

                     

                    The products that appear in the Integrated Emergency Formulary (IEF) will be dispensed for five (5) business days, except as
                        otherwise specified.

                    

                    

                    The same thing applies to analgesics, narcotics, combination drugs, and nonsteroidal anti-inflammatory drugs, which will also be
                        dispensed in amounts sufficient for five (5) business days.

                    

                    

                    Beneficiaries who have not been admitted into a hospital institution must visit their primary care physician for continuity of
                        treatment, including pharmacotherapy. We would like to remind you that the GHP model is a coordinated care plan. We also recommend that you verify that the products prescribed in an emergency room are included in the IEF.

                    

                    

                    If you have any questions about the prescription drug coverage, you may contact the insurance company contracted by ASES in your
                        region and/or the Pharmacy Benefit Manager (PBM) contracted by ASES.

                     

                      

                    
                      
                        	
                                 Page 52 of 83

                              


                      

                      
                        


                    

                    de mayo de 2017

                    
                      
                         

                         

                        

                        VIH-SIDA

                      

                    

                     

                      

                    GOVERNMENT HEALTHCARE PLAN

                     

                    FORMULARY OF DRUGS COVERED BY THE GHP (FDC)

                     

                    2017

                     

                    TABLE OF CONTENTS

                     

                    	
                            GENERAL ASPECTS OF THE PRESCRIPTION DRUG COVERAGE

                          	 
	
                            OF THE GOVERNMENT HEALTHCARE PLAN

                          	
                            3

                          
	
                            DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND

                          	 
	
                            REFERENCE GUIDES

                          	
                            8

                          
	 	
                            MONTHLY NET COST RANGE

                          	
                            8

                          
	 	
                            GENERIC DRUGS

                          	
                            9

                          
	
                            THERAPEUTIC CATEGORY

                          	
                            10

                          
	
                            ANESTHETICS

                          	
                            10

                          
	 	
                            Local Anesthetics

                          	
                            10

                          
	
                            ANTIBACTERIALS

                          	
                            10

                          
	 	
                            Macrolides

                          	
                            10

                          
	 	
                            Miscellaneous Antibacterials

                          	
                            11

                          
	 	
                            Penicillins

                          	
                            11

                          
	 	
                            Quinolones

                          	
                            11

                          
	 	
                            Sulfonamides

                          	
                            12

                          
	 	
                            Tetracyclines

                          	
                            12

                          
	
                            ANTIMYCOBACTERIALS

                          	
                            12

                          
	 	
                            Antituberculars

                          	
                            12

                          
	 	
                            Miscellaneous Antimycobacterials

                          	
                            12

                          
	
                            ANTIMYCOTIC AGENTS

                          	
                            12

                          
	 	
                            Antifungals

                          	
                            12

                          
	
                            ANTIPARASITICS

                          	
                            13

                          
	 	
                            Anthelmintics

                          	
                            13

                          
	 	
                            Antimalarials

                          	
                            13

                          
	 	
                            Antiprotozoals - Non-Antimalarials

                          	
                            13

                          


                    

                    

                    
                      
                        	
                                 Page 53 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          Revisado: 18 de mayo de 2017

                        

                        

                       

                      

                      VIH-SIDA

                    

                     

                    

                    	
                            ANTIVIRALS

                          	
                            13

                          
	 	
                            Anti-Cytomegalovirus (CMV) Agents

                          	
                            13

                          
	 	
                            Antiherpetic Agents

                          	
                            13

                          
	 	
                            Non-Nucleoside Reverse Transcriptase Inhibitors

                          	
                            13

                          
	 	
                            Nucleoside/Nucleotide Reverse Transcriptase Inhibitors

                          	
                            14

                          
	
                            BLOOD MODIFIERS

                          	
                            14

                          
	 	
                            Erythropoiesis-Stimulating Agents

                          	
                            14

                          
	 	
                            Iron

                          	
                            15

                          
	
                            CHEMOTHERAPIES

                          	
                            15

                          
	 	
                            Antineoplastic Progestins

                          	
                            15

                          
	 	
                            Folic Acid Antagonists Rescue Agents

                          	
                            15

                          
	
                            DENTAL AND ORAL AGENTS

                          	
                            15

                          
	 	
                            Antifungals

                          	
                            15

                          
	
                            HORMONAL AGENTS

                          	
                            16

                          
	 	
                            Mineralocorticoids

                          	
                            16

                          
	
                            IMMUNOSUPPRESSANTS

                          	
                            16

                          
	 	
                            Glucocorticosteroids

                          	
                            16

                          


                    

                    

                    
                      
                        	
                                 Page 54 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                    

                     

                      

                    DESIGN OF THE 2017 FORMULARY OF DRUGS COVERED BY THE GHP (FDC) AND REFERENCE GUIDES

                     

                    The drugs that appear on the FDC are the drugs covered under the Government Healthcare Plan. These drugs are selected based on their
                        safety profile, proven efficacy (cost-effectiveness), the existence of bioequivalent drugs, and cost of treatment. We suggest that physicians prescribe and pharmacists dispense only the drugs that appear in the FDC.

                     

                    The example below illustrates the information provided for the drugs included in the FDC.

                     

                    	 	
                            Drug Name

                          	
                            Net

                             Cost

                          	
                            Tier

                          	
                            Reference Name

                          	
                            Requirements/ 

                            Limits

                          
	 	
                            THERAPEUTIC CATEGORY

                          
	 	
                            Therapeutic Class

                          
	 	
                            ANESTHETICS

                          
	 	
                            Local Anesthetics

                          
	 	
                            lidocaine viscous 2%

                            mouth/throat soln

                          	
                            1

                          	
                            Preferred

                          	
                            XYLOCAINE

                          	 
	 	
                            ANTIBACTERIALS

                          
	 	
                            Aminoglycosides

                          
	 	
                            streptomycin sulfate 1 gm im soln

                          	
                            4

                          	
                            Preferred

                          	
                            STREPTOMYCIN

                          	 
	 	
                            Macrolides

                          
	 	
                            azithromycin 250 mg tab, 500 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            ZITHROMAX

                          	 
	 	
                            azithromycin 1 gm pckt, 100 mg/5 ml susp, 200 mg/5 ml susp, 600 mg tab

                          	
                            2

                          	
                            Preferred

                          	
                            ZITHROMAX

                          	 
	 	
                            clarithromycin 125 mg/5 ml susp, 250 mg tab, 500 mg tab

                          	
                            2

                          	
                            Preferred

                          	
                            BIAXIN

                          	 
	 	
                            clarithromycin 250 mg/5 ml susp

                          	
                            3

                          	
                            Preferred

                          	
                            BIAXIN

                          	 
	 	
                            ERY-TAB 500 mg tab dr

                          	
                            3

                          	
                            Preferred

                          	 	 


                    

                    

                    For each drug included in the FDC, the First Column
                        shows the name of the generic bioequivalent drug in lower-case letters if the drug is available in a generic version. If the drug is only available in its brand-name version, the brand name will appear in the First Column in upper-case letters.

                     

                    The Second Column shows the Monthly Net Cost Range
                        per Average Beneficiary (“Net Cost”). The Third Column shows the drug classification (tier): Preferred or Non-preferred. The Fourth Column shows the brand name only for reference, since the generic equivalent drug will always be dispensed if there is one. The Fifth Column shows the Reference Guides or Limits, as applicable.

                     

                      

                    
                      
                        	
                                 Page 55 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                      

                      

                    MONTHLY NET COST RANGE

                     

                    The monthly net cost range per average beneficiary (“Net Cost”) is included in the second column of the FDC to estimate the monthly net cost
                        of the therapy to be prescribed, including any negotiated discount and comparing the product with other therapeutic alternatives available as per the indication. Said exercise compares the average cost of monthly therapy for thirty
                        (30) days. The cost comparison is made based on all the products included in a therapeutic class (for example, the class of cardiovascular drugs). The net cost ranges next to each drug identify its average monthly cost and must be
                        interpreted as follows:

                     

                    	
                            1

                          	
                            less than $20

                          	
                            Least costly per month

                          
	
                            2

                          	
                            $20 - $49

                          	 
	
                            3

                          	
                            $50 - $99

                          	 
	
                            4

                          	
                            $100 - $199

                          	 
	
                            5

                          	
                            $200 - $349

                          	 
	
                            6

                          	
                            $350 - $549

                          	 
	
                            7

                          	
                            $550 - $799

                          	 
	
                            8

                          	
                            $800 - $1,099

                          	 
	
                            9

                          	
                            $1,100 - $1,499

                          	 
	
                            10

                          	
                            $1,500 - $1,999

                          	 
	
                            11

                          	
                            $2,000 - $2,499

                          	 
	
                            12

                          	
                            $2,500 - $2,999

                          	 
	
                            13

                          	
                            $3,000 - $3,499

                          	 
	
                            14

                          	
                            $3,500 - $3,999

                          	 
	
                            15

                          	
                            $4,000 - $4,499

                          	 
	
                            16

                          	
                            $4,500 - $4,999

                          	 
	
                            17

                          	
                            $5,000 - $5,499

                          	 
	
                            18

                          	
                            $5,500 - $5,999

                          	 
	
                            19

                          	
                            $6,000 - $6,499

                          	 
	
                            20

                          	
                            $6,500 - $6,999

                          	 
	
                            21

                          	
                            $7,000 - $7,499

                          	 
	
                            22

                          	
                            $7,500 - $7,999

                          	 
	
                            23

                          	
                            $8,000 - $8,499

                          	 
	
                            24

                          	
                            $8,500 - $9,000

                          	 
	
                            25

                          	
                            more than $9,000

                          	
                            Most costly per month

                          


                    

                    

                    We recommend that you consider prescribing the drug with the lowest monthly net cost within each therapeutic category (the
                        one with the lowest number in the scale from 1 to 25) when medically appropriate and when there are several clinically feasible alternatives for the beneficiary.

                     

                    The net cost analysis is an ongoing exercise subject to constant changes. Net costs as published here are current as of the date of this
                        edition of the FDC.

                     

                      

                    
                      
                        	
                                 Page 56 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                    

                     

                      

                    GENERIC DRUGS

                     

                    Generic bioequivalent drugs are
                          identified with lower-case letters. Certain generic bioequivalent drugs have a Maximum Allowable Cost (MAC List) to reimburse the pharmacies contracted in the network. Usually, this price covers the cost of acquiring the
                        generic product, but not the brand-name product. The products selected for inclusion in the MAC List are those that are more frequently prescribed and have been approved by the Food and Drug Administration (FDA) for marketing.

                     

                      

                    
                      
                        	
                                 Page 57 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                      

                    

                    	 	
                            Drug Name [Nombre del

                             Medicamento]

                          	
                            Net

                            Cost

                            [Costo

                            Neto]

                          	
                            Tier [Tier]

                          	
                            Reference Name

                            [Nombre de

                            Referencia]

                          	
                            Requirements/

                            Limits

                            [Requerimientos/

                             Límites]

                          
	 	
                            THERAPEUTIC CATEGORY [CATEGORÍA TERAPÉUTICA]

                          
	 	
                                      Therapeutic Class [Clase Terapéutica]

                          
	 	
                            ANESTHETICS [ANEST ÉSICOS]

                          
	 	
                            Local Anesthetics [Anestésicos Locales]

                          
	 	
                            lidocaine viscous 2 %  mouth/throat soln

                          	
                            1

                          	
                            Preferred

                          	
                            XYLOCAINE

                          	 
	 	
                            ANTIBACTERIALS [ANTIBACTERIANOS]

                          
	 	
                            Macrolides [Macrólidos]

                          
	 	
                            azithromycin 250 mg tab,  500 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            ZITHROMAX

                          	 
	 	
                            azithromycin 1 gm pckt, 100 mg/5ml susp, 200 mg/5ml susp, 600 mg tab

                          	
                            2

                          	
                            Preferred

                          	
                            ZITHROMAX

                          	 
	 	
                            clarithromycin 125 mg/5ml susp, 250 mg tab, 500 mg tab

                          	
                            2

                          	
                            Preferred

                          	
                            BIAXIN

                          	 
	 	
                            clarithromycin 250 mg/5ml susp

                          	
                            3

                          	
                            Preferred

                          	
                            BIAXIN

                          	 
	 	
                            ERY-TAB 500 mg tab dr

                          	
                            3

                          	
                            Preferred

                          	 	 
	 	
                            erythromycin base 250 mg cap dr prt, 250 mg tab, 500 mg tab

                          	
                            3

                          	
                            Preferred

                          	
                            ERY-TAB

                          	 
	 	
                            erythromycin ethylsuccinate 400 mg tab

                          	
                            3

                          	
                            Preferred

                          	
                            E.E.S.

                          	 
	 	
                            ERYTHROCIN STEARATE

                            250 mg tab

                          	
                            4

                          	
                            Non-Preferred

                          	 	 
	 	
                            E.E.S. GRANULES 200 mg/5ml susp

                          	
                            5

                          	
                            Preferred

                          	 	 
	 	
                            ERYPED 200 200 mg/5ml susp

                          	
                            5

                          	
                            Preferred

                          	 	 
	 	
                            ERYPED 400 400 mg/5ml susp

                          	
                            6

                          	
                            Preferred

                          	 	 


                    • PA – Prior Authorization [Pre Autorización] • aPA – Administrative Prior Authorization [Pre Autorización Administrativa] • QL – Quantity Limit [Límite de Cantidad] • ST – Step Therapy [Terapia Escalonada] • AL – Age Limit [Límite de Edad] • Net Cost [Costo Neto] –
                        Please refer to page 9 for monthly net cost range [Ver página 9 para rangos de costo neto mensual] • P – Preferred Contracted Product [Producto Contratado Preferido] 

                     

                    
                      
                        	
                                 Page 58 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                      

                    

                    	 	
                            Drug Name [Nombre del

                             Medicamento]

                          	
                            Net

                            Cost

                            [Costo

                            Neto]

                          	
                            Tier [Tier]

                          	
                            Reference Name

                             [Nombre de

                            Referencia]

                          	
                            Requirements/

                            Limits

                            [Requerimientos/

                             Límites]

                          
	 	
                            Miscellaneous Antibacterials [Antibacterianos Misceláneos]

                          
	 	
                            clindamycin hcl 150 mg cap,  300 mg cap, 75 mg cap

                          	
                            1

                          	
                            Preferred

                          	
                            CLEOCIN

                          	 
	 	
                            Penicillins [Penicilinas]

                          
	 	
                            amoxicillin 125 mg/5ml susp          , 200 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 400 mg/5ml susp, 500 mg cap, 500 mg tab, 875 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            AMOXIL

                          	 
	 	
                            amoxicillin-pot clavulanate 200-28.5 mg/5ml susp, 40057 mg/5ml susp, 500-125 mg tab, 875-125 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            AUGMENTIN

                          	 
	 	
                            ampicillin 125 mg/5ml susp, 250 mg cap, 250 mg/5ml susp, 500 mg cap

                          	
                            1

                          	
                            Preferred

                          	
                            PRINCIPEN

                          	 
	 	
                            penicillin v potassium 125 mg/5ml soln, 250 mg tab, 250 mg/5ml soln, 500 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            VEETIDS

                          	 
	 	
                            amoxicillin-pot clavulanate 250-125 mg tab, 250-62.5 mg/5ml susp

                          	
                            3

                          	
                            Preferred

                          	
                            AUGMENTIN

                          	 
	 	
                            BICILLIN L-A 600000 unit/ml im susp

                          	
                            3

                          	
                            Non-Preferred

                          	 	 
	 	
                            penicillin g procaine 600000 unit/ml im susp

                          	
                            3

                          	
                            Non-Preferred

                          	
                            BICILLIN LA

                          	 
	 	
                            BICILLIN L-A 1200000 unit/2ml im susp

                          	
                            4

                          	
                            Non-Preferred

                          	 	 
	 	
                            BICILLIN L-A 2400000 unit/4ml im susp

                          	
                            5

                          	
                            Non-Preferred

                          	 	 
	 	
                            Quinolones [Quinolonas]

                          
	 	
                            ciprofloxacin hcl 250 mg tab,  500 mg tab, 750 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            CIPRO

                          	 
	 	
                            levofloxacin 250 mg tab, 500 mg tab, 750 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            LEVAQUIN

                          	 
	 	
                            ciprofloxacin 500 mg/5ml (10%) susp

                          	
                            3

                          	
                            Preferred

                          	
                            CIPRO

                          	 


                    

                    

                    
                      
                        	
                                 Page 59 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                      

                    

                    	 	
                            Drug Name [Nombre del

                             Medicamento]

                          	
                            Net

                            Cost

                            [Costo

                            Neto]

                          	
                            Tier [Tier]

                          	
                            Reference Name

                             [Nombre de

                            Referencia]

                          	
                            Requirements/

                            Limits

                            [Requerimientos/ 

                            Límites]

                          
	 	
                            ciprofloxacin 250 mg/5ml (5%) susp

                          	
                            4

                          	
                            Preferred

                          	
                            CIPRO

                          	 
	 	
                            Sulfonamides [Sulfonamidas]

                          
	 	
                            sulfamethoxazole          -tmp ds 800-160 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            SEPTRA

                          	 
	 	
                            sulfamethoxazoletrimethoprim 200-40 mg/5ml susp, 400-80 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            SEPTRA

                          	 
	 	
                            sulfadiazine 500 mg tab

                          	
                            4

                          	
                            Preferred

                          	
                            SULFADIAZINE

                          	 
	 	
                            Tetracyclines [Tetraciclinas]

                          
	 	
                            minocycline hcl           100 mg cap, 50 mg cap, 75 mg cap

                          	
                            1

                          	
                            Preferred

                          	
                            MINOCIN

                          	 
	 	
                            doxycycline monohydrate 50  mg cap, 100 mg cap

                          	
                            2

                          	
                              

                            Non-Preferred

                          	
                            MONODOX

                          	 
	 	
                            ANTIMYCOBACTERIALS [ANTIMICOBACTERIANOS]

                          
	 	
                                      Antituberculars [Antituberculosos]

                          
	 	
                            isoniazid 100 mg tab, 300  mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            ISONIAZID

                          	 
	 	
                            rifampin 150 mg cap

                          	
                            1

                          	
                            Preferred

                          	
                            RIFADIN

                          	 
	 	
                            ethambutol hcl 100 mg tab

                          	
                            2

                          	
                            Non-Preferred

                          	
                            MYAMBUTOL

                          	 
	 	
                            pyrazinamide 500 mg tab

                          	
                            2

                          	
                            Non-Preferred

                          	
                            PYRAZINAMIDE

                          	 
	 	
                            rifampin 300 mg cap

                          	
                            2

                          	
                            Preferred

                          	
                            RIFADIN

                          	 
	 	
                            ethambutol hcl 400 mg tab

                          	
                            3

                          	
                            Non-Preferred

                          	
                            MYAMBUTOL

                          	 
	 	
                            isoniazid 50 mg/5ml syr

                          	
                            5

                          	
                            Non-Preferred

                          	
                            ISONIAZID

                          	 
	 	
                            rifabutin 150 mg cap

                          	 	 	
                            MYCOBUTIN

                          	
                            Puerto Rico Health

                            Department

                            Tuberculosis

                            Control

                            Program

                          
	 	
                            cycloserine 250 mg cap

                          	 	 	
                            SEROMYCIN

                          
	 	
                            RIFAMATE 50-300 mg cap

                          	 	 	 
	 	
                            TRECATOR 250 mg tab

                          	 	 	 
	 	
                            CAPASTAT 1 gm inj

                          	 	 	 
	 	
                            Miscellaneous Antimycobacterials [Antimicobacterianos Misceláneos]

                          
	 	
                            dapsone 100 mg tab, 25 mg  tab

                          	
                            2

                          	
                            Preferred

                          	
                            DAPSONE

                          	 
	 	
                            ANTIMYCOTIC AGENTS [ANTIMICÓTICOS]

                          
	 	
                                      Antifungals [Antifungales]

                          
	 	
                            fluconazole 10 mg/ml susp,  100 mg tab, 150 mg tab, 200 mg tab,
                                  50 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            DIFLUCAN

                          	 


                    

                    

                    
                      
                        	
                                 Page 60 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                      

                    

                    	 	
                             Drug Name [Nombre del

                             Medicamento]

                          	
                            Net

                            Cost

                            [Costo

                            Neto]

                          	
                            Tier [Tier]

                          	
                            Reference Name

                             [Nombre de

                            Referencia]

                          	
                            Requirements/

                            Limits

                            [Requerimientos/ 

                            Límites]

                          
	 	
                            ketoconazole 200 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            NIZORAL

                          	 
	 	
                            terbinafine hcl 250 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            LAMISIL

                          	 
	 	
                            fluconazole 40 mg/ml susp

                          	
                            2

                          	
                            Preferred

                          	
                            DIFLUCAN

                          	 
	 	
                            voriconazole 40 mg/ml susp

                          	
                            4

                          	
                            Preferred

                          	
                            VFEND

                          	 
	 	
                            itraconazole 100 mg cap

                          	
                            5

                          	
                            Preferred

                          	
                            SPORANOX

                          	 
	 	
                            SPORANOX 10 mg/ml soln

                          	
                            6

                          	
                            Preferred

                          	 	 
	 	
                            voriconazole 50 mg tab

                          	
                            8

                          	
                            Preferred

                          	
                            VFEND

                          	 
	 	
                            voriconazole 200 mg tab

                          	
                            10

                          	
                            Preferred

                          	
                            VFEND

                          	 
	 	
                            ANTIPARASITICS [ANTIPARASITARIOS]

                          
	 	
                            Anthelmintics [Antihelmínticos]

                          
	 	
                            ALBENZA 200 mg tab          

                          	
                            9

                          	
                            Preferred

                          	 	 
	 	
                            Antimalarials [Antimaláricos]

                          
	 	
                            DARAPRIM 25 mg tab          

                          	
                            7

                          	
                            Non-Preferred

                          	 	
                            PA

                          
	 	
                            Antiprotozoals - Non-Antimalarials [Antiprotozoarios No-Antimalaráricos]

                          
	 	
                            NEBUPENT 300 mg inh soln          

                          	
                            4

                          	
                            Preferred

                          	 	 
	 	
                            atovaquone 750 mg/5ml susp

                          	
                            9

                          	
                            Non-Preferred

                          	
                            MEPRON

                          	 
	 	
                            ANTIVIRALS [ANTIVIRALES]

                          
	 	
                            Anti-Cytomegalovirus (CMV) Agents [Agentes Anti-Citomegalovirus]

                          
	 	
                            valganciclovir hcl 450 mg  tab

                          	
                            13

                          	
                            Non-Preferred

                          	
                            VALCYTE

                          	 
	 	
                            Antiherpetic Agents [Agentes Antiherpéticos]

                          
	 	
                            acyclovir 200 mg cap, 400  mg tab, 800 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            ZOVIRAX

                          	 
	 	
                            acyclovir 200 mg/5ml susp

                          	
                            2

                          	
                            Preferred

                          	
                            ZOVIRAX

                          	 
	 	
                            Non-Nucleoside Reverse Transcriptase Inhibitors [Inhibidores No Nucleósidos De La

                            Transciptasa Reversa]

                          
	 	
                            nevirapine 200 mg tab          

                          	
                            1

                          	
                            Preferred

                          	
                            VIRAMUNE

                          	 
	 	
                            nevirapine 50 mg/5ml susp

                          	
                            5

                          	
                            Non-Preferred

                          	
                            VIRAMUNE

                          	 
	 	
                            RESCRIPTOR 200 mg tab

                          	
                            6

                          	
                            Non-Preferred

                          	 	 
	 	
                            SUSTIVA 200 mg cap

                          	
                            6

                          	
                            Preferred

                          	 	
                            P

                          
	 	
                            nevirapine er 100 mg tab er 24 hr, 400 mg tab er 24 hr

                          	
                            7

                          	
                              

                            Non-Preferred

                          	
                            VIRAMUNE XR

                          	 
	 	
                            SUSTIVA 50 mg cap, 600 mg tab

                          	
                            7

                          	
                            Preferred

                          	 	
                            P

                          
	 	
                            zidovudine 300 mg tab

                          	
                            2

                          	
                            Non-Preferred

                          	
                            RETROVIR

                          	 


                    

                    

                    
                      
                        	
                                 Page 61 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                    

                     

                    

                    	 	
                            Drug Name [Nombre del

                             Medicamento]

                          	
                            Net

                            Cost

                            [Costo

                            Neto]

                          	
                            Tier [Tier]

                          	
                            Reference Name

                             [Nombre de

                            Referencia]

                          	
                            Requirements/

                            Limits

                            [Requerimientos/ 

                            Límites]

                          
	 	
                            Nucleoside/Nucleotide Reverse Transcriptase Inhibitors [Inhibidores Nucleósidos/Nucleótidos De La
                                Transcriptasa Reversa]

                          
	 	
                            stavudine 1 mg/ml soln, 15  mg cap, 20 mg cap, 30 mg cap, 40 mg
                                  cap

                          	
                            3

                          	
                            Preferred

                          	
                            ZERIT

                          	 
	 	
                            didanosine 125 mg cap dr, 200 mg cap dr, 250 mg cap dr

                          	
                            4

                          	
                            Non-Preferred

                          	
                            VIDEX EC

                          	 
	 	
                            lamivudine 10 mg/ml
                                soln

                          	
                            4

                          	
                            Preferred

                          	
                            EPIVIR

                          	 
	 	
                            lamivudine 150 mg tab

                          	
                            4

                          	
                            Preferred

                          	
                            EPIVIR

                          	 
	 	
                            zidovudine 100 mg cap, 50 mg/5ml syr

                          	
                            4

                          	
                            Non-Preferred

                          	
                            RETROVIR

                          	 
	 	
                            abacavir sulfate 300 mg tab

                          	
                            5

                          	
                            Non-Preferred

                          	
                            ZIAGEN

                          	 
	 	
                            didanosine 400 mg cap dr

                          	
                            5

                          	
                            Non-Preferred

                          	
                            VIDEX EC

                          	 
	 	
                            lamivudine 300 mg tab

                          	
                            5

                          	
                            Preferred

                          	
                            EPIVIR

                          	 
	 	
                            VIDEX 2 gm soln

                          	
                            5

                          	
                            Non-Preferred

                          	 	 
	 	
                            lamivudine 100 mg tab

                          	
                            6

                          	
                            Preferred

                          	
                            EPIVIR

                          	
                            PA

                          
	 	
                            lamivudine-zidovudine 150300 mg tab

                          	
                            6

                          	
                            Preferred

                          	
                            COMBIVIR

                          	 
	 	
                            ZIAGEN 20 mg/ml soln

                          	
                            6

                          	
                            Non-Preferred

                          	 	 
	 	
                            abacavir-lamivudinezidovudine 300-150-300 mg tab

                          	
                            10

                          	
                            Non-Preferred

                          	
                            TRIZIVIR

                          	 
	 	
                            BLOOD MODIFIERS [MODIFICADORES DE LA SANGRE]

                          
	 	
                            Erythropoiesis-Stimulating Agents [Agentes Estimulantes De Eritropoiesis]

                          
	 	
                            ARANESP (ALBUMIN 

                            FREE) 100 mcg/0.5ml inj soln

                          	
                            1

                          	
                            Preferred

                          	 	
                            PA, P

                          
	 	
                            PROCRIT 3000 unit/ml inj soln

                          	
                            5

                          	
                            Preferred

                          	 	
                            PA, P

                          
	 	
                            ARANESP (ALBUMIN

                            FREE) 25 mcg/0.42ml inj soln, 25 mcg/ml inj soln

                          	
                            6

                          	
                            Preferred

                          	 	
                            PA, P

                          
	 	
                            PROCRIT 10000 unit/ml inj soln

                          	
                            6

                          	
                            Preferred

                          	 	
                            PA, P

                          
	 	
                            ARANESP (ALBUMIN

                            FREE) 40 mcg/0.4ml inj soln

                          	
                            7

                          	
                            Preferred

                          	 	
                            PA, P

                          


                    

                    

                    
                      
                        	
                                 Page 62 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                    

                     

                    

                    	 	
                            Drug Name [Nombre del

                             Medicamento]

                          	
                            Net

                            Cost

                            [Costo

                            Neto]

                          	
                            Tier [Tier]

                          	
                            Reference Name

                             [Nombre de

                            Referencia]

                          	
                            Requirements/

                            Limits

                            [Requerimientos/

                             Límites]

                          
	 	
                            ARANESP (ALBUMIN

                            FREE) 40 mcg/ml inj soln, 60 mcg/ml inj soln

                          	
                            8

                          	
                            Preferred

                          	 	
                            PA, P

                          
	 	
                            ARANESP (ALBUMIN

                            FREE) 150 mcg/0.3ml inj soln, 150 mcg/0.75ml inj soln, 200 mcg/0.4ml inj soln, 200 mcg/ml inj soln, 300 mcg/0.6ml inj soln,
                                300 mcg/ml inj soln, 500 mcg/ml inj soln, 60 mcg/0.3ml inj soln

                          	
                            9

                          	
                            Preferred

                          	 	
                            PA, P

                          
	 	
                            ARANESP (ALBUMIN

                            FREE) 100 mcg/ml inj soln

                          	
                            11

                          	
                            Preferred

                          	 	
                            PA, P

                          
	 	
                            PROCRIT 40000 unit/ml inj soln

                          	
                            11

                          	
                            Preferred

                          	 	
                            PA, P

                          
	 	
                            Iron [Hierro]

                          
	 	
                            iron 325 (65 fe) mg tab          

                          	
                            1

                          	
                            Preferred

                          	
                            IRON

                          	 
	 	
                            CHEMOTHERAPIES [QUIMIOTERAPIAS]

                          
	 	
                            Antineoplastic Progestins [Antineoplásicos De Progestina]

                          
	 	
                            megestrol acetate 20 mg  tab, 40 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            MEGACE

                          	 
	 	
                            megestrol acetate 40 mg/ml susp, 400 mg/10ml susp

                          	
                            2

                          	
                            Preferred

                          	
                            MEGACE

                          	 
	 	
                            Folic Acid Antagonists Rescue Agents [Antagonistas De Ácido Fólico]

                          
	 	
                            leucovorin calcium 5 mg tab          

                          	
                            3

                          	
                            Preferred

                          	
                            LEUCOVORIN

                          	 
	 	
                            leucovorin calcium 10 mg tab, 15 mg tab

                          	
                            4

                          	
                            Preferred

                          	
                            LEUCOVORIN

                          	 
	 	
                            leucovorin calcium 25 mg tab

                          	
                            9

                          	
                            Preferred

                          	
                            LEUCOVORIN

                          	 
	 	
                            leucovorin calcium 50 mg inj, 100 mg inj, 200 mg inj, 350 mg inj, 500 mg inj

                          	
                            9

                          	
                            Non-Preferred

                          	
                            LEUCOVORIN

                          	 
	 	
                            DENTAL AND ORAL AGENTS [AGENTES DENTALES Y ORALES]

                          
	 	
                            Antifungals [Antifungales]

                          
	 	
                            clotrimazole 10 mg  mouth/throat lozenge, 10 mg
                                  mouth/throat troche

                          	
                            1

                          	
                            Preferred

                          	
                            MYCELEX

                          	 


                    

                    

                    
                      
                        	
                                 Page 63 of 83

                              


                      

                      
                        


                    

                    
                      
                        
                          
                            Revisado: 18 de mayo de 2017

                          

                          

                         

                        

                        VIH-SIDA

                      

                      

                    

                    	 	
                            Drug Name [Nombre del

                             Medicamento]

                          	
                            Net

                            Cost

                            [Costo

                            Neto]

                          	
                            Tier [Tier]

                          	
                            Reference Name

                             [Nombre de

                            Referencia]

                          	
                            Requirements/

                            Limits

                            [Requerimientos/

                             Límites]

                          
	 	
                            nystatin 100000 unit/ml mouth/throat susp

                          	
                            1

                          	
                            Preferred

                          	
                            MYCOSTATIN

                          	 
	 	
                            HORMONAL AGENTS [AGENTES HORMONALES]

                          	 
	 	
                            Mineralocorticoids [Mineralocorticoides]

                          	 
	 	
                            fludrocortisone acetate 0.1  mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            FLORINEF

                          	 
	 	
                            IMMUNOSUPPRESSANTS [IMMUNOSUPRESORES]

                          	 
	 	
                             Glucocorticosteroids [Glucocorticoides]

                          	 
	 	
                            dexamethasone 0.5 mg tab,  0.5 mg/5ml oral elix, 0.5 mg/5ml soln, 0.75 mg tab, 1 mg tab, 1.5 mg tab, 2 mg tab, 4 mg tab, 6 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            DECADRON

                          	 
	 	
                            MEDROL 2 mg tab

                          	
                            1

                          	
                            Preferred

                          	 	 
	 	
                            methylprednisolone 32 mg tab, 4 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            MEDROL

                          	 
	 	
                            methylprednisolone (pak) 4 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            MEDROL

                          	 
	 	
                            prednisolone 15 mg/5ml soln, 15 mg/5ml syr

                          	
                            1

                          	
                            Preferred

                          	
                            PRELONE

                          	 
	 	
                            prednisone 1 mg tab, 10 mg tab, 2.5 mg tab, 20 mg tab, 5 mg tab, 50 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            DELTASONE

                          	 
	 	
                            prednisone (pak) 10 mg tab, 5 mg tab

                          	
                            1

                          	
                            Preferred

                          	
                            DELTASONE

                          	 
	 	
                            hydrocortisone 10 mg tab, 20 mg tab, 5 mg tab

                          	
                            2

                          	
                            Preferred

                          	
                            CORTEF

                          	 
	 	
                            methylprednisolone 16 mg tab, 8 mg tab

                          	
                            2

                          	
                            Preferred

                          	
                            MEDROL

                          	 


                     

                    

                    
                      
                        	
                                 Page 64 of 83

                              


                      

                      
                        


                    

                    
                      	
                              VIH-SIDA

                            	


                    

                     

                    

                    
                      
                        
                          	
                                  A

                                	 
	
                                  abacavir sulfate

                                	14
	
                                  abacavir-lamivudine-zidovudine

                                	14
	
                                  acyclovir

                                	13
	
                                  ALBENZA

                                	13
	
                                  amoxicillin

                                	11
	
                                  amoxicillin-pot clavulanate

                                	11
	
                                  ampicillin

                                	11

                                
	
                                  ARANESP (ALBUMIN FREE)

                                	14, 15
	
                                  atovaquone

                                	13
	azithromycin	10
	 	 
	
                                  B

                                	 
	
                                  BICILLIN L-A

                                	11
	 	 
	
                                  C

                                	 
	
                                  CAPASTAT

                                	12
	
                                  ciprofloxacin 

                                	11, 12

                                
	
                                  ciprofloxacin hcl

                                	11
	
                                  clarithromycin

                                	10
	
                                  clindamycin hcl

                                	11
	
                                  clotrimazole

                                	15
	
                                  cycloserine

                                	12
	 	 
	
                                  D

                                	 
	
                                  dapsone

                                	12
	
                                  DARAPRIM

                                	13
	
                                  dexamethasone

                                	16
	
                                  didanosine

                                	14

                                
	
                                  doxycycline monohydrate

                                	12
	 	 
	
                                  E

                                	 
	
                                  E.E.S. GRANULES

                                	10
	
                                  EPIVIR

                                	14
	
                                  ERYPED 200

                                	10
	
                                  ERYPED 400

                                	10
	
                                  ERY-TAB

                                	10
	
                                  ERYTHROCIN STEARATE

                                	10
	
                                  erythromycin base

                                	10
	
                                  erythromycin ethylsuccinate

                                	10
	
                                  ethambutol hcl

                                	12


                        

                      

                      
                        	
                                F

                              	 
	
                                fluconazole

                              	12, 13

                              
	
                                fludrocortisone acetate

                              	16
	 	 
	
                                H

                              	 
	
                                hydrocortisone

                              	16
	 	 
	
                                I

                              	 
	
                                iron 

                              	15
	
                                isoniazid

                              	12
	
                                itraconazole

                              	13
	 	 
	
                                K

                              	 
	
                                ketoconazole 

                              	13
	 	 
	
                                L

                              	 
	
                                lamivudine

                              	14
	
                                lamivudine-zidovudine

                              	14
	
                                leucovorin calcium

                              	15
	
                                levofloxacin

                              	11
	
                                lidocaine viscous

                              	10
	 	 
	
                                M

                              	 
	
                                MEDROL

                              	16
	
                                megestrol acetate

                              	15
	
                                methylprednisolone

                              	16
	
                                methylprednisolone (pak)

                              	16
	
                                minocycline hcl

                              	12
	 	 
	
                                N

                              	 
	
                                NEBUPENT

                              	13
	
                                nevirapine

                              	13
	
                                nevirapine er

                              	13
	
                                nystatin

                              	16
	 	 
	
                                P

                              	 
	
                                penicillin g procaine

                              	11
	
                                penicillin v potassium

                              	11
	
                                prednisolone

                              	16
	
                                prednisone

                              	16
	
                                prednisone (pak)

                              	16
	
                                PROCRIT

                              	14, 15

                              
	
                                pyrazinamide

                              	12


                      

                      
                        

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          

                          
                            	
                                     

                                  


                          

                          

                          

                          
                            
                              	
                                       Page 65 of 83

                                    


                            

                            
                              


                          

                          
                            
                              	
                                      VIH-SIDA

                                    	


                            

                          

                          

                          

                          
                            	
                                    R

                                  	 
	
                                    RESCRIPTOR

                                  	13
	
                                    rifabutin

                                  	12
	RIFAMATE	12
	
                                    rifampin

                                  	12
	 	 
	
                                    S

                                  	 
	
                                    SEROMYCIN

                                  	12
	
                                    SPORANOX

                                  	13
	
                                    stavudine

                                  	14
	
                                    sulfadiazine

                                  	12
	
                                    sulfamethoxazole-tmp ds

                                  	12
	 	 
	
                                    sulfamethoxazole-trimethoprim

                                  	12
	
                                    SUSTIVA

                                  	13


                          

                          
                            	
                                    T

                                  	 
	
                                    terbinafine hcl

                                  	13
	
                                    TRECATOR

                                  	12
	 	 
	
                                    V

                                  	 
	
                                    valganciclovir hcl

                                  	13
	
                                    VIDEX

                                  	14
	
                                    voriconazole

                                  	13
	 	 
	
                                    Z

                                  	 
	
                                    ZIAGEN

                                  	14
	
                                    zidovudine

                                  	13, 14

                                  


                          

                           

                          

                           

                          

                          

                          

                          

                          

                        

                      

                      
                        	
                                 

                              


                      

                    

                    

                      
                        
                          	
                                   Page 66 of 83

                                


                        

                      

                      
                        


                    

                  

                   

                 

              

            

          

        

      

    

  








  
    
      
         Attachment 6

          

         

        

        	
                

              	
                GOVERNMENT OF PUERTO RICO

              	 	
                Hon. Ricardo A. Rosselló Nevares

                Governor

                 

                  

                Ms. Ángela M. Ávila Marrero

                Executive Director

              
	
                Healthcare Insurance Administration

              


        

        

        REGULATORY LETTER 17-0502-A

        

        

        May 2, 2017

        

        

        
          
            
              
                
                  	TO:	
                          NATIONAL PHARMACY CHAINS THAT PARTICIPATE IN THE PUERTO RICO GOVERNMENT HEALTHCARE PLAN (GHP)

                        
	 	 
	
                          RE:

                        	
                          
                            
                              
                                
                                  NEW REIMBURSEMENT LEVELS EFFECTIVE JUNE 2, 2017

                                

                              

                            

                          

                        


                

              

            

          

        

         

          

        To preserve the continuity of the Puerto Rico Government Healthcare Plan (GHP), the Healthcare Services Insurance Administration (ASES, Spanish
            acronym) has decided to make adjustments in the reimbursement level of brand-name and high-cost drugs that are dispensed through the participating pharmacies in the network. The purpose is to guarantee our beneficiaries’ access to prescription
            drugs and control expenses. This is also in keeping with the provisions of the Fiscal Plan for Puerto Rico certified by the Financial Oversight and Management Board.

        

        

        The new reimbursement levels for National
                Pharmacy Chains effective June 2, 2017, are as follows:

        

        

        Up to 83 days’ supply (if applicable):

        

        

        Brand-name drugs: AWP - 18% + $1.75
            dispensing fee

        Generic bioequivalent drugs: ASES MAC List
            + $1.75 dispensing fee

        Generic bioequivalent drugs not on MAC List: AWP






            - 25% + $1.75 dispensing fee

        Drugs included on high-cost list (refer to
            Attachment 1): Discount for product on the list + $1.75 dispensing fee

        

        

        Greater than or equal to 84 days’ supply (if applicable):

        

        

        Brand-name drugs: AWP - 21% + $1.75
            dispensing fee (DF)

        Generic bioequivalent drugs: ASES MAC List
            + $1.75 dispensing fee

        Generic bioequivalent drugs not on MAC List: AWP






            - 25% + $1.75 dispensing fee

        

        

        We are counting on your participation as a provider in the pharmacy network of the Government Healthcare Plan to make sure our beneficiaries continue
            receiving the level and quality of service that you offer. MC-21 will soon send you the contract and instructions to follow. Thank you for your support and commitment.

        

        

        Cordially,

        

        

        	
                /s

              
	
                Ángela M. Ávila Marrero

              
	
                Executive Director

              
	
                c:

              	
                Marileny Lugo, MC-21

              


        

        

        	 	
                
                  
                    
                      
                        Puerto Rico Healthcare Insurance Administration

                      

                    

                  

                

              
	
                PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

              


        

        

        
          
            


        

        	
                

              	
                GOVERNMENT OF PUERTO RICO

              	 	
                Hon. Ricardo A. Rosselló Nevares

                Governor

                Ms. Ángela M. Ávila Marrero

                Executive Director

              
	
                Healthcare Insurance Administration

              


        

        

        REGULATORY LETTER 17-0205-B

        

        

        May 2, 2017

        

        

        
          
            
              
                
                  
                    
                      
                        
                          
                            	TO:	
                                    INDEPENDENT PHARMACIES AND LOCAL CHAINS THAT PARTICIPATE IN THE PUERTO RICO GOVERNMENT HEALTHCARE PLAN (GHP)

                                  
	 	 
	
                                    RE:

                                  	
                                    
                                      
                                        
                                          
                                            NEW REIMBURSEMENT LEVELS EFFECTIVE JUNE 2, 2017

                                          

                                        

                                      

                                    

                                  


                          

                        

                      

                    

                  

                

              

            

          

        

        

        

        To preserve the continuity of the Puerto Rico Government Healthcare Plan (GHP), the Healthcare Services Insurance Administration (ASES, Spanish
            acronym) has decided to make adjustments in the reimbursement level of brand-name and high-cost drugs that are dispensed through the participating pharmacies in the network. The purpose is to guarantee our beneficiaries’ access to prescription
            drugs and control expenses. This is also in keeping with the provisions of the Fiscal Plan for Puerto Rico certified by the Financial Oversight and Management Board.

        

        

        The new reimbursement levels for Independent
                Pharmacies and Local Chains effective June 2, 2017, are as follows:

        

        

        Up to 90 days’ supply (if applicable):

        

        

        Brand-name drugs: AWP - 14% + $2.50
            dispensing fee

        Generic bioequivalent drugs: ASES MAC List
            + $2.50 dispensing fee

        Generic bioequivalent drugs not on MAC List: AWP






            - 25% + $2.50 dispensing fee

        Drugs included on high-cost list (refer to
            Attachment 1): Discount for product on the list + $2.50 dispensing fee

        

        

        We are counting on your participation as a provider in the pharmacy network of the Government Healthcare Plan to make sure our beneficiaries continue
            receiving the level and quality of service that you offer.

        

        

        MC-21 will soon send you the contract and instructions to follow.

        

        

        Thank you for your support and commitment.

        

        

        Cordially,

        

        

        	
                /s

              
	
                Ángela M. Ávila Marrero

              
	
                Executive Director

              
	
                c:

              	
                Marileny Lugo, MC-21

              
	 	
                Nélida Luna, MC-21

              


        

          	 	
                  
                    
                      
                        
                          Puerto Rico Healthcare Insurance Administration

                        

                      

                    

                  

                
	
                  PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                


        

        

        
          
            


        

        	
                

              	
                GOVERNMENT OF PUERTO RICO

              	 	
                Hon. Ricardo A. Rosselló Nevares

                Governor

                 

                  

                Ms. Ángela M. Ávila Marrero

                Executive Director

              
	
                Healthcare Insurance Administration

              


        

        

        REGULATORY LETTER 17-0205-C

        

        

        May 2, 2017

        

        

        
          
            
              
                
                  
                    
                      
                        
                          
                            	TO:	
                                    EXTERNAL PHARMACIES OF HOSPITALS AND DIAGNOSTIC AND TREATMENT CENTERS THAT PARTICIPATE IN THE PUERTO RICO GOVERNMENT HEALTHCARE PLAN
                                        (GHP)

                                  
	 	 
	
                                    RE:

                                  	
                                    
                                      
                                        
                                          
                                            NEW REIMBURSEMENT LEVELS EFFECTIVE JUNE 2, 2017

                                          

                                        

                                      

                                    

                                  


                          

                        

                      

                    

                  

                

              

            

          

        

        

        

        To preserve the continuity of the Puerto Rico Government Healthcare Plan (GHP), the Healthcare Services Insurance Administration (ASES, Spanish
            acronym) has decided to make adjustments in the reimbursement level of brand-name and high-cost drugs that are dispensed through the participating pharmacies in the network. The purpose is to guarantee our beneficiaries’ access to prescription
            drugs and control expenses. This is also in keeping with the provisions of the Fiscal Plan for Puerto Rico certified by the Financial Oversight and Management Board.

        

        

        The new reimbursement levels for External
                Pharmacies of Hospitals and Diagnostic and Treatment Centers effective June 2, 2017, are as follows:

        

        

        Up to 90 days’ supply (if applicable):

        

        

        Brand-name drugs: AWP - 15% + $2.50
            dispensing fee

        Generic bioequivalent drugs: ASES MAC List
            + $2.50 dispensing fee

        Generic bioequivalent drugs not on MAC List: AWP






            - 25% + $2.50 dispensing fee

        Drugs included on high-cost list (refer to
            Attachment 1): Discount for product on the list + $2.50 dispensing fee

        

        

        We are counting on your participation as a provider in the pharmacy network of the Government Healthcare Plan to make sure our beneficiaries continue
            receiving the level and quality of service that you offer. MC-21 will soon send you the contract and instructions to follow.

        

        

        Thank you for your support and commitment.

        

        

        Cordially,

        

        

        	
                /s

              
	
                Ángela M. Ávila Marrero

              
	
                Executive Director

              
	 
	
                c:

              	
                Marileny Lugo, MC-21

              
	 	
                Nélida Luna, MC-21

              


        

        

        
          	 	
                  
                    
                      
                        Puerto Rico Healthcare Insurance Administration

                      

                    

                  

                
	
                  PO Box 195661, San Juan, PR 00919-5661 · Tel.: 787.474.3300 · Fax: 787.474.3348 · www.ases.pr.gov

                


        

        

        

        

      

      
        
 

    

  








  
    
      
        

      

      
                       Anexo 1: Lista de Descuentos para Medlcamentos de Alto costo que sean despachados por las
            Farmadas de C3denas Nadonales (2017)  Category  GP!  Drug Name  GPI Name        Actual Discount  Agents for Gaucher Disease  82700020002020  Ceredase  Alglucerase IV Soln 80Unit/ML        18.00%  Agents for Gaucher
            Disease  82700085102120  Vpriv  Vetaglucerase Alfa For lnj 400 Unit        18.001⁄4  Agents for Gaucher Disease  82700040600120  Cerdelga  Elig[ustat TartrateCap84 MG {Base Equivalent)        18.00%  Agents for Gaucher
            Disease  82700050002110  Cere2yme  lmiglucerase For lnj 200 Unit        18.00%  Agents for Gaucher DJsease  82700070000120  zavesca  Miglustat cap 100 MG        18.00%  Agents for Gaucher OJsease  82700080102120  Elelvso  TaHglucerase Alfa For
            lnj 200 Unit        18.00%  Agents for Gaucher Disease  82700050002120  Cerezyme  lm!glucerase For lnj 400 Unit        18.00%  ANALGES!CS-ANTHNFlAMMATORY  66200030002015  Gold Sodium Thiomalate  Gold Sodium Thioma\ate lnj 50
            MG/Ml        18.00%  ANALGESICS - NonNarcotic  64154090102020  Prlalt  Ziconotide Acetate lntrathecal lnj 100 MCG/ML        18.00%  ANALGESICS- NonNarcotic  64154090102030  Pria!t  Ziconotide Acetate lntrathecal lnj SOO
            MCG/SML        18.00%  ANALGESICS· NonNarcotic  64154090102010  Prialt  Ziconotide Acetate lntrathecal lnJ 500 MCG/20Ml {25 MCG/Ml)        18.00%  ANDROGENS-ANABOLIC  23100030802030  Aveed  Testosterone Undecanoate IM lnj in Oil 750 MG/3Ml
            (2SOMG/ML)        18.00%  ANTIARRHYTHMICS  35400025000110  Tlkosyn  Dofefrlide Cap 125 MCG {0,125 MG)        18.00%  ANTIARRHYTHMICS  35400025000120  T!kosyn  DofetiHde Cap 250 MCG {0.25
            MG)        18.00%  ANTIARRHYTHMICS  35400025000130  Tikosyn  Dofetllide Cap500 MCG {0.5 MG}        18.00%  ANTJASTHMATIC AND BRONCHOD!lATOR AGENTS  44603060002120  Xolair  Omaliwmab Forlnj 150
            MG        18.00%  ANTIBIOTICS-AMINOGLYCOSIDES  07000070102030  Tobramydn Sulfate  TOBRAMYCtN SULFATE INJ 40 MG/ML        41.75%  ANTIBIOTICS- AMINOGLYCOSIDES  07000070102020  Tobramydn Sulfate  Tobramycin Sulfate tnj 10
            MG/ML        41.75%  ANTIBIOTICS-AMINOGLYCOSIDES  07000070102034  Tobramycin Sulfate  Tobramycln Sulfate Jnj 80 MG/2ML {40 MG/ML)        41.75%  ANTIBIOTICS· AMINOGLYCOSIOES  07000070102105  Tobramycln Sulfate  Tobramycln Sulfate For lnj 1.2
            GM        41,75%  ANTIBIOTICS· AMINOGLYCOSIDES  07000070102039  Tobramycfn Sulfate  Tobramyc!n Sulfate lnj 2 GM/SOML (40 MG/Ml)        41.75%  ANTIBIOTICS· AMINOGLYCOSIDES  07000070102022  Tobramycln Sulfate  Tobramycln Sulfate IV Soln 10
            MG/Ml        41.75%  ANTIBIOTICS-AMINOGLYCOSlDES  07000070102038  Tobramycin Sulfate  Tobramycin Sulfate In] 1.2 GM/30ML (40 MG/Ml)        41.75%  Anti-Cataplectic Agents  62450060202020  Xyrem  Sodium Oxybate Oral Solution 500
            MG/ML        18.00%  ANTICOAGUlANTS  83101010102020  Fragmin  Dalteparin Sodium In] 2500 Unlt/0.2ML        18.003⁄4  ANTICOAGUlANTS  83101020102013  Lovenox  Enoxaparln Sodium lnj 40
            MG/0.4ML        18.00%  ANTICOAGULANTS  83103030102035  Arixtra  FondaparinuxSodlum Subcutaneous tnj 5 MG/0.4Ml        18.00%  ANTICOAGULANTS  83101010102065  Fragmin  Dalteparin Sodium lnj 25000
            Unit/ML        18.00%  ANTICOAGULANTS  831010201020S0  Lovenox  Enoxaparln Sodium lnj 300 MG/3ML        18.00%  ANTICOAGULANTS  83370060000340  xarelto  Rivaroxaban Tab 20 MG        18.00%  ANTICOAGULANTS  83101010102040  Fragmin  Dalteparin
            Sodium lnj 5000 Unit/0,2ML        18.00%  ANTICOAGULANTS  83101020102014  Lovenox  Enoxaparin Sodium lnJ 60 MG/0,6Ml        18.00%  ANTICOAGULANTS  83103030102040  Arixtra  Fondaparinux Sodium Subcutaneous lnj 7.5
            MG/0.6ML        18.00%  ANTICOAGULANTS  83101010102015  Fragmin  Dalteparin Sodium In] 10000 Unit/ML        18.00%  ANTICOAGULANTS  83101020102012  Lovenox  Enoxaparin Sodium lnj 30
            MG/0,3ML        18.00%  ANTICOAGULANTS  83103030102020  Arixtra  FondaparinuxSodium Subcutaneous lnj 2.S MG/0.SML        18.00%  ANTICOAGULANTS  83101010102045  Fragmin  DalteparinSodium lnj 7500
            Unlt/0.3ML        18.00%  ANTICOAGULANTS  83101020102015  lovenox  Enoxaparin Sodium lnj 80 MG/0.8ML        18.00%  ANTICOAGUlANTS  83103030102045  Arixtra  FondaparinuxSodium Subcutaneous lnj 10
            MG/0.SML        18.00%  ANTICOAGULANTS  83101010102056  Fragmin  Da\teparin Sodium lnj 15000 Unit/0.6Ml        18.00%  ANTICOAGULANTS  83101020102018  Lovenox  Enoxaparln Sodium lnj 120
            MG/0.8ML        18.00%  ANTICOAGULANTS  83370060000320  Xarelto  RivaroxabanTab 10 MG  ,,,·      18.00%  ANTICOAGULANTS  83101010102060  Fragmin  Dalteparin Sodium lnj 18000 Unit/0.72ML  ,;·  />-- _
            ;_  ,·{c-..  18.00%  ANTICOAGULANTS  83101020102020  Lovenox  Enoxaparln Sodium lnj 150 MG/ML  f/  d,...,  .....Z\'  18.003⁄4  ANTICOAGULANTS  83370060000330  xarelto  Rivaroxaban Tab 15 MG  /iJ
            ·=  OA  "-'<>,  18.00%  ANTICOAGULANTS  83101010102053  Fragmin  Da!teparin Sodium lnj 12500 Unit/0.SML  !J ,A  ".? -- 1-:  "\'.':  18.00%  ""'"  '<11:(l -1&,- Ii !  6  t:iJ.,"J,  "    \I0-s.,  IJJ/  ,,,  'Ii "'"•  _,-,, ,,t 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                               ANTICOAGULANTS  83101020102016




            Lovenox  ANTICOAGULANTS  83334050102120 Refludan  ANT!CONVULSANTS  72600043002020 Keppra  Enoxaparin Sodium 1nj 100 MG/ML  lepirudln For IV Soln 50 MG  Levetlracetam Oral Soln 100 MG/Ml  18.00%  18.00%18J)0%  ANTICONVULSANTS  72600043000340
            Keppra  Levetiracetam Tab 750 MG  18.00%  ANTICONVULSANTS  72600043002060 Keppra  levetkacetam lnj 500 MG/5Ml (100 MG/ML)  18.001⁄4  ANTICONVULSANTS  ANTICONVULSANTS  72600043000350 Keppra  72170085000320 Sabril  Levetiracetam Tab 1000 MG
            Vigabatrin Tab 500 MG  18.00%18.00%  ANTICONVULSANTS  72600043007520 Keppra XR  72600043000320 Keppra  Levetiracetam Tab SR 24HR 500 MG  18.00%  ANTICONVULSANTS  Levetiracetam Tab 250 MG  18.00%  ANTICONVULSANTS  ANTJCONVULSANTS  72600043000330
            Keppra  72170085003020 Sabril  Levetiracetam Tab 500 MG Vigabatrin Powd Pack 500 MG  18.00%18.00%  ANTICONVULSANTS  72600043007530 Keppra XR  Levetiracetam Tab SR 24HR 750 MG  18.00%  ANTIEMETICS  50250025200330 Anzemet  Dolasetron Mesylate Tab
            100 MG  18.00%  ANTlEMETICS  50280035102130 Emend  Fosaprepitant Dimeglumine For IV Infusion 150 MG {Base Eq)  18.00%  ANTIEMETICS  50280020000130 Emend  ANTIEMETICS  50250025202020 Anzemet  AprepltantCapsule125 MG  Dolasetron Mesylate JV lnj
            20 MG/Ml  18.00%  18.00%  ANTIEMETICS  50250025200320 Anzemet  18.00%  ANTIEMETICS  50280020006320 Emend  Do!asetron Mesy/ateTab 50 MG  Aprepitant Capsule Therapy Pack 80 & 125 MG  18.00%  ANTIEMETICS  50250070102010 Afoxl  Palonosetron HCI
            IV Sain 0.075 MG/1.SML (Base Equiv)  Antiemetics  50250065052030 Zofran  Ondansetron HCI lnj 40 MG/20ML (2 MG/Ml}  26.75%  18.00%  ANTIEMETICS  50280020000110 Emend  AprepitantCapsule 40 MG  18.00%  ANTIEMETICS  50280020000120 Emend  Aprepitant
            Capsule 80 MG  18.00%  Antiemetics  5025006S052024 Ondansetron HO  Ondansetron HCI lnj 4 MG/2ML (2 MG/ML)  18.00%  ANTJEMETICS  50250070102020 Aloxi  ANTJFUNGALS  11000010101920 Amphotec  Palonosetron HCI IVSoln 0.25 MG/5Ml {Base Equivalent)
            Amphotericin 8 Cholesteryl Sulfate Complex For lnj 100 MG  26.75%18.00%  ANTIFUNGAlS  11407060001820 Noxafll  ANTIFUNGALS  11500025102130 Cancldas  Posaconazole Susp 40 MG/ML  Caspofungin Acetate For IV Sofn 70
            MG  18.00%  18.00%  ANTJFUNGALS  11000010002105 Amphotericln B  ANTIFUNGALS  11407015022020 Diflucan In Dextrose  Amphotericin B For lnj 50 MG F!uconazoleln Dextrose lnj 400 MG/200Ml  18.00%18.00%  ANTIFUNGALS  11500010002130
            Eraxis  ANTIFUNGALS  11000010301820 Abelcet  ANTIFUNGALS  11407080000320 Vfend  Anidulafungin For IV Soln 100 MGAmphotericin B llpld lnjSusp (For IV Infusion) 5 MG/Ml  Voriconazole Tab 50
            MG  18.00%18.00%  18.00%  ANTIFUNGAlS  ANTIFUNGALS  11500050102120 Mycamine Micafungin Sodium For IV So!n 50 MG 11407015012020 Diflucan in Sodium Ch!oti Fluconazole in NaCl 0.9% lnj 400
            MG/200Ml  18.00%18.()()%  ANTJFUNGALS  ANTIFUNGALS  ANTIFUNGALS  11407080002120 Vfend IV Voriconazofe For lnj 200 MG  11407015022010 Dif/ucan in Dextrose Fluconazo/e in Dextrose lnj 200 MG/lOOMl 11500010002120 Eraxis Anidulafungin For IV So!n
            50 MG  18.00%  18.00%18.00%  ANT/FUNGALS  ANTIFUNGALS  11407015012010 omucan In Sodium Ch!ori F!uconazofe in NaCl 0.9% lnj 200 MG/100Ml 11407080001920 Vfend Voriconazole For Susp 40
            MG/ML  18.00%18.00%  ANTIFUNGALS  ANTIFUNGALS  ANTIFUNGALS  11000010101910 Amphotec Amphoteridn B Cholesteryl Sulfate Complex For fnj SO MG  11407035002020 Sporanox11500025102120 Cancidas  ltraeonazole Oral Soln 10 MG/Ml Caspofungin Acetate For
            JVSoln SO MG  18.00%  18.00%18.00%  ANTIFUNGALS  ANTJFUNGALS  11000010401920 AmBlsome11407080000340 Vfend  Amphotericin B Uposome IV ForSusp SO MG Voriconazole Tab 200 MG  18.00%18.00%  ANTIFUNGALS  Antihemophillc Products  Antihemophilic
            Products  11500050102130 Mycamine85100010002139 Hemofll M85100010006460 Monoclate-P  Antihemophl!ic Products  Antihemophilic Products  85100010202145 Recomblnate  85100010252150 Advate  Micafungin Sodium For IV So!n 100 MG Antihemophlllc Factor
            {Human) For lnj 801-1700 Unit Antihemophilic Factor (Human) For lnj Kit 1000 Unit  Antihemophi!ic Factor (Recombinant) For lnj 1241-1800 Unit  Antihemophilic Factor rAHF-PFM For lnj 1500 Unit  -·  <,fl  / -•\ \.:J l,//,,,..  - - - er
            ,  18.00%42.00%30.00%  ,,' ,..,._, 1f  40.00%  37.75% 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                             Antihemophilic




            Products  Antihemophilic Products  Antihemophilic Products  85100028202150 BeneFIX  85100010266470 Xyntha Solofuse  Coagulation Factor IX {Recombinant) For lnj 2000 Unit Antihemophl!ic Factor Recombinant PAF For lnj Kit 3000
            Unit  21.00%38.00%  Antihemophilic Ptoducts Antihemophilic Products  85100010502130 Obizur  85100015102139 Wilate85100020002100 Feiba NF  Antihemophilic Factor (Recomb Pore) rpFVIII For lnj 500 Unit Antihemophilic Factor/VWF {Human) For lnj
            1000--1000 Unit*AntifnhlbitorCoagulant Complex For tnj"'•  20.00%40.00%40.00%  Antihemophillc Products  85100028002160 Mononine  Coagulation Factor IX For lnj 250 Unit  40.00%  Antihemophi!ic Products Antihemophllic Products  Antihemophilic
            Products Antihemophillc Products  85100030002115 Profilnine SD85100010002125 Hemofil M  Antihemophilic Products AntihemophiHc Products  85100010006410 Monodate-P85100010202135 Recombinate  Factor IX Complex For lnj 1500 UnitAntihemophilic
            Factor {Human) For tnj 401-800 Unit Antihemophilic Factor {Human) For lnj Kit 250 Unit Antihemophilic Factor (Recombinant) For lnj 801-1240 Unit  Antihemophllic Products  85100010252130 Advate85100010266440 Xyntha  85100010002140 Hemofil
            M  Antlhemophillc Factor rAHF-PFM For tnj 500 Unit Antihemophilic Factor Recombinant PAF For lnj Kit 1000 Unit Antihemophilic Factor {Human) For lnj 1000 Unit  19.75%42.003⁄430.00%40.00%  37.75%38.00%42.00%  Antihemophillc
            Products  Antihemophllfc Products  85100010006475 Monoclate-P  AntihemophiHc Factor {Human) For lnj Kit 1500 Unit  30.00%  85100010302155 Eloctate  Antlhemophillc Factor {Recomb) rFVJIIFc For lnj 2000 Unit  20.00%  Antihemophl!ic
            Products  Antihemophllic Products  Antihemophilic Products  Antihemophlltc Products  85100028202140 BeneFIX  Coagulation factor JX {Recombinant) For lnj 1000 Unit  21.00%  37.00%40.00%  Antihemophilic Products  31.75%  19.75%  Antihemophllic
            Products  Antihemophillc Products  85100015102132 Humate-P Antihemophllic Factor/VWF (Human) For lnj 500 1200 Unit 85100015102190 Alphanate/VWF Compfe) Antihemophlllc Factor/VWF (Human) For lnj 1500 Unit 85100026202145 NovoSeven RT Coagulation
            Factor Vila (Re.comb) For lnj 5 MG (5000 MCG) 85100030002105 Profilnlne SD Factor IX Complex For lnj 500 Unit85100060106420 Kcentra Prothrombin Complex Cone Human For lnj Kit 500 Unit  20.00%  Antihemophilic Products  Antihemophl!ic
            Products  85100010202150 Novoeight85100010252170 Advate  Antihemophllic Factor {Recombinant) For tnj1500 Unit Antihemophilic Factor rAHF-PFM For lnj 2000 Unit  20.00%37.75%  Antihemophilic Products  Antihemophilic Products  85100028202160
            BeneFlX  Coagulation Factor IX {Recombinant) For lnj 3000 Unit  85100010302120 E!octate  Antihemophll!c Factor {Recomb) rFVIIIFc For lnj 250 Unit  21.00%  20.00%  Antihemophilic Products Antihemophllic Products  85100015102120
            Humate-P  85100015102140 Humate-P85100026202117 NovoSeven RT  Antihemophllic Factor/VWF (Human) For lnj 250-500 Unit Antihemophlllc Factor/VWF (Human) For tnj1000-2000 Unit Coagulation Factor Vita {Recomb) For Inf 1 MG (1000
            MCG)  37.00%37.00%31.75%  Antihemophi!ic Products  Antihemophilic Products  85100028002185 AlphaNJne SD85100030002150 Bebulin  Coagulation Factor IX For lnJ 1500 Unit Factor IX Complex For lnj 200-1200 Unit  30.00%20.00%  Antihemophilic
            Products  Antihemophilic Products  Antihemoph!lic Products  85100010206440 Hellxate FS85100010002130 Hemofil M  Antihemophilic Factor (Recomblnant) For lnJ Kit 1000 Unit Antlhemoph11!c Factor (Human} For lnJ 500
            Unit  41.75%42.00%  85100010006430 Monoclate-P  Antihemophillc Factor (Human) For lnj Kit 500 Unit  30.00%  Antihemophi!Jc Products Antihemophilic Products  85100010202140 B!OClATE84100040002010 Cyklokapron  ANTlHEMOPHILIC FACTOR (RECOMBINANT)
            FOR INJ 1000 UNITTranexamlc Acid lnj 100 MG/Ml  20.00%18.001⁄4  Antihemoph11!c Products  Antihemoph!llc Products  Antihemophlllc Products  85100010002146 Hemofi1 M85100010202115 Recomblnate  Antihemophilic Factor (Human) For lnj 1700 Unit
            Antihemophilic Factor(Recombinant) For lnj 220-400 Unit  42.00%40.003⁄4  Antihemophi!ic Products  Ant!hemophi!ic Products  85100010252140 Advate85100010266460 Xyntha  Antihemoph1Hc Factor rAHF-PFM For lnj 1000 Unit Antlhemophllic Factor
            Recombinant PAF For lnj Kit 2000 Unit  37.75%38.00%  Antlhemophilic Products  Antihemophll!c Products  85100028202120 BeneFIX  Coagulation Factor IX (Recombinant) For lnj 250 Unit  85100010302165 Eloctate85100015102138 Wilate  Antihemophilic
            Factor {Re.comb) rfVIIIFc For lnj 3000 Unit Antihemophilic Factor/VWF (Human) For lnj 900-900 Unit  21.00%  20.00%40.00%  Antihemophilic Products  Antihemophilic Products  Antihemophllic Products  85100015102193 A!phanate/VWF Complex
            Antihemophilic Factor/VWF {Human} For lnj 2000 Unlt  85100026202160 NovoSeven RT Coagulation Factor Vila (Recomb) For lnj 8 MG {8000 MCG)  40.00%31.75%  Antihemophi!lc Products  Antihemophi!ic Products  85100030002110 Profllnlne
            SD  85100060106430 Kcentra  Factor IX Complex Forlnj 1000 UnitProthrombln Complex Cone Human For Jnj Kit 1000 Unit  19.75%20.00%  85100028002170 AlphaNine SD  Coagulation Factor IX For lnj 500 Unit  AntihemophiHc Products  Antihemophllic
            Products  85100010202155 Recombinate85100010252180 Advate  Antlhemophilic Factor (Recombinant) For lnj 1801-2400 Unit Antihemophilic Factor rAHF-PFM For lnj 3000 Unit  40.00%40.00%37.75% 

      

    

     

    
      
        


    

    
      
        

      

      
                       Anti.hemophilic Products    85100010302125  Eloctate  Antihemophilic Factor (Recomb)
            rFVIJIFc For lnj 500 Unit    20.003⁄4  Antihemophi!ic Products    85100015102122  Humate-P  Antihemoph!lic FactorNWF (Human) For lnj 250-600 Unit    37.00%  Antihemophll!c Products    85100015102144  Humate-P  Antihemophilic Factor/VWF (Human)
            For Jnj 1000-2400 Unit    37.00%  AntihemophiHc Products    85100026202120  NovoSeven  Coagulation Factor VIia (Recomb) For lnj 1.2 MG (1200 MCG)    31.75%  Antihemophilic Products    85100028402110  Alprolix  Coagulation Factor IX (Recomb)
            (rFIXFc) For Jnj 500 Unit    22.00%  Antihemophilic Products    85100030002180  Profilnlne SD  FACTOR 1X COMPLEX FOR INJ 1000-1500 UNIT    20.05%  Antihemophilic Products    85100028002180  AlphaNine SD  Coagulation Factor IX For lnj 1000
            Unit    40.00%  Antihemophllic Products    85100010206460  Helixate FS  Antihemoph!llc Factor (Recombinant) For lnj Kit 3000 Unit    41.75%  Antihemophilic Products    85100010002110  HemofilM  Antihemophilic Factor (Human) For lnj 250
            Unit    42.00%  Antihemophilic Products    85100010002160  Hemofi!M  Antihemophilic Factor (Human) For lnj 801-1500 Unit    42.00%  Antihemophilic Products    85100010202125  Recombinate  Ant!hemophilic Factor (Recombinant) For lnj 401-800
            Unit    40.00%  AntihemophHic Products    85100010202170  Novoeight  Antihemophiltc Factor (Recombinant) For lnj 3000 Unit    20.00%  Antihemophi!ic Products    85100010266420  Xyntha  Antihemophllic Factor Recombinant PAF For lnj Kit 250
            Unit    38.00%  Antihemophilic Products    85100010302135  Eloctate  Antihemophilic Factor (Recomb) rfVIIIFc For lnj 1000 Unit    20.00%  Antihemophilic Products    85100015102129  Wilate  Antihemophilic Factor/VWF (Human) For lnj 500-500
            Unit    40.00%  Antihemophllic Products    85100015102170  Alphanate/VWF Complex  Antlhemophilic Factor/VWF (Human) For lnj 500 Unit    40.00%  Antihemophilic Products    85100026202130  NovoSeven  Coagulation Factor VIia (Recomb) For lnj 2.4
            MG (2400 MCG)    30.503⁄4  Antihemophil!c Products    85100028402130  Alprolix  Coagulation Factor IX (Recomb} (rFIXFc) For lnj 2000 Unit    22.00%  Antihemophilic Products    85100033006440  Cori-fact  Factor XU! Concentrate (Human) For lnj Kit
            1000-1600 Unit    21.00%  Antihemophll!c Products    85100010206420  Hefo:ate FS  Antihemophilic Factor (Recombinant} For lnj Kit 250 Unit    41.75%  Antihemophilic Products    85100010002112  ALPHANATE  ANTIHEMOPHIUC FACTOR (HUMAN) FOR INJ
            250-500 UNIT    41.75%  Antihemophillc Products    85100010002170  HemofilM  Antihemophilic Factor {Human} For lnj 1501-2000 Unit    42.00%  Antihemophilic Products    85100010202130  BIOCLATE  ANTIHEMOPHILIC FACTOR (RECOMBINANT) FOR INJ 500
            UNIT    20.00%  Antihemophilic Products    85100010252120  Advate  Antlhemophilic Factor rAHF-PFM For lnj 250 Unit    37.75%  Antihemophllic Products    85100010266430  Xyntha  Antihemophilic Factor Recombinant PAF For lnj Kit 500
            Unit    38.00%  Antihemophilic Products    85100010302145  Eloctate  Antihemophllic Factor {Recomb) rFVIIIFc For lnj 1500 Unit    20.00%  Ant!hemophHJc Products    85100028202130  BeneFIX  Coagulation Factor IX (Recombinant) For In] 500
            Unit    21.00%  Antlhemophl!Jc Products    85100015102130  Humate-P  Antihemophlllc Factor/VWF (Human) For lnj 500-1000 Unit    37.00%  Antihemophilic Products    85100015102180  A!phanateNWF Complex  Antihemophilic Factor/VWF (Human) For lnj
            1000 Unit    40.00%  Antihemophilic Products    85100026202140  NovoSeven  Coagulation Factor VIia (Recomb) For lnJ 4.8 MG {4800 MCG)    31.75%  Antihemophilic Products    85100028402140  A!prolix  Coagulation Factor IX (Recomb) (rFIXFc) For
            lnj 3000 Unit    22.00%  Antihemophllic Products    85100035002120  Ria5TAP  Fibrinogen Cone {Human) lnj Approximately 1 GM (900---1300 MG)    21.00%  Antihemoph1Hc Products    85100010206430  Helixate FS  Antihemophlllc Factor (Recombinant)
            For lnj KJtSOO Unit    41.75%  AntihemophlHc Products    85100010002109  Hemofil M  Antihemophllic Factor (Human} For lnj 220-400 Unit    42.00%  Antihemophil!c Products    85100010002147  HemofilM  Antihemophllic Factor (Human) For lnj
            1701-2000 Unit    42.00%  Antihemophilic Products    85100010202120  BIOCLATE  ANTIHEMOPHIUC FACTOR {RECOMBINANT) FOR INJ 250 UNIT    20.00%  Antihemophilic Products    85100010202160  Novoeight  Antlhemoph!lic Factor {Recombinant) For lnj 2000
            Unit    20.00%  Antihemophi1ic Products    85100010252185  Advate  Antihemoph!lic Factor rAHF-PFM For lnj 4000 Unit    37.75%  Antihemophilic Products    85100010302130  Efoctate  Antlhemophilic Factor (Recomb) rFVlllFc For Jnj 750
            Unit    20.00%  Antihemoph11ic Products    85100015102128  Wi!ate  Antihemophll!c Factor/VWF (Human) For lnj 450-450 Unit    40.00%  AntihemophlHc Products    85100015102160  Atphanate/VWF Complex  Antihemophilic Factor/VWF (Human) For lnJ 250
            Unlt    40.00%  Antihemophilic Products    85100026202126  NovoSeven RT  Coagulation Factor Vlla (Recomb) For lnj 2 MG (2000 MCG)    31.75%  Antihemophilic Products    85100028402120  Alpro!ix  Coagulation Factor IX {Recomb) {rFIXFc) For lnj
            1000 Unit    22.00%  Antihemoph1Hc Products    85100032102130  Tretten  Coagulation Factor XHI A-Subunit For lnJ 2000-3125 Unit    18.00%  Antlhemophl!ic Products    85100010206450  Helixate FS  Antfhemophi1ic Factor (Recombinant) For Jnj Kit
            2000 Unit    41.75%  ANTIHEMOPHILICS    30201010102015  Stimate  Desmopressin Acetate Nasal Soln 1.5 MG/ML    18.00%  ANTIHISTAMINES    41200030102900  DiphenhydrAMINE HCI  Diphenhydramine HCI Powder  .\\..\, ::>·1
            '"v<lr'\'  18.00%  ANTIHYPERLIPIDEMICSANTIHYPERUPIDEMICS    3950004010E52039480050200120  KynamroJuxtapid  Mipomersen Sodium So!n Pref!lled Syringe 200 MG/MLLomltapide Mesylate Cap 5 MG (Base Equiv)  ,:,., - ·...,_ "('\_"'c-,.Yu·
            <;-1,,'  18.00%18.00%  .,r,  ·-·        t;" "F<.,OntratoN- ·-o.-.J, ,j - , urnero..m\t()". us,,' \ii:-------...._ y    tr;.,  .  '((,,\ ' : , 9.  '/y .-,. ,v  .,;2_& DE. 5J>.,,. 

      

    

     

    
      
        


    

    
      
        

      

      
                       ,  ANTIHYPERLIPIDEMICS  39480050200130  Juxtap!d  Lomitaplde Mesylate Cap 10 MG {Base
            Equiv)            18.00%  ANTIHYPERLIPIDEMICS  39480050200140  Juxtapid  Lomitapide Mesylate Cap 20 MG (Base Equiv}              ANTI-INFECTIVE AGENTS- MISC.  16000005402120  Cayston  Aztreonam Lysine For lnhal Soln 75 MG (Base
            Equlvalent}            18.00%18.00%  ANTI-INFECTIVE AGENTS- MISC.  16000049000320  Xifaxan  Rifaximin Tab 200 MG            18.00%  ANTI-INFECTIVE AGENTS- MISC.  16000049000340  Xifaxan  Rifaxlmin Tab 550
            MG            18.003⁄4  Antfneoplastics  21353045001360  Arzerra  Ofatumumab Cone For JV Infusion 1000 MG/50ML            18.00%  Antineoplastics  213530600020110  Rituxan  Rituximab For IV lnj Cone 10
            MG/ML            18.00%  Antineoplastks  21534007100120  Alecensa  Alectinib HCI Cap 150 MG (Base Equfva!ent)            18.00%  Antineop!astics  21370060200120  Odomzo  SON!DEGIB PHOSPHATE CAP 200 MG (BASE
            EQUIVALENT)            18.00%  Antlneop!astics  21755050102030  Levoleucovorin Calcium  Levoleucovor!n Calcium IV Soln PF 250 MG/25ML (Base Equiv)            18.00%  Antineoplastics  21100010002020  Busulfex  Busulfan lnj 6
            MG/ML            18.00%  Antineoplastics  21574070401820  lmlygic  Talimogene Laherparepvec lntralesional lnj 1000000 Unit/ML            18.00%  Antineoplastics  21535570200320  Rubraca  Rucaparib Camsylate Tab 200 MG {Base
            Equivalent)            18.00%  Antineoplastics  21353060002040  Rltuxan  Rltuximab For IV lnj Cone 10 MG/ML            18.00%  Antineoplastics  21250010402125  Erwinaze  Asparaginase Erw!nia Chrysantheml for IM lnj 10000
            Unit            18.00%  Antineoplastics  21353060002040  Rituxan  Rltuximab For IV lnj Cone 10 MG/ML            18.00%  Antineoplastics  2147008000b720  Venclexta Starting Pack  VenetodaxTab Therapy Starter Pack 10 & SO & 100
            MG            18.00%  Ant!neoplastlcs  21755040102150  Leucovorin Calcium  Leucovorin Calcium For lnj 200 MG            18.00%  Antineoplastlcs  21500012001325  PACUtaxel  Paditaxel IV Cone 30 MG/SML (6
            MG/ML)            18.00%  Antineoplast!cs  21300050100320  Trexal!  Methotrexate Sodium Tab 5 MG (Base Equiv)            18.00%  Antineop!astics  21353027002030  Darzalex  Daratumumab JV Sein 400
            MG/20ML            18.00%  Antineop!astics  21534013100320  cabometyx  cabozantinib 5-Malate Tab 20 MG (Base Equfva!ent)            18.00%  Antineop!astics  21990002750320  Lonsurf  TRIFLURIDJNE-TIPIRAC!L TAB 15-6.14
            MG            18.00%  Antineoplast!cs  21708080000110  Vesanold  Tretinoln cap 10 MG            18.00%  Antineoplastics  21300050100350  Trexall  Methotrexate Sodium Tab 15 MG (Base
            Equiv)            18.00%  Antineoplastics  21755040102130  Leucovorin Calcium  Leucovorln calcium For lnj 100 MG            18.00%  Antineoplastics  21100015002045  CARBOplatln  Carboplatin IV Soln 600
            MG/60ML            18.00%  Antineoplastics  21536045100140  Ninlaro  lxazomlb Citrate Cap 4 MG (Base Equivalent)            18.00%  Antineoplastics  21100009102005  Bendeka  Bendamustine HCI IV Soln 100 MG/4ML {25
            MG/ML)            18.00%  Antineoplastics  21700013001930  Tice BCG  BCG Live lntravesical For Susp 50 MG            18.00%  Antineoplastlcs  21700020002110  Dacarbazine  Dacarbazine For lnj 200
            MG            18.00%  Antineoplastics  21200010102105  B!eomycin Sulfate  B!eomycin Sulfate For lnJ 15 Unit            18.00%  Antineoplastics  21100015002030  CARBOplatin  carboplatin IV So!n SO
            MG/5ML            18.00%  Antineoplastks  21574070401840 lmlygic    Talimogene Laherparepvec fntralesional lnj 100000000 Unit/ML            18.00%  Antineoplastics  21353030002120  Empllclti  Elotuzumab For rv Soln 300
            MG            18.00%  Antineoplastics  21535570200330  Rubraca  Rucaparib Camsylate Tab300 MG (Base Equivalent}            18.00%  Antineoplastics  21200050002120  Mitomydn  Mltomycin For lnJ 40
            MG            18.00%  Antineoplastics  21300007002015  Cladribine  dadribine IV So!n 10 MG/10ML {1 MG/ML}            18.00%  Antineoplastics  21470080000320  Venc\exta  Venetociax Tab 10
            MG            18.00%  Antineoplastlcs  21534013100330  cabometyx  cabozantinib S-Malate Tab 40 MG {Base Equivalent)            18.00%  Antlneoplastics  21990002750330  Lonsurf  TRIFLURlDINE-TlPIRACIL TAB 20-8.19
            MG            18.00%  Antineop\astics  21550040202220  Onlvyde  lrfnotecan HCI Llposome IV lnj 43 MG/10ML (4.3 MG/ML}            18.00%  Antineop\astlcs  21100020002020  CISplatin  Osplatln lnj 50 MG/50Ml
            {1MG/ML)            18.00%  Antineoplastics  21100015002040  CARBOplatin  carboplatin 1V Soln 450 MG/45ML            18.00%  Antineoplastics  21533530200320  Cotelllc  Coblmetinib Fumarate Tab 20 MG (Base Equivalent)  ,,-·.\\...- - _:_
            -          18.00%  Antineoplastics  21353030002130  Empliciti  Elotuzumab For IV Sein 400 MG            18.00%  Antineoplastics  21500005002075  DOCEtaxel (Non-Alcohol)  Docetaxel (Non-Alcohol Formula) IV 5oln 80 MG/4ML  ~· ,y ,:1..',v
            .'..          18.00%  Antineoplastics  21470080000340  Venclexta  VenetoclaxTab 50 MG  ; ."' 'i- "      _    18.00%  Antineoplastics  21500012001350  Onxol  Paclitaxe! IV Cone 300 MG/50ML {6 MG/ML)      ' VOnfratn
            ,.,,_.  V    18.00%  .            !) ., --,.., '. Ill                  \,IJ\<J\.\ ,.," . . ; >                              ,9  ..  'v '  \(",'··  -.- ,, .  s'\·'\; f'L.  ,, 0 .s D..E.. 51",  - 

      

    

     

    
      
        


    

    
      
        

      

      
                           )  Antineoplastics  21100020002025  C!Splatin  Cisplatin lnj 100 MG/lOOML (1
            MG/ML)          18.00%  Antineoplastics  21500020102005  VinCRIStine Sulfate  Vincristine Sulfate IV So!n 1 MG/ML          18.00%  Antineoplastlcs  21534065200330  Tagrisso  Osimertlnib Mesylate Tab 80 MG {Base
            Equivalent)          18.00%  Antineoplastics  21536045100120  Nlnlaro  lxazomlb Citrate Cap 2,3 MG (Base Equivalent)          18.00%  Antineoplastics  21500005002080  DOCEtaxel (Non-Alcohol)  Docetaxel (Non-Alcohol Formula) IV Sotn 160
            MG/8ML          18.00%  Antineoplastics  21470080000360  Venclexta  Venetoclax Tab 100 MG          18.00%  Antineoplastics  21755050102020  levoleucovorincatcium  Levo!eucovorin calcium lnj 175 MG/17.5Ml {Base
            Equiv)          18.00%  Antineoplastks  21755040102160  Leucovorln Calcium  Leucovorln Calcium For lnj 350 MG          18.00%  Antineoptastics  21755040102120  Leucovorin Calcium  Leucovorln Calcium For lnJ 50
            MG          18.00%  Antlneoptasttcs  21100015002035  CARBOplatin  Carbop!atin IV Soln 150 MG/15ML          18.00%  Antineoplastics  21353027002020  Darzalex  Daratumumab IV So!n 100
            MG/5ML          18.00%  Antineop!astics  21536045100130  Ninlaro  lxazomib Citrate Cap 3 MG (Base Equivalent)          18.00%  Antineop!astlcs  21500005002070  DOCEtaxel {Non-Alcohol  Docetaxel (Non-Alcohol Formula) IVSoln 20
            MG/Ml          18.00%  Antineop!astics  21101040102115  Evomela  Mefphalan HCI For lnj SO MG (Propylene Glycol {PG) Free)          18.00%  Antineop!astics  21534013100340  Cabometyx  Cabozantinib 5-Ma!ate Tab 60 MG (Base
            Equivalent)          18.00%  Antineop!astlcs  21107075002140  Yondelis  Trabectedin For lnj 1 MG          18.00%  Antineop!astics  21200010102115  Bleomycin Sulfate  Bleomycln Sulfate For lnj 30
            Unit          18.00%  Antineop!astics  21500012001335  PACLitaxel  Paclitaxel IV Cone 100 MG/16.7ML (6 MG/ML)          18.00%  Antineop!astics  21534065200320  Tagrlsso  Oslmert!nib Mesylate Tab 40 MG {Base
            Equivalent)          18.00%  Antineoplast!cs  21353047002020  Lartruvo  O!aratumab Soln for IV Infusion 500 MG/50ML {10 MG/Ml)          18.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21100009102010  Treanda  BendamusUne HCI IV Soln 45
            MG/0.SML (90 MG/ML)          18.00%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21100028002120  Oxa!iplatin  Oxa!iplatln For IV lnj 50 MG          30.00%  ANTlNEOPlASTICS ANO ADJUNCTIVE THERAPIES  21101025002025 lfosfamlde    lfosfamlde IV lnj 1
            GM/20ML (SO MG/ML)          18.00%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21102020000110  CeeNU  Lomustfne Cap 10 MG          18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200030102210  DAUNOrubicin HCI  Daunorubkin Hd lnj 5 MG/Ml
            {Base Equiv)          18.00%  ANTlNEOPlASTlCS AND ADJUNCTIVE THERAPIES  21200042102040  Epirubicin HCI  Epirubicin HCI lnj 150 MG/75ML (2 MG/ML)          18.00%  ANT1NEOPlASTlCS AND ADJUNCTIVE THERAPIES  21200055001325  Mitoxantrone
            HCI  Mitoxantrone Hd lnj Cone 25 MG/12.SML {2 MG/Ml)          18.00%  ANTlNEOPlASTlCS AND ADJUNCTIVE THERAPIES  21300010002115  Cytarabine  Cytarabine For lnj 1 GM          18.00%  ANTlNEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21300034102040  Gemcitabine HCl  Gemcltabine HCI lnj 1 GM/26.3ML {38 MG/ML) (Base Equiv)          30.00%  ANTlNEOPlASTlCS AND ADJUNCTIVE THERAPIES  21300054002025  Folotyn  Pralatrexate IV lnj 40
            MG/2Ml          18.003⁄4  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  21352020002120  Bl!ncyto  Bl!natumomab For IV Infusion 35 MCG          18.00%  ANTlNEOPlASTlCS AND ADJUNCTIVE THERAPIES  21402430000120  Xtandi  Enzalutamide Cap 40
            MG          18.00%  ANTlNEOPlASTlCS AND ADJUNCTIVE THERAPIES  21405010106410  Lupron Depot  leuprollde Acetate For lnj Kit 7.5 MG          18.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21405010256450  Lupron Depot  leuprolide Acetate {6
            Month) For lnj Klt45 MG          18.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21450080000115  Pomalyst  Pomalidom!de Cap 2 MG          18.25%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500005002040  DOCEtaxel  Docetaxel Soln for IV
            Infusion 80 MG/8Ml          35.00%  ANTINEOPlASTICS ANO ADJUNCTIVE THERAPIES  21500012201920  Abraxane  Paclitaxel Protein-Bound Particles For IV Susp 100 MG          18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21531060000130
            tbrance    Palboclcllb Cap 100 MG          18.00%  ANTlNEOPlASTICSANO ADJUNCTIVE THERAPIES  21532025100120  Tafin!ar  Dabrafenib Mesylate Cap 50 MG {Base Equivalent}          18.00%  ANTINEOPlASTICS ANO ADJUNCTIVE
            THERAPIES  21532530007320  Aflnltor Disperz  Everolimus Tab for Oral Susp 3 MG          18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21533070300140  Sutent  Sunltinib Malate Cap 50 MG {Base Equivalent)          18.00%  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21534012000320  Bosu!if  Bosutlnib Tab 100 MG          18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534020000320  Sprycel  Dasatlnib Tab 20 MG          18.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21534025100360  Tarceva  Erlotinib HCI Tab 150 MG (Base Equivalent)-          18.00%  ANT!NEOPlASTICS AND ADJUNCTIVE THERAPIES  21534054208240  Lenvima 14 MG Daily Do  Lenvatinlb Cap Therapy Pack 10 &4 MG {14 MG Daily Dose)
            .          18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21536015002120  Vekade  Bortezomlb For !nj 3.5 MG t\\ ...•- .-- ....i.c, "-'          18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21538040000330  Zydeltg  ldelalisib Tab 150 MG
            / /l' 4"" ':'V;,          18.00%  ANTlNEOPlASTJCS AND ADJUNCTIVE THERAPIES  21700020002105  Dat.:lrbazine  Dacarbazine For lnj 100 MG i v E          18.00%  ANTlNEOPlASTlCS ANO ADJUNCTIVE THERAPIES  21700060202135  lntron A  Interferon Alfa-2B
            For lnj 18000000 Unit    : vOntratn ,.. I,  \.I    18.00%  -···          l 9 n --0  tll              '> I" · l- ,;ff/f          •..  ' \ -\{.,\'  -9  ,, IV  ' '  '' (, 'I' ··.  .,.... ,>'  :---·. •, N ..  '-, O,oe:; 0'" sf•·  3⁄4. '--· .. 

      

    

     

    
      
        


    

    
      
        

      

      
                       ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21700075206420  Sylatron  Peginterferon affa-2b
            For lnj Kit 300 MCG          18.00%      ANTJNEOPLASTICSAND ADJUNCTIVE THERAPIES    2175S040100325  leucovorin Calcium  leucovorin Calcium Tab 10 MG          18.00%      ANTINEOPlASTlCS AND ADJUNCTIVE
            THERAPIES    21764065002140  Elite!<  Rasburicase For IV Soln 7.5 MG          18.00%      ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES    21100020002030  CISplatin  Cisp!atin lnj 200 MG/200ML (1 MG/ML}          20.00%      ANTJNEOPlASTICS AND
            ADJUNCTIVE THERAPIES    21101020002125  Cyclophospham!de  Cyclophosphamide For lnj 1 GM          32.30%      ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES    21101040102110  Atkeran  Melphalan HCIFor lnj SO MG (Base
            Equiv}          18.00%      ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES    21200030052210  DaunoXome  Daunorubicin Citrate Liposome lnJ 2 MG/ML          18.00%      ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21200042102025  Epirubicin
            HCI  Eplrubicin HCI lnj 10 MG/SML (2 MG/ML)          18.00%      ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES    21200045102035  ldamycin PFS  ldarubidn HCI IV lnj 20 MG/20Ml {1MG/ML)          18.00%      ANTlNEOPlASTlCS AND ADJUNCTIVE
            THERAPIES    21300010002105  Cytarabine  Cytarabine For lnj 100 MG          18.00%      ANTlNEOPlASTlCS AND ADJUNCTIVE THERAPIES    21300030002025  Fluorouracil  F!uorouracil lnj 1 GM/20Ml (SO MG/ML)          18.00%      ANTJNEOPlAST1CS AND
            ADJUNCTIVE THERAPIES    21300053102120  Alimta  Pemeuexed Dlsodium For JV Soln 500 MG (Base Equiv)          18.00%      ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES    2133S070002020  Cyramza  Ramucirumab IV So!n 100 MG/10ML{For
            Infusion)          18.00%      ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES    21353043002025  Gazyva  Obinutuwmab Sofn for IV Infusion 1000 MG/40ML (25 MG/Ml)          18.00%      ANTINEOPlASTICSAND ADJUNCTIVE
            THERAPIES    213530S4002020  Perjeta  Pertuwmab Soln for IV Infusion 420 MG/14Ml (30 MG/ML)          18.00%      ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21402250000320  lysodren  Mitotane Tab 500 MG          18.00%      ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES    21405007106450  Vantas  Histrelin Acetate Implant Kit 50 MG          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21405010206435  Eligard  leuprollde Acetate {4 Month) For Subcutaneous fnj Kit 30
            MG          25.00%      ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES    21100009102030  Treanda  Bendamustine HCI IVSoln 180 MG/2Ml {90 MG/Ml)          18.00%      ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES    21100028002130  Oxaliplatln  Oxaliplatin
            For IV lnj 100 MG          30.00%      ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES    21101025002030  lfosfam!de  lfosfam!de IV lnj 3 GM/60ML (50 MG/ML)          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21102020000115  CeeNU  lomustine Cap 40 MG          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21200040102010  Adtiamydn  Doxorubicin HCI lnj 2 MG/Ml          18.00%      ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21200042102045  Ellence  Epirublcln HCI IV Soln 200 MG/lOOMl (2 MG/Ml)          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21200055001330  Mitoxantrone HCI  Mitoxantrone HCI lnj Conc30 MG/1SML{2
            MG/ML)          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21300010002120  Cytarablne  Cytarablne For lnj 2 GM          18.00%      ANT1NEOPlASTICS AND ADJUNCTIVE THERAPIES    21300034102000  Gemcltab!ne HCl  Gemcitablne HCl lnJ 2
            GM/S2.6ML{38 MG/Ml) (Base Equiv)          30.00'%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21300060000305  Tabloid  Thioguanlne Tab 40 MG          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21353010002040  Campath  A!emtuzumab IV lnj 30 MG/ML (For Infusion)          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21353050002025  Vectibix  Panitumumab IVSoln 100 MG/5Ml          18.00%      ANTINEOPLAST1CS AND
            ADJUNCTIVE THERAPIES    21353070002120  Herceptin  Trastuzumab For IV Soln 440 MG          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21403020100105  Emcyt  Estramustlne Phosphate Sodium cap 140
            MG          18.00%      ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21405010106415  Ellgard  LeuproHde Acetate For Subcutaneous lnj Kit 7.5 MG          25.00%      ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21100010000305  Myleran  Busulfan
            Tab 2MG          18,00%      ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21101020000310  Cyclophosphamide  Cyc!ophosphamide Tab SO MG          32.30%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21101030102105  Mustargen  Mechlorethamlne
            HCI For lnj 10MG          18.00%      ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES    21104070002120  Temodar  Temozolomide For IV Soln 100 MG          18.00%      ANTlNEOPlASTtCS AND ADJUNCTIVE THERAPIES    21200040102115  Adrlamydn  Ooxorubkin
            HCI For lnj SO MG          18.00%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21200045102025  ldamydn PFS  !darubidn HCI IV lnj S MG/5Ml (1MG/ML)          18.003⁄4      ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21250060002020  Oncaspar  Pegaspargase lnj 750 Unit/ML          18.00%      ANTINEOPLASTJCS AND ADJUNCTIVE THERAPIES    21300025102020  F!udarabine Phosphate  Fludarablne Phosphate lnj 25 MG/Ml          18.00%      ANTINEOPlASTJCS
            AND ADJUNCTIVE THERAPIES    21300052002020  Arranon  Nelarabine N Soln S MG/Ml          18.00%      ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21335020002025  Avastin  Bevacizumab IV Soln 100 MG/4ML (For
            Infusion)          18.00      ANTJNEOPlASTICSAND ADJUNCTIVE THERAPIES    21353032002020  Yervoy  lpilimumab Soln for IV Infusion SO MG/lOML (S MG/Ml}          18.00      ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21353053002030  Keytruda  Pembro!izumab JV Soln 100 MG/4Ml {25 MG/Ml)          18.003⁄4      ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21355070302130  Kadcyla  Ado-Trastuzumab Emtansine For IVSoln 160 MG    ,/ ,,5TRA
            ·--,,      18.00%      ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21405005102310  Zoladex  Gosere!ln Acetate Implant 3.6 MG    .h'". •...:;. -.,.I'\,._      18.00      ANTtNEOPlASTJCS ANO ADJUNCTIVE
            THERAPIES    21405010156432  Ellgard  Leuprotide Acetate (3 Month} For Subcutaneous lnJ Kit 22.SMG    I /,-V    '\,"I;,  25.00      ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES    21100015002120  CARBOplatin  Carboplatin IV For lnj 150 MG  ;  Q"
            //,,.,    \    \  18.00  -' ,-,y  Y''''      '  i    t 9 -  '" ttmo,0 '.I\\ll ,                  m\\)' ',-J,.0ii2·                                      t  'v  e,V, 1y  "?..-=- v  "  0 8 oF-sl>,/ 

      

    

     

    
      
        


    

    
      
        

      

      
                           ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21101020002120  Cyc!ophosphamide  Cydophosphamide For lnj 500 MG                  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21101040000305  Alkeran  Melphalan Tab 2 MG                32.30%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21200020002105  Cosmegen  Dactinomycin For lnj 0.5 MG                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21200040402210  Doxil  Doxorubicin HCI Liposomal lnj {For IV Infusion) 2
            MG/Ml                18.00%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES    21200045102030  ldamycin PFS  ldarublcin HCI IV lnj 10 MG/10Ml {1MG/Ml)                18.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21300007002010  C!adribine  Cladribine In] 1 MG/ML                18.003⁄4  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21300025102120  F1udara  Fludarabine Phosphate For lnj 50 MG                18.00%18.00%  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES    21300053102110  Alimta  Pemetrexed Dlsodlum For IV So!n 100 MG (Base Equiv)                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21335020002030  Avastin  Bevacizi.Jmab N Solo 400 MG/16Ml (For
            Infusion)                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21353032002040  Yervoy  Jpllimumab So!n for IV Infusion 200 MG/40Ml {5 MG/Ml)                  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21353053002120  Keytruda  Pembrolizumab For IV So!n SO MG                18.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES    21370070000120  Erivedge  Vismodegib Cap 150 MG                18.00%  ANTlNEOPl.ASTICS AND ADJUNCTIVE
            THERAPIES    21405005102330  Zoladex  Goserelin Acetate Implant 10.8 MG                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21405010206430  Lupron Depot  LeuprolideAcetate (4 Month) For lnj Kit 30
            MG                18.00%  ANTINEOPlASTJCS AND ADJUNCTIVE THERAPIES    21104070000147  Temodar  Temozolomide Cap 180 MG                35.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES    99392070000135  Thalomid  Thalfdomide Cap 150
            MG                18.00%  ANTJNEOPlASTICS AND ADJUNCT/VE THERAPIES    21300034102140  Gemcltabine HCI  Gemcitablne HCI For lnj 1 GM                30.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21406010200320  Zytiga  Ab!raterone Acetate
            Tab 250 MG                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21500005001325  DOCEtaxel  Docetaxel For lnj Cone 80 MG/2ML {40 MG/Ml)                '>35.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21500011002140  lxempra
            Kit  txabeplfone For IV lnfuslon 45 MG                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21500050802025  Navelblne  Vinorelbine Tartrate lnj 50 MG/5ML (10 MG/Ml) (Base Equiv)                18.00%  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES    21S31560002120  lstodax  Romidepsin For IV lnj 10 MG                18.1)0%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21532530000330  Afinltor  Everolimus Tab 10 MG                18.003⁄4  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES    21533070300130  Sutent  Sunitinib Malate Cap 25 MG (Base Equivalent)                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21534008000320  lnlyta  Axit!nlb Tab 1 MG                18.00%  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES    21534015000120  Xalkori  Crizotinib Cap 200 MG                18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21534025100320  Tarceva  Erlotinib HCI Tab 25 MG {Base Equivalent)                18.00%  ANTINEOPlASTICS
            AND ADJUNCTIVE THERAPIES    2153405420B220  Lenvima 10 MG Daily Doi  lenvatlnlb Cap Therapy Pack 10 MG (10 MG Daily Dose)                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21534075100340  lclusig  Ponatinib HCI Tab 45 MG {Base
            Equiv}                22.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21537560200335  Jakafi  Ruxolitinib Phosphate Tab 25 MG (Base Equivalent)                18.003⁄4  ANT/NEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21700008102020  Trlsenox  Arsenic Trioxide fnj 10 MG/10Ml (1MG/Ml)                18.00%  ANTlNEOPlASTJCS AND ADJUNCTIVE THERAPIES    21700060202030  lntron-A  Interferon A!fa-2B lnj 10000000
            Unit/ML                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21700060702020  Actimmune  Interferon Gamma-18 lnj 100 MCG/0.5Ml (2000000 Unlt/0.SML)                18.00%  ANTINEOPlASTJCS AND ADJUNCTIVE
            THERAPIES    21707070102140  Photofrin  Porfimer Sodium For lnj 75 MG                18.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES    21758050002010  Mesna  Mesna lnj 100 MG/ML                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21405525102120  Firmagon  Degarelix:Acetate For lnj 80 MG {Base Equiv)                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21500005001317  DOCEtaxel  Docetaxel For lnj Cone 160 MG/8Ml (20
            MG/Ml)                35.00%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES    21500010602120  Etopophos  Etoposide Phosphate IV For lnj 100 MG                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21500030102105  VinBlASt!ne
            Sulfate  Vinblastlne Sulfate For lnj 10 MG                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21531550100130  Farydak  Panoblnostat lactate Cap 15 MG {Base Equivalent)                18.00%  ANTINEOPlASTICS AND
            ADJUNCTIVE  THERAPIES  21532530000320  Aflnltor  Everolimus Tab 5 MG                18.00%  ANTINEOPlASTICS ANO ADJUNCTIVE THERAPIES    21533060400320  NexAVAR  Sorafenib Tosylate Tab 200 MG {Base
            Equivalent)                18.00%  ANTINEOPlASTICS ANO ADJUNCTIVE THERAPIES    21534006100330  Gi!otrif  Afatinib Dlmaleate Tab 30 MG (Base Equivalent)                18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21534013106480  Cometriq
            (140 mg Daily [  Cabozantinib S-Ma\ Cap 1 X 80 MG & 3 X 20 MG {140 Dose) Kit                18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21534020000360  Sprycel  Dasatlnlb Tab 100 MG                18.003⁄4  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES    21534035100340  Gleevec  lmatinlb Mesylate Tab 400 MG (Base Equivalent)      .....l\,::, I I,/{('\,"-.          18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21534070100320  Votrient  Pazopanib HCI Tab 200 MG (Base
            Equiv)      h_\\    .a: ....      18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21537560200325  Jakafi  Ruxo!itin!b Phosphate Tab 15 MG (Base Equivalent)    (/  --          18.00%  ANTINEOPlASTlCSAND ADJUNCTIVE
            THERAPIES    21550080100140  Hycamt!n  Topotecan HCI Cap 1 MG {Base Equiv)  '      l/c ·.·  "'...  \V \_J    18.00%                  .  ,ro  ._ \\      \  9  '.  (,I,- :1 (i '.•  U1
            -----  ,  '  .  \.\\(\,\-.'..  ,._)  r·,  -,--  ,  V';,'i:->i ·:-o:- ...:c•'_-'-,-,•-.-,-r_•-"s"-'l-.·- V· 

      

    

     

    
      
        


    

    
      
        

      

      
                               ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21700050100105  Matulane  Procarbazine
            HCI Cap SO MG      18.00";-6    ANT!NEOPLASTlCS AND ADJUNCTIVE THERAPIES  21700060206470  lntron-A  Interferon A!fa-2B lnJ Kit 10000000 Unit/0.2Ml      18.003⁄4    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700075206470  Sytatron  Peginterferon
            a!fa-2b For lnj Kit 4 X 600 MCG      18.003⁄4    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21755050102120  Fusi!ev  levoteucovorin Calcium For IV lnj 50MG (Base Equiv)      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21405050201920  Trelstar Depot  Triptorelin Pamoate For IM Susp 3.75 MG      22.50%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21450080000120  Pomalyst  Pomalfdomlde Cap 3 MG      18.25%    ANTlNEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21500005002050  OOCEtaxel  Docetaxel Soln for IV Infusion 160 MG/16ML      35.00%    ANTINEOPL.ASTICS AND ADJUNCTIVE THERAPIES  21500015002020  Teniposide  Teniposide IV Soln 10 MG/ML      18.00%    ANTINEOPL.ASTICS AND ADJUNCTIVE
            THERAPIES  21531060000140  lbrance  Palbocidib Cap 125 MG      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21532025100130  Tafin!ar  Dabrafenib Mesylate Cap 75 MG (Base Equivalent)      18.00%    ANTINEOPL.ASTICS AND ADJUNCTIVE
            THERAPIES  21532530007340  Aflnitor Disperz  Everolimus Tab for Oral Susp 5 MG      18.003⁄4    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21533570100310  Mek!nlst  Trametinib Dimethyl Sulfoxide Tab 0.5 MG {Base
            Equivalent)      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534012000340  Bosulif  Bosutinib Tab 500 MG      18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534020000340  Sprycel  Dasatln!b Tab 50
            MG      18.00%    ANTINEOPlAST[CS AND ADJUNCTIVE THERAPIES  21534030000320 lressa    Gefitinib Tab 250 MG      18.00%    ANTlNEOPlAST!CSAND ADJUNCTIVE THERAPIES  2153405420B250  Lenvima 24 MG Dally Do  lenvatinib Cap Therapy Pack 10 {2) & 4
            MG (24 MG Daily Dose)      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21536025002120  Kyprolls  Carfi!zomib For lnj 60 MG      18.00%    ANTINEOPL.ASTICS AND ADJUNCTIVE THERAPIES  21550040102035  Camptosar  lrlnotecan HCI lnJ 300
            MG/1SML (20 MG/ML)      18.00%    ANTlNEOPLASTlCS AND ADJUNCTIVE THERAPIES  21700024002020  Ontak  Oenlleukin Diftitox IV Soln 150 MCG/Ml      18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21700060202160  lntron A  Interferon Alfa-2B For
            lnj 50000000 Unit      18.00%    ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES  21700075206430  Sylatron  Peginterferon alfa-2b For lnj Kit 600 MCG      18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21755040100335  Leucovorin
            Calcium  Leucovorin Calcium Tab 15 MG      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21765060002120  Keplvance  Pa!ifermin For IV lnj 6.25 MG      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  2140SS25102130  firmagon  Oegarelix
            Acetate For lnj 120 MG {Base Equiv)      18.00%    ANTINEOPlAST1CS AND ADJUNCTIVE THERAPIES  21500005001320  OOCEtaxel  Docetaxel For lnj Cone 20 MG/0.SML (40 MG/ML)      35.00%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21500011002120  lxempra Kit  lxabepi!one For IV Infusion 15 MG      18.00%    ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES  21500050802020  Navelb!ne  Vinorelbine Tartrate lnj 10 MG/ML (Base Equiv)      18.00%    ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21531550100140  Farydak  Panoblnostat Lactate Cap 20 MG (Base Equivalent)      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21532530000325  Aflnitor  Everollmus Tab 7.5 MG      18.00%    ANTlNEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21533070300120  Sutent  Sunltinib Malate Cap 12.S MG {Base Equivalent)      18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534006100340  Gilotrif  Afatinib Dimaleate Tab 40 MG (Base
            Equivalent)      18.00%    ANTlNEOPlAST!CS AND ADJUNCTIVE THERAPIES  21534014000130  Zykadia  Ceritinib Cap 150 MG      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534020000380  Sprycel  Dasatinlb Tab 140
            MG      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534050100320  Tykerb  Lapatinib Ditosylate Tab 250 MG (Base Equiv)      18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534075100320  lclusig  Ponatinib HCI Tab 15 MG {Base
            Equiv}      22.75%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21537560200330  Jakafi  Ruxolitinib Phosphate Tab 20 MG {Base Equivalent)      18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21550080102020  Topotecan HCI  Topotecan HCI lnj
            4 MG/4Ml {Base Equiv) (For Infusion)      18.00%    ANTINEOPlASTfCS AND ADJUNCTIVE THERAPIES  21700060202022  lntron·A  Interferon A!fa-28 lnj 6000000 Unit/ML      18.00%    ANT/NEOPLASTICS AND ADJUNCTIVE THERAPIES  21700060302020  Alferon
            N  Interferon A!fa-n3 lnj 5000000 Unit/ML      18.00%    ANTINEOPL.ASTICS AND ADJUNCTIVE THERAPIES  21703020002120  Proleukin  Aldesleukin For IV Soln 22000000 Unit      18.00%    ANTINEOPL.ASTlCS AND ADJUNCTIVE
            THERAPIES  21758050000320  Mesnex  Mesna Tab 400 MG      18.00%    ANTINEOPlASTICSAND ADJUNCTIVE THERAPIES  21100009102120  Treanda  Bendamustine HCl For IV Sein 100 MG      18.00%    ANT1NEOPLASTtC5 AND ADJUNCTIVE
            THERAPIES  21101020000305  Cydophosphamlde  Cyclophosphamlde Tab 25 MG      32.30%    ANTINEOPlASTJCS AND ADJUNCTIVE THERAPIES  21101025002130  lfex  lfosfamide For lnj 3 GM      18.00%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21102030002105  Zanosar  Streptozodn For lnj 1 GM      18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200040102110  Adrlamycin  Doxorubicin HCI For lnj 20 MG  ,s,.. .-,·r•- "v    18.00%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21200042102170  Epirubicin HCI  Eplrubicin HCI For lnj 200 MG  )' ,,,... . -:;,-"'1.' "'    18.00%    ANTlNEOPL.ASTICS AND ADJUNCTIVE THERAPIES  21300025100320  Oforta  Fludarab!ne Phosphate Tab 10 MG      ",',
            18.00    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300040001830  Purixan  Mercaptopurine Susp 2000 MG/100ML {20 MG/ML)  t,·_ %      18.00                  .· vvmrato N,imero ' 01 ':  .19-a ••  ' (/1 ·.·---  f  ·-  ; \\\ ·,.  s 2,,.  -  ,_ Q
            '  , , 0 0()  .,  \ 0/:>  \ 

      

    

     

    
      
        


    

    
      
        

      

      
                         ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21335010102030  Zaltrap  Ziv-Aflibercept IV
            Soln 200 MG/8ML (For Infusion)            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21353025002025  Erbltux  Cetuximab IV Solo 200 MG/lOOML {2 MG/ML)            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  213S3050002035  Vectibix  Panitumumab IV Soln 400 MG/20Ml            18.00%    ANTJNEOPlA5TICS AND ADJUNCTIVE THERAPIES  21355070302120  Kadcyla  Ado-Trastuzumab Emtansine For IV Soln 100 MG            18.00%    ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21403530002024  Faslodex  Fulvestrant Jnj 250 MG/SML            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21405010156430  lupron Depot  Leuprolide Acetate (3 Month) For lnj Kit 22.5
            MG            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21100028002035  Eloxatin  Oxaliplatin IV So!n 200 MG/40Ml            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21101020002130  Cyclophosphamide  Cyclophosphamide For
            lnj 2 GM            32.3CY'76    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21102010002105  BiCNU  Carmustine For lnj 100 MG            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200030102105  Cerubidine  Daunorubicin HCI For Inf 20
            MG            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200042102030  Ellence  Ep!rublcin HCI IVSoln 50 MG/25ML(2 MG/ML)            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200055001320  Mitoxantrone HCI  Mitoxantrone
            HCI lnj Cone 20 MG/10ML (2 MG/ML)            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300010002110  Cytarabine  Cytarabine For lnj 500 MG            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300034102020  Gemcltablne
            HCI  Gemcitabine HCI lnj 200 MG/5.26Ml (38 MG/ML) (Base Equiv)            30.00%    ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21300054002020  Folotyn  Pralatrexate IV lnj 20 MG/Ml            18.00%    ANTlNEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21335070002040  Cyramza  Ramuclrumab 1V Soln 500 MG/50ML (For Infusion)            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21353045001320  Arzerra  Ofatumumab Cone For IV Infusion 100
            MG/5ML            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21402420000320  Casodex  Bicalutamide Tab 50 MG            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21100009102110  Treanda  Bendamustine HCI For IVSoln 25
            MG            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21101010000305  leukeran  Chlorambucil Tab 2 MG            18.00%    ANT1NEOPLASTICS ANO ADJUNCTIVE THERAPIES  21101025002110  lfex  lfosfamide For lnj 1
            GM            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21102020000120  CeeNU  Lomustine Cap 100 MG            18.00%    ANTINEOPI.ASTICS AND ADJUNCTIVE THERAPIES  21200040102105  Adriamyc!n  Doxorub!cin HCI For lnj 10
            MG            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200042102140  Eplrubicin HCI  Epirubicin HCI For lnj 50 MG            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200080002020  Va!star  Valrubicin Soln For
            lntraveslcal Instillation 40 MG/ML            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300010301825  OepoCyt  Cytarabine Uposome lnj 50 MG/5ML            18.00%    ANTINEOPlAST!CS AND ADJUNCTIVE
            THERAPIES  21300034102160  Gemcitabine HCI  Gemcltabine HCI For lnj 2 GM            30.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21335010102020  Zaltrap  Ziv-Afllbercept IV Soln 100 MG/4Ml (For
            Infusion)            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21353025002020  Erbitux  Cetuximab N So!n 100 MG/SOML (2 MG/Ml)            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21353050002030  Vectibix  Panitumumab IV
            Soln 200 MG/10Ml            18.00%    ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES  21355020202120  Adcetris  Brentuximab Vedotin For N So!n 50 MG            18.00%    ANTINEOPlASTlCSAND ADJUNCTIVE THERAPIES  21403530002022  Faslodex  Fufvestrant
            lnj 125 MG/2.SML            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405050201930  Tre!star lA  Triptorelin Pamoate For IM Susp 11.25 MG            22.50%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21104070000140  Temodar  Temozolom!de Cap 100 MG            35.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500005001310  DOCEtaxel  Docetaxel For tnj Cone 20 MG/Ml            35.00%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  99392070000120  Thalomld  Thalidom!de Cap 50 MG            18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  99394050000145  Revlim!d  Lenalldom!de Cap 20 MG            18.003⁄4    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21405010256445  Eligard  leuprolide Acetate (6 Month) For Subcutaneous lnJ Kit 45 MG            25.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21450080000110  Pomalyst  Pomalidomide Cap 1 MG            18.25%    ANTINEOPLASTICS
            AND ADJUNCTIVE THERAPIES  21500005002030  DOCEtaxel  Docetaxel Solo for IV Infusion 20 MG/2Ml            35.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500012001340  PACUtaxel  Paclitaxel IV Cone 150 MG/25Ml {6
            MG/ML)            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21531060000120  lbrance  Palbociclib Cap 75 MG            18.00%    ANTINEOPlASTICS ANO ADJUNCTIVE THERAPIES  21531575000120  Zo!ima  Vorinostatcap 100
            MG            18.00%    ANTJNEOPlASTlCS ANO ADJUNCTIVE THERAPIES  21532530007310  Afinitor Disperz  Evero!imus Tab for Oral Susp 2 MG            18.00%    ANTINEOPLASTlCS AND ADJUNCTNE THERAPIES  21533070300135  Sutent  Sunitinib Malate Cap
            37.5 MG {Base Equivalent}    .    .    18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534008000340  lnlyta  Axitinib Tab 5 MG    . <:\\ :,, I ,_    01 "'-    18.00%    ANTINEOPI.ASTICS AND ADJUNCTIVE
            THERAPIES  21534015000125  Xalkori  Crlzotlnlb Cap 250 MG    •;;\\ 4,,-,..    :-.'-'  '  ' 18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534025100330  Tarceva  Erlotinib HCl Tab 100 MG (Base Equivalent)    /'        \,
            18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  2153405420B230  Lenvima 20 MG Dally Do  lenvatlnib Cap Therapy Pack 10 (2) MG (20 MG Daily Dose)  I  ',  Con1r,,,,,... ,.,,        18.00%  ,.,.- #,,,,,            :'_l I)
            5                    (ll ..\\,·. ()    'I        -  <> ·-  ·0  --v 'il(f"',.  "' ·-  '  \Qs or'.0 .1.V·  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                                   ANTlNEOPlASTICS




            AND ADJUNCTIVE THERAPIES  21535560000120 lynparza  ANTINEOPlASTICS ANO ADJUNCTIVE THERAPIES  lolaparib Cap SO MG  ldelal!sib Tab 100 MG  18.00%  18.00%  ANTINEOPLAST[CS AND ADJUNCTIVE THERAPIES  21538040000320 Zydelig  21700013001940
            TheraCys  BCG Live lntravesical For Susp 81 MG/VIAL  18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700060202130 lntron A  Interferon Alfa-2B For lnj 10000000 Unit  18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700075206410
            Sylatron  Peginterferon alfa-2b For lnj Kit 200 MCG  18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES  21708220000120 Targretin  21764065002120 Elitek  Bexarotene Cap 75 MG Rasburicase For IV Soln 1.5
            MG  18.00%18.ocr  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21104070000150 Temodar  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  99392070000140 Thalomid  Temozo!omide Cap 250 MG  Thalidomide Cap 200 MG  35.1)0%  18.00%  ANTINEOPLASTICS ANO
            ADJUNCTIVE THERAPIES  21405010106407 leuprolide Acetate  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21300015002120 Dacogen21500010002025 Etoposide21500010002030 Etoposide21450080000125 Poma!yst21500009202020 Halaven21500020201820 Marqibo  leuprolideAcetate lnj Kit 5
            MG/ML  Dedtabine For lnj SO MGEtoposide lnj 100MG/5Ml(20 MG/ML)Etopos!de lnj 500MG/25Ml (20 MG/ML) Pomalidomlde Cap 4 MGEribulin Mesylate lnj 1 MG/2Ml {O.S MG/ML)Vincristine Sulfate Uposome 1V Susp 5 MG/31ML (0.16
            MG/Ml}  52,25%  25.00%27.55%27.55%18.25%18.001⁄418.00%  ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21531520002120 Beleodaq21532080000320 Zelboraf  BeHnostat For IV Inf 500 MG Vemurafenib Tab 240
            MG  18.00%18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21532570002020 Torisel  Temslro!imusSo!n For IV Infusion 25 MG/Ml  18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  18.00%  ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES  21533570100330
            Meklnlst Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent) 21534013106460 Cometriq (60 mg Daily n, Cabozantinib S-Mafate Cap 3 X 20 MG {60 MG Dose) Kit  18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21534020000350 Sprycel21534033000120 lmbruvica  Dasatinib Tab 70 MG lbrutlnlb Cap 140 MG  18.00%18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21534060200115 Tasigna  Nllot!n!b HCI Cap 150 MG {Base Equivalent)  21537560200310 Jakafl  Ruxolitinib Phosphate Tab 5 MG {Base Equivalent)  21550040102040 lrinotecan HCI  !rinotecan Hd lnj 500 MG/25ML (20
            MG/ML)  18.00%  18.00%  30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES  21700040102120 Synribo21700060206450 lntron-A  Omacetaxine Mepesucdnate For lnj 3.5 MG Interferon Atfa-2B lnj Kit 3000000
            Unlt/0.2ML  18,00%18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES  2170007S206450 Sylatron 21755040102030 Leucovorin Calcium  Peginterferon alfa-2b For lnj Kit4 X 200 MCG Leucovorin Calcium lnj 10
            MG/Ml  18.00%18.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21104070000143 Temodar21500005001315 DOCEtaxel  Temozofomide Cap 140 MGDocetaxel For lnj Cone 80 MG/4Ml (20
            MG/ML)  35.00%35.00%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  99392070000130 Thalomid  Thalidomide Cap 100 MG  18.00%  ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  ANTINEOPIAST!CS AND ADJUNCTIVE THERAPIES  99394050000150 Revlimid21100028002030
            Eloxatin  lenaltdomlde Cap 25 MG Oxaliplatin 1V So!n 100 MG/20Ml  18.00%30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  99394050000110 Rev!imld21534085000320 Capre!sa  lenalidomide Caps 2.5 MG
            Vandetanlb Tab 100 MG  18.00%18.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21550040102025 camptosar  lrinotecan HCI lnj 40 MG/2Ml (20 MG/Ml}  30.00%  ANTINEOPtAST1CS AND ADJUNCTIVE THERAPIES  ANTlNEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21550080102120 Hycamtin21300034102110 Gemcitablne HCI  Topotecan HCI For lnj 4 MG Gemdtabine HCI For lnj 200 MG  18.00%30.00%  ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES  ANT!NEOPlASTICS AND ADJUNCTIVE THERAPIES  21500010002040
            Etoposlde21550040102030 Camptosar  Etoposide !nj 1 GM/50ML (20 MG/ML) lrinotecan Hd !nJ 100 MG/5Ml {20 MG/ML)  27.55%30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21250010402120 Erwinaze  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21104070000110 Temodar  Asparaginase Erwlnia Chrysantheml For lnj 10000 Unit  Temozolomide Cap 5 MG  18.00%  35.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300005000350 Capecitablne  Capecitabine Tab 500
            MG  40.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  99394050000130 Revlimld  21300030002030 Adrucil  lenalidornide Cap 10 MG  Fluorouraci! lnj 2.5 GM/SOMl(SO MG/ML)  - ....... · .,'  18.00%  7._,"0- .,..c.-,-. - ,,
            .......  18.00%  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  21104070000120 Ternodar  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300030002020 Adrucil  Temozolomide Cap 20 MG  Fluorouracll lnj 500 MG/lOMl
            (SO MG/Ml)  ! .--->'--.., {  '-\ ( ) 8.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                         ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  99394050000140  Rev!imid  lenalidomide Cap 15
            MG                18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300030002035  Adrucll  Fluorouracil lnj 5 GM/100Ml (SO MG/Ml)                18.00%    ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21300003001920  AzaCITIDlne  Azacitidine
            For lnj 100 MG                25.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21405050201940  Trelstar Mixject  Triptorelin Pamoate For IM Susp 22.5 MG                22.50%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21500003002020  Jevtana  Caba2itaxel lnj 60 MG/1.SMl (For N Infusion)                18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500010000120  Etoposide  Etoposide Cap 50 MG                27.55%    ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21500030102020  VinBLAStine Sulfate  Vinblastine Sulfate lnj 1 MG/Ml                18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21531550100120  Farydak  Panobinostat lactate Cap 10 MG {Base
            Equivalent)                18.00%    ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21532530000310  Afinitor  Evero!imus Tab 2.5 MG                18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  2153305000-0320  Stlvarga  Regorafenib Tab 40
            MG                18.00%    ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES  21534006100320  Gilotrif  Afatin!b Dlmaleate Tab 20 MG (Base Equlvalent)                18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534013106470  Cometriq (100 mg
            Daily I  Cabozantinib S-Mal Cap 1 X 80 MG & 1 X 20 MG (100 Dose) Kit                18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534020000354  Sprycel  Dasatinlb Tab 80 MG                18.00%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21534035100320  Gleevec  lmatinib Mesylate Tab 100 MG (Base Equivalent)                18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534060200125  Tasigna  Nilotinib HCI Cap 200 MG {Base
            Equivalent)                18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21537560200320  Jakafi  Ruxolitinib Phosphate Tab 10 MG (Base Equivalent)                18.00%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21550080100120  Hycamtin  Topotecan HCI Cap 0.25 MG {Base Equiv)                18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700045002120  Nipent  Pentostatin For lnJ 10 MG                18.00%    ANTINEOPlASTICS ANO
            ADJUNCTIVE THERAPIES  21700060206460 lntron-A    Interferon Alfa-2B lnj Kit 5000000 Unlt/0.2Ml                18.00%    ANTtNEOPLA.STICS AND ADJUNCTIVE THERAPIES  21700075206460  Sylafron  Peginterferon alfa-2b For lnj Kit 4 X 300
            MCG                18.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21755040102170  leucovorin calcium  leucovorfn Calcium For lnj 500 MG                18.00%,    ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21100028002025  Eloxatin  Oxalfp!atln N Sein 50 MG/10Ml                30.00%    ANT!NEOPLASTICS AND ADJUNCTIVE THERAPIES  21300005000320  capecitabine  capecitabine Tab 150 MG                40.00%    ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  99394050000120  Revlimid  lenaUdomlde Cap 5 MG                18.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534085000340  Caprelsa  Vandetanib Tab 300
            MG                18.00%    ANTINEOPLASTICSTOPJCAlS  90371050204030  Valchlor  Mech!orethamine HCI Gel 0.016% {Base Equivalent)                18.00%    ANTINEOPLASTICS TOPICAlS  90376015004020  Panretin  Alitretinoin Gel
            0.1%                18.00%    Antiparasitics  13000040000310  Darapr!m  Pyrimethamlne Tab 25 MG                18.00%    ANTIPARKINSON AGENTS  73203010102020  Apokyn  Apomorphlne Hydrochloride lnj 10
            MG/Ml                18.00%    Antipsychotics  59070070101930  RisperDAL Consta  R!speridone Microspheres For lnj 37.5 MG                18.00%    Antipsychotics  59250015001930  Abilify Maintena  Aripiprazole lM For Extended Release Susp 400
            MG                18.00%    Antipsychotlcs  59070070101920  RisperDAl Consta  Risperidone Microspheres For Inf 25 MG                18.00%    Antipsychotics  59070070101910  R!sperDAL Consta  Rlsper!done Mlcrospheres For lnj 12.5
            MG                18.00"76    Antfpsychot!cs  59070050101837  lnvega Sustenna  Pal!peridone Palmitate IM Extended-Release Susp 39 MG/0.25ML                18.00%    Antipsychotics  59070070101940  RisperDAL Consta  Risperidone Mlcrospheres For
            lnj 50 MG                18.00%    Antipsychotics  59070050101845  lnvega Sustenna  PaHperldone Pa!mitate \M Extended-Release Susp 234 MG/1.5Ml                18.00%    Antlpsychotics  59070050101838  lnvega Sustenna  Paliperidone Pa!mltate IM
            Extended-Release Susp 78 MG/0.5ML                18.00%    Antipsychotics  59070050101850  lnvega Trima  Pal!peridone Pa!mitate IM Extend-Release Susp 273 MG/0.875ML                18.00%    Antlpsychotics  59250015001920  Abilify
            Maintena  Arlplprazole IM For Extended Release Susp 300 MG                18.00%    Antipsychotics  5925001520E430  Aristada  ARlPIPRAZOLE lAUROXIL lM ER SUSP PREFlllED SYR 662
            MG/2.4Ml                18.00%    Antlpsychotics  59070050101839  lnvega Sustenna  Pallperidone Palmltate IM Extend-Release Susp 117 MG/0.75Ml                18.00%    Antipsychotics  59070050101870  lnvega Trima  Paliperidone Palmitate IM
            Extend•Release Susp 546 MG/1.75Ml                18.00%    Antipsychotics  5925001520E440  Arlstada  AR1PIPRAZOLE lAUROXll IM ERSUSP PREFILLED SYR 882 MG/3.2ML                18.00%    Antipsychotics  59070050101880  lnvega Trinza  Paliperidone
            Palmitate 1M Extend-Release Susp 819 MG/2.625Ml                18.00%    Antipsychotics  5925001520E420  Arlstada  ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFlllED SYR 441MG/1.6ML                18.00%    Antipsychotics  59070050101840  lnvega
            Sustenna  Paliperidone Palmitate IM Extended-Release Susp 156 MG/Ml        ---1:,,,r, --<......        18.00%    Antipsychotics  59070050101860  lnvega Trinta  Pa!iper!done Palmitate IM Extend•Release Susp 410 MG/1.315Ml        .,..
            \--.::-'" . -<·.•..t.o        ··, 18.00%    ANTIPSYCHOTICS/ANTlMANICAGENTS  59157060101950  ZyPREXA Relprew  Olanzap!ne Pamoate For Extended Rel IM Susp 210 MG {Base Eq)    ,J•,._,    p:v        ..",' ·
            18.00%    ANTIPSYCHOTICS/ANTIMAN!CAGENTS  59157060101970  ZyPREXA Relprew  Olamapine Pamoate For Extended Rel JM Susp 405 MG (Base Eq}      / \          18.00%    X            , Contrato Numero          '"            \      1 9  (I  ,)  '
            '                                l  Y(J  .  "''\·.    /..:,  <;& ·,. .-w ly  "y  "'"·  ty0 , 0  SLh . 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                                                                                                                                                                                                                       ANTlPSYCHOTICS/ANTIMANIC




            AGENTS  S9157060101960 ZyPREXA Relprew  Olanzapine Pamoate For Extended Rel IM Susp 300 MG (Base Eq)  18.00%  Antivirals  12200020102030 Foscavir  FoscarnetSod!um lnj 6000 MG/250ML (24 MG/ML)  18.00%  Antivirals  12359902300320
            Zepatier  Elbasvir-Grazoprev!rTab 50-100 MG  18.00%  Antivirals  12200020102040 Foscarnet Sodium  FoscarnetSodium lnj 12000 MG/SOOML (24 MG/ML}  18.00%  ANTIVIRALS INFLUENZA  12504065002020 Rapivab  Peramivir lnj 200 MG/20Ml (10
            MG/ML)  18.00%  Bisphosphonates  30042048100360 Bonlva  lbandronate Sodium Tab 150 MG (Base Equivalent)  18.00%  BLEEDING DISORDERS  84100010000320 Am!car  Aminocaproic Acid Tab 1000 MG  18.00%  BLEEDING DISORDERS  8410001000120S
            Amicar  Aminocaproic Acid Syrup 25%  18.00%  BLEEDING DISORDERS  84100010000305 Amlcar  AmlnocaproicAcid Tab 500 MG  18.00%  Blood Products/ Modifiers/Volume Expanders  8240101510E556 Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 5oln
            lnj 60 MCG/ML  18.00%  Blood Products/ Modifiers/ Volume Expanders  8240101510E575 Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 150 MCG/0.3ML  18.00%  Blood Products/ Modifiers/Volume Expanders  82401015102080 Aranesp
            {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 So!n Jnj 500 MCG/ML  18.00%  Blood Products/ Modifiers/Volume Expanders  8240102000E545 Epogen  Epoetin Alfa \nj10000 Unit/Ml  18.00%  Blood Products/ Modifiers/Volume Expanders  8240104010E515
            Mircera  Methoxy Polyethylene Glycol-Epoetin Beta Jnj 50 MCG/0.3ML  18.00%  Blood Products/ Modifiers/Volume Expanders  8240152000E545 Neupogen  Filgrastim lnj 300 MCG/O.SML(600 MCG/Ml}  18.00%  B!ood Products/ Modifiers/Volume
            Expanders  85100028402105 A!pro!ix  Coagulation Factor IX (Recomb) {rFIXFc} For lnj 250 Unit  18.00%  Blood Products/ Modifiers/Volume Expanders  85100015106440 Wilate  Antihemophilic Factor/WJF {Human) For lnJ 1000-1000 Unit Kit  18.00%  Blood
            Products/ Modifiers/Volume Expanders  85100028202145 lxinity  Coagulation Factor IX (Recombinant) For lnj 1500 Unit  18.00%  Blood Products/ Modifiers/Volume Expanders  85100010402130 Adynovate  AntihemophHic Factor Recomb Pegylated For lnj 500
            Unit  18.00%  Blood Products/ Modifiers/ Volume Expanders  85100031002140 Coagadex  Coagulat!on FactorX {Human) For lnj 500 Unit  18.00%  Blood Products/ Modifiers/Volume Expanders  8240101510E543 Aranesp (Albumin Free)  Darbepoetin
            A!fa-Po[ysorbate 80 Solo lnj 40 MCG/0.4Ml  18.00%  Blood Products/ Modifiers/Volume Expanders  8240101510E560 Aranesp (Albumin Free}  18.00%  B!ood Products/ Modifiers/Volume Expanders  8240101510E582 Aranesp {Albumin Free)  Darbepoetin
            Alfa-Po!ysorbate 80 So!n lnj 100 MCG/0.SML Darbepoetin Alfa-Polysorbate 80 Soln lnj 200 MCG/0.4Ml  18.00%  Blood Products/ Modifiers/Volume Expanders  85100028206430 BeneFIX Coagulation Factor 1X (Recombinant) For lnj Kit 500
            Unit  21.00%  Blood Products/ Modifiers/Volume Expanders  8240101510E543 Aranesp {Albumin Free) Darbepoetin Alfa-Potysorbate 80 Solo lnj 40 MCG/0.4Ml  18.00%  Blood Products/ Modifiers/ Volume Expanders  8240101510E560 Aranesp (Albumin
            Free}  18.00%  Blood Products/ Modifiers/ Volume Expanders  82401015102070 Aranesp (Albumin Free)  Darbepoetin A!fa-Polysorbate 80 Soln lnj 100 MCG/0.SML Darbepoetin Alfa-Polysorbate 80 Soln lnj 300 MCG/ML  18.00%  Blood Products/
            Modifiers/Volume Expanders  8240102000E545 Epogen  Blood Products/ Modifiers/Volume Expanders  8240102000E575 Epogen  Epoetln Alfa lnj 10000 Unit/ML Epoet!n Alfa lnj 40000 Unit/Ml  18.00%18.00%  Blood Products/ Modifiers/Volume Expanders  Blood
            Products/ Modifiers/Volume Expanders  8240152000E525 Neupogen 82401015102010 Aranesp (Albumin Free)  Fi1grastim lnj 300 MCG/MLDarbepoetin Alfa-Polysorbate 80 Soln lnj 25 MCG/Ml  18.00%18.1)0%  Blood Products/ Modifiers/Volume
            Expanders  8240101510ES52 Aranesp (Album!n Free)  Darbepoetln Alfa-Polysorbate 80 Soln lnj 60 MCG/0.3Ml  18.00%  Blood Products/ Modifiers/ Volume Expanders  8240101510E558 Aranesp (Albumin Free)  Darbepoetin Alfa-Po!ysorbate 80 Soln lnj 200
            MCG/Ml  18.00%  Blood Products/ Modifiers/Volume Expanders  82401015102080 Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80Sain lnj 500 MCG/Ml  18.00%  Blood Products/ Modifiers/ Volume Expanders  8240102000E545 Epogen  18.00%  Blood
            Products/ Modifiers/ Volume Expanders  8240104010E520 Mircera  Epoetin Alfa lnj 10000 Unit/MLMethoxy Polyethylene Glycol-Epoetln Beta lnj 75 MCG/0.3Ml  18.00%  Blood Products/ Modifiers/ Volume Expanders  8240152000E550 Neupogen  Filgrastim lnj
            480 MCG/0.SML (600 MCG/ML)  18.00%  Blood Products/ Modifiers/ Volume Expanders  Blood Products/ Modifiers/Volume Expanders  85100028352130 ldelvion85100028402150 Alprollx  Coagulation Factor IX (Recomb) {rlX-FP} For lnj 1000 Unit Coagulation
            Factor IX (Recomb} {rFIXFc) For lnj 4000 Unit  18.00%18.00%  Blood Products/ Modifiers/Volume Expanders  Blood Products/ Modifiers/Volume Expanders  8240104010E525 Mircera82401015102020 Aranesp (Albumin Free}  Methoxy Polyethylene
            G!ycol-Epoetln Beta lnJ 100 MCG/0.3ML Darbepoetin Alfa-Polysorbate 80 So!n lnj 40 MCG/ML  18.00%18.00%  Blood Products/ Modifiers/ Volume Expanders  82401015102040 Aranesp (Albumin Free) Darbepoetin Alfa-Polysorbate 80 Sain lnj 100
            MCG/ML  Blood Products/ Modifiers/Volume Expanders  8240101510E558 Aranesp {Albumin Free) Darbepoetin Alfa-Polysorbate 80 Solo lnj 200 MCG/ML  18.00%18.00%  Blood Products/ Modifiers/Volume Expanders  Blood _Products/ Modifiers/Volume
            Expanders  85100028206420 BeneFIX8240101510E556 Aranesp {Albumin Free)  Coagulation Factor IX {Recombinant) For In] Kit 250 Unit Darbepoetin Alfa-Polysorbate 80 Soln lnj 60 MCG/ML  c-·-, .,_,  21.00%18.00%  Blood Products/ Modifiers/Volume
            Expanders  82401015102050 Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 150 MCG/0.75Ml  ....,\ :. ""TC:1'/.,......"--  18.0<Y';,£  Blood Products/ Modifiers/ Volume Expanders  8240101510E588 Aranesp (Albumin
            Free}  Darbepoetln Alfa-Polysorbate 80 So[n lnj 300 MCG/0.6Ml  ,<.._....fP..  "'-·· 'YI  18.00%  Blood Products/ Modifiers/ Volume Expanders  8240102000E545 Epogen  Epoetfn Alfa lnj 10000 Unit/Ml  -:, I;  " :,  18.00%  B!ood Products/
            Modifiers/Volume Expanders  8240102000E575 Epogen  Epoetin Alfa lnj 40000 Unit/Ml  '  vuntfato Nli......A- - i  18.00%  I _I 9 r;    ,  J 5 2    q ,-  '·• (fl• --  -  - '--- ?"!J  '  '  ••(.,\(,".), -= V  ·v·-  SP·,, Os DF 01'·  >)._,_,,,
            •• 

      

    

     

    
      
        


    

    
      
        

      

      
                         Blood Products/ Modifiers/ Volume Expanders  8240101510E528  Aranesp {Albumin
            Free}  Darbepoet!nAlfa Polysorbate 80 Soln lnj 25 MCG/0.42ML            18.00%  Blood Products/ Modifiers/Volume Expanders  82401015102040  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 100 MCG/ML            18.00%  Blood
            Products/ Modifiers/Volume Expanders  8240101510E558  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 200 MCG/ML            18.W/4  Blood Products/ Modifiers/ Volume Expanders  8240102000E510  Epogen  Epoetin Alfa lnj 2000
            Unit/Ml            18.00%  B!ood Products/ Modifiers/Volume Expanders  8240102000E545  Epogen  Epoet!n Alfa lnj 10000 Unit/Ml            18.00%  Blood Products/ Modifiers/Volume Expanders  8240104010E525  Mircera  Methoxy Polyethylene
            Glycol-Epoetin Beta lnj 100 MCG/0.3ML            18J)O%  Blood Products/ Modifiers/Volume Expanders  85100028352140  ldelvion  Coagulation Factor IX (Recomb) {rlX-FP) For lnj 2000 Unit            18.W/4  Blood Products/ Modifiers/ Volume
            Expanders  85100015106430  Wilate  Antihemophlltc FactorMVF {Human} For lnj S00-500 Unit Kit            18.00%  Blood Products/ Modifiers/ Volume Expanders  85100010402140  Adynovate  Antihemophll!c Factor Re.comb Pegylated For lnj 1000
            Unit            18.00%  Blood Products/ Modifiers/Volume Expanders  8240157000£520  Neulasta  Pegfilgrastim lnj 6 MG/0.6ML            18.00%  Blood Products/ Modifiers/ Volume Expanders  82401015102070  Aranesp {Albumin Free)  Darbepoetin
            Alfa-Polysorbate 80 Soln lnj 300 MCG/ML            18.00%  Blood Products/ Modifiers/ Volume Expanders  8240104010E520  Mlrcera  Methoxy Polyethyfene Glycol-Epoetin Beta lnj 75 MCG/0.3Ml            18.00%  Blood Products/ Modifiers/Volume
            Expanders  85100028206450  BeneFIX  Coagulation Factor IX {Recombinant) For lnj Kit 2000 Unit            21.00%  Blood Products/ Modifiers/Volume Expanders  85100010402150  Adynovate  AntihemophiHc Factor Recomb Pegy!ated For lnj 2000
            Unit            18.00%  Blood Products/ Modifiers/ Volume Expanders  82401015102010  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnJ 25 MCG/Ml            18.00%  Blood Products/ Modifiers/ Volume
            Expanders  8240101510E556  Aranesp (Albumin Free)  Darbepoetln Alfa-Polysorbate 80 Soln lnj 60 MCG/ML            18.00%  Blood Products/ Modifiers/Volume Expanders  82401015102050  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 So!n
            lnj 150 MCG/0.75Ml            18.00%  Blood Products/ Modifiers/Volume Expanders  85100010402120  Adynovate  Antihemophllic Factor Recomb Pegy!ated For lnj 250 Unit            18.00%  Blood Products/ Modifiers/ Volume
            Expanders  85100031002120  Coagadex  Coagulation FactorX {Human) For lnj 250 Unit            18.00%  Blood Products/ Modifiers/ Volume Expanders  8240102000E545  Epogen  Epoetin Alfa lnj 10000 Unit/Ml            18.00%  Blood Products/
            Modifiers/Volume Expanders  8240152000E545  Neupogen  Filgrastim lnj 300 MCG/0.5Ml {600 MCG/Ml)            18.00%  Blood Products/ Modifiers/Volume Expanders  8240102000E575  Epogen  Epoetin Alfa lnj 40000 Unit/ML            18.00%  Blood
            Products/ Modifiers/ Volume Expanders  85100028206460  BeneFIX  Coagulation Factor IX (Recombinant) For lnj Kit 3000 Unit            21.00%  Blood Products/ Modifiers/Volume Expanders  82401015102020  Aranesp (Albumin Free)  Darbepoetin
            Alfa-Polysorbate 80 Soln lnj 40 MCG/ML            18.00%  Bloo<I Products/ Modifiers/Volume Expanders  82401015102040  Aranesp (Albumin Free)  Darbepoetln Affa-Polysorbate 80 Soln lnj 100 MCG/ML            18.00%  Blood Products/
            Modifiers/Volume Expanders  8240101510E558  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 200 MCG/Ml            18.00%  Blood Products/ Modifiers/Volume Expanders  8240102000ES20  Epogen  Epoetin Alfa lnj 4000
            Unit/ML            18.00%  Blood_ Products/ Modifiers/ Volume Expanders  8240102000E575  Epogen  Epoetin Alfa lnj 40000 Unit/Ml            18.00%  Blood Products/ Modifiers/ Volume Expanders  8240157000E520  Neulasta  Pegfilgrastim lnj 6
            MG/0.6Ml            18.00%  B!ood Products/ Modifiers/Volume Expanders  85100028352110  ldelvion  Coagulation Factor IX (Recomb) {rlX·FP) For lnj 250 Unit            18.00%  Blood Products/ Modifiers/Volume
            Expanders  85100010402145  Adynovate  Antihemophil[c Factor Recomb Pegylated For lnj 1500 Unit            18.00%  Blood Products/ Modifiers/Volume E>tpanders  8240101510E528  Aranesp {Albumin Free)  Darbepoetln Alfa-Polysorbate 80 So!n lnj
            25 MCG/0.42ML            18.00%  Blood Products/ Modlflers/Volume Expanders  8240101510E552  Aranesp {Albumin Free)  Darbepoetln Alfa-Polysorbate 80 So!n lnj 60 MCG/0.3ML            18.00%  Blood Products/ Modifiers/Volume
            Expanders  8240101510E575  Aranesp {Album!n Free)  Darbepoetfn Alfa-Polysorbate 80 Sein lnj 150 MCG/0.3Ml            18.00%  Blood Products/ Modifiers/ Volume Expanders  82401015102020  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80
            Soln lnj 40 MCG/ML            18.00%  Blood Products/ Modifiers/ Volume Expanders  82401015102040  Aranesp {Albumin Free)  Darbepoetln Alfa-Polysorbate80 Soln lnj 100 MCG/ML            18.00%  Blood Products/ Modifiers/ Volume
            Expanders  8240101510E582  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 200 MCG/0.4ML            18.00%  B!ood Products/ Modifiers/Volume Expanders  8240102000ES45  Epogen  Epoetin Alfa lnj 10000
            Unit/Ml            18.00%  Blood Products/ Modifiers/ Volume Expanders  8240102000E575  Epogen  Epoetin Alfa lnj 40000 Unit/Ml            18.00%  Blood Products/ Modifiers/ Volume Expanders  8240157000E520  Neulasta  Pegfilgrastim lnj 6
            MG/0.6Ml            18.00%  Blood Products/Modifiers/Volume Expanders  83334030002120  lprivask  Des!rudin For lnj 15 MG            18.00%  Blood Products/ Modifiers/ Volume Expanders  85100028352120  ldetvion  Coagulation Factor IX {Recomb)
            {rlX-FP) For lnj 500 Unit            18.00%  Blood Products/ Modifiers/ Volume Expanders  8240152000E525  Neupogen  Filgrastim lnJ 300 MCG/Ml            18.00%  Blood Products/ Modifiers/Volume Expanders  8240101510E588  Aranesp (Albumin
            Free)  Darbepoetln Alfa-Polysorbate 80 Soln lnj 300 MCG/0.6Ml            18.00%  Blood Products/ Modifiers/Volume Expanders  8240104010E51S  Mircera  Methoxy Polyethylene Glycol-Epoetin Beta lnj 50 MCG/0.3Ml    /" ,, • .,-..Tl=>
            A...........,.r...,."-.,        18.00%  Blood Products/ Modifiers/Volume Expanders  8240102000£520  Epogen  Epoetin Alfa lnj 4000 Unit/ML    , _t ,~        18.00%  Blood Products/ Modifiers/Volume Expanders  8240152000E550  Neupogen  Fi!grastim
            lnj 480 MCG/0.8ML(600 MCG/Ml) ,    E  4" '-.',      18.00%  Blood Products/ Modifiers/Volume Expanders  85100028206440  BeneFIX  Coagulation Factor JX {Recombinant) For lnj Kit 1000 Unit  V    N  ,a  I  21.00%  Blood Products/ Modifiers/Volume
            Expanders  82401015102020  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Sein lnj 40MCG/Ml      :v -.,uaro NU1n{:)_R-    ' 18.00%    ,            ,, J ,, (j                (Jl' U/j2                    \i\ fi <J            ,,  ()
            v,""' · •=,.,,/•. .,>/5  '"'' t N,,,  O.SDE3/,., --- ,9-' 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                         Blood




            Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/Volume Expanders  82401015102040 Aranesp {Albumin Free) 8240101510E558 Aranesp {Albumin Free)  Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume
            Expanders  8240104010E545 Mlrcera85100010402135 Adynovate  Darbepoet!n Alfa-Polysorbate 80 Soln lnj 100 MCG/ML Darbepoetin Alfa-Polysorbate 80 Soln lnj 200 MCG/ML  Methoxy Polyethylene Glycol-Epoetin Beta lnj 200 MCG/0.3ML Antlhemophilic Factor
            Recomb Pegylated For lnj 750 Unit  18.00%18.00%  18.00%18.00%  Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/Volume Expanders  84100040002025 Cyklokapron 8240102000E510
            Epogen82401015102080 Aranesp (Albumin Free)  Blood Products/ Modifiers/ Volume Expanders Bone Density Regulators  8240104010E545 Mircera30044530002020 Prolia  TranexamicAdd IVSo!n 1000 MG/10ML (100 MG/ML) Epoetin Alfa lnj 2000
            Unit/MLDarbepoetin Alfa-Polysorbate 80 Soln lnj 500 MCG/ML  Bone Density Regulators Bone Density Regulators  3004405510E140 Natpara3004405510E110 Natpara  Methoxy Polyethylene G[ycol-Epoetin Beta lnj 200 MCG/0.3ML Denosumab lnj 60 MG/ML  Bone
            Density Regulators  30044070002020 Forteo  Parathyroid Hormone (Recombinant) For lnj Cartridge 100 MCG Parathyroid Hormone (Recombinant) For lnj Cartridge 25 MCG  Teriparatide {Recombinant) lnj 600
            MCG/2.4ML  18.00%18.00%18.003⁄4  18.00%18.00%  18.00%18.00%  18.00%  Bone Density Regulators  Bone Density Regulators  30044530002030 Xgeva  Denosumab lnj 120 MG/1.7ML  18.00%  3004405510E120 Natpara  Bone Density Regulators Cardiovascular
            Agents  3004405510E130 Natpara37100020000305 Keveyis  Parathyroid Hormone (Recombinant) For lnj Cartridge 50 MCG  CASTLEMAN DISEASE  99473080002120 Sylvant  Parathyroid Hormone {Recombinant) For tnj Cartridge 75 MCG D!ch!orphenamfde Tab 50
            MG  Siltuximab For IV Infusion 100 MG  18.00%  18.00%18.00%  18.00%  CASTLEMAN DISEASE  18.00%  Central Nervous System Agents  18.00%  Central Nervous System Agents  Central Nervous System Agents  Central Nervous System Agents  central Nervous
            System Agents  Central Nervous System Agents  18.00%  18.00%  18.00%  18.00%  18.00%  Central Nervous System Agents  Central Nervous System Agents  99473080002140 Sylvant Siltuximab For IV Infusion 400 MG6240306045DS60 Rebif Rebldose Titration
            Interferon Beta-la lnj 6 X 8.8 MCG/0.2ML & 6 X 22 MCG/0.SML 6240306045E540 Rebif Interferon Beta-la lnj 44 MCG/0.5ML{24MU/ML) {88 MCG/ML)6240306045D560 Reblf Rebidose litratlon Interferon Beta-la lnj 6X 8.8 MCG/0.2:ML & 6 X 22 MCG/0.5ML
            74400020202140 Xeomin tncobotu!tnumtoxinA For IM lnj 200 Unit6240306045E540 Reblf Interferon Beta-la lnj 44 MCG/0.5ML (24MU/ML) (88 MCG/ML)6240306045D520 Reblf Rebldose Interferon Beta-la lnj 22 MCG/0.5ML {12MU/ML) (44 MCG/ML) 6240306045D520
            Reblf Rebidose Interferon Beta-la lnj 22 MCG/0.5Ml (12MU/Ml) (44MCG/ML)  6240306045DS60 Reblf Rebidose Titration Interferon Beta-la lnj 6 X 8.8 MCG/0.2Ml & 6 X 22 MCG/0.SML  18.00%  18.00%  Central Nervous System Agents  624030604SD520
            Reblf Rebidose  Central Nervous System Agents  6240306045F530 Avonex Pen  Interferon Beta-la lnj 22 MCG/0.5ML(12MU/ML) (44 MCG/ML) Interferon Beta-la IM lnj Klt30 MCG/0.5ML  18.00%18.00%  Central Nervous System Agents  Central Nervous System
            Agents  Central Nervous System Agents  Central Nervous System Agents  Central Nervous System Agents  Central Nervous System Agents  62609902300120 Nuedexta  Dextromethorphan HBr-Quinidine Sulfate Cap 20-10 MG  6240306045FS30 Avonex Pen
            624030604SES40 Rebif  Interferon Beta-la IM lnj Kit 30 MCG/0.SMLInterferon Beta-la lnJ 44 MCG/0.SML {24MU/Ml) (88 MCG/ML)  6240306045DS20 Rebif Rebidose 6240306045F530 Avonex Pen  Interferon Beta-la lnj 22 MCG/0.5Ml {12MU/ML) (44 MCG/ML)
            Interferon Beta-la lM lnj Kit 30 MCG/0.SML  18.00%  18.00%18.00%  18.00%18.00%  CMV Agents  6240306045E540 Rebif  Interferon Beta-la lnj 44 MCG/0.SML {24MU/ML) (88 MCG/ML)  12200010002020 Vistide  Cidofovir IV lnj 75
            MG/ML  18.00%  18.00%  CMVAgents  12200020102020 FoscarnetSodium  FoscarnetSodium lnj 24 MG/ML  18.00%  CMV Agents  CMV Agents  12200066102120 Valcyte  12200066100320 Valcyte  Valganc!clovir HCl For Soln SO MG/ML {Base Equiv} Valganciclovir HCI
            Tab 450 MG (Base Equivalent)  18.00%18.00%  CMV Agents  12200030102110 Cytovene  Gandc!ovlrSodfum For lnJ 500 MG  60.00%  CONGESTIVE HEART FAILURE  CORTICOSTEROIDS  401800S0002120 Natrecor Neslritlde For Jnj 1.5 MG22100020202011 Dexamethasone
            Sod Pho Dexamethasone Sod Phosphate Preservative Free lnj 10
            MG/ML  18.00%18.00%  CORTICOSTEROlDS  CORTICOSTEROlDS  18.00%  18.00%  CORTICOSTEROIDS  CORTICOSTEROIDS  CORTICOSTEROIDS  CORTICOSTEROIDS  CORTICOSTEROIDS  CORTICOSTEROIDS  22100030202115 Solu-MEDROL Methylprednlsolone Sodium Succlnate For lnj
            500 MG 22100020002900 Dexamethasone Dexamethasone Powder22100030202105 Solu-MEDROL Methylprednisolone Sodium Succlnate For lnj 40 MG 22100020001320 Dexamethasone lntensol Dexamethasone Cone 1 MG/Ml22100025402161 Solu-CORTEF Hydrocortisone
            SodiumSuccinate PF For lnj 500 MG 22100050101810 Kenalog Triamcinolone Acetonlde lnj Susp 40 MG/ML22100020202900 Dexamethasone Sodium Dexamethasone Sodium Phosphate Powder 22100030202120 5o!u-MEDROL Methylpredn\solone Sodium Succinate For lnj
            1000 MG  ' • ' Contrat.... •··1  18.00%  18.00%18.00%  18.00%18.00%18.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                         ,  CORTICOSTEROIDS  22100020002005  Dexamethasone  Oexamethasone Soln 0.S
            MG/5ML              CORTICOSTEROIDS  22100025402165  Solu-CORTEF  Hydrocortisone Sodium Sucdnate PF For lnj 1000 MG            18.00%  CORTICOSTEROIDS  22100020102900  Dexamethasone Acetate  Dexamethasone Acetate
            Powder            18.00%  CORTICOSTEROIDS  22100030202110  Solu-MEDROL  Methylprednisolone Sodium Succinate For lnj 125 MG            18.00%  Corticosteroids  22100017001830  Emf!aza  DeflazacortSusp 22.75
            MG/ML            18.00%  CORTICOSTEROIDS  22100020000325  Dexamethasone  Dexamethasone Tab 1 MG            18.00%18.00%  CORTICOSTEROIDS  22100025402150  Solu-CORTEF  Hydrocortisone Sodium Succinate PF For lnj 100
            MG            18.00'.i  CORTICOSTEROIDS  22100030202130  Sofu-MEDROl  Methylprednisolone Sodium Succinate For lnj 2000 MG              Corticosteroids  22100017000340  Emflaza  DeflazacortTab 6
            MG            18.00%18.00%  Corticosteroids  22100017000360  Emflaza  Deflazacort Tab 30 MG              Corticosteroids  22100017000365  Emflaza  DeflazacortTab 36
            MG            18.00%18.00%  CORTICOSTEROIDS  22100020000335  Dexamethasone  Dexamethasone Tab 2MG            18.00%  CORTICOSTEROIDS  22100025402155  So!u-CORTEF  Hydrocortlsone Sodium Sucdnate PF For lnj 250
            MG            18.00%  CORTICOSTEROIDS  22100050101805  Kena!og  Triamcinolone Acetonide lnj Susp 10 MG/ML            18.00%  Corticosteroids  22100017000350  Emflaza  DeflazacortTab 18 MG            18.00%  CVSTIC FIBROSIS
            AGENTS  07000070000120  Tobi Podhaler  Tobramydn lnhal Cap 28 MG            18.00%  CVSTIC FIBROSIS AGENTS  45302030003030  Kalydeco  lvacaftor Packet 75 MG            18.00%  CYSTIC FIBROSIS AGENTS  07000070002530  Bethkis  Tobramycin Nebu
            So1n 300 MG/4Ml            18.00%  CYSTIC FIBROSIS AGENTS  45302030000320  Kalydeco  lvacaftor Tab 150 MG            18.00%  CYSTIC FIBROSlS AGENTS  45304020002010  Pulmozyme  Dornase Alfa lnhal Soln 1 MG/Ml            18.00%  CVSTIC FIBROSlS
            AGENTS  07000070002520  Kitabis Pak  Tobramycin Nebu Soln 300 MG/SML            41.75%  CYSTIC FIBROSIS AGENTS  45302030003020  Ka!ydeco  lvacaftor Packet 50 MG            18.00%  CystlnoslsAgents  56400030106530  Procysbi  Cysteamlne
            Bitartrate Cap Delayed Release 75 MG (Base Equiv)            18.00%  Cystinosis Agents  56400030100140  Cystagon  Cysteamine Bltartrate Cap 150 MG            18.00%  Cystinosls Agents  56400030106520  Procysbi  Cy:steamine Bitartrate Cap
            Delayed Release 25 MG (Base Equiv)            18.00%  Cystinosis Agents  56400030100120  Cystagon  Cysteamine Bitartrate cap SO MG            18.00%  DERMATOLOGICALS  90890020002110  Botox Cosmetic  OnabotuHnumtoxinA {Cosmetic) For lnj 50
            Unit            18.00%  DERMATOLOG!CALS  90890020002120  Botox Cosmetic  OnabotulinumtoxinA {Cosmetic) For lnj 100 Unit            18.00%  DERMATOLOGICALS  90890018002120  Dysport {Glabellar lines)  AbobotulinumtoxinA (Glabel!ar Lines) For lnj
            300 Unit            18.00%  DERMATOLOG!CALS  90550085103400  Kena!og  Triamcinolone Acetonide Aerosol Soln            18.00%  DIAGNOSTIC PRODUCTS  94200037002105  Cortrosyn  Cosyntropln For lnj 0.25 MG            18.00%  DIAGNOSTIC
            PRODUCTS  94200090102120  Thyrogen  Thyrotropin Alfa For lnj 1.1 MG            18.00%  Digestive Enzymes  S1200024006760  Creon  Pancre11pase jllp-Prot-Amyl) DR Cap 24000-76000-120000 Unit            18.00%  Digestive
            Enzymes  51200024006750  Pancreaze  Pancrellpase (Up-Prot-Amyl) DR Cap 16800·40000-70000 Un!t            18.00%  Digestive Enz.ymes  51200024006705  Creon  Pancrel!pase jlip-Prot-Amyl) DR Cap 3000-9500-15000Unit            18.00%  Digestive
            Enzymes  51200024006780  Creon  Pancrelipase {Up-Prot-Amyl) DR Cap 36000-114000--180000 Unit            18.00%  Digestive Enzymes  51200024006754  Pancreaze  Pancrelipase (Up-Prot-Amyl} DR Cap 21000-37000-61000 Unit            18.00%  Digestive
            Enzymes  51200024006710  Pancreaze  Pancrelipase (Up-Prot-Amyl) DR Cap 4200-10000-17500 Unit            18.00%  Digestive Enzymes  51200060002030  Sucra!d  Sacros!dase Soln 8500 Unit/Ml            18.00%  Digestive
            Enzymes  51200024006734  Pancreaze  Pancrelipase {llp-Prot-Amyl) DR Cap 10500-25000-43750 Unit            18.00%  Digestive Enzymes  51200024006740  Creon  Pancre!Jpase (Lip-Prot-Amyl) DR Cap 12000·38000-60000 Unit            18.00%  Digestive
            Enzymes  51200024006720  Creon  Pancre!ipase (Llp--Prot-Amyl) DR Cap 6000-19000-30000 Unit            18.00%  Direct Muscle Relaxants  75200010101920  Ryanodex  Dantrolene Sodium For IV Susp 250 MG            18.00%  ENDOCRINE AND METABOLIC
            AGENTS - MISC.  30080050106440  Lupron Depot-Ped  leupro!ide Acetate For lnj Pediatrfc Kit 15 MG  ...          18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070106420  SandoSTATIN LAR Depot  OctreotideAcetate For IM lnj Kit 20
            MG            18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30180060002120  Somavert  Pegvisomant For lnJ 10 MG (As Protein)  ..r"..,\-\\':>    -"'n...........      18.00%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30454060000330  Samsca  To!vaptan Tab 30 MG  / ,,,,t-. #"-    v,      18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30905070000120  Zemplar  Paricalcltol cap 2 MCG  I' rr' I.    -s,,v.i      18.00%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30906550002020  Atdurazyme  Laronidase Soln For IV Infusion 2.9 MG/SMl  ' : V0ntratn ,., •      v_    18.00%  ...          ·-•O,1 fl , {-·} r .    111 l,              "'    f        \ \(,)' 3⁄4,..-- ' )  v  \ ,.,.,. 1-V  r,  N.  1⁄4. S DE5
            '•  -.,.,.   -;- ·- 

      

    

     

    
      
        


    

    
      
        

      

      
                           ,,,,,,.=  ENDOCRINE AND METABOLIC AGENTS- MISC.  30908565107320  Kuvan  Sapropterin
            Dihydroch!oride Soluble Tab 100 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30908060002950  Buphenyl  Sodium Phenylbutyrate Oral Powder 3 GM/Teaspoonful        24.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30080050106420  lupron
            Depot-Ped  leupro!ideAcetate for lnj Pediatric Kit 7.5 MG        18.003⁄4  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170050102040  Somatuline Depot  Lanreotlde Acetate Extended Release In] 120 MG/0.SML        18.00%  ENDOCRINE AND METABOLIC
            AGENTS- MISC.  30170075401930  Signifor LAR  Pasireotide Pamoate For IM ER Susp 40 MG {Base Equiv)        18.00-%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30904520002920  Cystadane  *Betaine Powder For Oral Solution*"'*        18.00%  ENDOCRINE
            AND METABOLIC AGENTS- MISC.  30905225100340  Sensipar  Cinacalcet HCI Tab 90 MG {Base Equiv)        18.003⁄4  ENDOCRINE AND METABOLIC AGENTS- MISC.  30908230000320  Carbaglu  CarglumfcAcid Tab 200 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30090040102020  GanirelixAcetate  Ganlrellx Acetate lnj 250 MCG/0.SMl        18.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30170050102025  Somatuline Depot  lanreotlde Acetate Extended Release lnj 60 MG/0.2Ml        18.00%  ENDOCRINE
            AND METABOLIC AGENTS- MISC.  30170075202040  Signifor  Pasireotide Diaspartate lnj 0.9 MG/Ml {Base Equiv)        18.00%  ENDOCRINE ANO METABOLIC AGENTS- MISC.  30180060002160  Somavert  Pegvisomant For lnj 30 MG{As
            Protein)        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30904045000120  Orfadin  Nftlsinone Cap 5 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30905225100320  Sensipar  Cinacalcet HCI Tab 30 MG (Base
            Equiv)        18.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30908030000920  Ravicti  Glycerol Phenylbutyrate liquid1,1GM/ML        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC,  30080050156420  lupron Depot-Ped  Leuprolide Acetate {3 Month)
            For lnj Pediatric Kit 11.25 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30150085102120  Egrifta  Tesamorelln Acetate For lnj 1 MG (Base Equiv)        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070106430  SandoSTATIN lAR
            Depot  Octreotide Acetate For IM lnj Kit 30 MG        18.003⁄4  ENDOCRINE AND METABOLIC AGENTS- MISC.  30180060002130  Somavert  Pegvisomant For lnj 15 MG{As Protein}        18.00%  ENDOCRINE AND METABOLIC AGENTS -
            MISC.  30903610102110  Fabrazyme  Agalsidase beta For IV Soln 5 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30905070000140  Zemplar  Parlca!citol Cap 4 MCG        18.00%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30906850002020  Elaprase  ldursulfase Sain for IV Infusion 6 MG/3ML (2 MG/Ml)        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30080045106450  Supprel!n LA  Histrelin Acetate {CPP) Implant Kit 50 MG        18.00%  ENDOCRINE AND
            METABOLIC AGENTS- MISC.  30170050102030  Somatuline Depot  Lanreotide Acetate Extended Release lnj 90 MG/0.3Ml        18.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30170075401920  Signifor LAR  Pasireotide Pamoate For IM ER Susp 20 MG (Base
            Equiv)        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30904045000130  Orfadin  Nitisinone Cap 10 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30905225100330  Sensipar  Cinacalcet HCITab 60 MG (Base
            Equiv)        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30908060000320  Buphenyl  Sodium Phenylbutyrate Tab SOO MG        18.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30080050106430  Lupron Depot-Ped  leuprolideAcetate For lnj Pediatric
            Kit 11.25 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070106410  SandoSTATIN LAR Depot  Octreotide Acetate For IM lnj Kit 10 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170075401940  Signifor LAR  Pasireotide
            Pamoate For IM ER Susp 60 MG {Base Equiv)        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30454060000320  Samsca  To!vaptan Tab 15 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30905070000110  Zemp!ar  Parlcalcitol Cap 1
            MCG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30906050002120  Myalept  Metreleptln For Subcutaneous fnj 11.3 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30908S65103020  Kuvan  Sapropterln DlhydrochtoridePowder Packet
            100 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30170070102030  Octreotlde Acetate  Octreotide Acetate lnj 1000 MCG/ML (1 MG/ML)        52.25%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30080050156440  Lupron
            Depot-Ped  leuprolideAcetate (3 Month) For lnj Pediatric Kit30 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30150085102130  Egrifta  Tesamorelfn Acetate For lnj 2MG {Base Equiv)        18.00%  ENDOCRINE AND METABOUCAGENTS-
            MISC.  30170075202020  Signifor  Pasireotide Diaspartate lnj 0.3 MG/Ml(Base Equiv)        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30180060002140  Somavert  Pegvisomant For In] 20 MG (As Protein)        18.00%  ENDOCRINE AND METABOLIC
            AGENTS- MISC,  30903610102120  Fabrazyme  Agals!dase beta For IVSo!n 35 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30905070002010  Zemplar  Paricalcitol IV So!n 2 MCG/Ml        18.00%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30907030052020  Vimizim  Elosulfase Alfa Soln For IV lnfuslon S MG/SML (1 MG/Ml)        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070102005  Octreotide Acetate  Octreotide Acetate lnj 50 MCG/ML (0.05 MG/Ml)  ,.. ·.isTR--"
            .      52.25%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30907715002120  Lumizyme  Alglucosidase Alfa For IV Soln 50 MG        18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070102015  Octreotide Acetate  Octreotide Acetate lnj 200 MCG/ML
            (0.2 MG/ML)  ,<",,._J·:'-" -....Ir-."\\_      52.25%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070102020  Octreotide Acetate  Octreotide Acetate lnj 500 MCG/ML(0.5 MG/ML)  1,.,,/f - ,,.,,      52.25%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30080055102020  Synarel  Nafarelfn Acetate Nasal Soln 2 MG/ML  ./ 'I I ('"\      18.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30160045002020  lncrelex  Mecasermin lnj 40 MG/4ML (10 MG/ML)    ., ..,JfV(JmA/'A    ' 18.00%            9 .
            (i '    '          (J\ ·\ Ii 51;        -./  .d  \Q(,,'-rii!JY  -  ,:,, '°'• -~· V  •.  -,  3⁄4I"'·•  'Os OS sf',  •,  - .. 

      

    

     

    
      
        


    

    
      
        

      

      
                     •-"--  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170075202030  Signffor  Pasireotlde
            Diaspartate lnj 0.6 MG/Ml {Base Equiv)                18.00%    ENDOCRINE AND METABOLIC AGENTS- MISC.  30180060002150  Somavert  Pegvisomant For lnj 25 MG {As Protein)                18.00%    ENDOCRINE AND METABOLIC AGENTS -
            MISC.  30904045000110  Orfadin  Nitisinone Cap 2 MG                18.00%    ENDOCRINE AND METABOLIC AGENTS - MISC.  30905070002020  Zemplar  Paricalcltol IV Soln 5 MCG/Ml                18.00%    ENDOCRINE AND METABOLIC AGENTS -
            MISC.  30907535002020  Naglazyme  Galsulfase Solo For IV Infusion 1 MG/Ml                18.00%    ENDOCRINE AND METABOLIC AGENTS - MISC.  30170070102010  Octreotide Acetate  Octreotide Acetate In] 100 MCG/Ml
            (0.1MG/Ml)                52.25%    ENZVME REPLACEMENT  20000050002025  Adagen  Pegademase Bovine lnj 250 Unit/Ml                18.00"/4    Enzyme Replacements/Modifiers  30903875203020  Xur!den  Urid!ne Triacetate Oral Granules Packet 2
            GM                18.00%    Enzyme Replacements/Modifiers  30905610002040  Strensiq  Asfotase Alfa Subcutaneous lnj 40 MG/Ml                18.00%    Enzyme Replacements/Modifiers  30906360002020  Kanuma  Sebelipase Alfa IV Soln 20 MG/10Ml {2
            MG/ML)                18.00%    Enzyme Replacements/Modifiers  30905610002050  Strens!q  AsfotaseA!fa Subcutaneous lnj 80 MG/0.8ML                18.00%    Enzyme Replacements/Modifiers  30905610002020  Strensiq  AsfotaseAffa Subcutaneous lnj
            18 MG/0.45Ml                1800%    Enzyme Replacements/Modifiers  30905610002030  Strensiq  Asfotase Alfa Subcutaneous lnj 28 MG/0.7Ml                18.00%    Enzymes  99350035002120  Xiaflex  Collagenase C!ostridium Histo!yticum For lnj 0.9
            MG                18.00%    Enzymes  99350040102020  Hylenex  Hya!uronidase Human lnj 150 Unit/Ml                18.00%    Fertility Regulators  30062030052020  Gonal-f RFF Pen  Follitrop!n Alfa lnj 300
            Unlt/0.5Ml                18.00%    fertility Regulators  30062030102030  Fo!llstimAQ  Follitropin Beta lnj 600 Unit/0.72Ml                22.80%    fertility Regulators  30062030102006  Folllstlm AQ  Fol!itropin Beta lnj 150
            Unit/0.SML                22.80%    Fertllity Regulators  30062030052150  Gonal-f  Follltropln Alfa For lnj 1050 Unit                18.00%    Fertility Regulators  30062090102112  Bravelle  Urofollitropin Purified For lnj 75
            Unit                18.00%    Fertility Regulators  30062030052040  Gonal·f RFF Pen  Fo!litropln Alfa lnJ 900 Un!t/1.5Ml                18.00%    Fertility Regulators  30062030102040  Fol!istfmAQ  Follitropin Beta lnj 900
            Unit/1.0SML                22.801⁄4    Fertility Regulators  30062030102003  FollistlmAQ  Follitrop!n Beta lnj 75 Unlt/0.SML                22.80%    Fertility Regulators  30062030102020  Fo!listimAQ  FolHtropln Beta lnj 300
            Unit/0.36Ml                22.80%    Fertility Regulators  30062030052115  Gonal-f RFF  Fol!Jtropin Alfa For lnj 75 Unit                18.00%    Fertility Regulators  30062050002155  Repronex  Menotropins For lnj 75
            Unit                18,00%    Fertility Regulators  30062030052140  Gonal-f  Fo!litropln Alfa For lnj 450 Unit                18.00%    Fert!lity Regulators  30062050002175  Menopur  Menotropins For Subcutaneous lnJ 75
            Unit                18.00%    GASTROINTESTINAL AGENTS - MISC.  52300020112900  Metodopram!de HCI Mo  Metoclopramlde HCl Monohydrate Powder                18.00%    GASTROINTESTINAL AGENTS- MISC.  52700025000140  Cholbam  Cholic Acid Cap 250
            MG                18.00%    GASTROINTESTINAL AGENTS- MISC.  52300020102900  Metoc!opramide HCI  Metodopramide HCI Powder                18.00%    GASTROINTESTINAL AGENTS- MISC.  52700025000120  Cholbam  Ch olic Acid Cap SO
            MG                18.00%    Genitourinary Agents  99200030000110  cuprimine  Penicillamine Cap 250 MG                18.00%    GENITOURINARY AGENTS - MISCELLANEOUS  56500010002010  Rlmso-50  Dimethyl Sulfoxlde Soln
            50%                18.00%    GOUT AGENTS  68000050002020  Krystexxa  Pegloticase lnj 8 MG/Ml (For IV Infusion)                18.00%    Growth Hormones  30100020002066  Norditropin FlexPro  Somatropin lnj 30
            MG/3Ml                18.00%    Growth Hormones  30100020002140  Nutropin  Somatropln For lnj 10 MG                18.00%    Growth Hormones  30100020002178  Genotropin MiniQuick  Somatropin For [nj 1.4 MG                18.(){)%    Growth
            Hormones  30100020102130  Salzen  Somatropin (Non-Refrigerated) For lnj 8.8 MG                18.00    Growth Hormones  30100020002050  Norditrop!n  Somatropln tnJ 5 MG/1.5Ml                18.00%    Growth
            Hormones  30100020002062  Nordltropin  Somatropln lnj 15 MG/1.5Ml                18.00%    Growth Hormones  30100020002132  Humatrope  Somatropin For lnj 12 MG {36 Unit)                18.00%    Growth Hormones  30100020002174  Genotropln
            MiniQuick  Somatropin For lnj 1 MG                18.00%    Growth Hormones  30100020102121  serostim  Somatropin {Non-Refrigerated} For Subcutaneous lnj 5 MG                18.00    Growth Hormones  30100020002125  Humatfope  Somatrop!n For
            lnJ 6 MG {18 Unit)            .    18.00%    Growth Hormones  30100020002170  Genotropin M!niQuick  Somatropin For lnj 0.6 MG      jlj)..o    I  ,.._  ..................  18.00%    Growth Hormones  30100020102118  Serostim  Somatropin
            {Non-Refrigerated) For Subcutaneous lnj 4 MG      ,?'...P' --s --·1...." -"          18.00%    Growth Hormones  30100020002118  Norditropin  SOMATROPJN FOR lNJ 4 MG (12 UNIT)      ()' /;-'.          18.00    Growth
            Hormones  30100020002150  Humatrope  Somatropin For lnj 24 MG  .  I  ·t•'-          '  18.00  ,P=·-          t    -f,, 9i"-"O(Q3Nume1ro j rn..,_ f.1 ·'                      1,11 -                (;\ .""  ,,Q  - (,"' • - ,,_?-'
            ,>'  --.,  .  O& DE sf>·  "  ";,-  -  -- 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                               Growth




            Hormones  30100020002180 Genotropln M1n1Qulck  Somatropln For tnj 1.6 MG  Growth Hormones  30100020002015 Nutrop!n AQNuSpln 5  Somatropln lnj 5 MG/2Ml  Growth Hormones  30100020002127 Norditropln  SOMATROPIN FOR INJ 8 MG  Growth
            Hormones  30100020002172 Genotropin MiniQuick  Growth Hormones  30100020102120 Saizen  Somatropin for lnj 0.8 MG  Somatropin (Non-Refrigerated) for lnj 5 MG  Growth Hormones  30100020102132 Serostlm  Somatropin (Non-Refrigerated) For
            Subcutaneous lnj 8.8 MG  Growth Hormones  Growth Hormones  30100020002064 Nutropin AQNuSpin 20  30100020002134 Genotropin  Somatropin lnj 20 MG/2Ml  Somatropin For lnj 12 MG {13.8 MG overfill)  Growth Hormones  30100020002176 Genotropln
            Mln!Qulck  Growth Hormones  Growth Hormones  Growth Hormones  Growth Hormones  Growth Hormones  Growth Hormones  Grovlf:h Hormones  Growth Hormones  Growth Hormones  Gro\'lf:h Hormones  H-2 Antagonists  H-2 Antagonists  HEMATOLOGICALAGENTS-
            MISC.  HEMATOLOGICAL AGENTS - MISC.  HEMATOLOGICAL AGENTS- MISC.  Hematopoletic Growth Factors  Hematopoietic Growth Factors  Hematopo!eticGrovlthFactors  Hematopoietic Growth Factors  Hematopoietlc Grovlth Factors  Hematopoletic Growth
            Factors  Hematopoietic Growth factors  Hematopoietic Grovtth Factors  Hematopoletic Growth Factors  30100020102125 Serostim30100020002121 Genotropin30100020002120 Humatrope30100020002166 Genotropin MiniQuick30100020002182 Genotropin
            MiniQuick30100020002056 Norditropin FlexPro30100020002020 Nutropin AQ30100020002123 Omnltrope30100020002168 Genotropin MiniQuick30100020002184 Genotropin MJnlQuick49200030112020 Famotidfne Premixed49200010002900 Cimetidine  85550060102120
            Ceprotln85550060102140 Ceprotin85800050002020 Soliris82403060002120 Neumega82402050002025 leukine82405060002130 Nplate82405030100310 Promacta82401520002012 Neupogen82402050002120 leukine  8240152070E530 Granlx82405030100320
            Promacta82401060102050 Dmontys  Somatrop!n For lnj 1.2 MG  Somalropin {Non-Refrigerated) For Subcutaneous lnj 6 MG Somatropin For Subcutaneous lnj 5 MGSomatropin For lnj 5 MG Somatropin For lnj 0.2 MG Somatropin For Jnj 1.8 MG Somatropin lnj 10
            MG/1.SMLSomatropin lnj 10 MG/2Ml Somatropin For lnj 5.8 MG Somatropin For Jnj 0.4 MG Somatrop!n for lnJ 2 MGfamotfdine In NaCl 0.9% IV Soln 20 MG/SOMl Cimetidine PowderProtein C Concentrate (Human) For IVSoln 500 Unit Protein C Concentrate
            (Human) For IV Soln 1000 Unit Eculizumab IV Soln 10 MG/Ml {For Infusion) Oprelvekin for lnj 5 MGSargramostim lnj 500 MCG/Ml Romlp/ostim For lnj 500 MCGEltrombopag Olamine Tab 12.5 MG (Base Equfv)Fi1grastim lnj 480 MCG/1.6Ml (300 MCG/Ml)
            Sargramostim lyophi!ized for lnJ 250 MCGTbo-Fflgrastim Soln Prefllled Syringe 300 MCG/0.5Ml EltrombopagOlamine Tab 25 MG {Base Equiv) Peginesatlde Acetate Soln lnj 10 MG/Ml  Hematopoletic Growth Factors  82405030100340 Promacta  Hematopoletic
            Growth Factors  82401060102055 Omontys  Eltrombopag Olamine Tab 75 MG (Base Equiv)  Peginesatide Acetate So1n lnj 20 MG/2Ml  Hematopoletic Gro\•lth Factors  Hematopolet!cGrowth factors  82405060002120 Nplate  82401020002015 Epogen  Romipfostim
            For lnj 250 MCG  Epoetln Alfa lnj 3000 Unit/Ml  Hematopoletic Growth Factors  Hematopoietic Growth Factors  Hematopoietic Growth Factors  HEREDITARY ANGIOEOEMA  HEREDITARY ANGIOEDEMA  HEREDITARY ANGIOEDEMA  HEREDITARY ANGIOEDEMA  HEREDITARY
            ANGtOEOEMA  Hormonal Agents, Suppressant (Pituitary)  HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS  82401020002050 Epogen8240152070E540 Granix82405030100330 Promacta85820040102020 f!razyr85840030002020 Kalbltor85802022006420 Berlnert85802022102130
            Ruconest85802022002120 Cinryze  Hormonal Agents, Stimu!ant/Replacement/Modifylni 30062022052220 Dvidrel  21404010101840 Depo•Provera60250070000130 Hetlioz  Epoetfn Alfa lnj 20000 Unit/MlTbo-Fi!grastlm Sotn Prefilled Syringe 480 MCG/0.8Ml
            Eltrombopag Olamine Tab SO MG {Base Equiv) lcatibant Acetate lnj 30 MG/3Ml (Base Equivalent) Ecallantlde lnj 10 MG/MlCl Esterase Inhibitor (Human) for IV lnj Kit 500 UnitCl Esterase Inhibitor (Recombfnant) For IV lnj 2100 Unit Cl Esterase
            Inhibitor (Human) For IV lnj 500 Unit Choriogonadotropln Alfa 1nj 250 MCG/0.SMl  Hormonal Agents, Stimulant/Rep!acement/Modifyini 30062020002140 Chorionfc Gonadotropin Chorlonic Gonadotropin For lnj 10000 Un!t  Medroxyprogesterone Acetate IM
            Susp 400 MG/Ml Taslmelteon capsule 20 MG  
            ------  18.00%  18.00%  18.00%  18.00%  18.001⁄4  18.00%  18.00%  18.00%  18.00%  18.00"18.00%18.00%18.00%18.00%18.00%18.00%  18.00%18.00%  18.00%18.00%  18.00%18.003⁄418.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%  18.00%  18.00%  18.00%  18.00%  \  .




            \  18.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%18.00%  t 

      

    

     

    
      
        


    

    
      
        

      

      
                         IMMUNOGLOBULINS  19100020102046  Octagam  Immune Globulin (Human) IV Sain 25
            GM/500ML        24.25%      IMMUNOGLOBULINS  19100020102125  CARIMUNE  Immune Globulin {Human) IV For Soln 6 GM        25.00"70      IMMUNOGLOBULINS  19100020302080  Gammagard  Immune Globulin {Human) IV or Subcutaneous Soln 30
            GM/300ML        27.55%      IMMUNOGLOBULINS  19100020102020  Flebogamma  Immune Globulin (Human) IV Soln 0,5 GM/10Ml        18.003⁄4      IMMUNOGLOBUUNS  19100020102113  Gammagard S/D  Immune Globulin (Human) IVFor So!n 0,5
            GM        27.55%      IMMUNOGlOBUUNS  19100020202058  Hizentra 20%  Immune Globulin {Human) Subcutaneous In] 4 GM/20Ml        24.50%      IMMUNOGLOBULINS  191000SOOOES40  RhoGAM Ultra-Filtered Pl  Rho O Immune Globulin IM Sotn Pref Syr 1500
            Unlt(300MCG)        18.00%      IMMUNOGLOBULINS  19990002356450  Hyqvia  lmmun Glob lnj 30 GM/300ML-Hyaluron lnj 2400 Unt/15 ML Kit        20.00%      IMMUNOGLOBULINS  19100020102060  Gamunex  Immune Globulin (Human) IVSoln 1
            GM/10Ml        24.25%      IMMUNOGLOBULINS  19100020102130  Gammagard 5/D  Immune Globulin (Human) IV For So!n 10 GM        27.55%      IMMUNOGLOBULINS  19100020302084  Gamunex-C  Immune Globulfn (Human) IV or Subcutaneous So!n 40
            GM/400ML        23.003⁄4      IMMUNOGLOBULINS  19100020102090  Privigen  Immune Globu!fn (Human) IV Soln 40 GM/400ML        19.00%      IMMUNOGLOBUUNS  19100020202050  Hizentra 20%  Immune Globulin (Human) Subcutaneous lnj 1
            GM/SML        24.50%      IMMUNOGLOBULINS  19100050002060  WinRhoSDF  Rho D Immune G!obufln (Human) lnj 1S00 Unlt/1.3ML        18.00%      IMMUNOGLOBUUNS  19990002356430  Hyqvia  lmmun G!ob lnJ 10GM/100ML-Hyaluron tnj 800 Unt/5
            MLKit        20.00%      IMMUNOGLOBULINS  1910000S002200  Cytogam  Cytomegalovirus Immune Globulin (Human} IV lnj        18.00%      IMMUNOGLOBULINS  19100020102112  GAMMAR-P 1.V.  IMMUNE GLOBULIN (HUMAN) IV FOR SOLN 1
            GM        31.25%      IMMUNOGLOBUUNS  191000202020S4  Hizentra 20%  Immune Globulin {Human) Subcutaneous lnj 2 GM/lOML        24.50%      IMMUNOGLOBULINS  1910005000206S  WinRhoSDF  Rho D Immune Globulin {Human) In] 15000
            Unit/13Ml        18.00%      IMMUNOGLOBULINS  19990002356440  Hyqvia  lmmun Glob lnj 20 GM/200ML-Hyaluron lnj 1600 Unt/10 Ml Kit        20.()()%      IMMUNOGLOBULINS  19100020102120  Gammagard S/0  Immune Globulin (Human) IV For Sofn 5
            GM        27.55%      IMMUNOGLOBULINS  19100020102034  Flebogamma  Immune Globulin (Human) IV Soln 2.S GM/SOML        25.00%      IMMUNOGLOBUUNS  19100020102068  Biv!gam  Immune Globulin {Human) IVSo!n5
            GM/SOML        24.25%      IMMUNOGLOBULINS  19100020302068  Gammagard  Immune Globulin (Human} IV or Subcutaneous Soln 5 GM/SOML        27.55%      IMMUNOGLOBUUNS  19100020102064  Gamunex  Immune Globulin (Human) IVSoln 2.5
            GM/25ML        24.25%      IMMUNOGLOBUUNS  19100020202020  Vivaglobin  Immune Globulin (Human) Subcutaneous lnj 160 MG/Ml (16%)        23.75%      IMMUNOGLOBULINS  19100050002055  WinRho SDF  Rho D Immune Globulin (Human) lnj 5000
            Unit/4.4Ml        18.00%      IMMUNOGLOBULINS  19990002356425  Hyqv!a  lmmun Glob lnj S GM/SOMl-Hya!uron lnj 400 Unt/2.5 ML Kit        20.00%      IMMUNOGLOBULINS  19100020102030  Octagam  Immune Globulin (Human) IV Soln 1
            GM/20Ml        24.25%      IMMUNOGLOBULINS  19100020102117  Qirimune NF  Immune Globulin (Human) IV ForSoln 3 GM        25.00%      IMMUNOGLOBULINS  19100020202065  Hizentra  Immune Globulin (Human) Subcutaneous lnj 10
            GM/SOML        24.50%      IMMUNOGLOBULINS  1910005000E550  Rhophylac  Rho D Immune Globulin Sol Pref Syr 1500 Unt/2Ml {300MCG/2Ml)        18.25%      IMMUNOGLOBULINS  19100020102063  Octagam  Immune Globulin (Human) IV Soln 2
            GM/20ML        24.25%      IMMUNOGLOBULINS  19100020102135  Carimune NF  Immune Globulin {Human) IV For Sotn 12 GM        25.00%      IMMUNOGLOBUUNS  191000S0002050  W!nRhoSDF  Rho D Immune Globulin (Human} lnj 2500
            Unit/2.2ML        18.00%      lMMUNOGLOBULINS  19990002356420  Hyqvia  lmmun Glob lnj 2.5 GM/25ML-Hyaluron lnj 200 Unt/1,25 Ml Kit        20.00%      IMMUNOGLOBULINS  19100020002200  GamaSTAN S/D  Immune Globulin (Human)
            lnj        23.75%      IMMUNOGLOBULINS  19100020102044  Flebogamma DIF  Immune Globulin {Human) IVSoln 20 GM/400ML        25.00%      IMMUNOGLOBULINS  19100020302064  Gammagard  Immune Globul!n {Human) IV or Subcutaneous Soln 2.5
            GM/25ML        27.55%      IMMUNOGLOBULINS  19100020102115  Gammagard S/D  Immune Globulin {Human) lV For Soln 2.5 GM        27.55%      IMMUNOGLOBULINS  19100020102205  GAMIMUNEN  IMMUNE GLOBULIN (HUMAN) IV SOlN
            5%        47.75%      IMMUNOGLOBUUNS  1910CH)20302060  Gammagard  Immune G!obulfn (Human} IV or Subcutaneous So!n 1 GM/10ML        27.55%      IMMUNOGLOBUUNS  19100020102034  F!ebogamma  Immune Globulin (Human) IV Soln 2.5
            GM/SOML        25.00%      IMMUNOGLOBUUNS  19100020102072  BivJgam  Immune Globulin (Human) IV Soln 10 GM/100Ml        24.25%      IMMUNOGLOBULINS  19100020302072  Gammagard  Immune Globulin (Human) IV or Subcutaneous Soln 10
            GM/lOOML      ··-.  27.55%      IMMUNOGLOBULINS  19100020102038  Flebogamma  Immune Globulin {Human) IVSoln S GM/lOOML  _ .,.-r·, , 51    1 V i_n,
            _  25.00%      IMMUNOGLOBULINSIMMUNOGLOBULINS  1910002010207219100020302072  BivigamGammagard  Immune Globulin (Human) IV So!n 10 GM/100MLImmune Globulin (Human) IV or Subcutaneous Soln 10 GM/lOOML  ,I ,.l•f ·z7
            /-'    .'()'<'.1    \  24.25%27.55%  IMMUNOGLOBULINS  19100020102068  Bivigam  Immune Globulin (Human) IV Sain 5 GM/SOML    •uu,,ro"t      I)  24.25%  ··-          I.I                              (Jl ._91·. •.t ,2
            ,j·j  -----  \\c\,,...  /..,().  C'y  .  ('l,)> - \'.-  '  \s DE£-,• 

      

    

     

    
      
        


    

    
      
        

      

      
                             fl\;  IMMUNOGlOBUUNS  19100020302068  Gammagard Immune Globu!Jn {Human) IV or
            Subcutaneous Soln 5 GM/SOMl        27.55%  IMMUNOGLOBULINS  19100020102042  Flebogamma 1lmrnune Globulin (Human) IV So!n 10 GM/200ML        25.00%    19100020102076  Ffebogarnrna Dlf Immune Globulln {Human) IV Soln 20
            GM/200ML        24.25%  IMMUNOGLOBULINSIMMUNOGLOBULINS  19100020302076  Garnmagard  Immune Globulin (Human) IV or Subcutaneous Soln 20 GM/200Ml      27.55%  IMMUNOGLOBULINS  19100020102042  Flebogamrna  Immune Globulin {Human} !VSoln 10
            GM/200ML      25.003⁄4  IMMUNOGLOBULINS  19100020302064  Gammagard  Immune Globulin (Human) lVor Subcutaneous Sain 2.5 GM/25Ml      27.55%  IMMUNOGLOBULINS  19100020102038  Flebogamma  Immune Globulin (Human) IVSoln s
            GM/100Ml      25.003⁄4  lMMUNOGLOBULINS  19100020102076  Flebogamma DJF  Immune Globulin (Human) IV Sain 20 GM/200ML      24.25%  IMMUNOGlOBULINS  19100020302076  Gammagard  Immune Globulin {Human) IV or Subcutaneous Sain 20
            GM/200ML      27.55%  lmmunological Agents  9025055400e520  Taltz  lxeklwmab Subcutaneous Soln Prefilled Syringe 80 MG/Ml      18.00%  lmrnuno!ogkal Agents  4460405S002120  Nucala  Mepollzumab For lnj 100 MG      18.00%  Immunological
            Agents  19200040002100  Antivenin Micrurus Fulvi1  Antivenin Micrurus Fulvius For IV Soln      18.00%  Immunological Agents  99450060203030  Ve!tassa  Patiromer Sorbltex Calcium For Susp Packet 16.8 GM (Base Eq)      18.00%  Immunological
            Agents  52SOS040202120  lnflectra  lnflixlmab--dyybFor IV lnj 100 MG      18.00%  Immunological Agents  994S0060203040  Veltassa  Patiromer Sorbitex Calcium For Susp Packet 25.2 GM (Base Eq)      18.00%  lmmunologlcal
            Agents  66290030002120  Enbrel  Etanercept For Subcutaneous lnj 25 MG      18.00%  lmmuno!oglcal Agents  99450060203020  Veltassa  Pat!romerSorbitex Calcium For Susp Packet8.4 GM {Base Eq)      18.00%  lmmunosuppressive
            Agents  99402020000110  SandlMMUNE  Cyc!osporine Cap 25 MG      18.00%  lmmunosuppressive Agents  99402540102220  Atgam  Lymphocyte Immune Globulin Anti-Thymocyte G lnj 50 MG/Ml(Eq)      18.00%  lmmunosuppressive
            Agents  9940403S000325  Zortress  Everollmus Tab 0.5 MG      18.00%  lmmunosuppressive Agents  99404080000120  Prograf  Tacro!imus Cap 5 MG      18.00%  11mmunosuppr essive Agents  99402020300150  Neoral  Cydosporine Modified Cap 100
            MG      18.003⁄4  lmmunosuppressive Agents  99403030300630  Myfortic  Mycophenolate Sodium Tab DR 360 MG (MycophenolicAdd Equiv)      18.00%  lmmunosuppress!ve Agents  99404080000105  Prograf  Tacro!imus Cap 0.5 MG      18.00%  lmmunosuppressive
            Agents  99402020000140  SandlMMUNE  Cyc!osporine Cap 100 MG      18.00%  lmmunosuppressive Agents  99403030100120  Cel!Cept  Mycophenolate Mofetil Cap 250 MG      18.00%  lmmunosuppressive Agents  9940403S000330  Zortress  Everolimus Tab 0.75
            MG      18.00%  lmmunosuppresslve Agents  99404080002010  Prograf  Tacro!imus lnj 5 MG/Ml      18.00%  lmmunosuppressive Agents  99402020302020  Neoral  Cyc!osporine Modified Oral Sain 100 MG/Ml      18.00%  lmmunosuppressive
            Agents  99404035000320  Zortress  Everollmus Tab 0.25 MG      18.00%  lmmunosuppressive Agents  99404080000110  Prograf  Tacrolimus Cap 1 MG      18.00%  lmmunosuppressive Agents  99402020002005  SandlMMUNE  Cyclosporine IV Soln 50
            MG/ML      18.00%  lmmunosuppressive Agents  99403030100330  Cel!Cept  Mycopheno1ate Mofetil Tab 500 MG      18.00%  lmmunosuppressive Agents  99404070000310  Rapamune  Sirolimus Tab 0.5 MG      18.00%  lmmunosuppressive
            Agents  99405015002110  5imulect  Basiliximab For IV So!n 10 MG      18.00%  lmmunosuppressive Agents  99402020300120  Neoral  Cydosporine Modified Cap 25 MG      18.00%  lmmunosuppressive Agents  99403030202120  Cel!Cept
            Intravenous  Mycophenolate Mofetil HCI For IV Solo 500 MG {Base Equiv}      18.00%  lmmunosuppressive Agents  99404070000330  Rapamune  Sirolimus Tab 2 MG      18.00%  lmmunosuppresslve Agents  99406010000305  lmuran  Azathioprlne Tab SO
            MG      18.00%  lmmunosuppressive Agents  99402020300130  CydoSPORINE Modified  Cyc!osporine Modified cap SO MG      18.00%  Immunosuppressive Agents  99403030300620  Myfort!c  Mycophenolate Sodium Tab DR 180 MG
            (MycophenolicAcidEquiv)      18.00%  lmrnunosuppressive Agents  99404070002020  Raparnune  srro11mus Oral So!n 1 MG/ML      18.00%  lmmunosuppressive Agents  99408020002120  Nu!ojlx  Belatacept For IV Infusion 250
            MG      18.00%  Immunosuppresslve Agents  99402020002010  SandlMMUNE  Cyclosporine Oral Sain 100 MG/Ml      18.00%  Immunosuppressive Agents  99403030101920  CellCept  Mycophenolate Mofetil For Oral Susp 200 MG/Ml.,Cl p,.
            _-,..      18.00%  lmmunosuppressive Agents  99404070000320  Rapamune  Sirolimus Tab 1 MG ._(:,;• . ,,. •· "'      18.00%  lmmunosuppressive AgentsInflammatory Bowel Agents  994050150021205250308000212  Sfmu!ect0 Entyvio  Baslliximab For IV
            Sofn 20 MGVedolizumab For 1V Solution 300 MG I)'# "'  .,    18.00%18.00%  Interleukin ! Blockers  6645006000212  0 Arca[yst  R!lonacept For lnj 220 MG . ([.fl '  l    18.00%  i [=-m.• . -- ; U\l\\ --------:(} ,r!/_'2Q,              r, ['()
            I"·  (;  .,)      (,/.A_'),as-n- '.::-eJ•\/.....,.,,.. ·••------0•-,..,.-... 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                                         Anakinra




            Subcutaneous Soln Prefilled Syringe 100 MG/0.67ML Deferoxamine Mesylate For lnj 500 MG  18.00%18.00%  Deferiprone Tab 500 MGDeferasirox Tab For Oral Susp 250 MG  18.00%18.00%  Deferoxamine Mesylate For lnj 2 GM  DeferasiroxTab For Oral Susp 500
            MG  18.00%  18.00%  Deferasirox Tab 90 MG  18.00%  DeferasiroxTab 360 MG  18.00%  Deferasirox Tab For Oral Susp 125 MG  18.()0%  Deferas!rox Tab 180 MG  18.00%  Sod Ferric Gluc Cmplx in Sucrose IVSoln 12.5 MG/ML {Fe Eq)  18.00%  Iron Sucrose
            lnj 20 MG/ML {Fe Equiv)  18.00%  Leuprolide Acetate For lnj Klt3.7S MG  18.003⁄4  lnterJeukin-1 Receptor Antagonist {lL-1Ra) RHEUMAT 6626001000ES20 Kineret IRON OVERLOAD-ANTIDOTES 93000020102110 Desfera1IRON OVERLOAD-ANTIDOTES 93100028000320
            FerriproxIRON OVERLOAD-ANTIDOTES 93100025007330 &:jadeIRON OVERLOAD-ANTIDOTES 93000020102130 DesferalIRON OVERLOAD-ANTIDOTES 93100025007340 ExjadeIRON OVERLOAD-ANTIDOTES 93100025000320 JadenuIRON OVERLOAD-ANTIDOTES 93100025000340 JadenuIRON
            OVERLOAD-ANTIDOTES 93100025007320 &:jadeIRON OVERLOAD-ANTIDOTES 93100025000330 JadenuIRON REPlACEMENTS 82300085102020 FerrlecltIRON REPLACEMENTS 82300048002020 VenoferLHRH Analogs 21405010106405 Lupron DepotLHRH Analogs 21405010156420
            lupron Depot  Leupro!fde Acetate (3 Month) For lnj Kit 11.25 MG  18.00%  Local Anesthetics - Topical 90850025306420 Qutenza Capsaidn Patch 8% & Cleansing Gel Kit  18.00%  MEDICAL DEVICES  MOUTH/THROAT/DENTAL AGENTS  Movement Disorder Drug
            Therapy  Movement Disorder Drug Therapy  88501000002000 Caphosol62380070000310 Xenazine  62380070000320 Xenazine  97051050106300 Omnitrope Pen 10 lnj De *Injection Device- Mi sc0 *  *Artificial Saliva - Solution•*• Tetrabenazfne Tab 12.5
            MG  Tetrabenazine Tab 25 MG  18.00%  18.00%18.00%  18.00%  MULTIPLE SCLEROSIS  30300010004010 Acthar HP  Corticotropin lnj Gel 80 Unit/Ml  18.00%  MULTIPLE SCLEROSIS AGENTS  6240003010ES20 Copaxone  Glatlramer Acetate Sotn Prefi!led Syringe 20
            MG/Ml  18,00%  MULTIPLE SCLEROSIS AGENTS  MULTIPLE SCLEROSIS AGENTS  6240307530D2SO Plegridy Starter Pack 62405525006520 Tecfidera  Peginterferon Beta-la So!n Pen-lnj 63 & 94 MCG/0.SML Pack Dlmethyf Fumarate Capsule Delayed Release 120
            MG  18.00%18.00%  MULTIPLE SCLEROSIS AGENTS  62403060506420 Betaseron  Interferon Beta-lb For lnJ Kit0.3 MG  Nata!izumab for IV lnj Cone 300 MG/15Ml  18.00%  MULTIPLE SCLEROSIS AGENTS  62405050001320 Tysabri  18.00%  MULTIPLE SCLEROSIS
            AGENTS  MULTIPLE SCLEROSIS AGENTS  6240003010E540 Copaxone 6240307530ES20 Plegridy  Glatiramer Acetate So!n Prefilled Syringe 40 MG/Ml Peginterferon Beta-la Soln Prefilled Syringe 125 MCG/0.SML  18.00%18,00%  MULTIPLE SCLEROSIS
            AGENTS  62405525006540 Tecfidera  MULTIPLE SCLEROSIS AGENTS  6240307530D220 Plegridy  Dlmethy[ Fumarate Capsule Delayed Release 240 MG  Peginterferon Beta-la Soln Pen-injector 125 MCG/0.5ML  18.00%  18.00%  MULTIPLE SCLEROSIS
            AGENTS  62405525006320 Tecfidera  Dimethyl Fumarate Capsule DR Starter Pack 120 MG & 240 MG  18.00%  MULTIPLE SCLEROSIS AGENTS  62403060456420 Avonex  MULTIPLE SCLEROSIS AGENTS  6240307530E550 PlegridyStarter Pack  Interferon Beta-la For IM
            lnj Kit 30MCG {33MCG{6.6 MU}/Vial)  Peginterferon Beta-la Soln Pref Syr 63 & 94 MCG/0.SML Pack  18.00%  18.00%  MULTIPLE SCLEROSIS AGENTS  MULTIPLE SCLEROSIS AGENTS  62406030007420 Ampyra62404070000330 Aubagio  Dalfamprldine Tab SR 12HR 10
            MG Teriflunomide Tab 14 MG  18.00%23.75%  MULTIPLE SCLEROSIS AGENTS  62403060S02120 Betaseron  MULTIPLE SCLEROSIS AGENTS  62405010002020 Lemtrada  Interferon Beta-lb For Jnj 0.3 MG  Atemtuzumab JV lnj 12 MG/1.2ML (10 MG/ML)  MULTIPLE SCLEROSIS
            AGENTS  62404070000320 Aubagio  Teriflunom!de Tab 7 MG  18.00%18.00%  23.75%  MULTIPLE SCLEROSIS AGENTS  MUSCULOSKELETALTHERAPY AGENTS  6240702S100120 Gilenya7S840015002300 Carticel  Fingol!mod HCI Cap 0.5 MG (Base Equiv)*Autofogous Cultured
            Chondrocytes for lmplantatfon°  18.00%18.00%  Neurogen!c Orthostatic Hypotension (NOH) Agents 38700030000150 Northera Neurogenlc Orthostatic Hypotens!on (NOH)-Agents 38700030000130 Northera  Droxidopa Cap 300 MG Droxidopa Cap 100
            MG  18.00%18.00%  Neurogenic Orthostatic Hypotension {NOH)-Agents 38700030000140 Northera NEUROMUSCULAR AGENTS 74400020052140 Botox  Drox!dopa Cap 200 MG OnabotullnumtoxinA For lnj 200 Unit  18.00%18.00%  AbobotulinumtoxinA For lnj 500
            Unit  18.00%  NEUROMUSCULAR AGENTS 74400020032120 DysportNEUROMUSCULAR AGENTS 74503070000320 Rilutek  Ri!uzole Tab 50 MG  R!mabotulinumtoxinB lnj 2500 Unlt/0.SML  NEUROMUSCULAR AGENTS 74400020102018 Myob!ocNEUROMUSCUlARAGENTS 74400020052120
            Botox  Onabotu!lnumtoxinA For tnj 100 Unit RlmabotulinumtoxinB Jnj 5000 Unit/Ml  NEUROMUSCULAR AGENTS 74400020102020 MyoblocNEUROMUSCULAR AGENTS 74400020202120 Xeomin  lncobotulinumtoxinA For lnj 50 Unit  18.00%18.00%18.00%18.00%18.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                               NEUROMUSCULAR




            AGENTS  74400020032115 Dysport  AbobotullnurntoxinA For lnj 300 Unit  18.00%  NEUROMUSCULAR AGENTS  74400020202130 Xeornin  lncobotu!inurntoxinAFor lnj 100 Unit  18.00%  NEUROMUSCULAR AGENTS  74400020102022 Myobloc  RirnabotuHnurntoxinB lnj
            10000 Unit/2ML  18.00"Ai  OBSOLETO  90250515002120 AMEVIVE  ALEFACEPT FOR IV INJ 7.5 MG  18.00%  OPHTHALMIC AGENTS  86300010002320 Ozurdex  Dexarnethasone lntravitreal lrnplant0.7 MG  18.00%  OPHTHALMIC AGENTS  86700065002120
            Visudyne  OPHTHALMIC AGENTS  86300017102320 Retisert  Verteporfin For IV Soln 15 MG (2 MG/ML)  Fluocinolone Acetonide lntravitreal lmp!ant0.59 MG  18.00-Yo  18.00%  OPHTHALMIC AGENTS  86801060002020 Jetrea  OPHTHALMIC AGENTS  86655010002020
            Ey!ea  Ocriplasmin lntravitreal lnj 0.5 MG/0.2ML (2.S MG/Ml)  Afllbercept lntravitreal lnj 2 MG/0.05ML {40 MG/ML)  18.00%  18.00%  OPHTHALMIC AGENTS  86655060002012 Lucentis  OPHTHALMIC AGENTS  86655060002020 Lucentls  Ranlblzumab lntravitreal
            lnj 0.3 MG/0.05ML (6 MG/ML) Ranibizumab lntravitreal lnJ 0.5 MG/0.05ML (10 MG/ML)  OPHTHALMIC AGENTS  86655050302020 Macugen  Ophthalmic Agents  86300080101820 Triesence  Pegaptanlb Sodfum lntravitreous 1nj 0.3 MG/90 Microllter Triamcinolone
            AcetonideOphth tnj 40 MG/ML  OSTEOARTHRITIS OF THE !{NEE  OSTEOARTHRITIS OF THE KNEE  7580004000E530 Synvisc  7580004000E560 Synvlsc One  Hylan Intra-articular Solution Prefilled Syringe 16 MG/2ML Hylan Intra-articular Solution Prefi1!ed
            Syringe 48 MG/6ML  OSTEOARTHRITIS OF THE KNEE  7580006000E520 OrthoVisc  OSTEOARTHRITIS OF THE KNEE  7580007010ES20 Euf!exxa  Hya!uronan Intra-articular So!n Prefilled Syringe 30 MG/2ML Sodium Hya!uronate Intra-articular So!n PrefSyr 20
            MG/2ML  OSTEOARTHRITIS OF THE KNEE  OSTEOARTHRITIS OF THE KNEE  7580007010E525 Supartz  75800070102024 Hyalgan  Sodium Hyaluronate Intra-articular Soln Pref5yr 25 MG/2.SML Sodium Hyaluronate lntra articular lnj 20
            MG/2ML  18.00%18.00%  18.00%18.00%  18.00%18.00%  18.00%18.00%  18.00%18.00%  OSTEOPOROSIS- BISPHOSPHONATES  30042090002120 Zoledronic Acid  ZotedronicAcid For IV Soln 4 MG  35.00%  OSTEOPOROSIS- BISPHOSPHONATES  30042090001320 Zoledronlc
            Acid  Zoledronic Add lnj Cone For N Infusion 4 MG/SML  34.20%  OSTEOPOROSIS- BlSPHOSPHONATES  30042060102012 Pamidronate Dlsodium  Pamidronate Dlsodlum IV Soln 9 MG/ML  18.00%  OSTEOPOROSIS- B!SPHOSPHONATES  30042060102006 Pamidronate
            Disodium  Pamidronate Disocffum IV Soln 3 MG/ML  18.00%  OSTEOPOROSIS- BISPHOSPHONATES  30042060102009 Pamldronate Disodium  OSTEOPOROSIS- B\SPHOSPHONATES  30042090002016 Zoledronlc Acid  Pamldronate Disodium IV Soln 6 MG/ML  Zoledronfc Acid IV
            So!n 4 MG/100ML  18.00%35.00%  OSTEOPOROSIS- BISPHOSPHONATES  30042060102120 Aredia  OSTEOPOROSIS- BISPHOSPHONATES  30042090002020 Reclast  Pamidronate Disodium For lnj 30 MG ZoledronlcAcld IVSoln 5 MG/100ML  18.00%35.00%  OSTEOPOROSIS·
            BISPHOSPHONATES  OSTEOPOROSIS- BISPHOSPHONATES  30042060102140 Ared[a  30042048102030 Bonlva  Pamidronate Dlsodium For lnj 90 MG lbandronateSodlum 1V Soln 3 MG/3ML (Base Equivalent)  18.00%18.00%  Progesterone Receptor Antagonists ANTIDIABETICS
            Progestin Contraceptives - IUD  273040S0000330 Korfym  25200050005320 Mirena  Mifepristone Tab 300 MGLevonorgestrel Releasing IUD 20 MCG/24HR {52 MG Total)  Progestin Contraceptives- IUD  PROGESTlNS  25300005002320 lmplanon26000010101710
            Makena  PSORIASIS  9025058500E520 Ste!ara  Etonogestrel Subdermal Implant 68 MG Hydroxyprogesterone Caproate IM In Oil 250 MG/ML Usteklnumab Soln Prefilled Syringe 45 MG/0.SML  18.00%18.00%  18.00%18.00%18.00%  PSORIASIS  66700015000330
            Otezla  ApremilastTab 30 MG  PSORIASIS  PSORIASIS  9025058500E540 Stelara  90250515002130 AMEVlVE  Ustekinumab Sain Prefi1!ed Syringe 90 MG/ML Alefacept For IM lnj 15 MG  18.00%  18.00%18.00%  PSORIASIS  9025057500ES20
            Cosentyx  PSORIASIS  90250585002020 Stelara  Secukinumab Subcutaneous Soln Prefilled Syringe 150 MG/ML USTEKlNUMAB lNJ 45 MG/0.5Ml  18.00%18.00%  PSORIASIS  PSORIASIS  6670001500B720 Otezla ApremilastTab Starterlllerapy Pack 10 MG & 20 MG
            & 30 MG 9025057500D520 CosentyxSensoready Pen Secukinumab Subcutaneous Solo Auto-injector 150 MG/ML  PULMONARY ARTERIAL HYPERTENSION  PULMONARY ARTERIAL HYPERTENSION  401340S0000340 Adempas4016001S000330 Tracleer  PULMONARY ARTERIAL
            HYPERTENSION  40170080050415 Orenitram  Riociguat Tab 2 MG Bosentan Tab 125 MGTreprostlnil Dio!amine Tab CR 0.25 MG {Base Equiv)  18.00%  18.00%18.00%18.00%18.00%  PULMONARY ARTERIAL HYPERTENSION  40134050000320 Adempas  RioclguatTab 1
            MG  PULMONARY ARTERIAL HYPERTENSION PULMONARY ARTERIAL HYPERTENSION  PULMONARY ARTERIAL HYPERTENSION  40160007000320 Letairis40170080002020 Tyvaso40134050000350 Adempas  PULMONARY ARTERIAL HYPERTENSION  40160050000320 Opsumit  Ambrisentan Tab
            10 MGTreprostinil lnhalatlon Solution 0.6 MG/ML RloclguatTab 2.5 MG  Macitentan Tab 10 MG  ·•STl'vi --"-  '·"h'' ,,.., - .- •r ,.,.,  18.00%18.00%18.00%18.00%18.00%  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                     PULMONARY




            ARTERIAL HYPERTENSION  PULMONARY ARTERIAL HYPERTENSION  40134050000310 Adempas  40160007000310 Letairis  Rioc!guat Tab 0.5 MG Ambrisentan Tab 5 MG  18.00%18.00%  PULMONARY ARTERIAL HYPERTENSION  40170080102040 Remodulin  PULMONARY ARTERIAL
            HYPERTENSION  40170080050420 Orenitram  Treprostin1\Sodlum lnj 10 MG/ML (Base Equiv)  Treprostinil Dio!arnine Tab CR 1 MG {Base Equiv)  18.00%  18.00%  PULMONARY ARTERIAL HYPERTENSION  PULMONARY ARTERIAL HYPERTENSION  40134050000330
            Adempas  40160015000320 Trac!eer  RlociguatTab 1.5 MG Bosentan Tab 62.5 MG  18.00%18.003⁄4  PULMONARY ARTERIAL HYPERTENSION  40143060101920 Revatio  PULMONARY ARTERIAL HYPERTENSION  401700800S041D orenitram  Sildenafil Citrate For Suspension 10
            MG/ML  Treprostinil Diolam!ne Tab CR 0.125 MG (Base Equiv)  18.00%18.00%  PULMONARY ARTERIAL HYPERTENSION  40170040102110 Epoprostenol Sodium  PULMONARY ARTERIAL HYPERTENSION  40170080050425 orenitrarn  PULMONARY ARTERIAL
            HYPERTENSION  40143060100320 Revat!o  Epoprostenol Sodium For lnj 0.5 MG  Treprostini1 D!olarnine Tab CR 2.5 MG {Base Equiv)  Sildenafll Citrate Tab 20 MG  18.00%18.00%  40.00%  PULMONARY ARTERIAL HYPERTENSION  40143080000320 Adclrca  Tadalafll
            Tab 20 MG {PAH)  lloprost Inhalation Solution 10MCG/ML  18.00%  PULMONARY ARTERIAL HYPERTENSION  40170060002020 Ventavis  18.00%  PULMONARY ARTERIAL HYPERTENSION  40170080102020 Remodulin  PULMONARY ARTERIAL HYPERTENSION  40170060002040
            ventavis  Treprostinil Sodium lnJ 2.5 MG/ML (Base Equiv)  lloprost Inhalation Solution 20 MCG/ML  18.00%  18.00%  PULMONARY ARTERIAL HYPERTENSION  40170080102030 Remodulin  PULMONARY ARTERIAL HYPERTENSION  40143060102020 Revatio  Treprostinll
            Sodium lnj 5 MG/ML (Base Equiv)  Sildenafil Citrate IV Sofn 10 MG/12.5ML (Base Equivalent)  18.00%  18.00%  PULMONARY ARTERIAL HYPERTENSION  40170040102130 Epoprostenol Sodium  PULMONARY ARTERIAL HYPERTENSION  40170080102010
            Remodulin  Pulmonary Fibrosis Agents Pulmonary Fibrosis Agents  45550060000120 Esbriet45554050200130 Ofev  Epoprostenol Sodium For lnJ 1.5 MG  Treprostinil Sodium lnj 1 MG/ML(Base Equ'rv)  Pulmonary Fibrosis Agents  45554050200120
            Ofev  Pirfenidone cap 267 MGNintedanib Esy!ate Cap 150 MG (Base Equivalent)  Nintedanib Esy!ate Cap 100 MG {Base Equivalent)  18.00%18.00%  18.00%18.00%  18.00%  RESPIRATORY AGENTS- MISC.  45100010102110 Aralast NP  RESPIRATORY AGENTS-
            MISC.  45000070001820 surfaxin  Alphal-Protelnase Inhibitor (Human) For IV Soln 500 MG  Lucinactant lntratracheal Susp 30 MG/ML  18.00%  18.00%  RESPIRATORY AGENTS - MISC.  45100010102108 Aralast  RESPIRATORY AGENTS - MISC.  45100010102118
            Aralast  Alphal-Proteinase Inhibitor (Human) For IV Sain 400 MG Alphal-Proteinase Inhibitor (Human) For IV Soln 800 MG  18.00%18.00%  RESPIRATORY AGENTS - MISC.  45100010102020 Glassia  RESPIRATORY AGENTS - MISC.  45100010102120 Aralast
            NP  ResplratorySyncytia[ Virus (RSV) Agents Respiratory Syncytial Virus (RSV) Agents  19502060002015 Synagis19502060002020 Synagis  Alphal-Protelnase Inhibitor (Human) Jnj 1000 MG/SOML Alpha1-Prote!nase Inhibitor (Human) For IV Sain 1000
            MG  Palivhumab lM Soln 50 MG/0.SML Palivizumab IM Soln 100 MG/ML  18.00%18.00%  18.00"7618.00%  RespiratorySyncytial Virus {RSV) Agents  12604075002120 VJrazoJe  Ribavirin For lnhat Soln 6 GM  18.00%  Respiratory Tract Agents Resplratory Tract
            Agents  40120070000310 Uptravi  40120070000340 Uptravi  SelexlpagTab 200 MCGSe!exipagTab 1400 MCG  18.00%18.00%  Respiratory Tract Agents Respiratory Tract Agents  40120070000315 Uptrav/40120070000320 Uptravi  Setexipag Tab 400 MCG SelexipagTab
            600 MCG  SelexipagTab Therapy Pack 200 MCG {140) & 800 MCG {60)  18.00%18,00%  ResplratoryTract Agents  4012007000B720 Uptravi  18.00%  Respiratory Tract Agents  40120070000345 Uptravi  Selexipag Tab 1600 MCG  18.00%  Respiratory Tract
            Agents  40120070000330 Uptravi  Se/exipag Tab 1000 MCG  18.00%  Respiratory Tract Agents Respiratory Tract Agents  40120070000335 Uptravi40120070000325 Uptravi  SelexipagTab 1200 MCG  Selexipag Tab 800 MCG  18.00%18.00%  RHEUMATOID ARTHRITIS
            MISC  6650007000ES20 Actemra  Tocilizumab Subcutaneous Soln Pref!lled Syringe 162 MG/0.9ML  18.00%  RHEUMATOID ARTHRITIS MISC  66S00070002035 Actemra  RHEUMATOID ARTHRJTJS MISC  66400010002120 Orencia  Tocilfzumab IV lnj 200 MG/lOML  Abatacept
            For IVSoln 250 MG  18.00%  18.00%  RHEUMATOID ARTHRITJS MISC  66603065100320 Xeljanz  RHEUMATOID ARTHRITlS MISC  66S00070002040 Actemra  Tofacitinib Citrate Tab 5 MG (Base Equivalent) Tocl!izumab IV lnj 400 MG/20ML  18.00%18.00%  RHEUMATOID
            ARTHRITIS MISC  6640001000E520 Orencia  AbataceptSubcutaneous Soln Prefilled Syringe 125 MG/Ml  RHEUMATOID ARTHRITIS MISC  66280050000320 Arava  Leflunomlde Tab 20 MG  RHEUMATOID ARTHRITIS MISC  66460020002120 llaris  Canaklnumab For lnj 180
            MG  RHEUMATOID ARTHRITIS MISC  66500070002030 Actemra  Toc!l!zumab IV lnj 80 MG/4Ml  - ..  18.00%  18.00%18.00%18.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                 RHEUMATO!D ARTHRITIS MISC  66280050000310  Arava  leflunomide Tab 10 MG  18.00%  Short Bowel
            Syndrome (SBS) Agents  52533070006420  Gattex  Teduglutide {rDNA) For lnj Kit 5 MG  18.00%  Stem Cell Mobilizers  82502060002020  Mozobi1  P!erixaforSubcutaneous lnj 24 MG/1.2Ml {20 MG/ML)  18.00%  Systemic Lupus Erythematosus
            Agents  99422015002120  Benlysta  Belimumab For 1V Soln 120 MG  18.00%  Systemic lupus Erythematosus Agents  99422015002140  Benlysta  Be!imumab For IV Soln 400 MG  18.00%  Therapeutic
            Nutrients/Minerals/Electrolytes  93100028002020  Ferriprox  Deferiprone Oral So!n 100 MG/ML  18.00%  TUBERCULOSIS  09000015100320  Sirturo  Bedaquiline Fu ma rate Tab 100 MG (Base Equiv)  18.00%  Tumor Necrosis Factor Alpha
            Blockers  52505020106460  Cimzia Starter Kit  Certollzumab Pegol lnj Kit 6 X 200 MG/ML  18.00%  Tumor Necrosis Factor Alpha Blockers  6627004000D540  Simponi  Golimumab Subcutaneous Solo Auto-.-injector 100 MG/ML  18.00%  Tumor Necrosis Factor
            Alpha Blockers  6629003000E530  Enbrel  Etanercept Subcutaneous Solo Prefi!led Syringe SO MG/ML  18,00%  Tumor Necrosis Factor Alpha Blockers  52505020106420  Cimzla  Certolizumab Pegol For lnj Kit 2 X 200 MG  18.00%  Tumor Necrosis Factor
            Alpha Blockers  66270040002015  S!mponl Aria  Go!imumab IV Soln SO MG/4ML  18.00%  Tumor Necrosis Factor Alpha Blockers  6629003000D530  Enbrel SureClick  EtanerceptSubcutaneousSolution Auto ln]ector 50 MG/ML  18,00%  Tumor Necrosis Factor
            Alpha Blockers  52505040002120  Remicade  lnfliximab Fot IV lnj100 MG  18,00%  Tumor Necrosis Factor Alpha Blockers  6627004000E520  Simponi  Golimumab Subcutaneous Sotn Prefil!ed Syringe SO MG/0,5ML  18.00%  Tumor Necrosis Factor Alpha
            Blockers  52505020106440  Cimzia  Certolizumab Pegol lnJ Kit 2 X 200 MG/Ml  18.00%  Tumor Necrosis Factor Alpha Blockers  6627004000D520  Simponi  Golimumab Subcutaneous So!n Auto-injector SO MG/0,SML  18,001⁄4  Tumor Necrosis Factor Alpha
            Blockers  6629003000E525  Enbrel  EtanerceptSubcutaneousSoln Prefilled Syringe 25 MG/0.SML  18.00%  Tumor Necrosis Factor Alpha Blockers  6627001500F420  Humira Pen  Adalimumab Pen-injector Kit40 MG/0.8ML  18.00%  Tumor Necrosis Factor Alpha
            Blockers  6627004000£540  S!mponi  Golimumab Subcutaneous Soln Prefllled Syringe 100 MG/Ml  18.00%  Tumor Necrosis Factor Alpha Blockers  6627001500F810  Humira  Adalimumab Prefilled Syringe Kit 20 MG/0.4Ml  18.00%  Tumor Necros!s Factor Alpha
            Blockers  6627001500F820  Humira  Adalimumab Prefi!led Syringe Kit 40 MG/0.8Ml  18.00%  Tumor Necrosis Factor Alpha Blockers  66290030006420  Enbrel  Etanercept For Subcutaneous lnj Kit 25 MG  18.00%  Tumor Necrosis Factor Alpha
            Blockers  6627001500F805  Humira  Adalimumab Prefllled Syringe Kit 10 MG/0,2Ml  18.00%  Viscosupp!ements  7580006000e515  Hymovis  Hyaluronan Intra-articular Soln Prefllled Syringe 24
            MG/3Ml  18.00%  {blank)  96544244002900  Gabapentin  Gabapentin Powder  18.00%  {blaok)  30201010102030  DDAVP  Desmopressin Acetate In] 4 MCG/ML  18.00%  {blank)  30089902506420  Lupaneta Pack  leuprolide (1 Mon) lnj 3.75 MG &
            Norethlndrone Tab 5 MG Kit  18.00%  (blank)  21700030000105  Hydroxyurea  Hydroxyurea Cap 500 MG  18.00%  {blank)  85153060101310  Aggrastat  Tirofiban HC! IV Cone 3.75 MG/15ML (250 MCG/ML) {Base Equiv)  18.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                               Anexo




            1: Lista de Desc.uentos para Medkamentos de Alto Costo que sean despachados por las Farmacias Extemas de Hospitales y CDT (2017)  Category  Agents for Gaucher Disease  Agents for Gaucher Disease  GP! Drug Name 82700020002020 Ceredase  GP!
            Name  A!glucerase IV Solo 80 Unit/ML  Actual Discount  16.00"/4  82700085102120 Vpriv  Agents for Gaucher Disease  82700040600120 Cerdelga  Velaglucer.ise Alfa For lnj 400 Unit  EliglustatTartrate Cap 84 MG (Base
            Equivalent)  16.00%  16.00%  Agents for Gaucher Disease  82700050002110 Cerezyme  lmiglucerase For lnJ 200 Unit  16.00%  11aents for Gaucher Disease  Agents for Gaucher Disease  82700070000120 zavesca  Mfglustat Cap 100 MG  82700080102120
            Efelyso  Tafiglucerase Alfa For Jnj 200 Unit  16.00%  16.00%  Agents for Gaucher Disease  ANALGESICS -ANTI-INFLAMMATORY  82700050002120 Cerezyme lmiglucerase For lnj 400 Unit  66200030002015 Gold Sodium Thiomalate Gold Sodium Thiomalate lnJ 50
            MG/ML  16.00%16.00%  ANALGESICS - NonNarcotic  ANALGESICS- NonNarcotic  64154090102020 Prialt  64154090102030 Prialt  Ziconotide Acetate lntrathecal lnj 100 MCG/Ml Ziconotide Acetate lntrathecal Jnj 500 MCG/5Ml  16.75%16.75%  ANALGESICS-
            NonNarcotic  ANDROGENS-ANABOLIC  ANTIARRHYTHMICS  641S4090102010 Prialt  Ziconotide Acetate lntrathecal lnj 500 MCG/20Ml {25 MCG/Ml)  23100030802030 Aveed  35400025000110 Tikosyn  Testosterone Undecanoate IM lnj in Oil 750 MG/3Ml {250MG/ML)
            Dofet!llde Cap 125 MCG {0.125 MG)  16.75%  16.00".i15.50"  ANTIARRHYTHMICS  ANTIARRH'l'THM!CS  35400025000120 Tikosyn35400025000130 Tikosyn  Dofetilide Cap 250 MCG {0.25 MG) Dofetilide Cap SOO MCG (0.5 MG)  15.50%15.50%  ANTIASTHMATlCAND
            BRONCHODILATORAGENTS  ANTIB!OTICS-AMINOGLYCOSIDES  ANTIBIOTICS-AMINOGLYCOSIDES  44603060002120 Xola!r07000070102030 Tobramycin Sulfate  Omalizumab For lnj 150 MG TOBRAMYCIN SULFATE INJ 40 MG/Ml  07000070102020 Tobramycin Sulfate  Tobramycin
            Sulfate lnj 10 MG/ML  16.25%41.75%  41.75%  ANTIBIOTICS- AMINOGLYCOSIDES  ANTIBIOTICS- AMlNOGLYCOSIDES  07000070102034 Tobramydn Sulfate07000070102105 Tobramycin Sulfate  Tobramycin Sulfate lnj 80 MG/2Ml {40 MG/Ml) Tobramycin Sulfate For lnj
            1.2 GM  41.75%41.75%  ANTIB!OTICS-AMINOGLYCOSIDES  ANTIBIOTICS- AMINOGLYCOSIDES  07000070102039 Tobramydn Sulfate07000070102022 Tobramycln Sulfate  Tobramycin Sulfate lnJ 2 GM/SOMl {40 MG/Ml) Tobramydn Sulfate IV Sotn 10
            MG/Ml  41.75%41.75%  ANT!BIOTICS-AMINOGLYCOSIDES  Anti-Catap!ectic Agents ANTICOAGULANTS  ANTICOAGULANTS  07000070102038 Tobramyc!n Sulfate62450060202020 Xyrem8310101010f020 Fragmin 83101020102013 Lovenox  Tobramycin Sulfate lnj 1.2 GM/30ML {40
            MG/ML) Sodium Oxybate Oral Solution 500 MG/Ml Dalteparin Sodium lnj 2500 Unit/0.2Ml Enoxaparin Sodium lnJ 40 MG/0.4Ml  41.75%16.00%16.00%16.00%  ANTICOAGULANTS  ANTICOAGULANTS  ANTICOAGULANTS  83103030102035 Arixtra83101010102065
            Fragmin  Fondaparinux Sodium Subcutaneous lnj 5 MG/0.4ML Dalteparin Sodium lnj 25000 Unit/Ml  83101020102050 Lovenox  Enoxaparin Sodium lnj 300 MG/3Ml  16.00%16.00%  16.00%  ANTICOAGULANTS  83370060000340 Xarelto  Rivaroxaban Tab 20
            MG  16.00%  ANTICOAGULANTS  83101010102040 Fragmin  Dalteparin Sodium lnj 5000 Unit/0.2Ml  16.00%  ANTICOAGULANTS  83101020102014 lovenox  ANTICOAGULANTS  83103030102040 Arixtra  ANTICOAGULANTS  83101010102015 Fragmin  Enoxaparin Sodium lnj 60
            MG/0.6Ml FondaparinuxSodium Subcutaneous lnj 7.5 MG/0.6Ml  Dalteparin Sodium lnj 10000 Unit/ML  16.00%16.00%  16.00%  ANTICOAGULANTS  83101020102012 Lovenox  ANTICOAGULANTS  83103030102.020 Arixtra  Enoxaparin Sodium lnj 30 MG/0,3MlFondaparinux
            Sodium Subcutaneous. lnj 2.5 MG/0.5Ml  16.00%16.00%  ANTICOAGULANTS  83101010102045 Fragmin  ANTICOAGULANTS  83101020102015 Lovenox  ANTICOAGULANTS  83103030102045 Arixtra  Dalteparin Sodium lnj 7500 Unit/0.3Ml Enoxaparin Sodium lnj 80
            MG/0.8Ml  FondaparinuxSodium Subcutaneous lnj 10 MG/0.8ML  16.00%16.00%  16.00%  ANTICOAGULANTS  ANTICOAGULANTS  83101010102056 Fragmin83101020102018 Lovenox  Dalteparin Sodium lnJ15000 Un!t/0.6Ml Enoxaparin Sodium lnj 120
            MG/0.8Ml  16.00%16.00%  ANTICOAGULANTS  83370060000320 Xarelto  Rivaroxaban Tab 10 MG  -·-...  16.00%  ANTICOAGULANTS  83101010102060 Fragmin  Dalteparin Sodium lnj 18000 Unit/0.72Ml  ·.,::-...\\•:>
            '  "{().°""--  ANTICOAGULANTS  8310102.0102020 Lovenox  ANTICOAGULANTS  83370060000330 Xarelto  •:)' '.,,,p--,-.•·- ---, \.-' "<:I.  Enoxaparin Sodium lnj 150 MG/ML Rivaroxaban Tab 15 MG  '-/ .('"  's.'\ v  16.00%16.00%16.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                                       .  3⁄4  ANTICOAGULANTS ANTICOAGULANTS ANTICOAGULANTS ANTICONVULSANTS
            ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTICONVULSANTS ANTIEMETICS ANTIEMETICS ANTIEMETICS ANTIEMETICS ANTIEMETICS ANTIEMETICS
            ANTIEMETICSAntiemeticsANTIEMETICS ANTIEMETICSAntiemeticsANTIEMETICS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGAlS ANTIFUNGALS ANTIFUNGALS
            ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALS ANTIFUNGALSAntlhemophilic ProductsAntihemoph!lic Products Antihemoph!llc Products  q t::r Ir····  85100010002139 Hemofi!M  83101010102053 Fragmin83101020102016
            lovenox83334050102120 Refludan72600043002020 Keppra72600043000340 Keppra72600043002060 Keppra72600043000350 Keppra72170085000320 Sabril72600043007520 Keppra XR72600043000320 Keppra72600043000330 Keppra72170085003020 Sabril72600043007530 Keppra
            XR50250025200330 Anzemet50280035102130 Emend50280020000130 Emend50250025202020 Anzemet50250025200320 Anzemet50280020006320 Emend50250070102010 Aloxi50250065052030 Zofran50280020000110 Emend50280020000120 Emend50250065052024 Ondansetron
            HCl50250070102020 Aloxi11000010101920 Amphotec11407060001820 Noxafil11500025102130 Cancldas11000010002105 Amphotericin B 11407015022020 Diflucan in Dextrose 11500010002130 Eraxis11000010301820 Abeket11407080000320 Vfend11500050102120
            Mycamine  Dafteparin Sodium lnj 12500 Unit/0.SML Enoxaparln Sodium lnJ 100 MG/ML Leplrudin For IV Sain 50 MG levetiracetam Oral Solo 100 MG/Ml levetiracetam Tab 750 MGlevetiracetam lnj 500 MG/SML {100 MG/ML) Levetiracetam Tab 1000 MGVigabatrin
            Tab 500 MG levetiracetam Tab SR 24HR 500 MG levetiracetam Tab 2S0 MG levetiracetam Tab 500 MG Vigabatr!n Powd Pack 500 MG levet!racetam Tab SR 24HR 750 MG Dolasetron Mesylate Tab 100 MGFosaprepitant Dlmeglum!ne For IV Infusion 150 MG {Base Eq)
            Aprepitant Capsule 125 MGDolasetron Mesylate IV lnj 20 MG/Ml Dolasetron Mesy!ate Tab 50 MGAprepitant Capsule Therapy Pack 80 & 125 MG Pa!onosetron HCI IV Soln0.075 MG/1.SML {Base Equiv) Ondansetron HCI lnj 40 MG/20Ml {2 MG/ML) Aprepitant
            Capsule 40 MGAprepitant Capsule 80 MGOndansetron HCI lnj 4 MG/2ML(2 MG/ML) Palonosetron Hd IV Sofn 0.25 MG/SML (Base Equivalent)Amphotericin B Cholesteryl Sulfate Complex For lnj 100 MG Posaconazole Susp 40 MG/MlCaspofungin Acetate For IV So!n
            70 MGAmphoteridn B For lnj 50 MGFluconazole in Dextrose lnj 400 MG/200ML Anldulafungln For JV So1n 100 MGAmphoterlcln B Lipid lnj Susp (For IV Infusion) 5 MG/MLVoriconazole Tab 50 MGMicafungin Sodium For IVSoln 50 MG  11407015012020 Diflucan In
            Sodium Ch!ori F!uconazole In NaCl 0.9% lnj 400 MG/200Ml  11407080002120 Vfend IV11407015022010 Diflucan in Dextrose 11500010002120 Eraxis  Vorkonazole For lnj 200 MGFluconazole In Dextrose lnj 200 MG/100ML Anidulafungin For IV Sain 50
            MG  11407015012010 Diflucan in Sodium Chlori F[uconazo!e in NaCl 0.9% lnj 200 MG/lOOML  11407080001920 Vfend11000010101910 Amphotec11407035002020 Sporanox11500025102120 Cancidas11000010401920 AmBisome11407080000340 Vfend11500050102130
            Mycamine  Vorkonazole ForSusp40 MG/MlAmphoterlcln B Cho!esteryl Sulfate Complex For lnj 50 MG ltraconazole Oral Soln 10 MG/MlCaspofungin Acetate For IV So!n 50 MGAmphoteridn 8 Uposome IV For Susp 50 MG Voriconazole Tab 200 MGMlcafung!n Sodium
            For IV Sain 100 MG  Antihemophil!c Factor (Human) For lnj 801 1700 Unit  85100010006460 Monodate-P  85100010202145 Recombinate  Antihemophilic Factor {Human) For lnj Kit lOOO•Unit--,  ,,t.  Antihemophl!ic Factor (Recombinant)
Fnr.lhfti.11:::l!U'V't!l'nu_"-  16.00%16.00%16.00%16.00%16.00%16.00%16.00%15.75%16.00%16.00%16.00%15.75%16.00%16.00%16.00%16.00%16.00%16.00%16.00%26.75%15.50%16.00%16.00%15.50%26.75%16.00%16.00%16.00%16.00%15.25%16.00%16.00%16.00%16.00%15.25%16.00%15.25%16.00%15.25%16.00%16.00%16.00%16.00%16.00%16.00%16.00%  42.00%  30.00%40.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                             AntihemophiHc  Products  85100010252150  Advate  Antihemophilic Factor rAHF-PFM For
            lnj 1500 Unit              37.75%  Antihemophil!c Products    85100028202150  BeneFIX  Coagulation Factor IX (Recombinant) For lnj 2000 Unit              21.00%  Antihemophllic Products    85100010266470  Xyntha So!ofuse  Antihemophilic Factor
            Recombinant PAF For lnj Kit 3000 Unit              38.00%  Antihemophilic Products    85100010502130  Obizur  Antlhemophllic Factor(Recomb Pore) rpFVIII For lnj 500 Unit              20.00%  Antihemophi!ic
            Products    85100015102139  Wilate  AntihemophHic Factor/VWF (Human) For lnj 1000--1000 Unit              40.00%  Antihemophi!ic Products    85100020002100  Feiba NF  *Antiinhibitor Coagulant Complex For
            Jnj*t              40.00%  Antlhemophllic Products    85100028002160  Mononine  Coagulation Factor IX For lnJ 250 Unit              40.00%  Antihemophllic Products    85100030002115  Profilnine SO  FactorlX Complex For lnj 1500
            Unit              19.75%  Antihemophllic Products    85100010002125  HemofilM  Antihemophllic Factor (Human) For lnj 401-800 Unit              42.00%  Antihemophilic Products    85100010006410  Monodate-P  Antihemophi!ic Factor (Human) For lnj
            Kit 250 Unit              30.00";{;  Antihemophilic Products    85100010202135  Recombinate  Antihemophi!ic Factor {Recombinant) For lnj 801-1240 Unit              40.00%  Antihemophilic Products    85100010252130  Advate  AntihemophiHc Factor
            rAHF-PFM For lnj 500 Unit              37.75%  Antihemophi!iC Products    85100010266440  Xyntha  Antihemophilic Factor Recombinant PAF For lnj Kit 1000 Unit              38.00%  Antihemophi!rc
            Products    85100010002140  Hemofi\M  Antihemophilic Factor (Human) For lnj 1000 Unit              42.00%  Antihemophilic Products    85100010006475  Monoc!ate•P  Antihemophilic Factor {Human) For lnj Kit 1500
            Unit              30.00%  Antihemophilic Products    85100010302155  Eloctate  Antihemophilic Factor {Recomb} rFVIIIFc For lnj 2000 Unit              20.00%  Antihemophilic Products    85100028202140  BeneflX  Coagulation Factor IX
            {Recombinant) For lnj 1000 Unit              21.00%  Antihemophilic Products    85100015102132  Humate-P  Antihemophilic Factor/VWF (Human) For lnj 500-1200 Unit              37.00%  Antihemophlllc Products    85100015102190  Alphanate/VWF
            Complex  Antlhemophilic Factor/VWF (Human} For lnj 1500 Unit              40.00%  Antihemophflic Products    85100026202145  NovoSeven RT  Coagulation Factor VJla (Recomb) For lnj 5 MG (5000 MCG)              31.75%  Antihemophilic
            Products    85100030002105  Profilnfne SO  Factor IX Complex For lnj 500 Unit              19.75%  Antihemophiltc Products    85100060106420  Kcentra  Prothrombin Complex Cone Human For lnj Klt500 Unit              20.00%  Antihemoph!lfc
            Products    85100010202150  Novoeight  Antihemophilic Factor (Recombinant) For lnj 1500 Unit              20.00%  Antihemophllic Products    85100010252170  Advate  Antihemophilic Factor rAHF-PFM For lnj 2000
            Unit              37.75%  Antihemophilic Products    85100028202160  BeneFIX  Coagulation Factor IX (Recombinant) For lnj 3000 Unit              21.00%  Antihemophi!ic Products    85100010302120  Eloctate  Antihemophi!ic Factor {Recomb)
            rFVIIIFc For lnj 250 Unit              20.00%  Antihemophi!!c Products    85100015102120  Humate-P  Antihemophi!ic Factor/VWF {Human) For lnj 250-500 Unit              37.00%  Antihemophllic Products    85100015102140  Humate-P  Antihemophl!ic
            Factor/WJF (Human) For lnj 1000--2000 Unit              37.00%  Antihemophilic Products    85100026202117  NovoSeven RT  Coagulation Factor VIia {Recomb} For lnj 1 MG (1000 MCG)              31.75%  Antihemophilic
            Products    85100028002185  AlphaNine SO  Coagulation Factor IX For lnj 1500 Unit              30.00%  Antihemophilic Products    85100030002150  Bebulin  Factor IX Complex For lnJ 200-1200 Unit              20.00%  Antihemophilic
            Products    85100010206440  Helixate FS  Antihemophi!ic Factor (Recombinant) For lnJ Kit 1000 Unit              41.75%  Antihemophilic Products    85100010002130  Hemofi!M  Antihemophilic Factor {Human) For lnj 500
            Unit              42.00%  Antihemophil!c Products    85100010006430  Monoclate-P  Antihemophi!ic Factor (Human) For lnj Kit 500 Unit              30.00%  Antihemophil!c Products    85100010202140  BIOClATE  ANT\HEMOPHlllC FACTOR (RECOMBINANT)
            FOR INJ 1000 UNIT              20.00%  Antihemophilic Products    84100040002010  Cyklokapron  TranexamicAcid lnj 100 MG/ML              16.00%  Antihemophilic Products    85100010002146  Hemofil M  Antihemophilic Factor (Human) For lnj 1700
            Unit              42.00%  Antihemophil!c Products    85100010202115  Recomblnate  AntihemophHic Factor (Recombinant) For lnj 220-400 Unit              40.00%  Antihemophilic Products    85100010252140  Advate  Antihemophillc Factor rAHF-PFM For
            lnj 1000 Unit              37.75%  Antihemophilic Products    85100010266460  Xyntha  Antihemophllic Factor Recombinant PAF For lnj Kit 2000 Unit              38.00%  Antlhemophilic Products    85100028202120  BeneFIX  Coagulation Factor IX
            {Recombinant) For lnj 250 Unit              21.00%,  Antihemophilic Products    85100010302165  Eloctate  Antihemophilic Factor (Recomb) rFVIIIFc For lnj 3000 Unit              20.003⁄4  Antihemophil!c
            Products    85100015102138  Wilate  Antihemophilic Factor/VWF (Human) For lnj 900-900 Unit              40.00%  Antihemophilic Products    85100015102193  Alphanate/VWF Complex  Antihemophilic Factor/VWF (Human) For lnj 2000
            Unit              40.00%  Antihemophilic Products    85100026202160  NovoSeven RT  Coagulation Factor VIia (Recomb) For lnj 8 MG (8000 MCG)          .    31.75%  Antlhemophllic Products    85100030002110  Profilnine SO  Factor IX Complex For
            lnj 1000 Unit              19.75%  Antlhemophl!ic Products    85100060106430  Kcentra  Prothrombin Complex Cone Human For lnj Kit 1000 Unit      /t"--..1\\\ ,..,,_. I    '( .i '.'<.    20.00%  Antlhemophific
            Products    85100028002170  AlphaNine SD  Coagulation Factor IX For lnj 500 Unit    i      -..."-..... -/ .......    40.00%  Antihemophilic Products    85100010202155  Recombinate  Antlhemophllic Factor (Recombinant) For lnj 1801-2400
            un·(      '" ,1;,'_        40.00%                          ,1- -,,,r8to  ([)9·'.'.() NvflJe,IO  ,  #•'"'  \ Q  ' ..  .  -  •..  \ l  . 'v  ,,\·, .. . .9 ..· 

      

    

     

    
      
        


    

    
      
        

      

      
                       Antihemophllic Products  851000102S2180  Advate  AntihemophHic Factor rAHF-PFM For lnj 3000
            Unit          37.75%  Antihemophil!c Products  85100010302125  Eloctate  Antihemophillc Factor (Recomb) rFVIIJFc For lnj 500 Unit          20.00%  Antihemophi!ic Products  8510001S102122  Humate-P  Antihemophilic Factor/VWF (Human) For lnj
            250-600 Un[t          37.00%  Antihemophlfic Products  85100015102144  Humate-P  Antihemophilic FactorMVF (Human) For lnj 1000-2400 Unit          37.001⁄4  Antihemophilic Products  85100026202120  NovoSeven  Coagulation Factor VIia {Recomb) For
            lnj 1.2 MG (1200 MCG}          31.75%  Antihemophillc Products  85100028402110  A!prolix  Coagulation Factor IX (Recomb) (rFIXFc) For lnj SOO Unit          22.00%  Antihemophi1ic Products  85100030002180  Profilnine SD  FACTOR IX COMPLEX FDR
            INJ 1000-1500 UNIT          20.05%  Antihemophilic Products  85100028002180  AlphaNine SD  Coagulation Factor IX For lnj 1000 Unit          40.00%  Antihemoph!lic Products  85100010206460  Helixate FS  Antihemophilic Factor(Recomb!nant) For lnJ
            !<it 3000 Unit          41.75%  Antihemophlllc Products  85100010002110  Hemofi!M  Antihemoph!licFactor (Human) For lnj 250 Unit          42.00%  Antihemophilic Products  85100010002160  HemofilM  AntihemophiHc Factor (Human) For lnj
            801-1500 Unit          42.00%  Antihemophi!ic Products  85100010202125  Recombinate  Antihemophi!Jc Factor {Recombinant) For lnj 401-800 Unit          40.00%  Antihemophilic Products  85100010202170  Novoefght  Antihemophilic Factor
            (Recombinant) For In] 3000 Unit          20.00%  Antihemophilfc Products  85100010266420  Xyntha  Antihemophillc Factor Recombinant PAF For lnj Kit 250 Unit          38.00%  Antihemophilic Products  85100010302135  Eloctate  Antihemophitic
            Factor {Recomb) rFVIIIFc For lnj 1000 Unit          20.00%  Antihemophmc Products  85100015102129  Wilate  Antihemophl!ic Factor/VWF (Human) For fnj 500-500 Unit          40.00%  Antihemophilic Products  85100015102170  Alphanate/VWF
            Complex  Antihemophllic Factor/VWF (Human) For lnj 500 Unit          40.00%  Antihemophilic Products  85100026202130  NovoSeven  Coagulation Factor VIia {Recomb) For lnj 2.4 MG {2400 MCG)          30.50%  AntihemophilJc
            Products  85100028402130  Alprolix  Coagulation Factor IX {Recomb) (rFJXFc) For fnj 2000 Unit          22.00%  Antihemophllic Products  85100033006440  Corifact  Factor XU! Concentrate {Human) For lnj Kit 1000-1600
            Unit          21.00%  Antihemophl!ic Products  85100010206420  Helixate FS  Antihemophilic Factor (Recombinant) For lnj Kit 250 Unit          41.75%  Antihemophillc Products  85100010002112  AlPHANATE  ANTIHEMOPHILJC FACTOR (HUMAN) FOR INJ
            2S0-500 UNIT          41.75%  Antlhemophilic Products  85100010002170  Hemofil M  Antihemophi!ic Factor (Human) For JnJ 1501-2000 Unit          42.00%  Antihemophilic Products  85100010202130  B!OClATE  ANTIHEMOPHIUC FACTOR (RECOMBINANT) FOR
            !NJ 500 UNIT          20.00%  Antihemophi!ic Products  85100010252120  Advate  Antihemophilic Factor rAHF-PFM For lnj 250 Unit          37.75%  Antihemoph!IJc Products  85100010266430  Xyntha  Antihemophi!ic Factor Recombinant PAF for /nj Kit
            500 Unit          38.00%  Antihemophllic Products  85100010302145  Eloctate  AntihemophHlc Factor (Recomb} rFVHIFc For In] 1500 Unit          20.00%  Antihemophl!ic Products  85100028202130  BeneFtX  Coagulation Factor IX (Recombinant) For In]
            500 Unit          21.00%  Antihemophilic Products  85100015102130  Humate-P  Antihemophilic Factor/VWF {Human) For lnj 500-1000 Unit          37.()()%  Antihemoph!l!c Products  85100015102180  Alphanate/VWF Complex  Antihemophi!ic Factor/VWF
            (Human} Forlnj 1000 Unit          40.00%  Antihemophllic Products  85100026202140  NovoSeven  Coagulation Factor VIia (Recomb} For Jnj 4.8 MG (4800 MCG)          31.75%  Antihemophi!ic Products  85100028402140  Alprolix  Coagulation Factor IX
            (Recomb) (rFJXFc} For fnJ 3000 Unit          22.00%  Antihemophitic Products  85100035002120  RiaSTAP  Fibrinogen Cone (Human) lnj Approximatety 1 GM {900-1300 MG)          21.00%  Antihemophilic Products  85100010206430  Helixate
            FS  Antihemophillc Factor {Recombinant) For lnj Kit 500 Unit          41.75%  Antihemophi!ic Products  85100010002109  HemofilM  Antihemophilic Factor (Human) Forlnj 220-400 Unit          42.00%  Antihemophilic
            Products  85100010002147  HemofilM  Antihemophillc Factor(Human) For lnj 1701-2000 Unit          42.00%  Antihemophilic Products  85100010202120  BIOClATE  ANTJHEMOPHIUC FACTOR (RECOMBINANT) FOR INJ 250 UNIT          20.00%  Antihemophilic
            Products  85100010202160  Novoelght  Antlhemophi!ic Factor {Recombinant) for lnj 2000 Unit          20.00%  Antihemophillc Products  85100010252185  Advate  Antihemophillc factor rAHF-PFM For Jnj 4000 Unit          37.75%  Antihemophllic
            Products  85100010302130  Eloctate  Antihemophilic Factor (Recomb) rFVIIIFc For lnj 750 Unit          20.00%  Antihemophi!ic Products  85100015102128  Wl!ate  Antihemophilic Factor/VWF (Human) For lnj 450-450
            Unit          40.00%  Ant!hemophilfc Products  85100015102160  Alphanate/VWF Complex  Ant!hemophilfc Factor/VWF {Human) For lnj 250 Unit          40.00%  Antihemophil!cProducts  85100026202126  NovoSeven RT  Coagulation Factor VIia (Recomb} For
            Jnj 2 MG (2000 MCG)          31.75%  Antihemophlllc Products  85100028402120  Alprolix  Coagulation Factor IX {Recomb) {rFIXFc) For lnj 1000 Unit          22.00%  Antihemophilic Products  85100032102130  Tretten  Coagulation Factor XUI
            A-Subunit For lnj 2000-3125 Unit          16.00%  Antihemophi!ic Products  85100010206450  He!ixate FS  Antihemophi!ic Factor{Recombinant) For lnj Kit 2000 Unit  -- -,- "        41.75%  ANTIHEMOPHIUCS  30201010102015  Stimate  Desmopressin
            Acetate Nasal Soln 1.5 MG/Ml  3    --  1('\.,',  15.75%  ANTIHISTAMINES  41200030102900  DiphenhydrAMINE HCI  Diphenhydramine HCI Powder  ()      """...;u.  16.00%  ANTIHYPERUPIDEMICS  3950004010E520  Kynamro  MipomersenSodium Soln Prefllled
            Syringe 200 MG/Ml  X.u,..,.        16.00%  ;                  .."'«to Nurr, 1_ 1\  $ .. •·· ero,m!  . fl f•  2. '•  I·  A  r  (IJ ·,--(\\<>):,.' .§)  ........  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                             ANTIHVPERLIPIDEMlCS  39480050200120  Juxtapid  lomitapide Mesylate Cap 5 MG {Base
            Equiv)  16.00%  ANTJHYPERLIPJDEMICS  39480050200130  Juxtapid  lomitapide Mesylate Cap 10 MG {Base Equ1v)  16.00%  ANTlHYPERUPIDEMICS  39480050200140  Juxtapid  lomitaplde Mesylate Cap 20 MG (Base Equiv)  16.00%  ANTl·INFECTIVE AGENTS -
            MISC.  16000005402120  Cayston  Aztreonam lysine For lnhal So!n 75 MG {Base Equivalent)  16.00%  ANTI-INFECTIVE AGENTS- MISC.  16000049000320  Xifaxan  Rifaximin Tab 200 MG  16.00-3⁄4  ANTI-INFECTIVE AGENTS-
            MISC.  16000049000340  Xifaxan  Rifaximin Tab 550 MG  16.00%  Antineop!astics  21353045001360  Arzerra  Ofatumumab Cone for IV Infusion 1000 MG/50ML  16.75%  Antineoplastics  21353060002040  Rituxan  Rltuximab for IV lnjCone 10
            MG/Ml  16.00%  Antineoplastks  21534007100120  Alecensa  Afectinib HCI Cap 150 MG (Base Equivalent)  15.50%  Antlneop!astfcs  21370060200120  Odomzo  SONIDEGIB PHOSPHATE CAP 200 MG {BASE
            EQUIVALENT)  15.50%  Antineoplastics  21755050102030  Levo!eucovorin Calcium I  Levoleucovorin Calcium IV Solo PF 250 MG/25ML {Base Equiv)  15.50%  Antineoplastics  21100010002020  Busulfex  Busulfan lnj 6
            MG/ML  15.50%  Antineoplastlcs  21574070401820  lmlygic  Talimogene Laherparepvec lntralesional lnj 1000000 Unit/ML  15.50%  Antineop!astics  21535570200320  Rubraca  Rucaparib Camsylate Tab 200 MG (Base
            Equivalent)  15.503⁄4  Ant!neoplastics  21353060002040  Rituxan  Rituxlmab For IV lnj Cone 10 MG/Ml  16.00%  Antineoplastics  21250010402125  Erwinaze  Asparaginase Erwlnia Chrysanthemi For IM lnj10000
            Unit  16.00%  Antineoplastics  21353060002040  Rituxan  Rituximab For IV lnjCone 10 MG/Ml  16.00%  Antineop!astics  2147008000b720  Venclexta Starting Pack  Venetoclax Tab TherapyStarter Pack 10 & 50 & 100
            MG  15.50%  Antineoplastics  21755040102150  Leucovorin Ca!clum  Leucovorin calcium For lnj 200 MG  15.50%  Antineoplastics  21500012001325  PAClitaxel  Paclitaxel IV Cone 30 MG/SML (6
            MG/ML)  15.50%  Antineoplastlcs  21300050100320  Trexall  Methotrexate Sodium Tab 5 MG (Base Equiv)  15.50%  Antineoplastics  21353027002030  Danalex  Daratumumab IVSo!n 400
            MG/20ML  15.50%  Antineop!astics  21534013100320  Cabometyx  Cabozantln!b S-Malate Tab 20 MG (Base Equlva!ent)  15.50%  Antineoplastics  21990002750320  Lonsurf  TRlFLURIDINE-TIPIRACIL TAB 15-6.14
            MG  15.50%  Ant!neoplastics  21708080000110  Vesanold  Tretlno!n Cap 10 MG  15.50%  Antineoplastics  21300050100350  Trexall  Methotrexate Sodium Tab 15 MG {Base Equiv)  15.50%  Antlneoplastics  21755040102130  leucovorin Calcium  leucovorin
            Calcium For lnj100 MG  15.50%  Antineop!astics  21100015002045  CARBOp!atin  Carboplatin IV Solo 600 MG/60ML  15.50%  Antineoplast!cs  21536045100140  Ninlaro  lxazomib Citrate Cap4 MG (Base
            Equivalent)  15.50%  Antineop!astics  21100009102005  Bendeka  Bendamustine HCI IV Soln 100 MG/4ML (25 MG/Ml)  15.50%  Antineoplastics  21700013001930  Tice BCG  BCG live lntravesical For Susp 50
            MG  15.50%  Antineoplastics  2170002000?110  Dacarbazlne  Dacarbazine For lnj 200 MG  15.50%  Antlneoptastics  21200010102105  Bleomycin Sulfate  B!eomydn Sulfate For lnj15 Unit  15.50%  Antlneop!astics  21100015002030  CARBOp!at!n  Carboplatin
            IV Soln 50 MG/SML  15.50%  Antlneop!astics  21574070401840  lmlygie  Talimogene laherparepvee lntralesional lnj100000000 Unit/ML  15.50%  Ant!neoplastics  21353030002120  Empl!citi  Elotuzumab For IVSoln 300
            MG  15.50%  Antineoplastics  21535570200330  Rubraca  Rucaparib Camsylate Tab 300 MG {Base Equll/alent}  15.50%  Antineoplastics  21200050002120  Mitomycin  Mitomycin For lnj 40
            MG  15.50%  Antineoplastics  21300007002015  Cladribine  Cladribine IV Sain 10 MG/10ML (1 MG/ML)  16.00%  Antineoplastics  21470080000320  Venclexta  Venetoclax Tab10 MG  15.50%  Antlneoptastics  21534013100330  Cabometyx  Cabozantinib S·Malate
            Tab 40 MG (Base Equivalent)  15.50%  Antfneoplastfcs  21990002750330  lonsurf  TRIFlURlDINE-TIPIRACIL TAB 20-8.19 MG  15.50%  Antineop!astics  21550040202220  Onivyde  lrinotecan HCI Liposome IV lnj 43 MG/10Ml {4.3
            MG/Ml}  15.50%  Antineop!ast!cs  21100020002020  CISplatin  Cisp!atin lnj 50 MG/50ML (1 MG/ML)  15.50%  Antineoplastics  21100015002040  CARBOp!atin  Carboplatin IV So!n 450
            MG/45ML  15.50%  Antineop!astics  21533530200320  Cotelllc  Cobimetinlb Fumarate Tab 20 MG {Base Equivalent)., T'- .,. -  15.50%  Antineoplastics  21353030002130  Empliciti  E!otuzumab For IVSoln 400
            MG(-  15.50%  Antineoplastics  21500005002075  DOCEtaxel (Non-Alcohol}  Docetaxel (Non-Alcohol Formula) IV So!n 80 MG/4ML ,:;_J•\\ T ...,._- I ' "\,( J /-_,... ... \\  15.50%  Antineoplastics  21470080000340  Venclexta  Venetoclax Tab 50
            MG  15.50%  '<f  ,v,  0 \  j Contrato N'l  ..  •  '.Iii - a Umeroim .  ' (JI ·-  I /i Z, I  -  \i\ ·• -----.,i,i'  ;~, \ i'l-·,  \,Cc  _/,fl  A) .-"  o r•''  ·, ... ,.,DE5 . 

      

    

     

    
      
        


    

    
      
        

      

      
                   Antineoplastics  21500012001350  Onxol  Paclitaxel IV Cone 300 MG/50Ml
            (6MG/Ml)    15.50%  Antineoplastics  21100020002025  Cl5p!atin  Cisplatln lnj 100 MG/100Ml{1MG/Ml)    15.50%  Antineop!astics  21500020102005  VinCRIStine Sulfate  Vincristine Sulfate IV Sofn 1
            MG/Ml      Antineop!astics  21534065200330  Tagris.so  Oslmertinib Mesylate Tab 80 MG (Base Equivalent)    15.50%15.50%  Antineop!ast!cs  21536045100120  Ninlaro  lxazomib Citrate Cap 2.3 MG (Base
            Equivalent)    15.50%  Antineop!astics  21500005002080  DOCEtaxel {Non-Alcohol)  Docetaxel (Non-Alcohol Formula) IV 5o!n 160 MG/8ML    15.50%  Antineop!astics  21470080000360  Venclexta  Venetoclax Tab 100
            MG    15.50%  Antineoplastics  21755050102020  Levoleucovorin calcium  Levoleucovorin calcium lnj 175 MG/17.5Ml (Base Equiv)    15.50%  Antineoplastfcs  21755040102160  Leucovorin calcium  Leucovorln calclum For lnj 350
            MG    15.50%  Antlneop!astics  21755040102120  Leucovorin Calcium  Leucovorin Calcium For lnj SO MG    15.50";{;  Antineoplastics  21100015002035  CARBOplatin  carboplatin IV Soln 150
            MG/15Ml    15.50%  Antineop!ast!cs  21353027002020  Darzalex  Daratumumab N Soln 100 MG/SML    15.50%  Antineop!ast!cs  21536045100130  Ninlaro  lxazom!b Citrate Cap 3 MG {Base Equivalent)    15.50%  Antineop!astics  21500005002070  DOCEtaxel
            {Non-Alcohol)  Docetaxel (Non-Alcohol Formula) IV Soln 20 MG/Ml    15.50%  Antineoplastics  21101040102115  Evomela  Melphalan HCl For lnj SO MG {Propylene Glycol {PG) Free)    15.50%  Antineoplastics  21534013100340  cabometyx  cabozantinib
            S-Malate Tab 60 MG (Base Equivalent)    15.50%  Antineop!astics  21107075002140  Yondells  Trabectedin For lnJ 1 MG    15.50%  Antineop!ast!cs  21200010102115  Bleomycin Sulfate  Bleomycin Sulfate For lnj 30
            Unit    15.50%  Antineop!astics  21500012001335  PACLltaxel  Paclitaxel IV Cone 100 MG/16.7Ml {6 MG/ML)    15.50%  Antineoplastics  21534065200320  Tagris.so  Osimertinib Mesylate Tab 40 MG {Base
            Equivalent)    15.50%  Antineoplastics  21353047002020  lartruvo  Olaratumab Sofn for 1V Infusion 500 MG/50ML {10 MG/ML)    15.50%  ANT1NEOPLASTICS AND ADJUNCTIVE THERAPIES  21100009102010  Treanda  Bendamustine HCl IVSo!n 45 MG/0.5ML (90
            MG/ML)    16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21100028002120  Oxaliplatin  Oxalip!atin For IV Jnj 50 MG    30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21101025002025  lfosfamide  lfosfam!de IV lnj 1 GM/20Ml {SO
            MG/Ml)    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21102020000110  CeeNU  Lomustine Cap 10 MG    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200030102210  DAUNOrubicin HCI  Daunorubicin Hd lnj 5 MG/Ml(Base
            Equiv)    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200042102040  Epirubicin HCI  Epirublcin HCI lnj 150 MG/75ML {2 MG/ML)    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200055001325  Mitoxantrone HCI  Mitoxantrone HCI lnj
            Cone 25 MG/12.5Ml (2 MG/ML)    15.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300010002115  Cytarablne  Cytarabine For tnj 1 GM    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300034102040  Gemc!tabine HCI  Gemcitabine HC! lnj 1
            GM/26.3ML {38 MG/ML) {Base Equiv)    30.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300054002025  Folotyn  Pralatrexate IV lnj 40 MG/2Ml    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21352020002120  Blincyto  Btrnatumomab For IV
            Infusion 35 MCG    16.00%  ANTJNEOPLASTJCS AND ADJUNCTIVE THERAPIES  21402430000120  Xtandl  Enzalutamide Cap 40 MG    16.00%  ANTINEOP1A5TICS ANO ADJUNCTIVE THERAPIES  21405010106410  Lupron Depot  Leuprolide Acetate For Jnj Kit 7.5
            MG    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405010256450  Lupron Depot  Leuprolide Acetate (6 Month) For lnj Kit 45 MG    16.00%  ANTINEOPlASTICS ANO ADJUNCTIVE THERAPIES  21450080000115  Pomalyst  Pomalidomide Cap
            2MG    18.25%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500005002040  DOCEtaxel  Oocetaxel Soln for IV Infusion 80 MG/BML    35.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500012201920  Abraxane  Paclitaxel Protein-Bound Particles For
            IV Susp 100 MG    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21531060000130  lbrance  Palbocidib Cap 100 MG    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  2153202S100120  Tafinlar  Dabrafenib Mesylate Cap 50 MG (Base
            Equivalent)    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21532530007320  Afinitor Dlsperz  Everolimus Tab for OralSusp 3 MG    16.00%  ANTINEOPLA5TICS ANO ADJUNCTIVE THERAPIES  21533070300140  Sutent  Sunitinib Malate Cap 50 MG {Base
            Equivalent)    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534012000320  Bosulif  Bosutinib Tab 100 MG    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534020000320  Sprycel  Dasatinlb Tab 20 MG    16.00%  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21534025100360  Tarceva  Erlotinib HC!Tab 150 MG {Base Equivalent)    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  2153405420B240  Lenvima 14 MG Daily Do  Lenvatinib Cap Therapy Pack 10 & 4 MG (14 MG Dalfy Dose)
            ,,1\STt ... ·s,    16.00%  ANTINEOPlAST/CS AND ADJUNCTIVE THERAPIES  21536015002120  Vekade  Bortezomib For lnJ 3,5 MG c-.1' ...,-_.!:"''--,...;;,:;.,._,,:'-/-'\.    16.75%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21538040000330  Zydefig  ldelalisib Tab 150 MG ,..,,r- "'i_,_'-':. \\f 'I' f c(' .    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700020002105  Dacarbazine  Dacarbaz!ne For lnj 100 MG._) \\"    16.00%  ':,,.  fVrjniero0.;,V
            m0j.  ,u,•/J- n  ..,  .  1\\ .  •J ?)', 

      

    

     

    
      
        


    

    
      
        

      

      
                           ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700060202135  Jntron A  Interferon Alfa-2B
            For lnj 18000000 Unit  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700075206420  Sylatron  Peginterferon alfa-2b For lnj Kit 300 MCG  16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21755040100325  leucovorin Calcium  leucovorin
            Calcium Tab 10 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21764065002140  Elitek  Rasbur!case For IV Solo 7.5 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21100020002030  C/Splatin  Cisplatin lnj 200 MG/200ML (1
            MG/ML}  20.00%  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  21101020002125  Cydophosphamide  Cydophosphamide For lnj 1 GM  32.303⁄4  ANTlNEOPlASTICSAND ADJUNCTIVE THERAPIES  21101040102110  Alkeran  Melphalan HCI For lnj SO MG (Base
            Equiv)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200030052210  DaunoXome  Daunorub!cin Citrate Uposome lnj 2 MG/Ml  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200042102025  Epirubicin HCI  Ep!rub!cln HCI lnj 10 MG/5Ml (2
            MG/Ml)  16.00%  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  21200045102035  ldamycin PFS  tdarublcin HCI IV lnj 20 MG/20ML{1MG/ML)  16.00%  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  2130001000210S  Cytarabine  Cytarabine For lnj 100
            MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300030002025  Fluorourac!I  F!uorouracll lnj 1 GM/20ML (SO MG/ML)  16.25%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21300053102120  Allmta  Pemetrexed Disodfum For IV Soln 500 MG (Base
            Equiv)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21335070002020  Cyramza  Ramucirumab IV Soln 100 MG/10Ml {For Infusion)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21353043002025  Gazyva  Obinutuzumab Solo for IV Infusion 1000
            MG/40Ml (25 MG/ML)  16.00%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21353054002020  Perjeta  Pertuzumab So!n for IV lnfuslon 420 MG/14Ml (30 MG/ML)  16.00%  ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21402250000320  Lysodren  Mltotane Tab 500
            MG  16.00%  ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21405007106450  Vantas  Histrelin Acetate Implant Kit 50 MG  15.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21405010206435  Ellgard  Leupro!ideAcetate(4 Month) For Subcutaneous lnj Kit 30
            MG  25.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21100009102030  Treanda  Bendamustine HCI IV Solo 180 MG/2Ml (90 MG/ML)  16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21100028002130  Oxaliplatin  Oxalip!atln For IV lnj 100
            MG  30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21101025002030  lfosfamide  lfosfamide IV lnj 3 GM/GOML {50 MG/Ml)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21102020000115  CeeNU  Lomustlne cap 40 MG  16.00%  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21200040102010  Adriamycin  Doxorublcin HCI lnj 2 MG/Ml  16.00%  ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES  21200042102045  Ellence  Ep!rubicin HCI IV Soln 200 MG/lOOML (2 MG/ML)  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21200055001330  Mitoxantrone HCI  Mitoxantrone HCI lnj Cone 30 MG/15ML {2MG/ML)  15.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300010002120  Cytarabine  Cytarablne For lnj 2 GM  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21300034102060  Gemcitablne HC\  Gemcltabine HCI lnj 2 GM/52.6Ml {38 MG/ML) (Base Equiv}  30.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300060000305  Tabloid  Thioguanine Tab 40 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21353010002040  campath  Alemtuzumab IV lnj 30 MG/ML(For Infusion)  16.00%  ANTINEOPLASTICSANDADJUNCTIVE THERAPIES  21353050002025  Vectibix  Panitumumab IVSo!n 100 MG/5Ml  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21353070002120  Herceptin  Trastuzumab For IV Soln 440 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21403020100105  Emcyt  Estramustine Phosphate Sodium cap 140 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21405010106415  E!fgard  LeuprolideAcetate For Subcutaneous lnj Kit7.5 MG  25.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21100010000305  Myleran  Busulfan Tab 2 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21101020000310  Cyc!ophosphamide  Cyclophosphamlde Tab SO MG  32.30%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21101030102105  Mustargen  Mechlorethamine HCI For lnj 10 MG  16.00%  ANTINEOPLASTJCS AND ADJUNCTIVE
            THERAPIES  21104070002120  Temodar  Temozo!omide For IV So!n 100 MG  16.00%  ANTINEOPLASTICS ANO ADJUNCTIVE THERAPIES  21200040102115  Adriamycin  Doxorubicin HCI For lnj 50 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21200045102025  ldamycin PFS  ldarublcin HCIIV lnj 5 MG/SML {1 MG/Ml)  16.00%  ANTINEOPLASTICS ANO ADJUNCTIVE THERAPIES  21250060002020  Oncaspar  Pegaspargase lnj 750 Unit/ML  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21300025102020  Fludarabine Phosphate  Fludarab!ne Phosphate lnj 25 MG/ML  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300052002020  Arranon  Ne!arabine IV Soln 5 MG/ML  16.00%  ANTJNEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21335020002025  Avastin  Bevacizumab IV So!n 100 MG/4ML (For Infusion)  15.50%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21353032002020  Yervoy  lpiHmumab Soln for IV Infusion 50 MG/10ML {5 MG/ML)  16.75%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21353053002030  Keytruda  Pembrolizumab IVSoln 100 MG/4ML {25 MG/Ml)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21355070302130  Kadcyla  Ado Trastuzumab Emtans!ne For IV Soln 160 MG -:' _\\S CR;-.:i;.-
            ...,,  16.00%  ANTINEOPLASTICS ANO ADJUNCTIVE THERAPIES  21405005102310  Zoladex  Goserelin Acetate lmp!ant3.6 MG <;-,J\ ·_..... .::-•...-, "' /f'-\ "\  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21405010156432  Ellgard  leuprolfdeAcetate {3 Month) For Subcutaneous lnj Kit 22.5MG YF '\_'\·1.,  25.00%  l  ..,  ff C  , '·  0  0  i ntrat N,  () '  "  y 9.  urnero ; Ill '.  to·- 052  i  ,,  \\(\ ,)\ \  ,/l9  r·,,.. "''  0'Yo
            "=,"';.",'.7,0  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                         I  Am1NEOPLASTJCS AND ADJUNCTIVE THERAPIES  21100015002120  CARBOplatin  Carboplatin IV
            For lnj 150 MG    16.25%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21101020002120  Cydophosphamide  Cyclophosphamide For lnj 500 MG    32.30%    ANT1NEOPlAST!CS AND ADJUNCTIVE THERAPIES  21101040000305  Alkeran  Melphalan Tab 2
            MG    16.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200020002105  Cosmegen  Dactinomycin For lnj 0.5 MG    16.00%    ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21200040402210  Doxil  Doxorublcin HCI Liposomal lnj {For IV Infusion) 2
            MG/ML    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200045102030  ldamycin PFS  \darubicin HCI JV lnj 10 MG/10ML (1 MG/ML}    16.00%    ANTINEOPLASTJCS AND ADJUNCTIVE THERAPIES  21300007002010  Cladribine  dadribine lnJ 1
            MG/ML    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300025102120  Fludara  F!udarabine Phosphate For lnj so MG    16.00%    ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21300053102110  Alimta  Pemetrexed Disodlum For JV Soln 100 MG
            (Base Equiv)    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21335020002030  Avastin  Bevacizumab JV Sotn 400 MG/16ML {For Infusion)    15.501⁄4    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21353032002040  Yervoy  lpilimumab Soln for IV
            Infusion 200 MG/40ML (5 MG/Ml)    16.75%    ANTINEOPLASTJCS AND ADJUNCTIVE THERAPIES  21353053002120  Keytruda  Pembrolizumab For IVSoln 50 MG    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21370070000120  Erivedge  Vismodegib Cap 150
            MG    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405005102330  Zoladex  Goserel!n Acetate Implant 10.8 MG    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  2140S010206430  lupron Depot  leuprolldeAcetate(4 Month) For lnj Kit 30
            MG    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21104070000147  Temodar  Temozolomide Cap 180 MG    35.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  99392070000135  Tha!omid  Thalidomide Cap 150 MG    16.00%    ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21300034102140  Gemcitabine HO  Gemcitabine HCI For lnj 1 GM    30.00%    ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES  21406010200320  Zytiga  Abiraterone Acetate Tab 250 MG    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21500005001325  DOCEtaxel  Docetaxel For lnj Cone 80 MG/2Ml (40 MG/ML)    35.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500011002140  lxempra Kit  lxabepilone For IV Infusion 45 MG    16.75%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21500050802025  Nave\b!ne  Vinore!blne Tartrate lnj 50 MG/SML (10 MG/ML) (Base Equiv)    16.001⁄4    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21531S60002120  lstodax  Romldepsln For IVlnj10 MG    16.75%    ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21532530000330  Afinltor  Evero11mus Tab 10 MG    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21533070300130  Sutent  Sunitinlb Ma\ate Cap 25 MG (Base Equivalent)    16.00%    ANTlNEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21534008000320  lnlyta  Axitinib Tab 1 MG    16.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534015000120  Xalkorl  Crizotinib Cap 200 MG    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534025100320  Tarceva  Erlotinib
            HCI Tab 25 MG (Base Equivalent)    16.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  215340S420B220  Lenvlma 10 MG Daily Do  Lenvatlnib Qlp Therapy Pack 10 MG {10 MG Dally Dose)    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21534075100340 lcluslg    Ponatinib HCI Tab 45 MG {Base Equiv}    22.75%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21537560200335  Jakafi  Ruxolitinib Phosphate Tab 25 MG {Base Equivalent}    15.25%    ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21700008102020  Trlsenox  Arsenlc Trioxide lnj 10 MG/10Ml (1MG/ML)    16.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21700060202030  lntron-A  Interferon Alfa-2B lnj 10000000 Unit/ML    16.00%    ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21700060702020  Actimmune  Interferon Gamma-18 lnj 100 MCG/0.5Ml {2000000 Unit/0.SML)    16.75%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21707070102140  Photofrin  Porfimer Sodium For lnj 75
            MG    16.00%    ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21758050002010  Mesna  Mesna lnj 100 MG/ML    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405525102120  Firmagon  Degarelix.Acetate For lnj 80 MG (Base
            Equiv)    15.75%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500005001317  DOCEtaxel  Docetaxel For lnj Cone 160 MG/8ML (20 MG/Ml)    35.00%    ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21500010602120  Etopophos  Etoposide Phosphate JV For
            lnj 100 MG    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  2150003010210S  VinBLA5tine Sulfate  Vinb!astine Sulfate For lnj 10 MG    16.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21531550100130  Farydak  Panoblnostat lactate Cap 15
            MG (Base Equivalent)    16.00%    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21532530000320  Aflnitor  Everolimus Tab 5 MG    16.003⁄4    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21533060400320  NexAVAR  Sorafenib Tosylate Tab 200 MG (Base
            Equivalent)    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534006100330  Gilotrif  Afatinlb Dimaleate Tab 30 MG (Base Equivalent)    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534013106480  Cometrlq {140 mg
            Daily  Cabozantinib S·Mal Qlp lX 80 MG & 3 X 20 MG (140 Dose} Kit    16.00%    ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534020000360  Sprycel  Dasatinib Tab 100 MG    16.00%    ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21534035100340  Gleevec  lmatinib Mesylate Tab 400 MG {Base Equivalent} P ·\S-11-..)/,    17.25%,.,-,"    ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  2153407010032021537560200325  Votrient
            Jakafi  Pazopanib HCI Tab 200 MG {Base Equiv) .'7 ,.J..... "Ruxo!itinib Phosphate Tab 15 MG {Base Equivalent) l <J /7    -._-1,, \ 16.00%1s.2s%    •. , ., ....        ''l'f[-..',\\)) \ IJ 5 2(.                    \\\ ()  rt ,  0  Qv,,y =,s:9
            ',  OsDE::J•·  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                                             3⁄4  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS
            AND ADJUNCTIVE THERAPIES ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTlNEOPLASTlCS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
            ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANT/NEOPlASTICS AND ADJUNCTIVE
            THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIES ANTINEOPtASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND-ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTJCS
            AND ADJUNCTIVE THERAPIES ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTJNEOPlASTJCS AND ADJUNCTIVE THERAPIES
            ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTJNEOPLASTICS AND
            ADJUNCTIVE THERAPIES ANTINEOPLAST/CS AND ADJUNCTIVE THERAPIES  .'t,,.,,  --  -""'""'''-  21550080100140 Hycamtin21700050100105 Matulane21700060206470 lntron-A21700075206470 Syfatron21755050102120 Fusilev21405050201920 Trelstar
            Depot21450080000120 Poma!yst21500005002050 DOCEtaxel21500015002020 Teniposide21531060000140 lbrance  21532025100130 Tafin\ar21532530007340 Afinitor Disperz21533570100310 Mekinlst21534012000340 Bosullf  Topotecan HCI Cap 1 MG {Base Equiv)
            Procarbazine HCI Cap SO MGInterferon Alfa-2B lnJ Kit 10000000 Unit/0,2ML Peglnterferon alfa-2b For lnj Kit 4 X 600 MCG Levoleucovorln Calcium For IV lnj 50 MG {Base Equiv)Triptorelin Pamoate For IM Susp 3.75 MG Pomaffdomide Cap 3 MGDocetaxel
            Solo for IV Infusion 160 MG/16ML TeniposJde IVSoln 10 MG/MLPalboc!dib Cap 125 MGDabrafenib Mesylate Cap 75 MG (Base Equivalent) Evero!imus Tab for Oral Susp 5 MGTrametin"1b Dimethyl Sulfoxide Tab 0.5 MG (Base Equivalent)Bosutinib Tab 500
            MG  21534020000340 Sprycel21534030000320 lressa  Dasatinib Tab 50 MG Gefitinib Tab 250 MG  21534054208250 Lenvima 24 MG Daily Do lenvatin·1b c.ap Therapy Pack 10 (2) & 4 MG {24 MG Daily Dose)  Carfifzomib For lnj 60 MG  frinotecan HCI lnj
            300 MG/15Ml (20 MG/ML)  Deni!eukln Diftitox JV Soln 150 MCG/ML Interferon Alfa-2B For lnj 50000000 Unit  Peginterferon alfa-2b For lnj Kit 600 MCG  Leucovorln Calcium Tab 15 MG Pafifermln For JV In] 6.25 MG  DegarelixAcetate For lnj 120 MG
            (Base Equiv) Docetaxel for lnj Cone 20 MG/0.SML (40 MG/ML)  Jxabepilone For IV Infusion 15 MG  Vinorelblne Tartrate lnj 10 MG/ML {Base Equiv} Panoblnostat Lactate Cap 20 MG (Base Equivalent)  21536025002120 Kyprolis21550040102035
            Camptosar21700024002020 Ontak21700060202160 lntron A21700075206430 Sylatron21755040100335 Leucovorin Calcium21765060002120 Kepivance21405525102130 Firmagon21500005001320 DOCEtaxel21500011002120 lxempra Kit21500050802020 Navelbine21531550100140
            Farydak21532530000325 Afinitor21533070300120 Sutent21534006100340 Gilotrif21534014000130 Zykadla21534020000380 Sprycel21534050100320 Tykerb21534075100320 lclusig21537560200330 Jakafi21550080102020 Topotecan HCI21700060202022
            lntron-A21700060302020 Alferon N21703020002120 Profeukin21758050000320 Mesnex21100009102120 Treanda21101020000305 Cyclophosphamide21101025002130 lfex21102030002105 Zanosar21200040102110 Adriamycin21200042102170 Epirubicin HCI  EverolimusTab 7.5
            MGSunitinib Malate Cap 12.5 MG {Base Equivalent)  Afatinib Dima!eate Tab 40 MG {Base Equivalent) Cerltinib Cap 150 MGDasatlnlb Tab 140 MGlapatlnfb Ditosy!ate Tab 250 MG {Base Equiv) Ponatlnlb HCI Tab 15 MG {Base Equiv)Ruxo!itinib Phosphate Tab
            20 MG (Base Equivalent) Topotecan HCl lnj 4 MG/4Ml{Base Equiv} {For Infusion}  Interferon Alfa-2B fnj 6000000 Unit/ML Interferon Alfa-n3 Jnj 5000000 Unit/ML  A!des!eukin For IV Soln 22000000 Unit Mesna Tab 400 MGBendamustine HCI For IV Soln 100
            MG  Cyclophosphamide Tab 25 MG  lfosfamlde For lnj 3 GM Streptozocin For tnj 1 GM Doxorubicin HCJ For lnj 20 MG  21300025100320 Oforta  EplrubiclnHCI ForlnJ 200 MG Fludarabine Phosphate Tab
            10MG  16.00%16.00"/416.00%16.75%16.75%22.50%18.25%3S.00%16.00%16.00%16.00"/416.00%16.00"/416.00%  (  16.00%15.25%    .,,,,. , ?TRA, "-J ·I• .._,- , .,, , ,"'{\,  s.'
            V  16.00%16.00%16.00%16.00%16.00%16.75%16.00%16.CJO%15.75%35,00%16.75%16.003⁄416.00%16.00%16.00%16.00%16.00%16.00%16.00%22.75%15.25%17.00%16.00%15.75%16.75%16.00%16.75%32.30%16.00%16.00%16.00%16.00%  I ( ',,Y.;v ll-  \\'.J S.75% 

      

    

     

    
      
        


    

    
      
        

      

      
                             Q,  l  '(IICont1-810  Numero ; (it\  -9-(lr •  (j) •- . ., 2  ANTlNEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21300040001830  Purixan  Mercaptopurine Susp 2000 MG/lOOMl (20 MG/Ml)      16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21335010102030  Zaltrap  Ziv-Aflibercept JV Soln 200 MG/8ML (For
            Infusion)      16.00%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21353025002025  Erbitux  Cetuximab IV Solo 200 MG/100ML (2 MG/ML)      16.25%    21353050002035  Vectibix  Panitumumab IV Soln 400 MG/20ML      16.75%  ANTINEOPlASTICS AND
            ADJUNCTIVE THERAPIESANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21355070302120  Kadcyla  Ado-Trasrozumab Emtansine For IV So!n 100 MG      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21403530002024  Fastodex  Fufvestrant lnj 250
            MG/5ML      16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21405010156430  lupron Depot  leuprolide Acetate {3 Month) For lnj Kit 22.5 MG      16.00%  ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES  21100028002035  Eroxatin  Oxaliplatln IV Soln
            200 MG/40ML      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21101020002130  Cydophosphamide  Cydophosphamide For In] 2 GM      32.30%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21102010002105  BiCNU  Carmustlne For lnj 100
            MG      16.00"1,i  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200030102105  Cerubidine  Daunorubidn HCI For lnj 20 MG      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200042102030  Ellence  Epirublcin HCI IV Soln 50 MG/25Ml{2.
            MG/ML)      16.003⁄4  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200055001320  Mitoxantrone HCI  Mltoxantrone HCI lnj Cone 20 MG/10Ml (2 MG/Ml)      15.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300010002110  Cytarabine  Cytarabine For lnj
            500 MG      16.00%  ANTINEOPlAST!CS AND ADJUNCTIVE THERAPIES  2.1300034102020  Gemdtabine HCI  Gemcltablne HCI tnj 200 MG/5.26Ml {38 MG/ML} {Base Equiv)      30.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21300054002020  Folotyn  Pralatrexate IV lnj 20 MG/ML      16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21335070002.040  Cyramza  Ramucirumab IVSoln 500 MG/50Ml {For Infusion)      16.00%  ANTlNEOPlASTICSAND ADJUNCTIVE
            THERAPIES  21353045001320  Arzerra  Ofatumumab Cone For IV Infusion 100 MG/5Ml      16.75%  ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES  21402420000320  Casodex  Bicalutamide Tab 50 MG      16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21100009102110  Treanda  Bendarnustine HCI For IV So!n 25 MG      16.75%  ANTINEOPLA5TICS AND ADJUNCTIVE THERAPIES  21101010000305  Leukeran  Chlorambucil Tab 2 MG      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21101025002110  lfex  lfosfamide For lnj 1 GM      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21102.020000120  CeeNU  Lomustlne Cap 100 MG      16.00%  ANTJNEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21200040102105  Adriamycln  Doxorubicin HCI For lnj 10 MG      16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200042102.140  Epirubicin HCI  Ep!rubicin HCI For lnj 50MG      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21200080002020  Valstar  Valrub!cln So!n For lntravesical Instillation 40 MG/Ml      16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300010301825  DepoCyt  Cytarablne Uposome lnj 50MG/5Ml      16.00%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21300034102160  Gemcltabine HCI  Gemcitabine HCI For lnj 2 GM      30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21335010102020  Zaltrap  Ziv-Aflibereept IV Soln100 MG/4Ml {For Infusion)      16.00%  ANTINEOPLASTICS
            AND ADJUNCTIVE THERAPIES  21353025002020  Erbitux  Cetuximab NSoln 100 MG/50Ml (2 MG/ML)      16.25%  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  21353050002030  Veetibix  Panitumumab lVSoln 200 MG/10ML      16.75%  ANTINEOPLASTlCS AND ADJUNCTIVE
            THERAPIES  21355020202120  Adcetris  Brentuximab Vedotin For IV Soln 50 MG      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21403530002022  Fas!odex  Fulvestrant lnj 125 MG/2.5ML      16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  214050502.01930  Trelstar LA  Triptorelin Pamoate For IM Susp 11.25 MG      22.50%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21104070000140  Temodar  Temozolomide cap 100 MG      35.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  2150000S001310  DOCEtaxel  Docetaxel For lnj Cone 20 MG/Ml      35.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  9939207000012.0  Thalomid  Thalidomide Cap 50 MG      16.00%  ANTlNEOPLASTICS AND ADJUNCTIVE
            THERAPIES  99394050000145  Revlimid  leoalidomlde cap 20 MG      16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405010256445  Eligard  leuprolideAcetate {6 Month) For Subcutaneous lnJ Kit 45 MG      25.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21450080000110  Pomafyst  Pomaltdomlde Cap 1 MG      18.25%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21500005002030  DOCEtaxel  Docetaxel So!n for IV Infusion 20 MG/2ML      3S.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21500012001340  PACUtaxel  Paditaxel IV Cone 150 MG/25Ml (6MG/ML)      16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21531060000120  lbrance  Palbocidib Cap 75 MG      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21531575000120  Zol!nza  Vorlnostat Cap 100 MG      16.00%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21532530007310  Afinitor Disperz  Everol!musTab for Oral Susp 2 MG --      16.00"/2  ANTlNEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21533070300135  Sutent  Sunitinib Malate Cap 37.5 MG {Base Equivalent)      16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534008000340  lnlyta  Axitinlb Tab 5 MG J . o\5 11«.,,,., -...,_      16.00%  ANTlNEOPLASTICS AND
            ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  2153401500012521534025100330  Xa\kori Tarceva  Crizotinib Cap 250 MG /' .;.:1:• ..,.0·v'-''·      16.00%16.00%        Erlotln!b HCJ Tab 100 MG (Base Equivalent) .I
            VF        --·~              \t,.-:-:---:;;<.:?  '  r"'v  : ..•  VA'l --' :v  \0 8 nr;_sr_..  - 

      

    

     

    
      
        


    

    
      
        

      

      
                       ANTINEOPlAST[CS AND ADJUNCTIVE THERAPIES  2153405420B230  lenvlma 20 MG Daily
            Do  Lenvatinlb cap Therapy Pack 10 {2) MG (20 MG Dally Dose)            ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21535560000120  lynparza  Olaparib Cap 50 MG          16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21538040000320  Zydelig  ldelalisib Tab 100 MG            ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21700013001940  TheraCys  BCG live lntravesicat For Susp 81 MG/VIAL            ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21700060202130  lntron A  Interferon Alfa-28 For lnj 10000000 Unit          16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21700075206410  Sylatron  Peginterferon a!fa-2b For lnj Kit 200 MCG          16.00%  ANTINEOPlAST!CS AND
            ADJUNCTIVE THERAPIES  21708220000120  Targretin  Bexarotene Cap 75 MG          16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21764065002120  Elitek  Rasburicase For IVSoln 1.5 MG          16,00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21104070000150  Temodar  Temozolomide Cap 250 MG          16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  99392070000140  Thalomid  Thalidomide Cap 200 MG          35.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21405010106407  Leuprolide Acetate  leuprolide Acetate lnj Kit 5 MG/Ml          16.00%52.25%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300015002120  Dacogen  Dedtab!ne For lnj SO MG          25.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21500010002025  Etoposide  Etoposlde lnj 100MG/5Ml (20 MG/ML)          27.55%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500010002030  Etoposide  Etoposide lnj 500MG/25ML (20 MG/ML)          27.55%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21450080000125  Pomalyst  Pomalidomide Cap 4 MG            ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21500009202020  Halaven  Erlbutin Mesylate lnj 1 MG/2Ml (0.5 MG/Ml)          16.75%  ANTJNEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21500020201820  Marqibo  Vincristine Sulfate Uposome IV Susp 5 MG/31Ml (0.16 MG/ML)          16.00%  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  21531520002120  Beleodaq  Belinostat For IV lnj 500 MG          16.00%  ANTINEOPLASTICS
            AND ADJUNCTIVE THERAPIES  21532080000320  Zelboraf  Vemurafenib Tab 240 MG            ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21532570002020  Torisel  Temsiro!imus So!n For IV Infusion 25 MG/Ml          16.75%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21533570100330  Meklnlst  Trametinib Dimethyl Sulfoxide Tab 2MG (Base Equivalent)          16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534013106460  Cometriq (60 mg Daily D,  Cabozantlnib S-Ma!ate Cap 3 X 20 MG (60 MG Dose}
            Kit          16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534020000350  Sprycel  Dasatinib Tab 70 MG          16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534033000120  lmbruvlca  lbrutinib Cap 140
            MG          16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534060200115  Taslgna  Nilotinlb HCI Cap 150 MG (Base Equivalent}          16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21537560200310  Jakafi  Ruxolitinib Phosphate Tab 5 MG
            (Base Equivalent}          15.25%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21550040102040 lrinotecan HC!    lrinotecan HCI lnj 500 MG/2SML (20 MG/Ml)          30.00%  ANTJNEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21700040102120  Synribo  Omacetaxine Mepesuccinate For lnj 3.5 MG          16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21700060206450  lntron-A  Interferon Alfa-28 lnj Kit 3000000 Unit/0.2ML          16.00%  ANTINEOPLA5TICS AND
            ADJUNCTIVE THERAPIES  21700075206450  Sylatron  Peginterferon alfa-2b For lnj Kit 4 X 200 MCG          16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21755040102030  leucovorin calcium  leucovorin Calcium lnJ10
            MG/Ml          16.00%  ANTINEOPI.ASTICS AND ADJUNCTIVE THERAPIES  21104070000143  Temodar  Temozolomlde cap 140 MG          35.00%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21500005001315  OOCEtaxel  Docetaxel For lnj Cone BO MG/4Ml{20
            MG/ML)          35.00%  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  99392070000130  Thalomld  Thalidomfde cap 100 MG          16.00%  ANTlNEOPI.ASTICS AND ADJUNCTIVE THERAPIES  99394050000150  Revllmfd  Lenc:11idomide Cap 2S
            MG          16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21100028002030  Efoxatin  Oxaliplatin IV Soln 100 MG/20Ml          30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  99394050000110  Revlimid  Lenafldomide caps 2.5
            MG          16.75%  ANTINEOPLASTICS ANO ADJUNCTIVE THERAPIES  21534085000320  Caprelsa  Vandetanib Tab 100 MG          16.00%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21550040102025  Camptosar  lrinotecan HCI lnj 40 MG/2Ml (20
            MG/ML)          30.00%  ANTlNEOPLASTICS ANO ADJUNCTIVE THERAPIES  21550080102120  Hycamtin  Topotecan HCIFor lnj 4 MG          17,00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300034102110  Gemcitabine HCt  Gemcitablne HCIFor lnj 200
            MG          30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500010002040  Etoposide  Etoposide lnj 1 GM/SOML {20 MG/Ml)          27.55%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21550040102030  Camptosar  lrinotecan HCI lnj 100 MG/SMl (20
            MG/ML)          30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21250010402120  Erwinaze  Asparaginase Erwinia Chrysanthemi For lnj 10000 Unit          16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21104070000110  Temodar  Temozolomide
            Cap 5 MG          35.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  213000050003SO  C.apecitablne  CapecitabineTab 500 MG    . , c .:1 r--.      40.00%  ANTINEOPLASTJCS AND ADJUNCTIVE THERAPIES  99394050000130  Revlimid  lenalidomlde cap 10
            MG    <;S,\' "'  - 1<....'.,....'.\    16.75%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21300030002030  Adrucil  F!uorouracil lnj 2.5 GM/SOML (50 MG/ML)    '(}·.1,.,,-  '<:,Y.,.1..%..,    16.25%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21104070000120  Temodar  Temozolomide Cap 20 MG  j  ff-  -,    35.00%  iV' 9 ..'."'O·.N( mero 1 '!11\                  , <fl ,-  (I •'> 2 . ,,  ..  J  '  ·--  I \ \\ (.,\  /_0  :--,  ,_c,,v"" -=,--. \v  ",..,o...  c:::; OE sf
            .... "  ,  ...,.. ,,,,,,, .  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                                 "v  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21300030002020  Adrucil  Fluorouracil lnj 500 MG/lOML {SO MG/ML)    16.25%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES .    99394050000140  RevHmld  Lenalidomide Cap 1S MG    16.75%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    2130003000203S  Adruci\  Fluorouracil lnj 5 GM/lOOML{SO MG/ML)    16.25%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21300003001920  AzaCITIDine  Azacitidine For lnj 100 MG    25.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21405050201940  Trelstar Mlxject  Triptorelin Pamoate For IM Susp 22.5 MG    22.50%  ANTINEOPl.ASTICS AND ADJUNCTIVE THERAPIES    21500003002020  Jevtana  Cabazitaxel lnj 60 MG/1.SML {For IV Infusion)    16.75%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES    21500010000120  Etoposide  Etoposide Cap so MG    27.55%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21500030102020  VinBlAStine Sulfate  Vlnblastine Sulfate lnj 1 MG/Ml    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21531550100120  Farydak  Panobinostat lactate cap 10 MG {Base Equivalent)    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21532530000310  Afinitor  Everolimus Tab 2.5 MG    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    215330S0000320  Stivarga  Regorafenib Tab 40 MG    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21534006100320  Gilotrif  Afatinib Dimaleate Tab 20 MG (Base Equivalent)    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21534013106470  Cometriq {100 mg Daily [  cabozantinib S-Mal Cap 1 X 80 MG & 1 X 20 MG (100 Dose) K!t    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21534020000354  Sprycel  Dasatin!b Tab 80
            MG    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21534035100320  G!eevec  lmatlnib Mesylate Tab 100 MG (Base Equivalent}    17.25%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21534060200125  Taslgna  Nilotinib HCI Cap 200 MG {Base
            Equivalent)    16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21537560200320  Jakafl  Ruxo!itinib Phosphate Tab 10 MG {Base Equivalent)    15.25%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21550080100120  Hycamtin  Topotecan HCI Cap 0.25
            MG (Base Equiv)    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21700045002120  Nlpent  Pentostatin For lnj 10 MG    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21700060206460  lntron-A  Interferon Alfa-2B lnj Kit5000000
            Unlt/0.2Ml    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21700075206460  Sy!atron  Peginterferon alfa-2b For lnj Kit 4 X 300 MCG    16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21755040102170  Leucovorin catcJum  Leucovorin
            Calcium For lnj 500 MG    16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21100028002025  Eloxatin  Oxa!ip1atln IV Soln 50 MG/10ML    30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21300005000320  Capedtabine  Capecitablne Tab 150
            MG    40.00%  ANTINEOPLAST\CS AND ADJUNCTIVE THERAPIES    99394050000120  Revlimid  lenalldomlde Cap 5 MG    16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21534085000340  Caprelsa  Vandetanlb Tab 300 MG    16.00%  ANTINEOPLASTICS
            TOPICAL$    90371050204030  Valchlor  Mech1orethamine HCI Gel 0.016% {Base Equivalent)    16.00%  ANTINEOPlASTICSTOPICALS    90376015004020  Panretin  Alitretinoin Gel 0.1%    16.00%  Antiparasitics    13000040000310  Daraprlm  Pyrimethamine
            Tab 25 MG    15.50%  ANTIPARKINSON AGENTS    73203010102020  Apokyn  Apomorphine Hydrochloride lnj 10 MG/Ml    15.75%  Antipsychotics    59070070101930  RisperDAl Consta  Rlsperldone Mlcrospheres For lnj 37.5
            MG    15.501⁄4  Antipsychotics    59250015001930  Abilify Maintena  Aripiprazo!e IM For Extended Release Susp 400 MG    15.50%  Antipsychotics    59070070101920  RlsperDAL Consta  Risperidone Microspheres For lnj 25
            MG    15.50%  Antlpsychotics    59070070101910  RisperDALConsta  Rlsperidone Microspheres For lnj 12.5 MG    15.50%  Antipsychotics    59070050101837  lnvega Sustenna  Paliperidone Palmitate IM Extended-Release Susp 39
            MG/0.25Ml    15.50%  Antipsychotics    59070070101940  RisperDAL Consta  Rlsperidone Microspheres For lnJ SO MG    15.50%  Antipsychotics    59070050101845  lnvega Sustenna  Paliperidone PaImitate IM Extended-Release Susp 234
            MG/1.SML    15.50%  Antipsychotics    59070050101838  lnvega Sustenna  Pa[iperidone Palmitate IM Extended-Release Susp 78 MG/0.SML    15.50%  Antipsychotics    59070050101850  lnvega Trinza  Pa!fperidone Palmitate IM Extend-Release Susp 273
            MG/0.875Ml    15.50%  Antlpsychotics    59250015001920  Abilify Ma!ntena  Aripiprazo!e IM For Extended Release Susp 300 MG    15.50%  Antipsychotics    5925001520E430  Aristada  ARIPlPRAZOLE l.AUROXtLIM ERSUSP PREFILLED SYR 662
            MG/2.4Ml    15.50%  Antipsychotics    590700S0101839  lnvega Sustenna  Paliperidone Pa!mitate 1M Extend-Release Susp 117 MG/0.75Ml    15.50%  Antipsychotics    59070050101870  lnvega Trinza  Pal!peridone Palmitate IM Extend-Release Susp 546
            MG/1.75Ml    15.50%  Antipsychotics    5925001520£.440  Aristada  ARlPIPRAZOLE lAUROXU IM ER SUSP PRE.FILLED SYR882 MG/3.2Ml    15.50%  Antipsychotics    59070050101880  lnvega Trlnza  Pallperidone Palmitate IM Extend-Release Susp 819
            MG/2.62SML    15.50%  Antipsychotics    5925001520E420  Aristada  ARIPIPRAZOLE LAUROXIL IM ER SUSP PREFlllED SYR 441MG/1.6ML    15.50%  Antipsychotics    59070050101840  lnvega Sustenna  Paliperidone Palmitate IM Extended-Release Susp 156 MG/ML
            .,.,<, tS fD /.'.i "'-    15.50%  Antipsychotics ANTIPSYCHOTICS/ANTIMANJCAGENTS    5907005010186059157060101950  lnvega Trinza ZyPREXA Relprew  Pallperidone Palmitate IM Extend-Release Susp 410 MG/1.3).S L•,. "i'..--..,,0/anzapine Pamoate
            For Extended Rel IM Susp 210 MG (Bas' e'." }.1_-:, -'-;,;I<    15.50%16.00"ii  -- -'-""        ' ,Ir Contrato N' ' 0,,; JJsi umero,m(.f:\ - ' () ) _/\-\\  :'    --  C>}_/--  _,// Q  \;  - ·"'0 ""=, ,-;>  ls-..:....,._c---y--:-:=:---e-
            f>· 

      

    

     

    
      
        


    

    
      
        

      

      
                                   59157060101970 ZyPREXA Relprew59157060101960 ZyPREXA Relprew12200020102030
            Foscavlr12359902300320 Zepatier12200020102040 FoscarnetSodium 1250406S002020 Rapivab30042048100360 Boniva84100010000320 Amicar84100010001205 Amicar84100010000305 Amlcar  8240102000ES45 Epogen8240104010E515 Mircera8240152000E545 Neupogen
            85100028402105 Alprolix85100015106440 W!late85100028202145 lxinity85100010402130 Adynovate 8S100031002140 Coagadex  85100028206430 BeneFIX  8240102000E545 Epogen8240102000E575 Epogen8240152000E525 Neupogen  8240102000£545 Epogen8240104010E520
            Mircera8240152000E550 Neupogen 85100028352130 Jdelvion85100028402150 A!pro!ix8240104010E525 Mircera  ANTIPSYCHOTICS/ANTIMANlC AGENTS ANTlPSYCHOTICS/ANTIMANIC AGENTSAntivirals Antivirals AntiviralsANTIVIRALS INFLUENZABisphosphonates BLEEDING
            DISORDERS BLEEDING DISORDERSBLEEDING DISORDERSBlood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/
            Modifiers/ Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modlf!ers/ Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume
            Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/
            Modifiers/Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume
            Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/
            Modifiers/Volume ExpandersBlood Products/ Modifiers/Volume Expanders Blood Products/ Modiffers/ Volume ExpandersBlood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Modifiers/Volume Expanders
            Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume Expanders Blood Products/ Modifiers/ Volume- Expanders Blood Products/ Modifiers/Volume Expanders Blood Products/ Mocfifiers/ Volume Expanders Blood Products/
            Modifiers/Volume Expanders Blood Products/ Modifiers/Volume Expanders  Olamaplne Pamoate For Extended Rel IM Susp 405 MG (Base Eq) Olanzaplne Pamoate For Extended Rel 1M Susp 300 MG {Base Eq) FoscarnetSodium lnj 6000 MG/250ML(24
            MG/ML)Elbasv!r-GrazoprevirTab 50·100 MG FoscarnetSodium lnj 12000 MG/500ML (24 MG/ML)Peramivir lnj 200 MG/20ML (10 MG/ML)lbandronate Sodium Tab 1S0 MG (Base Equivalent) Aminocaproic Add Tab 1000 MGAminocaproic Add Syrup 25% Am1nocaproicAdd Tab
            500 MG  8240101510E556 Aranesp {Albumin Free) Darbepoetln Affa•Polysorbate 80 Sain lnj 60 MCG/ML 8240101510E575 Aranesp (Albumin Free) Darbepoetin Atfa-Polysorbate- 80 Sain lnj 150 MCG/0.3ML 82401015102080 Aranesp (Albumin Free) Darbepoetin
            Alfa-Polysorbate 80 Soln lnj 500 MCG/ML  Epoetin Alfa lnj 10000 Unit/MLMethoxy Polyethylene Glycol-Epoetin Beta lnj SO MCG/0.3ML Filgrastlm lnj 300 MCG/0.5ML (600 MCG/ML}Coagulation Factor IX {Recomb) (rFIXFc} For lnj 250 Unit Antihemophllic
            Factor/WJF (Human) For lnj 1000-1000 Unit KitCoagulation Factor IX (Recombinant) For lnj 1500 Unit Antihemophillc Factor Recomb Pegyfated For lnj 500 Unit Coagulation FactorX (Human) For lnj 500 Unit  8240101510E543 Aranesp (A!bum!n Free}
            Darbepoetin Alfa-Po!ysorbate 80Soln lnj 40 MCG/OAML 8240101510E560 Aranesp (Albumin Free} Darbepoetin A!fa-Polysorbate 80 Sain lnj 100 MCG/0.SML 8240101510E582 Aranesp (Albumin Free) Darbepoetln A!fa-Pofysorbate 80 Soln lnj 200
            MCG/0.4ML  Coagulation Factor IX (Recombinant) For lnJ Kit 500 Unit  8240101510ES43 Aranesp (Albumin Free) Darbepoetin Alfa-Polysorbate 80 Sain lnj 40 MCG/0.4ML 8240101510ES60 Aranesp (Albumin Free) Darbepoetln Alfa-Polysorbate80 Soln lnj 100
            MCG/0.5ML 82401015102070 Aranesp (Albumin Free) Darbepoetln Alfa-Polysorbate 80 So!n lnj 300 MCG/ML  Epoet!n Alfa lnj 10000 Unit/ML Epoetin Alfa lnj 40000 Unit/ML Fifgrastim lnj 300 MCG/ML  82401015102010 Aranesp {Albumin Free) Darbepoetin
            Affa-Polysorbate 80 Soln lnj 25 MCG/Ml 8240101510ES52 Aranesp (Albumin Free) Darbepo-etin Alfa-Polysorbate 80Soln lnj 60 MCG/0.3ML 8240101510E558 Aranesp (Albumin Free) Darbepoetin Alfa-Polysorbate80 Soln lnj 200 MCG/Ml 82401015102080 Aranesp
            (Albumin Free) DarbepoetinAlfa-Polysorbate80 Sain lnj 500 MCG/ML  Epoetin Alfa lnj 10000 Unit/MLMethoxy Polyethylene Glycol-Epoetin Beta lnj 75 MCG/0.3ML Filgrastim tnj 480 MCG/0.8ML{600 MCG/ML)Coagulation Factor IX (Recomb) (rlX-FP) For lnj
            1000 Unit Coagulatlon Factor IX (Recomb) (rFIXFc) For lnj 4000 Unit Methoxy Polyethylene G!yco!-EpoetinBeta !nj 100 MCG/0.3Ml  82401015102020 Aranesp (Albumin Free} Darbepoetin Alfa-Po!ysorbate 80 Sain lnJ 40 MCG/ML 82401015102040 Aranesp
            (Albumin Free) Darbepoetln A!fa-Polysorbate 80 Soln lnj 100 MCG/ML 8240101510E558 Aranesp {Albumin Free) Darbepoetin Atfa-Potysorbate 80Soln lnj 200MCG/ML  85100028206420 Bene-FIX Coagulation Factor IX (Recombinant) For lnJ Kit 250 Unit
            8240101510E556 Aranesp {Albumin Free) Darbepoetln Alfa-Polysorbate 80 So!n fnj 60 MCG/ML 82401015102050 Aranesp {Albumin Free) Darbepoetln Alfa-Polysorbate 8DSo!n lnj 150 MCG/0.75ML 8240101510E588 Aranesp {Albumin Free) Darbepoetin
            Alfa-Polysorbate 80 Sain lnj 300 MCG/0.6ML 8240102000E545 Epogen Epoetin Alfa lnj 10000
Unit/ML  '  16.00%16.00%16.00%15.50%16.00%16.00%16.00%16.{)0%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%15.50%15.50%15.50%15.50%15.50%16.00%16.00%16.00%21.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.001⁄416.00%15.50%15.50%16.00%16.00%16.00%16.00%21.00%16.00%16.00%16.00%16.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                                 Blood Products/ Modifiers/Volume Expanders    8240102000E575  Epogen      Epoetin
            Alfa lnj 40000 Unit/ML      16.00%  Blood Products/ Modifiers/ Volume Expanders    8240101510E528  Aranesp  (Albumin  Free)  Darbepoetin Alfa-Polysorbate 80 So!n lnj 25 MCG/0.42Ml      16.00%  Blood Products/ Modifiers/ Volume
            Expanders    82401015102040  Aranesp  (Albumin  Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 100 MCG/Ml      16.00%  Blood Products/ Modifiers/Volume Expanders    8240101510E558  Aranesp  (Albumin Free)    Darbepoetin Alfa-Polysorbate 80
            Soln lnj 200 MCG/Ml      16.00"ii  Blood Products/ Modifiers/Volume Expanders    8240102000E510  Epogen      Epoetin Alfa lnj 2000 Unit/ML      16.00%  Blood Products/ Modifiers/Volume Expanders    8240102000E545  Epogen      Epoetin Alfa lnj
            10000 Unit/Ml      16.00%  Blood Products/ Modifiers/Volume Expanders    8240104010E525  Mlrcera      Methoxy Polyethylene Gtycol-Epoetin Beta lnj 100 MCG/0.3ML      16.00%  Blood Products/ Modifiers/ Volume
            Expanders    85100028352140  ldelvion      Coagulation Factor IX (Recomb) (rlX-FP) For lnj 2000 Unit      15.50%  Blood Products/ Modifiers/ Volume Expanders    85100015106430  Wllate      Antihemophilic Factor/WJF {Human) For lnj 500-500 Unit
            Kit      15.50%  Blood Products/ Modifiers/Volume Expanders    85100010402140  Adynovate      Antihemophl!ic Factor Recomb Pegylated For lnj 1000 Unit      15.50%  Blood Products/ Modifiers/ Volume
            Expanders    8240157000E520  Neulasta      Pegfilgrastim lnj 6 MG/0.6ML      16.00%  Blood Products/ Modifiers/ Volume Expanders    82401015102070  Aranesp (Albumin Free)      Darbepoetin Alfa-Po\ysorbate 80 Soln lnj 300
            MCG/ML      16.00%  Blood Products/ Modifiers/Volume Expanders    8240104010E520  Mircera      Methoxy Polyethylene Glycol-Epoetin Beta lnj 75 MCG/0.3ML      16.1)0%  Blood Products/ Modifiers/ Volume
            Expanders    85100028206450  BeneFIX      Coagulation Factor IX (Recombinant) For lnj Kit 2000 Unit      21.00%  Blood Products/ Modifiers/Volume Expanders    85100010402150  Adynovate      Antlhemophillc Factor Recomb Pegylated For lnj 2000
            Unit      15.50%  Blood Products/ Modifiers/Volume Expanders    82401015102010  Aranesp (A!bumin Free)      OarbepoetlnAlfa-Polysorbate 80 Soln lnj 25 MCG/ML      16.00%  Blood Products/ Modifiers/Volume Expanders    8240101510E556  Aranesp
            (Albumin Free)      Darbepoetin Alfa-Po!ysorbate 80 Soln lnj 60 MCG/ML      16.00%  Blood Products/ Modifiers/ Volume Expanders    82401015102050  Atanesp (Albumin Free)      Darbepoetfn Alfa-Polysorbate 80 Soln lnj 150
            MCG/0.75ML      16.00%  Blood Products/ Modifiers/ Volume Expanders    85100010402120  Adynovate      Antihemophl!ic Factor Recomb Pegylated For lnj 250 Unit      15.50%  Blood Products/ Modifiers/ Volume
            Expanders    85100031002120  Coagadex      Coagulation Factor X {Human) For lnj 250 Unit      15.50%  Blood Products/ Modifiers/ Volume Expanders    8240102000ES45  Epogen      Epoetin Alfa lnj 10000 Unit/ML      16.00%  Blood Products/
            Modifiers/ Volume Expanders    8240152000£545  Neupogen      Filgrastim lnj 300 MCG/0.SML (600 MCG/ML)      16.001⁄4  Blood Products/ Modifiers/ Volume Expanders    8240102000E575  Epogen      Epoet!n Alfa lnj 40000 Unit/ML      16.00%  Blood
            Products/ Modifiers/Volume Expanders    85100028206460  BeneFIX      Coagulation Factor IX (Recombinant) For lnJ Kit 3000 Unit      21.001⁄4  Blood Products/ Modifiers/Volume Expanders    82401015102020  Aranesp (Albumin Free}      Darbepoetin
            A!fa-Polysorbate 80 Soln lnj 40 MCG/ML      16.00%  Blood Products/ Modifiers/Volume Expanders    82401015102040  Aranesp (Albumin Free}      Darbepoetin Alfa-Polysorbate 80 Soln lnj 100 MCG/ML      16.00%  Blood Products/ Modifiers/Volume
            Expanders    8240101510E558  Aranesp (Albumin Free)      Darbepoetln Alfa-Polysorbate 80 Soln lnj 200 MCG/ML      16.00%  Blood Products/ Modifiers/ Volume Expanders    8240102000E520  Epogen      EpoetinAlfa lnj 4000 Unit/Ml      16.00%  Blood
            Products/ Modifiers/ Volume Expanders    8240102000E575  Epogen      Epoetin Alfa lnJ 40000 Unit/ML      16.00%  Blood Products/ Modifiers/Volume Expanders    8240157000ES20  Neu!asta      Pegfilgrastim lnj 6 MG/0.6ML      16.00%  Blood
            Products/ Modifiers/ Volume Expanders    85100028352110  ldelvion      Coagulation Factor IX (Recomb) (rlX-FP) For lnj 250 Unit      15.50%  Blood Products/ Modifiers/ Volume Expanders    85100010402145  Adynovate      Antihemophilic Factor
            Reconlb Pegylated For lnj 1500 Unit      15.50%  Blood Products/ Modifiers/ Volume Expanders    8240101510E528  Aranesp (Albumin Free}      Darbepoetin Alfa-Po!ysorbate 80 Soln lnj 25 MCG/0.42ML      16.00%  Blood Products/ Modifiers/ Volume
            Expanders    8240101510E552  Aranesp (Albumin Free}      Darbepoetin Alfa-Po!ysorbate 80 Soln lnj 60 MCG/0.3ML      16.00%  Blood Products/ Modifiers/ Volume Expanders    8240101510£575  Aranesp (Albumin Free}      Darbepoet!nAJfa-Polysorbate
            80 Soln lnj 150 MCG/0.3ML      16.00%  Blood Products/ Modifiers/ Volume Expanders    82401015102020  Aranesp {Albumin Free)      Darbepoetin Alfa-Polysorbate 80 Soln lnj 40 MCG/ML      16.00%  Blood Products/ Modifiers/Volume
            Expanders    82401015102040  Aranesp (Albumin Free)      Darbepoetin Alfa-Polysorbate 80 Soln lnj 100 MCG/Ml      16.00%  Blood Products/ Modifiers/ Volume Expanders    8240101510E582  Aranesp (Albumin Free)      Darbepoetfn Alfa-Polysorbate 80
            Soln lnj 200 MCG/0.4ML      16.00%  Blood Products/ Modifiers/ Volume Expanders    8240102000ES45  Epogen      Epoetin Alfa lnj 10000 Unit/ML      16.00%  Blood Products/ Modifiers/Volume Expanders    8240102000E575  Epogen      Epoetin Alfa
            lnj 40000 Unit/ML      16.00%  Blood Products/ Modifiers/Volume Expanders    8240157000E520  Neulasta      Pegfilgrastim Jnj 6 MG/0.6ML      16.ocr  Blood Products/ Modifiers/ Volume Expanders    83334030002120  lprivask      Desirudin For lnj
            15 MG      15.50%  Blood Products/ Modifiers/ Volume Expanders    85100028352120  ldelvlon      Coagulation Factor IX (Recomb} (rlX-FP) For lnj 500 Unit      15.50%  Blood Products/ Modifiers/ Volume
            Expanders    8240152000E525  Neupogen      Fflgrastfm lnJ 300 MCG/ML      16.00%  Blood Products/ Modifiers/Volume Expanders    8240101510E588  Aranesp {Albumin Free)      Darbepoetin Alfa-Polysorbate 80 Soln lnj 300
            MCG/0.GML      16.00%  Blood Products/ Modifiers/Volume Expanders    8240104010£515  Mircera      Methoxy Polyethylene Glycol-Epoetin Beta lnj 50 MCG/0.3ML      16.00%  Blood Products/ Modifiers/ Volume
            Expanders    8240102000E520  Epogen      Epoetin Alfa lnJ 4000 Unit/ML  ---,._).\STl1'A '<    16.00%  Blood Products/ Modifiers/ Volume Expanders    8240152000E550  Neupogen      Fl1grastim lnj 480 MCG/0.8ML (600 MCG/ML)  _<;S<· o-----
            - -:;-.,._ _.....h,. '\,    16.00%  Blood Products/ Modifiers/ Volume Expanders    85100028206440  BeneFIX      Coagulation Factor IX (Recombinant) For lnj Kit 1000 Unit  ://" '/,"-    21.00%  -  ---            ' { Com_r.ato N. \ (l/: 1 9
            umero;m\,f,, ·. ----0-."..;.:::,!  ,'    -..,. ),. f''k  Q,•,  -()  \V'"v -'  =- ,0  '  fr,_,, -os o-r.:: C. r,,.v  --- ·•°"<-c;,-,,': =- ....,  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                             Blood Products/ Modifiers/ Volume Expanders  82401015102020  Aranesp (Albumin
            Free)  Darbepoetin Alfa-Polysorbate 80 Sein lnj 40 MCG/ML  16.00%  Blood Products/ Modifiers/ Volume Expanders  82401015102040  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 100 MCG/ML  16.00%  Blood Products/ Modifiers/
            Volume Expanders  8240101510E558  Aranesp (Albumin Free}  Darbepoetin Alfa-Polysorbate 80 Soln lnj 200 MCG/ML  16.00%  Blood Products/ Modifiers/Volume Expanders  8240104010E545  Mircera  Methoxy Polyethylene Glycol-Epoetin Beta lnj 200
            MCG/0.3ML  16.00%  Blood Products/ Modifiers/Volume Expanders  85100010402135  Adynovate  Anlihemoph!llc Factor Recomb Pegylated For _]nj 750 Unit  15.50%  Blood Products/ Modifiers/Volume Expanders  84100040002025  Cyklokapron  TranexamfcAcid
            NSoln 1000 MG/10Ml {100 MG/ML)  16.003⁄4  Blood Products/ Modifiers/Volume Expanders  8240102000E510  Epogen  Epoetin Alfa lnj 2000 Unit/ML .  16.00%  Blood Products/ Modifiers/Volume Expanders  82401015102080  Aranesp {Albumin Free)  Darbepoetin
            Alfa-Po!ysorbate 80 So!n fnj 500 MCG/ML  16.00%  Blood Products/ Modifiers/ Volume Expanders  8240104010E545  Mircera  Methoxy Polyethylene Glycol-Epoetin Beta lnj 200 MCG/0.3ML  16.00%  Bone Density
            Regulators  30044530002020  Pro!ia  Denosumab lnj 60 MG/Ml  15.75%  Bone Density Regulators  3004405510E140  Natpara  Parathyroid Hormone {Recombinant) For lnj Cartridge 100 MCG  16.00%  Bone Density
            Regulators  3004405510E110  Natpara  Parathyroid Hormone (Recombinant) For lnj Cartridge 25 MCG  16.00%  Bone Density Regulators  30044070002020  Forteo  Teriparatide {Recombinant) lnj 600 MCG/2.4Ml  16.00%  Bone Density
            Regulators  30044530002030  Xgeva  Denosumab lnj 120 MG/1.7ML  16.00%  Bone Density Regulators  3004405510E120  Natpara  Parathyroid Hormone {Recombinant) For lnj Cartridge 50 MCG  16.00%  Bone Density
            Regulators  3004405510E130  Natpara  Parathyroid Hormone (Recombinant) For lnj Cartridge 75 MCG  16.00%  Cardiovascular Agents  37100020000305  Keveyis  Dlchlorphenamide Tab 50 MG  15.50%  CASTLEMAN DISEASE  99473080002120  Sytvant  Si1tuximab
            For IV Infusion 100 MG  16.00%  CASTLEMAN DISEASE  99473080002140  Sylvant  Siltuximab For IV Infusion 400 MG  16.00%  Central Nervous System Agents  62403060450560  Rebif Rebidose Titration  Interferon Beta-la lnj 6 X 8.8 MCG/0.2ML & 6X 22
            MCG/0.5ML  16.50%  Central Nervous System Agents  624030604SE540  Rebif  Interferon Beta-la lnj 44 MCG/O.SML(24MU/ML) (88 MCG/ML)  16.50%  Central Nervous System Agents  6240306045D560  Rebif Rebidose Titration  Interferon Beta-la lnj 6 X 8.8
            MCG/0.2Ml & 6X 22 MCG/0.5ML  16.50%  Central Nervous System Agents  74400020202140  Xeomin  lncobotu!inumtoxlnA For IM lnj 200 Unit  15.50%  Central Nervous System Agents  6240306045E540  Rebif  Interferon Beta-la lnj 44 MCG/0.5Ml (24MU/ML)
            {88 MCG/Ml)  16.50%  Central Nervous System Agents  62403060450520  Rebif Rebidose  Interferon Beta-la lnJ 22 MCG/0.5ML {12MU/ML} (44 MCG/Ml}  16.50%  Central Nervous System Agents  624030604-50520  Rebif Rebidose  Interferon Beta-la fnj
            22MCG/0.SML (12MU/ML) (44 MCG/ML)  16.50%  Central Nervous System Agents  624030604-50560  Rebif Rebldose TTtration  Interferon Beta-la lnj 6X 8.8 MCG/0.2Ml& 6 X 22 MCG/0.5Ml  16.50%  Central Nervous System Agents  62403060450520  Reb!f
            Rebldose  Interferon Beta-la lnj 22 MCG/0.SML (12MU/Ml) (44 MCG/ML)  16.50%  Central Nervous System Agents  6240306045F530  AvonexPen  Interferon Beta-la IM lnj Kit30 MCG/0.SML  16.75%  Central Nervous System Agents  62609
            2300120  Nuedexta  DextromethorphanHBr-Quinidine Sulfate Cap 20-10 MG  15.50%  Central Neivous System Agents  6240306045F530  AvonexPen  Interferon Beta-la IM lnj Kit 30 MCG/0.SML  16.75%  Central Nervous System
            Agents  624030604SE540  Rebif  Interferon Beta-la lnj 44 MCG/0.SML (24MU/ML) (88 MCG/Ml)  16.50%  Central Nervous System Agents  6240306045D520  Rebif Rebldose  Interferon Beta-la lnj 22 MCG/0.SML {12MU/ML) {44 MCG/ML)  16.50%  Central Nervous
            System Agents  624030604-5FS30  AvonexPen  Interferon Beta-la IM lnj Kit30 MCG/0.SML  16.75%  Central Nervous System Agents  624030604-SES40  Reblf  Interferon Beta-la lnj 44 MCG/O.SML(24MU/Ml) (88 MCG/ML}  16.50%  CMV
            Agents  12200010002020  Vistide  Cidofovir IVlnJ 75 MG/ML  16.00%  CMVAgents  12200020102020  Foscarnet Sodium  Foscarnet Sodium lnJ 24 MG/ML  16.00%  CMV Agents  12200066102120  Va!cyte  Va!gancidovir HCI ForSoln 50 MG/ML (Base
            Equiv)  16.00%  CMV Agents  12200066100320  Valcyte  Valganciclovfr HCI Tab 450 MG {Base Equivalent)  16.00%  CMV Agents  12200030102110  Cytovene  Ganciclovir Sodium For lnj 500 MG  60.00%  CONGESTIVE HEART
            FAILURE  40180050002120  Natrecor  Neslrit!de For lnj 1.5 MG  16.00%  CORTICOSTEROIDS  22100020202011  Dexamethasone Sod Pho  Dexamethasone Sod Phosphate Preservative Free lnj 10
            MG/ML  16.00%  CORTICOSTEROIDS  22100030202115  Solu-MEDROL  Methyfprednisolone Sodium Succinate For lnJ 500 MG  16.00%  CORTICOSTEROIDS  22100020002900  Dexamethasone  Dexamethasone
            Powder  16.00%  CORTICOSTEROIDS  22100030202105  Solu-MEDROL  Methylprednlsolone Sodium Succlnate For lnj 40 MG  16.00%  CORTICOSTEROIDS  22100020001320  De>:amethasone Intense!  Dexamethasone Cone 1
            MG/ML  16.00%  CORTICOSTEROIDS  22100025402161  Solu-CORTEF  Hydrocortisone Sodium Succinate PF For lnj 500 MG  16.00%  CORTICOSTEROIDS  22100050101810  Kena!og  TriamcinoloneAcetonide JnjSusp 40 MG/ML .,..
            ,-,.-.-....  16.00%  CORTICOSTEROIDS  22100020202900  Dexamethasone Sodium  Dexamethasone Sodium Phosphate Powder t.\\·\\•...._.' -.ri.("\'  16.00%  ()·,- --  ,_,,_ 1-,',1  V.  '-'  'f Contra/oN- \ 0  ., V'''  ";J!J. .,,
            {.j"5mer,,o1\m::  (J  ..  ': l_ ·.-  , ' 2. I, I  n...  -  \ \\\ '--------------4 

      

    

     

    
      
        


    

    
      
        

      

      
                                     0  CORTICOSTEROJDS  22100030202120  Solu-MEDROL  Methylprednisolone Sodium
            Succlnate For lnj 1000 MG      16.00%  CORTICOSTEROIDS  2210002000200S  Dexamethasone  Dexamethasone So!n 0.S MG/5Ml      16.00%  CORTICOSTEROIDS  22100025402165  Solu-CORTEF  Hydrocortisone Sodium Succlnate PF For lnj 1000
            MG      16.00%  CORTICOSTEROIDS  22100020102900  Dexamethasone Acetate  Dexamethasone Acetate Powder      16.1)0%  CORTICOSTEROIDS  22100030202110  So!u-MEDROL  Methylprednlsofone Sodium Sucdnate For Jnj 125
            MG      16.00"  Corticosteroids  22100017001830  Emflaza  Deflazacort Susp 22,75 MG/Ml      lS.50%  CORTICOSTEROIDS  22100020000325  Dexamethasone  Dexamethasone Tab 1 MG      16.00%  CORTICOSTEROIDS  22100025402150  Solu-CORTEF  Hydrocortlsone
            Sodium Succinate PF For lnj 100 MG      16.00%  CORTICOSTEROIDS  22100030202130  Solu-MEDROL  Methylprednlsolone Sodium Sucdnate For lnj 2000 MG      16J)0%  Corlicosterofds  22100017000340  Emflaza  Def/azacortTab 6
            MG      15.50%  Corticosteroids  22100017000360  Emflaza  Deflazacort Tab 30 MG      15.50%  Corticosteroids  22100017000365  Emflaza  Deflazacort Tab 36 MG      15.50%  CORTICOSTEROIDS  22100020000335  Dexamethasone  Dexamethasone Tab 2
            MG      16.00%  CORTICOSTEROIDS  22100025402155  Solu-CORTEF  Hydrocortisone Sodium Succinate PF For lnj 250 MG      16.00%  CORTICOSTEROIDS  22100050101805  Kenalog  Triamdno!one Acetonide lnj Susp 10
            MG/Ml      16.00%  Corticosteroids  22100017000350  Emflaza  Deflazacort Tab 18 MG      15.50%  CYSTIC FIBROSIS AGENTS  07000070000120  Tobi Podha!er  Tobramycin lnhal Cap 28 MG      17.10%  CYSTIC FIBROSIS
            AGENTS  45302030003030  Katydeco  fvacaftor Packet 75 MG      15.75%  CYSTIC FIBROSIS AGENTS  07000070002530  Bethk!s  Tobramycin Nebu So!n 300 MG/4Ml      16.00%  CYSTIC FIBROSIS AGENTS  45302030000320  Kalydeco  lvacaftor Tab 150
            MG      15.75%  CYSTIC FIBROSIS AGENTS  45304020002010  Pu1mozyme  Dornase Alfa fnhal Soln 1 MG/Ml      16.00%  CYSTIC FIBROSIS AGENTS  07000070002520  Kitabls Pak  Tobramycin NebuSoln 300 MG/SML      41.75%  CVSTIC FIBROSIS
            AGENTS  45302030003020  Kalydeco  lvacaftor Packet SO MG      15.75%  Cystinosis Agents  56400030106530  Procysbi  Cysteamine Bitartrate Cap Delayed Release 75 MG {Base Equiv)      16.00%  Cystinosls Agents  56400030100140  Cystagon  Cysteamlne
            Bitartrate Cap 150 MG      15.25%  Cystinosls Agents  56400030106520  Procysbl  Cysteamine Bitartrate Cap Delayed Release 25 MG (Base Equiv}      16.00%  Cystinosis Agents  56400030100120  Cystagon  Cysteamine Bltartrate Cap 50
            MG      15.25%  DERMATOLOGICALS  90890020002110  BotoxCosmet!c  OnabotutinumtoxinA (Cosmetic) For lnj 50Unit      16.75%  DERMATOLOGICAlS  90890020002120  Botox Cosmetic  OnabotulinumtoxinA {Cosmetic) For lnj 100
            Unit      16.75%  OERMATOLOGICAlS  90890018002120  Oysport (Glabellar lines)  AbobotuHnumtoxinA {Glabellar Unes) For lnj 300 Unit      16.75%  DERMATOLOGICAL$  90550085103400  Kenalog  Triamcinolone AcetonldeAerosol Soln      16.00%  DIAGNOSTIC
            PRODUCTS  94200037002105  Cortrosyn  CosyntroplnForlnj 0.25 MG      16.00%  DIAGNOSTIC PRODUCTS  94200090102120  Thyrogen  Thyrotropin Alfa For lnj 1.1 MG      16.7S%  Digestive Enzymes  51200024006760  Creon  Pancrelipase {lip-Prot-Amyl) DR
            Cap 24000-76000-120000 Unit      16.00%  Digestive Enzymes  51200024006750  Pancreaze  Pancrellpase (Up-Prot•Amyl} OR Cap 16800-40000-70000 Unit      16.00%  Digestive Enzymes  51200024006705  Creon  Pancrefipase {llp•Prot-Amyl) DR Cap
            3000-9500---15000 Unit      16.00%  Digestive Enzymes  51200024006780  Creon  Pancrelipase (Lip-Prot-Amyl) DR Cap 36000-114000-180000 Unit      16.00%  Digestive Enzymes  51200024006754  Pancreaze  Pancrel!pase (Up-Prot-Amyl) DR Cap
            21000-37000-61000 Unit      16.00%  Digestive Enzymes  51200024006710  Pancreaze  Pancre!ipase (lip-Prot-Amyl) DR Cap 4200-10000-17500 Unit      16.00%  Digestive Enzymes  51200060002030  Sucraid  Sacrosldase Soln 8500
            Unit/Ml      16.00%  Digestive Enzymes  51200024006734  Pancreaze  Pancrelipase {lip-Prot-Amyl) DR Cap 10500-25000-43750 Unit      16.00%  Digestive Enzymes  51200024006740  Creon  Pancrelipase (Up-Prot-Amyl) OR Cap 12000-38000-60000
            Unit      16.00%  Digestive Enzymes  51200024006720  Creon  Pancreflpase (Lip-Prot-Amyl) DR Cap 6000-19000-30000 Unit      16.00%  Direct Muscle Relaxants  75200010101920  Ryanodex  Dantrolene Sodium For IV Susp 250 MG      16.00%  ENDOCRINE
            AND METABOLIC AGENTS- MISC.  30080050106440  lupron Depot-Ped  leuprolide Acetate For lnj Pediatric Kit 15 MG      16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30170070106420  SandoSTATIN LAR Depot  Octreotide Acetate For IM lnj Kit 20
            MG      16.50%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30180060002120  Somavert  Pegvisomant For lnj 10 MG (As Protein)  ,,,';_ \\S l R/..• ~''.(,_    15.75%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30454060000330  Samsca  Tolvaptan Tab 30
            MG  ,.,i·,• .6 •-.rr,".,    16.75%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30905070000120  Zemplar  Parica[citol Cap 2 MCG  .(_/ μ "i,,, "I    16.00%          t '{tContrato N • ! ()      umero :  '  ,1 5 #  ,  tf(>  y  [" "'·-·  .  '  , \
            \\\ ',  c,1." o  \ v'\'· ., . _.'7,  v  '8o.,,. E-51'-' 

      

    

     

    
      
        


    

    
      
        

      

      
                               '  1  .. (f  i '  . !!7  .  '  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30906550002020  Aldurazyme  Laronidase Soln For IV Infusion 2.9 MG/5Ml      15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30908565107320  l(uvan  Sapropterin Dlhydrochloride Soluble Tab 100 MG      16.75%  ENDOCRINE ANO METABOLIC
            AGENTS- MISC.  30908060002950  Buphenyl  Sodium Phenylbutyrate Oral Powder 3 GM/Teaspoonful      24.00%  ENDOCRINE AND METABOLIC AGEITTS- MISC.  30080050106420  lupron Depot-Ped  leupro!ide Acetate For lnj Pediatric Kit 7.S
            MG      16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170050102040  Somatuline Depot  Lanreotide Acetate Extended Release lnj 120 MG/0.SML      16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC,  30170075401930  Slgnlfor LAR  Pasireotide Pamoate
            For IM ERSusp 40 MG {Base Equiv)      16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30904520002920  Cystadane  *Betalne Powder For Oral Solution*••      16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30905225100340  Senslpar  Clnacalcet HCI
            Tab 90 MG {Base Equiv)      16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30908230000320  Carbaglu  Carglumic Acid Tab 200 MG      16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30090040102020  Ganlrelix Acetate  GanfrellxAcetate lnj 250
            MCG/0.5Ml      15.25%  ENDOCRINE AND METABOLIC AGENTS- MISC,  30170050102025  Somatuline Depot  lanreotideAcetateExtended Release lnj 60 MG/0.2Ml      16.75%  ENDOCRINE ANO METABOLIC AGENTS- MISC.  30170075202040  Signifor  Pasireotide
            Diaspartate lnj 0.9 MG/Ml(Base Equiv)      16.00%  ENDOCRINE AND METABOLIC AGENTS MISC.  30180060002160  Somavert  Pegvlsomant For lnj 30 MG {As Protein)      15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30904045000120  Orfadln  Nitisinone
            Cap 5 MG      16.00%  ENDOCRINE ANO METABOLIC AGENTS MISC.  30905225100320  Sensipar  Cinacalcet HCl Tab 30 MG {Base Equiv)      16.75%  ENDOCRINE ANO METABOLIC AGENTS MISC.  30908030000920  Ravicti  Glycerol Phenylbutyrate Uquld 1.1
            GM/Ml      16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30080050156420  Lupron Depot-Ped  leuprolideAcetate {3 Month) For lnj Pediatric Kit 11.25 MG      16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30150085102120  Egrifta  Tesamorelin
            Acetate For lnj 1 MG {Base Equiv)      16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070106430  SandoSTATIN lAR Depot  Octreotide Acetate For IM lnj Kit 30 MG      16.50%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30180060002130  Somavert  Pegvlsomant For lnj 15 MG (As Protein)      15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30903610102110  Fabrazyme  Agalsidase beta For IV Soln 5 MG      16.00%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30905070000140  Zemp!ar  Parkalcitol Cap 4 MCG      16,00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30906850002020  Elaprase  ldursulfase So!n for IV Infusion 6 MG/3Ml (2 MG/Ml)      15.75%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30080045106450  Supprelin lA  Histrelin Acetate (CPP) Implant Kit 50 MG      15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170050102030  Somatuline Depot  Lanreotide Acetate Extended Release lnJ 90 MG/0.3Ml      16.75%  ENDOCRINE AND
            METABOLIC AGENTS- MISC,  30170075401920  Signifor LAR  Paslreotide Pamoate For 1M ER Susp 20 MG (Base Equiv}      16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30904045000130  Orfadin  Nltls!none Cap 10 MG      16.00%  ENDOCRINE AND METABOLIC
            AGENTS - MISC,  30905225100330  Sensipar  Cinaca!cet HCI Tab 60 MG {Base Equiv)      16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30908060000320  Buphenyl  Sodium Phenylbutyrate Tab 500 MG      16.00%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30080050106430  Lupron Depot-Ped  Leupro!ide Acetate For lnj Pediatric Kit 11.25 MG      16.00%  ENDOCRINE AND METABOllCAGENTS- MISC.  30170070106410  SandoSTATIN LAR Depot  Octreotide Acetate For IM !nj Kit 10 MG      16.50%  ENDOCRINE
            AND METABOLIC AGENTS - MISC.  30170075401940  Slgnifor LAR  Pasireotide Pamoate For IM ERSusp 60 MG (Base Equiv)      16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30454060000320  Samsca  Tolvaptan Tab 15 MG      16.75%  ENDOCRINE AND
            METABOLIC AGENTS- MISC.  30905070000110  Zemplar  Paricakitol Cap 1 MCG      16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30906050002120  Myalept  Metreleptln For Subcutaneous lnj 11.3 MG      16.00%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.  30908565103020  Kuvan  Sapropterin Oihydrochloride Powder Packet 100 MG      16.75%  ENDOCRINE AND METABOllC AGENTS- MISC.  30170070102030  Octreotide Acetate  Octreotide Acetate lnj 1000 MCG/Ml (1 MG/Ml)      52.25%  ENDOCRINE ANO
            METABOLIC AGENTS- MISC,  30080050156440  lupron Depot-Ped  leupro!ide Acetate (3 Month) For lnj Pediatric Kit 30MG      16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30150085102130  Egrifta  Tesamorelin Acetate For lnj 2 MG (Base
            Equiv)      16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170075202020  Slgnifor  Pas!reotlde Diaspartate lnj 0.3 MG/Ml(Base Equiv}      16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30180060002140  Somavert  Pegvisomant For lnJ 20 MG {As
            Protein)      15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30903610102120  Fabrazyme  Agalsidase beta For IV Soln 35 MG      16.00%  ENDOCRINE ANO METABOllCAGENTS- MISC.  30905070002010  Zemplar  Paricalcitol IV So!n 2
            MCG/Ml      16.003⁄4  ENDOCRINE AND METABOllCAGENTS-MISC.  30907030052020  Vimlzim  E!osulfase Alfa Sain For JV Infusion 5 MG/SMl (1MG/ML)      16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC,  30170070102005  Octreotide Acetate  Octreotide Acetate
            lnj 50 MCG/Ml {0.05 MG/Ml)  .,- ,<: ,,- -. - .,    52.25%  ENDOCRINE AND METABOllCAGENTS-MISC.  30907715002120  lumizyme  A!glucosfdase Alfa For IV Soln 50 MG      15.75%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30170070102015  Octreotide
            Acetate  Octreotide Acetate lnj 200 MCG/ML (0.2 MG/Ml}  /: \·\'.,_.,_,_ - < "' "l (.:'., "'--.    52.25% .  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070102020  Octreotide Acetate  Octreotide Acetate tnj 500 MCG/Ml {O.S MG/Ml)  .t /:f'-
            ,,""'i' \\.    52.25%  ENDOCRINE AND METABOLIC AGENTS- MISC,  30080055102020  Synarel  Nafarelln Acetate Nasal Soln 2 MG/ML  i v' // \\ l,i :;\\    16.00%  -,..., .•..        i !  ·~,uraro Ntimero X•;'\(1 \\                  (fl -,..''"(,\
            ',·.  -;•J 0 

      

    

     

    
      
        


    

    
      
        

      

      
                               ENDOCRINE AND METABOLJCAGENTS- MISC.  30160045002020  lncre!ex  Mecasermin Jnj 40
            MG/4Ml (10 MG/Ml)    16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170075202030  Signifor  Pasireotide Diaspartate lnj 0.6 MG/ML (Base Equiv)    16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30180060002150  Somavert  Pegvisomant For lnj 25
            MG {As Protein)    15.75%  ENDOCRINE AND METABOLIC AGEITTS- MISC.  30904045000110  Orfadfn  Nitisinone Cap 2 MG    16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30905070002020  Zemplar  Parica!citol IV Sain 5 MCG/ML    16.00%  ENDOCRINE AND
            METABOUCAGENTS- MISC,  30907535002020  Nagla2.yme  Galsulfase Soln For JV Infusion 1 MG/Ml    15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070102010  Octreotide Acetate  Octreotide Acetate lnj 100 MCG/ML {0.1MG/Ml)    52.25%  ENZVME
            REPLACEMENT  20000050002025  Adagen  Pegademase Bovine lnj 250 Unit/ML    16.00%  Emyme Replacements/Modifiers  30903875203020  Xuriden  Uridlne Triacetate Oral Granules Packet2 GM    15.50%  Enzyme
            Replacements/Modifiers  30905610002040  Strenslq  Asfotase Alfa Subcutaneous lnj 40 MG/Ml    15.50%  Enzyme Replacements/Modifiers  30906360002020  Kanuma  Sebelipase Alfa IV Sain 20 MG/10Ml (2MG/ML)    15.50%  Enzyme
            Replacements/Modifiers  309056100020S0  Strenslq  Asfotase Alfa Subcutaneous Jnj 80 MG/0.8ML    15.50%  En2.yme Replacements/Modifiers  30905610002020  Strensiq  Asfotase Alfa Subcutaneous lnj 18 MG/0.45Ml    15.503⁄4  Emyme
            Replacements/Modifiers  30905610002030  Strensiq  Asfotase Alfa Subcutaneous lnj 28 MG/0.7Ml    15.503⁄4  Emymes  99350035002120  Xiaflex  Co!lagenase dostridium Histo!ytkum For lnj 0.9
            MG    16.75%  Enzymes  99350040102020  Hyfenex.  Hyaturonidase Human lnj 150 Unit/Ml    16.00%  Fertility Regulators  30062030052020  Gona\-f RFF Pen  Follitrop!n Alfa lnj 300 Unit/0.SML    15.25%  Fertility
            Regulators  30062030102030  FollistimAQ  Fo!litropin Beta lnj 600 Unit/0.72Ml    22.80%  Fertility Regulators  30062030102006  FollistimAQ  Follltropin Beta lnj 150 Unit/0.5Ml    22.80%  Fertility
            Regulators  30062030052150  Gonal-f  Follitropin Alfa For Jnj 1050 Unit    15.25%  Fertility Regulators  30062090102112  Brave!le  UrofollitroplnPurified For fnj 75 Unit    15.25%  Fertility Regulators  30062030052040  Gonal-f RFF
            Pen  Follltropin Alfa lnj 900 Unit/1.5ML    15.25%  Fertility Regulators  30062030102040  FollistlmAQ  Follitropin Beta lnj 900 Unit/1.08ML    22.80%  Fertility Regulators  30062030102003  FollistimAQ  Follitropln Beta lnj 75
            Unit/0.SML    22.80%  fertility Regulators  30062030102020  FollistimAQ  Fol!itrop!n Beta lnj 300 Unit/0.36Ml    22.80%  Fertility Regulators  30062030052115  Gona\-fRFF  Follttropin Alfa For lnJ 75 Unit    15.25%  Fertility
            Regulators  30062050002155  Repronex.  Menotroplns For lnj 75 Unit    15.25%  Fertility Regulators· .  30062030052140  Gonal-f  FolHtrop!n Alfa For lnj 450 Unit    15.25%  Fertility Regulators  30062050002175  Menopur  Menotropins For
            Subcutaneous lnj 75 Unit    15.25%  GASTROINTESTINAL AGENTS- MISC.  52300020112900  Metoclopramide HCI Mo  Metoc!opramide HCI Monohydrate Powder    16.00%  GASTROINTESTINAlAGENTS- MISC.  52700025000140  Cholbam  Cholic Acid Cap 250
            MG    16.00%  GASTROINTESTINAL AGENTS - MISC.  52300020102900  Metodopramide HCI  Metodopramide HCI Powder    16.00%  GASTROINTESTINAlAGENTS- MISC.  52700025000120  Cho!bam  CholJc Acid Cap 50 MG    16.00%  Genitourinary
            Agents  99200030000110  Cuprimine  Pen!dllamine Cap 250 MG    15.50%  GENITOURINARY AGENTS- MISCEllANEOUS  56500010002010  Rimso-50  Dlmethyl Sulfoxide Soln 50%    16.00%  GOUT AGENTS  68000050002020  Krystexxa  Peglot!case lnj 8 MG/Ml(For IV
            Infusion)    16.75%  Growth Hormones  30100020002066  Nordltropin Flex.Pro  Somatropln lnj 30 MG/3Ml    17.25%  Growth Hormones  30100020002140  Nutropin  Somatropin For lnJ 10 MG    16.75%  Growth Hormones  30100020002178  Genotropin
            MiniQuick  Somatropln For lnj 1.4 MG    16.75%  Growth Hormones  30100020102130  Salzen  Somatropln {Non-Refrigerated) For lnJ 8.8 MG    16.25%  Growth Hormones  301000200020$0  Norditrop!n  Somatropin lnJ 5 MG/1.5Ml    17.25%  Growth
            Hormones  30100020002062  Norditropin  Somatropin lnj 15 MG/1.5Ml    17.25%  Growth Hormones  30100020002132  Humatrope  Somatropin For lnJ 12 MG {36 Unit)    16.75%  Growth Hormones  30100020002174  Genotropin MiniQu!ck  Somatropin For lnj 1
            MG    16.75%  Growth Hormones  30100020102121  Serostlm  Somatropin {Non-Refrigerated) For Subcutaneous lnj 5 MG    16.00%  Growth Hormones  30100020002125  Humatrope  Somatropln For lnJ 6 MG (18 Unit)    16.75%  Growth
            Hormones  30100020002170  Genotropin MJniQuick  Somatropin For lnj 0.6 MG ,,,, ·-··--    16.75%  Growth Hormones  30100020102118  Serostim  Somatropin {Non-Refrigerated) For Subcutaneous lnj 4 MG ,i" r'-8• ::T-:'_,._v    16.00%  Growth
            Hormones  30100020002118  Nordftropin  SOMATROPJN FOR !NJ 4 MG {12 UNIT)  / .,,,., ....---- ... "()·'\.,_  16.50%              ! <',? .•  \i- \  ".  1  mer0,  11\"  --.,.,,.,  I [""9 ... r  •'  \tr(-··.1521  ,  ,,...  f  r,  ri,,  \.(,\.·"'
            Ji' 0  v  -.;-',,.,, ''-"..--=!:•---- ,,,Y  1: ?s o!:=. sr  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                                 Growth Hormones  30100020002150  Humatrope  Somatrop!n For Jnj 24
            MG  16.75%  Growth Hormones  30100020002180  Genotropin MlniQuick  Somatropin For lnj1.6 MG  16.75%  Growth Hormones  30100020002015  Nutropin AQ NuSpin 5  Somatropin lnj 5 MG/2ML  16.75%  Growth
            Hormones  30100020002127  Norditropln  SOMATROPIN FOR INJ 8 MG  16.50%  Growth Hormones  30100020002172  Genotropln MinJQukk  Somatropin For lnj 0.8 MG  16.75%  Growth Hormones  30100020102120  Saizen  Somatropin (Non-Refrigerated) For lnj 5
            MG  16.25%  Growth Hormones  30100020102132  Serostim  Somatropin {Non-Refrigerated) For Subcutaneous lnj8.8 MG  16.25%  Growth Hormones  30100020002064  Nutropin AQ NuSpin 20  Somatropin lnj 20 MG/2ML  16.75%  Growth
            Hormones  30100020002134  Genotrop!n  Somatropln For lnj 12 MG {13.8 MG overfill)  16.75%  Growth Hormones  30100020002176  Genotropin MiniQuick  Somatropin For lnj1.2 MG  16.75%  Growth Hormones  30100020102125  Serostim  Somatropin
            (Non-Refrigerated) For Subcutaneous lnj 6 MG  16.00%  Growth Hormones  30100020002121  Genotropln  Somatropln For Subcutaneous lnj 5 MG  16.75%  Growth Hormones  30100020002120  Humatrope  Somatropin For lnj 5 MG  16.75%  Growth
            Hormones  30100020002166  Genotropin MiniQuick  Somatropln For lnj 0.2 MG  16.75%  Growth Hormones  30100020002182  Genotrop!n MiniQuick  Somatropln For Jnj1.8 MG  16.75%  Growth Hormones  30100020002056  Nordltropln FlexPro  Somatropin lnj10
            MG/1.SML  17.25%  Growth Hormones  30100020002020  NutropinAQ  Somatropin lnj10 MG/2Ml  16.75%  Grmvth Hormones  30100020002123  Omnitrope  Somatropin For lnj5.8 MG  16.25%  Growth Hormones  30100020002168  Genotropin MiniQuick  Somatropln For
            lnj 0.4 MG  16.75%  Growth Hormones  30100020002184  Genotropin MiniQuick  Somatropln For Jnj 2 MG  16.75%  H-2 Antagonists  49200030112020  Famotidine Premixed  Famotldine in NaCl 0.9% IV Soln 20 MG/SOML  16.00%  H·2
            Antagonists  49200010002900  Cimetidlne  Cimetidine Powder  16.00%  HEMATOLOGICAL AGENTS - MISC.  85550060102120  Ceprotin  Protein C Concentrate {Human) For IV Soln 500 Unit  16.00%  HEMATOLOGICAL AGENTS-
            MISC.  85550060102140  Ceprotin  Protein C Concentrate {Human) For IV Soln 1000 Unit  16.00%  HEMATOlOGICALAGENTS- MISC.  85800050002020  Soliris  Ecul!wmab IV Soln 10 MG/Ml {For Infusion)  15.75%  Hematopoietic Growth
            Factors  82403060002120  Neumega  Oprelvekln For lnj 5 MG  16.25%  Hematopoietic Growth Factors  82402050002025  Leukine  5argramostim lnj500 MCG/ML  16.75%  Hematopoietic Growth Factors  8240S060002130  Nplate  Romiplostim For lnJ 500
            MCG  16.75%  Hematopoletic Growth Factors  82405030100310  Promacta  Eltrombopag O!amine Tab 12.5 MG (Base Equiv)  16.75%  Hematopoietic Growi:h Factors  82401520002012  Neupogen  F!lgrastim lnj 480 MCG/1.6Ml (300 MCG/Ml)  16.00%  Hematopoletic
            Growth Factors  82402050002120  Leukine  Sargramostim Lyophftlzed For lnJ 250 MCG  16.75%  Hematopoietic Growth Factors  8240152070£530  Grano:  Tbo-Fi!grastim Soln Prefil!ed Syringe 300 MCG/0.SML  16.00%  Hematopoietic Growth
            Factors  82405030100320  Promacta  EltrombopagO!amine Tab 25 MG (Base Equiv)  16.75%  Hematopoietic Growth Factors  82401060102050  Omontys  Peginesatide Acetate 5oln lnj10 MG/Ml  16.00%  Hematopoietic Growth
            Factors  82405030100340  Promacta  EltrombopagOlamine Tab 75 MG {Base Equiv)  16.75%  Hematopoietic Growth Factors  82401060102055  Omontys  Peglnesatlde Acetate Soln lnj 20 MG/2ML  16.00%  Hematopoietic Growth
            Factors  82405060002120  Np!ate  Romiplostim For lnJ 250 MCG  16.75%  Hematopoietic Growth Factors  82401020002015  Epogen  Epoetin Alfa lnj 3000 Unit/ML  16.00%  Hematopoietlc Growth Factors  82401020002050  Epogen  Epoetin Alfa lnj 20000
            Unit/ML  16.00%  Hematopoietic Growth Factors  8240152070E540  Granix  Tbo-Filgrastim Sain Prefil/ed Syringe 480 MCG/0.8ML  16.00%  Hematopoietic Growth Factors  82405030100330  Promacta  Eltrombopag Olamine Tab 50 MG (Base
            Equiv)  16.75%  HEREDITARY ANGIOEDEMA  85820040102020  Firazyr  lcatibant Acetate lnj 30 MG/3Ml {Base Equivalent)  15.75%  HEREDITARY ANGIOEDEMA  85840030002020  Kalb!tor  Ecallantide loj10 MG/ML  16.00%  HEREDITARY
            ANGIOEDEMA  85802022006420  Berinert  Cl Esterase Inhibitor (Human) For IV lnj Kit 500 Unit  16.25%  HEREDITARY ANGlOEDEMA  85802022102130  Ruconest  Cl Esterase Inhibitor (Recombinant) For IV lnJ 2100 Unit  16.00%  HEREDITARY
            ANGIOEDEMA  85802022002120  Cinryze  Cl Esterase Inhibitor (Human) For IV lnj 500 Unit-  15.25%  Hormonal Agents, Stimulant/Replacement/Modifying  30062022052220  Ovidrel  Choriogonadotropln Alfa loj 250 MCG/0.5Ml  15.50%  Hormonal Agents,
            Stimulant/Replacement/Modifying  30062020002140  Chorionic Gonadotropin  ChorionlcGonadotropin For lnj10000 Unit ;,,• , ,\\,:, I J-..{_/:., - ''<.._/ f '' .,...-_,_.:. ·· ".. '-t,,_  15.50%  Hormonal Agents, Suppressant
            {Pituitary)  21404010101840  Depo•Provera  Medroxyprogesterone Acetate IM Susp 400 MG/ML ·':c., t'"\  15.50%  , ,C'/!rjc"  ""'/,-·  0  / · '  ntrato N·umero '0j\ \I\ :  ,,  9 ( - '  ,,,  (f  f)')i  \_ ) -- " ,, '  h\  \; (.,\;1  -;;-Q'
            I  N-,  \.,1⁄2y .._"--""'--=!.:.:;  -  ., 0 .-:::: c.J>,,,,. 

      

    

     

    
      
        


    

    
      
        

      

      
                           HYPNOT!CS/SEDAllVES/SLEEP DISORDER AGENTS  60250070000130  Hetlioz  Tasimelteon Capsule
            20 MG  16.00%  IMMUNOGLOBUUNS  19100020102046  Octagam  Immune Globulfn (Human) IV Soln 25 GM/SOOML  24.25%  IMMUNOGLOBULINS  19100020102125  CARIMUNE  Immune Globulfn (Human) IV For Soln 6
            GM  25.00%  IMMUNOGLOBULINS  19100020302080  Gammagard  Immune Globulin {Human) IV or Subcutaneous Soln 30 GM/300Ml  27.55%  IMMUNOGLOBULINS  19100020102020  Flebogamma  Immune Globulin {Human) IVSoln 0.5
            GM/10Ml  18.001⁄4  IMMUNOGLOBULINS  19100020102113  Gammagard S/D  Immune Globulin (Human) IV For Soln 0.5 GM  27.55%  IMMUNOGLOBULINS  19100020202058  Hizentra 20%  Immune Globulin (Human) Subcutaneous lnj 4
            GM/20Ml  24.50%  IMMUNOGLOBULINS  191000SOOOE540  RhoGAM Ultra-Filtered P  l Rho D Immune Globulin IM So1n PrefSyr 1500 Unit (300MCG}  16.00%  IMMUNOGLOBUUNS  19990002356450  Hyqvia  Im mun Glob lnj 30 GM/300Ml-Hyaluron lnj 2400 Unt/15 Ml
            Kit  20.00%  IMMUNOGLOBULINS  19100020102060  Gamunex  Immune Globulfn (Human) IVSoln 1 GM/10Ml  24.25%  IMMUNOGLOBULINS  19100020102130  Gammagard S/D  Immune Globulfn (Human) IV For Soln 10
            GM  27.55%  IMMUNOGLOBULINS  19100020302084  Gamunex-C  Immune Globulin (Human) IV or Subcutaneous So!n 40 GM/400Ml  23.00%  IMMUNOGLOBULINS  19100020102090  Privigen  Immune Globulin {Human} IV Soln 40
            GM/400ML  19.00%  IMMUNOGLOBULINS  19100020202050  Hfzentra 20%  Immune Globulin (Human} Subcutaneous lnj 1 GM/5ML  24.50%  IMMUNOGLOBULINS  19100050002060  WinRhoSDF  Rho D Immune Globulin (Human) lnj 1500
            Unit/1.3ML  17.75%  IMMUNOGLOBULINS  19990002356430  Hyqvia  Im mun Glob lnj 10 GM/100ML-Hya1uron fnj 800 Unt/5 Ml Kit  20.00%  IMMUNOGLOBULINS  19100005002200  Cytogam  Cytomegalovirus Immune Globulin (Human) IV
            lnj  18.00%  IMMUNOGLOBULINS  19100020102112  GAMMAR-P I.V.  IMMUNE GLOBULIN (HUMAN} IV FORSOLN 1 GM  31.25%  IMMUNOGLOBULINS  19100020202054  Hizentra 20%  Immune Globulin (Human) Subcutaneous lnJ 2
            GM/10ML  24.50%  IMMUNOGLOBULINS  19100050002065  WinRhoSDF  Rho D Immune Globulin (Human) lnj 15000 Unit/13ML  17.75%  IMMUNOGLOBULINS  19990002356440  Hyqvla  lmmun Glob lnj 20 GM/200ML-Hyaluron lnj 1600 Unt/10 ML
            Kit  20.00%  IMMUNOGLOBULINS  19100020102120  Gammagard S/D  Immune Globuffn (Human} JV For So!n 5 GM  27.55%  IMMUNOGLOBULINS  19100020102034  Flebogamma  Immune Globulin (Human) lVSo!n 2.5
            GM/50ML  25.00%  IMMUNOGLOBULINS  19100020102068  Blvlgam  Immune Globulin (Human) N So!n 5 GM/50ML  24.25%  JMMUNOGLOBULINS  19100020302068  Gammagard  Immune Globulin {Human) IV or Subcutaneous Sain 5
            GM/50ML  27.55%  IMMUNOGLOBULIN5  19100020102064  Gamunex  Immune G!obultn {Human) IVSo!n 2.5 GM/25ML  24.25%  IMMUNOGLOBULINS  19100020202020  Vivaglobln  Immune G!obulfn (Human} Subcutaneous lnj 160 MG/ML
            (16%)  23.75%  IMMUNOGLOBUUNS  19100050002055  WinRhoSDF  Rho D Immune Globulin (Human) lnj 5000 Unit/4.4Ml  17.75%  IMMUNOGLOBUUNS  19990002356425  Hyqvia  lmmun Glob lnJ 5 GM/50ML-Hya!uron lnj 400 Unt/2.5 ML
            Kit  20.00%  IMMUNOGLOBULINS  19100020102030  Octagam  Immune Globulin {Human) IV Soln 1 GM/20ML  24.25%  IMMUNOGLOBULINS  19100020102117  carimune NF  Immune Globulin (Human} N For Sain 3
            GM  25.00%  IMMUNOGLOBULINS  19100020202065  Hizentra  Immune Globulin (Human) Subcutaneous lnj 10 GM/SOML  24.50%  IMMUNOGLOBULINS  1910005000ES50  Rhophylac  Rho D Immune Globulin Sol Pref Syr 1500 Unt/2ML
            (300MCG/2ML)  18.25%  IMMUNOGLOBULINS  19100020102063  Octagam  Immune Globulin {Human} IV Sain 2 GM/20ML  24.25%  IMMUNOGLOBULINS  19100020102135  Carimune NF  Immune Globulin (Human) IV For Sain 12
            GM  25.00%  IMMUNOGLOBULINS  19100050002050  WinRhoSDF  Rho D Immune Globulin (Human) lnj 2500 Unlt/2.2ML  17.75%  IMMUNOGLOBULINS  19990002356420  Hyqvia  lmmun Glob lnj 2.5 GM/2SML-Hyaluronlnj 200 Unt/1.25 ML
            Kit  20.00%  IMMUNOGLOBULINS  19100020002200  GamaSTAN S/D  Immune Globulin (Human) tnj  23.75%  IMMUNOGLOBULINS  19100020102044  F!ebogamma DIF  Immune Globulin (Human) IV Solo 20
            GM/400ML  25.00%  IMMUNOGLOBUUNS  19100020302064  Gammagard  Immune Globulin (Human) IV or Subcutaneous Sain 2.5 GM/2SML  27.55%  IMMUNOGLOBULINS  19100020102115  Gammagard 5/D  Immune Globulin {Human) JV ForSo!n 2.5
            GM  27.55%  IMMUNOGLOBULINS  19100020102205  GAMJMUNEN  IMMUNE GLOBULIN (HUMAN) IV SOLN 5%  47.75%  IMMUNOGLOBULINS  19100020302060  Gammagcird  Immune Globulin !Human) IV or Subcutaneous Sain 1
            GM/lOMl  27.55%  IMMUNOGLOBULINS  19100020102034  Flebogamma  Immune Globulin (Human) IV Sain 2.5 GM/SOML  25.00%  IMMUNOGLOBULINS  19100020102072  Blvigam  Immune Globulin {Human) IV Sain10
            GM/100Ml  24.25%  IMMUNOGLOBULINS  19100020302072  Gammagard  Immune Globulin (Human) IV or Subcutaneous Sain 10 GM/lOOML  27.55%  IMMUNOGLOBULINS  19100020102038  Flebogamma  Immune GlobuHn (Human) IV Sain 5
            GM/lOOML'  25.00%  lMMUNOGLOBULINS  19100020102072  Bivigam  Immune Globulin (Human) IV So!n 10 GM/100ML ,-•;,_</.;\:::-;;>'l'.f'1⁄4r,'  24.25%  IMMUNOGLOBULINS  19100020302072  Gammagard  Immune Globulin (Human} IV or Subcutaneous Soln 10
            GM/lOOML ,:.-: -4,..:> ---"'(\_\'  27.55%            "-f.' '3⁄4','t, '  ·  mcro rt Ill  .  9  \: ( · £;  I k " \Q'' '  I  '(/[ ---  V 2,J ,  t \ \\ .._ -----------!  '  "l  \(,1. '-,  ,/_"'◊  ,  .'<vo.'.\0'  ·• .=,;·c·'."f\·>·:> 

      

    

     

    
      
        


    

    
      
        

      

      
                                   IMMUNOGLOBULINS IMMUNOGLOBULINS IMMUNOGLOBULINS IMMUNOGLOBUUNS IMMUNOGLOBULINS
            IMMUNOGLOBULINS IMMUNOGLOBULINS IMMUNOGLOBULINS lMMUNOGLOBULINS  '  ,-....  --..._,_  3⁄4  "  IMMUNOGLOBULINSImmunological Agents Immunological AgentsImmunological Agents lmmunolog!cal Agents Immunological Agents Immunological Agents
            Immunological Agents Immunological Agents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppresslve Agents tmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents
            lmmunosuppressive Agents lmmunosuppresslve Agents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents ImmunosuppressiveAgents lmmunosuppressive
            Agents fmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppresslve Agents ImmunosuppressiveAgents ImmunosuppressiveAgents lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppressive Agents
            lmmunosuppressive Agents lmmunosuppressive Agents lmmunosuppresslve Agents Inflammatory Bowel Agents  :',"'  19100020102068 Bivigam19100020302068 Gammagard19100020102042 Flebogamma19100020102076 F!ebogamma Dlf19100020302076
            Gammagard19100020102042 Flebogamma19100020302064 Gammagard19100020102038 F!ebogamma19100020102076 Flebogamma DIF19100020302076 Gammagard 9025055400e520 Taltz  44604055002120 Nuca!a  99403030300620 Myfortic99404070002020 Rapamune99408020002120
            Nulojix99402020002010 SandlMMUNE99403030101920 CelJCept99404070000320 Rapamune99405015002120 51mulect  Immune Globulin {Human) lVSoln S GM/50MLImmune GlobuHn (Human) IV or Subcutaneous Soln 5 GM/50ML Immune Globul!n (Human) JV Soln 10
            GM/200MLImmune Globulin (Human) IV Soln 20 GM/200MLImmune Globulin (Human) IV or Subcutaneous Soln 20 GM/200ML Immune Globulin {Human) IVSoln 10 GM/200MlImmune Globulin (Human} JV or Subcutaneous Soln 2.5 GM/25MLImmune Globulin {Human) IV Soln
            5 GM/lOOML Immune Globulin (Human) IV Soln 20 GM/200MLImmune Globulin {Human) JV or Subcutaneous Soln 20 GM/200MLlxekizumab Subcutaneous Soln Prefil!ed Syringe 80 MG/ML Mepol!zumab For lnj 100 MG  19200040002100 Antivenin Micrurus Fulvil
            Antivenin Micrurus Fulvlus For IVSoln  Patlromer Sorbitex calcium For Susp Packet 16.8 GM (Base Eq) lnfllximab-dyyb For IV lnj 100 MGPatiromer Sorbitex Calcium For Susp Packet 25.2 GM (Base Eq) Etanercept For Subcutaneous lnj 25
            MG  99450060203030 Veltassa52505040202120 lnflectra99450060203040 Veltassa66290030002120 Enbrel99450060203020 Ve!tassa99402020000110 SandlMMUNE99402540102220 Atgam99404035000325 Zortress99404080000120 Prograf99402020300150 Neoral99403030300630
            Myfortic99404080000105 Prograf99402020000140 SandlMMUNE99403030100120 Ce!ICept99404035000330 Zortress99404080002010 Prograf99402020302020 Neora!99404035000320 Zortress99404080000110 Prograf99402020002005 SandlMMUNE99403030100330
            CelfCept99404070000310 Rapamune99405015002110 S!mulect99402020300120 Neoral99403030202120 CelJCept Intravenous99404070000330 Rapamune99406010000305 lmuran  Patkomer Sorbitex calcium For Susp Packet 8.4 GM {Base Eq) Cydosporine Cap 25
            MGLymphocyte Immune Globulin Anti-Thymocyte G lnj 50 MG/ML(Eq}Everollmus Tab 0.5 MG Tacro!imus cap 5 MGCyclosporine Modified cap 100 MGMycophenolate Sodium Tab DR 360 MG (Mycophenolic Add Equiv} Tacrolimus Cap 0.5 MGCyclosporinecap 100 MG
            Mycophenolate Mofetil Cap 250 MG Evero!imusTab 0.75 MGTacrolimus lnJ 5 MG/MLCyclosporine Modified Oral So!n 100 MG/Ml Everolimus Tab 0.25 MGTacrolimus Cap 1 MG Cyclosporine IV So!n 50 MG/MLMycophenolate Mofeti1Tab 500 MG Siro!imus Tab 0.5
            MGBaslliximab For IV Soln 10 MGCyclosporlne Modified cap 25 MGMycopheno!ate Mofetil Hd For IV Soln 500 MG (Base Equiv)Sirolimus Tab 2 MG Azathioprine Tab SO MG  99402020300130 CycloSPORINE Modified Cyclosporlne Modified Cap 50 MG  Mycophenolate
            Sodium Tab DR 180 MG (Mycophenoltc Add Equiv) Skolimus Oral Soln 1 MG/MLBelatacept For IV Infusion 250 MG Cyclosporine Oral Soln 100 MG/MLMycophenolate Mofetil For Oral Susp 200 MG/ML Sirolimus Tab 1 MGBasi!ix!mab For IV Soln 20 MG  ,/
            ,5..),\,-:,. I f"{"i- -,  ,.;.-.;!' .o· ,,......._. - ·r,"  52503080002120 Entyvio  Vedolizumab For IV Solution 300
            MG  24.25%27.55%25.00%  24.25%27.55%25.00%  27.SS%  25.00%24.25%27.55%15.50%15.50%15.50%15.50%15.50%15.50%16.75%15.50%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16J)0%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%  ,_'::;I//  ''\




            •·l,t, :  16.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                         lnterleukin•l Blockers  66450060002120  Arcalyst  Rilonacept For lnj 220
            MG    16.75%    lnterleukin-1Receptor Antagonist{lL-lRa) RHEUMAT  6626001000E520  Kineret  Anakinra Subcutaneous So!n Prefilled Syringe 100 MG/0.67ML    16.00%    IRON OVERLOAD-ANTIDOTES  93000020102110  Desferal  Deferoxamine Mesylate For lnj
            500 MG    16.75%    IRON OVERLOAD-ANTIDOTES  93100028000320  Ferriprox  Deferlprone Tab 500 MG    16.00%    IRON OVERLOAD-ANTIDOTES  93100025007330  ExJade  Deferasirox Tab For Oral Susp 250 MG    15.25%    IRON
            OVERLOAD-ANTIDOTES  93000020102130  Desferal  Deferoxamine Mesylate For lnj 2 GM    16.7S%    IRON OVERLOAD-ANTIDOTES  93100025007340  Exjade  Deferaslrox Tab For Oral Susp 500 MG    15.25%    IRON
            OVERLOAD-ANTIDOTES  93100025000320  Jadenu  DeferaslroxTab 90 MG    16.00%    IRON OVERLOAD-ANTIDOTES  9310002S000340  Jadenu  Deferasirox Tab 360 MG    16.00%    IRON OVERLOAO-ANTIDOTES  93100025007320  Exjade  DeferasiroxTab For Oral Susp 125
            MG    15.25%    IRON OVERLOAD-ANTIDOTES  93100025000330  Jadenu  DeferaslroxTab 180 MG    16.00%    IRON REPLACEMENTS  82300085102020  Ferr!ecit  Sod Ferric Gluc Cmplx In Sucrose IV Soln 12.S MG/Ml {Fe Eq)    16.00%    IRON
            REPLACEMENTS  82300048002020  Venofer  Iron Sucrose fnj 20 MG/ML (Fe Equiv)    16.00%    LHRH Analogs  21405010106405  Lupron Depot  leuprofide Acetate For lnj Kit3.75 MG    16.00%    LHRH Analogs  21405010156420  Lupron Depot  leupro!ide
            Acetate {3 Month) For lnj Kit 11.25 MG    16.00%    Local Anesthetics- Topical  90850025306420  Qutenza  Capsalcln Patch 8% & Cleansing Gel Kit    16.00%    MEDICAL DEVICES  97051050106300  Omnitrope Pen 10 lnJ De  *Injection Device -
            Misc***    16.25%    MOUTH/THROAT/DENTAL AGENTS  88501000002000  Caphosol  *Artificial Saliva - Solution*0    16.00%    Movement Disorder Drug Therapy  62380070000310  Xenazine  TetrabenazineTab 12.5 MG    16.75%    Movement Disorder Drug
            Therapy  62380070000320  Xenazine  Tetrabenazine Tab 25 MG    16.75%    MULTIPLE SCLEROSIS  30300010004010  Acthar HP  Cortkotropin lnj Gel 80 Unit/ML    16.00%    MULTIPLE SCLEROSIS AGENTS  6240003010E520  Copaxone  Glatiramer Acetate Soln
            Prefllled Syringe 20 MG/Ml    16.75%    MULTIPLE SCLEROSIS AGENTS  62403075300250  Plegridy Starter Pack  Peginterferon Beta-la So!n Pen·lnj 63 & 94 MCG/0.SMl Pack    16.00%    MULTIPLE SCLEROSIS AGENTS  62405525006520  Tecftdera  Dimethyl
            Fumarate Capsule Delayed Release 120 MG    16.00%    MULTIPLE SCLEROSIS AGENTS  62403060506420  Betaseron  Interferon Beta-lb For lnj Kit 0.3 MG    16.25%    MULTIPLE SCLEROSIS AGENTS  62405050001320  Tysabri  Natal!zumab for IV lnj Cone 300
            MG/15Ml    18.00%    MUlTJPLE SCLEROSIS AGENTS  6240003010ES40  Copaxone  Glatiramer Acetate Soln Prefilled Syringe 40 MG/ML    16.75%    MUlTIPLE SCLEROSIS AGENTS  6240307530E520  Plegridy  Peginterferon Beta-la Soln Prefi!led Syringe 125
            MCG/0.SML    16.00%    MULTIPLE SCLEROSIS AGENTS  62405525006540  Tetfidera  Dimethyl Fumarate Capsule Delayed Release 240 MG    16.00%    MULTIPLE SCLEROSIS AGENTS  62403075300220  Plegricly  Peglnterferon Beta-la Soln Pen-injector 125
            MCG/0.5Ml    16.00%    MULTIPLE SCLEROSIS AGENTS  62405525006320  Tecfidera  Dimethyl Fumarate Capsule DR Starter Pack 120 MG & 240 MG    16.00%    MULTIPLE SCLEROSIS AGENTS  62403060456420  Avonex  Interferon Beta-la For IM lnj Kit30MCG
            (33MCG{6.6MU)/Vial)    16.75%    MULTIPLE SCLEROSIS AGENTS  6240307530ESSO  P/egridy Starter Pack  Peginterferon Beta-la Soln Pref Syr 63 & 94 MCG/0.SML Pack    16.00%    MULTJPLE SCLEROSIS AGENTS  62406030007420  Ampyra  Dalfamprfdine Tab
            SR 12HR 10 MG    15.25%    MULTIPLE SCLEROSIS AGENTS  62404070000330  Aubagio  Terlffunomlde Tab 14 MG    23.75%    MULTIPLE SCLEROSIS AGENTS  62403060502120  Betaseron  Interferon Beta-lb For In] 0.3 MG    16.25%    MULTIPLE SCLEROSIS
            AGENTS  62405010002020  Lemtrada  Alemtuzumab IV lnj 12 MG/1.2ML (10 MG/ML)    16.00%    MUlTIPLE SCLEROSIS AGENTS  62404070000320  Aubaglo  Teriflunomide Tab 7 MG    23.75%    MULTIPLE SCLEROSIS AGENTS  62407025100120  Gilenya  Flngofimod HCI
            Cap 0.5 MG (Base Equiv)    16.50%    MUSCULOSKELETAL THERAPY AGENTS  75840015002300  Carticel  *Autologous Cultured Chondrocytes for Implantation*"    16.00%    Neurogenic Orthostatic Hypotenslon (NOH)
            Agents  38700030000150  Northera  Droxldopa Cap 300 MG    16.00%    Neurogenic Orthostatic Hypotension (NOH) -Agents  38700030000130  Northera  Droxidopa Cap 100 MG    16.00%    Neurogenic Orthostatic Hypotension {NOH) -
            Agents  38700030000140  Northern  Droxidopa Cap 200 MG    16.00%    NEUROMUSCULAR AGENTS  74400020052140  Botox  OnabotulinumtoxinA For lnj 200 Unit    16.75%    NEUROMUSCULAR AGENTS  74400020032120  Dysport  Abobotul!numtoxfnA For lnj 500
            Unit    16.75%    NEUROMUSCULAR AGENTS  74503070000320  Ri1utek  Riluzole Tab 50MG    16.00%    NEUROMUSCULAR AGENTS  74400020102018  Myobloc  RimabotufinumtoxinB lnj 2500 UniVO.SML  -\1STP.z,L "-  16.25%    NEUROMUSCULAR
            AGENTS  74400020052120  Botox  Onabotulinumtox!nA For lnj 100 Unit  <,-_\:-, _i;:;;::,· ~/:---.....'\  16.75%    NEUROMUSCULAR AGENTS  74400020102020  Myobloc  Rimabotulinumtox!nB lnj 5000 Unit/ML  <)j7 -¥/.  "  16.25%  ')'',  , ' ,V
            Ye  r,  !.'] omrato Ntim \ •  Gro;H\,  \lf'  ··o,,,i.  .......,  )_ >----' •} '/  \\"'  . ,  ,.,// (J  i°"• ''"'  \ \(;V\ r;,·.,,._ ,Y'cc=1,5"' _  '  ..  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                                 NEUROMUSCULAR




            AGENTS  NEUROMUSCULAR AGENTS  NEUROMUSCUlAR AGENTS  NEUROMUSCULAR AGENTS  OBSOLETO  OPHTHALMIC AGENTS  OPHTHALMIC AGENTS  OPHTHALMIC AGENTS  OPHTHALMIC AGENTS  OPHTHALMIC AGENTS  OPHTHALMIC AGENTS  OPHTHALMIC AGENTS  OPHTHALMIC
            AGENTS  Ophthalmic Agents OSTEOARTHRITIS OF THE KNEE  OSTEOARTHRITIS OF THE KNEE  OSTEOARTHRITIS OF THE KNEE  OSTEOARTHRITIS OF THE KNEE  OSTEOARTHRITIS OF THE KNEE  OSTEOARTHRITIS OF THE KNEE  OSTEOPOROSIS- BISPHOSPHONATES  OSTEOPOROSIS-
            BlSPHOSPHONATES  OSTEOPOROSIS- BlSPHOSPHONATES  OSTEOPOROSIS- BlSPHOSPHONATES  OSTEOPOROSIS· BISPHOSPHONATES  OSTEOPOROSIS- BISPHOSPHONATES  OSTEOPOROSIS· BISPHOSPHONATES  OSTEOPOROSIS· BISPHOSPHONATES  OSTEOPOROSIS·
            BISPHOSPHONATES  OSTEOPOROSIS- BISPHOSPHONATES  Progesterone Receptor Antagonists ANTIDlABETICS  Progestin Contraceptives- IUD  Progestln Contraceptives -
            IUD  PROGESTINS  PSORIASIS  PSORIASIS  PSORIASIS  PSORIASIS  PSORIASIS  PSORIASIS  PSORIASIS  PSORIASIS  PULMONARY ARTERIAL HYPERTENSION  PUlMONARY ARTERIAL HYPERTENSION  PULMONARY ARTERIAL HYPERTENSION  PULMONARY ARTERIAL
            HYPERTENSION  PULMONARY ARTERIAL HYPERTENSION  PULMONARY ARTERIAL HYPERTENSION  PULMONARY ARTERIAL HYPERTENSION  74400020202120 Xeomln  74400020032115 Dysport  74400020202130 Xeomin  74400020102022 Myob!oc  90250515002120
            AMEVIVE  86300010002320 Ozurdex86700065002120 Visudyne86300017102320 Retisert86801060002020 Jetrea86655010002020 Eylea8665S060002012 Lucentls 86655060002020 lucentis86655050302020 Macugen86300080101820 Triesence 7580004000ES30
            Synvlsc7580004000E560 Synvlsc One 7580006000E520 OrthoVisc 7580007010ES20 Euf!exxa7580007010ES25 Supartz75800070102024 Hyafgan30042090002120 Zoledronic Acid30042090001320 Zo!edronic Add30042060102012 Pamldronate Disodium30042060102006
            Pam!dronate Dlsodlum30042060102009 Pamldronate Dlsodium30042090002016 2oledron!c Acid  30042060102120 Aredia30042090002020 Redast  30042060102140 Aredla30042048102030 Boniva  27304050000330 Korlym25200050005320 Mirena25300005002320
            lmplanon26000010101710 Makena  9025058500E520 Stelara  66700015000330 otezla  9025058500E540 Stelara90250515002130 AMEVIVE  9025057500E520 Cosentyx  90250585002020 Ste1ara  66700015008720 otezla  40134050000340 Adempas40160015000330
            Tracleer40170080050415 Orenltram40134050000320 Adempas40160007000320 Letairis40170080002020 Tyvaso40134050000350 Adempas  lncobotulinumtoxinA For lnJ 50 Unit AbobotuHnumtoxinA For lnj 300 Unit lncobotulinumtoxinA For lnj 100 Unit
            RimabotulinumtoxinB lnj 10000 Unit/2Ml  ALEFACEPT FOR IV INJ 7.5 MG  Dexamethasone lntravitreal lmplant0.7 MG Verteporfin For IV So!n 15 MG {2 MG/ML) F!uoclnolone Acetonide lntravitreal lmp!ant0.59 MG  Ocrip!asmin lntravitreal lnj 0.5 MG/0.2ML
            (2.5 MG/ML) Aflibercept lntravitreal lnj 2 MG/0.0SML (40 MG/ML)  Ranibizumab lntravitreal lnJ 0.3 MG/0.05Ml {6 MG/ML) Ranibizumab lntravitreal lnj 0.5 MG/0.0SML (10 MG/ML)  Pegaptanib Sodium lntravitreous lnj 0.3 MG/90 Micro!iter Triamcinolone
            Acetonlde Ophth lnj 40 MG/MLHylan Intra-articular Solution Prefilled Syringe 16 MG/2MLHylan Intra-articular Solution Prefilled Syringe 48 MG/6ML Hyaluronan lntra-articularSofnPrefi![ed Syringe 30 MG/2ML Sodium Hyaluronate lntra-art!CtJ!ar Soln
            Pref Syr 20 MG/2Ml Sodium Hyaluronate Intra-articular Solo PrefSyr 25 MG/2.5Ml Sodium Hyaluronate Intra-articular lnj 20 MG/2MLZoledronlc Acid For IV Soln 4 MGZoledronic Acid lnj Cone For N Infusion 4 MG/SML Pamidronate Dlsodtum IV So!n 9
            MG/MlPamidronate Disodium IV So!n 3 MG/Ml Pamidronate Disodium IV Soln 6 MG/Ml 2oledron!c Acid IV Soln 4 MG/lOOMLPam!dronate Dlsodium For lnj 30 MG Zo!edronic Acid IV Soln 5 MG/lOOMl Pamidronate Dlsodium For lnj 90 MGlbandronate Sodium IVSoln 3
            MG/3ML (Base Equivalent)Mifepristone Tab 300 MGlevonorgestrel Re!easlng IUD 20 MCG/24HR {52 MG Total) Etonogestrel Subdermal Implant 68 MG Hydroxyprogesterone Caproate lM in Oil 250 MG/ML Ustekinumab Soln Prefilled Syringe 45 MG/0.5Ml
            ApremilastTab 30 MGUstekinumab Soln Prefilled Syringe 90 MG/ML Alefacept For IM lnj 15 MGSecukinumab Subcutaneous So!n Prefilled Syringe 150 MG/Ml U5TEKINUMAB INJ 45 MG/0.SMLApremilastTab Starter Therapy Pack 10 MG & 20 MG & 30
            MG  90250575000520 Cosentyx Sensoready Pe Secukinumab Subcutaneous Soln Auto-injector 150 MG/ML  Riociguat Tab 2 MG Bosentan Tab 125 MGTreprostlnll Ololamfne Tab CR 0.25 MG (Base Equiv) RiociguatTab 1 MGAmbrlsentan Tab 10 MGTreprostinil
            Inhalation Solution 0.6 MG/Ml RiociguatTab 2.5
MG  16.25%16.75%16.25%16.25%15.50%16.00%16.25%16.00%16.00%16.75%16.75%16.75%16.25%15.50%16.75%16.75%16.75%16.75%16.25%16.75%.35.00%34.20%16.00%16.00%16.00%35.00%16.00%35.00%16J)O%16.00%16.00%15.50%15.25%16.75%16.00%16.00%16.00%15.50%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00%16.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                 q:-.{S,  PULMONARY ARTERIAL HYPERTENSION  40160050000320  Opsumit  Macitentan Tab 10
            MG  16.00%  PULMONARY ARTERIAL HYPERTENSION  40134050000310  Adempas  Riodguat Tab 0.5 MG    PULMONARY ARTERIAL HYPERTENSION  40160007000310  Letairis  Ambrisentan Tab S MG  16.00%16.00%  PULMONARY ARTERIAL
            HYPERTENSION  40170080102040  Remodulin  Treprostinil Sodium JnJ 10 MG/ML(Base Equiv)  16.00%  PULMONARY ARTERIAL HYPERTENSION  40170080050420  Orenitram  Treprostinil Diolamine Tab CR 1 MG (Base Equiv)  16.00%  PULMONARY ARTERIAL
            HYPERTENSION  40134050000330  Adempas  Riodguat Tab 1.5 MG  16.00%  PULMONARY ARTERIAL HYPERTENSION  40160015000320  Tradeer  Bosentan Tab 62.5 MG  16.00%  PULMONARY ARTERIAL HYPERTENSION  40143060101920  Revatio  Si1denafil Citrate For
            Suspension 10 MG/ML  16.75%  PULMONARY ARTERIAL HYPERTENSION  40170080050410  o,enitram  Treprostinil Diolamine Tab CR 0.125 MG (Base Equiv)  16.00%  PULMONARY ARTERIAL HYPERTENSION  40170040102110  Epoprostenol Sodium  Epoprostenol Sodium For
            Inj 0.5 MG  16.00%  PULMONARY ARTERIAL HYPERTENSION  40170080050425  Orenitram  Treprostinil Diolamlne Tab CR 2.5 MG (Base Equiv)  16.00%  PULMONARY ARTERIAL HYPERTENSION  40143060100320  Revatio  Si!denafil Citrate Tab 20 MG  40.00%  PULMONARY
            ARTERIAL HYPERTENSION  40143080000320  Adcirca  Tadalafil Tab 20 MG (PAH)  15.75%  PULMONARY ARTERIAL HYPERTENSION  40170060002020  Ventavls  lloprost Inhalation Solution 10 MCG/ML  16.00%  PULMONARY ARTERIAL
            HYPERTENSlON  40170080102020  Remodulln  Treprostinil Sodium lnj 2.5 MG/Ml {Base Equiv)  16.00%  PULMONARY ARTERIAL HYPERTENSION  40170060002040  Ventavis  l!oprost Inhalation Solution 20 MCG/ML  16.00%  PULMONARY ARTERIAL
            HYPERTENSlON  40170080102030  RemoduHn  Treprostinll Sodium lnj 5 MG/ML {Base Equiv}  16.00%  PULMONARY ARTERIAL HYPERTENSION  40143060102020  Revatio  Sildenafil atrate IV Soln 10 MG/12.SML (Base Equivalent)  16.75%  PUlMONARY ARTERIAL
            HYPERTENSION  40170040102130  Epoprostenol Sodium  Epoprostenol Sodium For lnj 1.5 MG  16.00%  PULMONARY ARTERIAL HYPERTENSION  40170080102010  Remodulin  Treprostinll Sodium lnj 1 MG/Ml(Base Equiv)  16.00%  Pulmonary Fibrosis
            Agents  45550060000120  Esbriet  Pirfenidone Cap 267 MG  16.00%  Pulmonary Fibrosis Agents  45554050200130  Ofev  Nintedanib Esylate Cap 150 MG {Base Equivalent)  16.00%  Pulmonary Fibrosis Agents  45554050200120  Ofev  Nintedanib Esylate Cap
            100 MG (Base Equivalent}  16.00%  RESPIRATORY AGENTS- MISC.  45100010102110  Ara!astNP  Alphal-Proteinase Inhibitor (Human) For IVSoln 500 MG  16.00%  RESPIRATORY AGENTS - MISC.  45000070001820  Surfaxin  Lucinactant lntratracheal Susp 30
            MG/ML  16.00%  RESPIRATORY AGENTS- MISC.  45100010102108  Arafast  A!phal-Proteinase Inhibitor (Human) For IV Solo 400 MG  15.50%  RESPIRATORY AGENTS - MISC.  45100010102118  Aralast  Afphal-Proteinase Inhibitor (Human) For JV Soln 800
            MG  15.50%  RESPIRATORY AGENTS- MISC.  45100010102020  Glassia  Alphal-ProteinaseInhibitor (Human) lnj 1000 MG/SOML  15.75%  RESPIRATOR'r AGENTS- MISC.  45100010102120  Aralast NP  Alphal-ProteinaseInhibitor {Human) For IV Solo 1000
            MG  16.00%  ResplratorySyncytia!Virus {RSV) Agents  19502060002015  Synagis  Palivlzumab IM So!n 50MG/0.SML  15.75%  Respiratory Syncytial Virus {RSV) Agents  19502060002020  synagis  Palivizumab IM Soln 100 MG/Ml  15.75%  Respiratory Syncytial
            Virus (RSV) Agents  1260407S002120  Vlrazole  Rlbavirin For lnhal Soln 6 GM  16.00%  Respiratory Tract Agents  40120070000310  Uptravi  SelexipagTab 200 MCG  15.50%  Respiratory Tract Agents  40120070000340  Uptravi  SelexipagTab 1400
            MCG  15.50%  Respiratory Tract Agents  40120070000315  Uptravi  Selexlpag Tab 400 MCG  15.50%  Respiratory Tract Agents  40120070000320  Uptravi  Selexipag Tab 600 MCG  15.50%  Respiratory Tract Agents  40120070008720  Uptravi  Se!exipagTab
            Therapy Pack200 MCG (140) & 800 MCG (60)  15.50%  Respiratory Tract Agents  40120070000345  Uptravi  Selexipagfab 1600 MCG  15.50%  Respiratory Tract Agents  40120070000330  Upt,avi  Selexipag Tab 1000 MCG  15.50%  Respiratory Tract
            Agents  40120070000335  Uptravl  Selexipag Tab 1200 MCG  15.50%  Respiratory Tract Agents  40120070000325  Uptravi  Selexipag Tab 800 MCG  15.50%  RHEUMATOID ARTHRITIS MISC  6650007000E520  Actemra  Tocilizumab Subcutaneous Solo Prefilled
            Syringe 162 MG/0.9Ml  15.50%  RHEUMATOID ARTHRITIS MISC  66500070002035  Actemra  Toci!izumab IV lnj 200 MG/lOML  15.50%  RHEUMATOJD ARTHRITIS MISC  66400010002120  Orenda  Abatacept For IV So!n 250 MG  16.25%  RHEUMATOJD ARTHRITIS
            MISC  66603065100320  Xeljanz  Tofacitinib Citrate Tab 5 MG (Base Equivalent)  16.00%  RHEUMATOID ARTHRITIS MISC  66500070002040  Actemra  Tocftizumab IVlnj 400 MG/20ML  15.50%  RHEUMATOID ARTHRITIS MISC  6640001000£520  Orencia  Abatacept
            Subcutaneous Sofn Prefil!ed Syringe 125 MG/ML . ---··.-1-  16.25%  RHEUMATOID ARTHRITIS MISC  66280050000320  Arava  Leflunomlde Tab 20 MG ( \\•l1::T._'c,••- • 1(,'J""  16.00%  RHEUMATOID ARTHRITIS MISC  66460020002120  llaris  canak:!numab For
            lnJ 180 MG /;''.r,:'7 ...,_i,J'\-v.),,,,\-  \ 16.75%  I  ' f Contrato Nu \ \) \.  1  mer, i 

      

    

     

    
      
        


    

    
      
        

      

      
                   RHEUMATOID ARTHRITIS MISC  66500070002030  Actemra  Tocilfzumab IV lnj80 MG/4Ml    RHEUMATOID
            ARTHRITIS MISC  66280050000310  Arava  leflunomide Tab 10 MG  15.50%16.00%  Short Bowel Syndrome (SBS) Agents  52533070006420  Gattex  Teduglutide (rDNA) For lnj Kit 5 MG    Stem Cell Mobllizers  82502060002020  Mozobil  Plerixafor Subcutaneous
            lnj 24 MG/1.2Ml (20 MG/Ml)  16.00%16.75%  Systemic lupus Erythematosus Agents  99422015002120  Ben!ysta  Belimumab For IVSoln 120 MG  16.75%  Systemic lupus Erythematosus Agents  99422015002140  Benlysta  Belimumab For IV Soln 400
            MG  16.75%  Therapeutic Nutrients/Minerals/Elect,olytes  93100028002020  Ferriprox  Deferiprone Oral Soln 100 MG/ML  15.50%  TUBERCULOSIS  09000015100320  Sirturo  Bedaquiline Furna rate Tab 100 MG (Base Equiv)  16.00%  Tumor Nec,osls Factor
            Alpha Blockers  52S05020106460  Cimzia Starter Kit  Certo!izumab Pegol lnj Kit 6X 200 MG/Ml  16.75%  Tumor Nec,osis Factor Alpha Blockers  6627004000DS40  Simponi  Go!imumab Subcutaneous Sein Auto-injector 100 MG/ML  16.25%  Tumor Necrosis
            Factor Alpha Blockers  6629003000ES30  Enbrel  EtanerceptSubcutaneous Soln Prefilled Syringe SO MG/ML  16.75%  Tumor Necrosis Factor Alpha Blockers  52505020106420  Cimzia  Certo!izumab Pegol For lnj Kit 2 X 200 MG  16.75%  Tumor Necrosis
            Factor Alpha Blockers  66270040002015  SimponiAria  Gofimumab IV Soln SO MG/4ML  16.25%  Tumor Necrosis Factor Alpha Blockers  6629003000D530  Enbrel SureC!ick  EtanerceptSubcutaneous Solution Auto-injector 50 MG/Ml  16.75%  Tumor Necrosis
            Factor Alpha Blockers  52505040002120  Remicade lnflbdmab Fot IV lnj100 MG    16.00%  Tumor Necrosis Factor Alpha Blockers  6627004000E520  5imponi  Golimumab Subcutaneous So!n Prefi!led Syringe SO MG/0.SML  16.2S%  Tumor Necrosis Factor Alpha
            Blockers  S2S05020106440  Cimzia  Certolizumab Pegol lnj Kit 2X 200 MG/Ml  16.75%  Tumor Necrosis Factor Alpha Blockers  6627004000D520  Simponi  Golimumab Subcutaneous Soln Auto-injector 50 MG/0.SML  16.25%  Tumor Necrosis Factor Alpha
            Blockers  6629003000E525  Enbrel  Etanercept Subcutaneous Soln Prefi!led Syringe 25 MG/0.SML  16.75%  Tumor Necrosis Factor Alpha Blockers  6627001500F420  Humira Pen  Ada!Jmumab Pen-injector Kit 40 MG/0.8Ml  16.75%  Tumor Necrosis Factor Alpha
            Blockers  6627004000E540  Simponi  Golimumab Subcutaneous Soln Prefilled Syringe 100 MG/ML  16.25%  Tumor Necrosis Factor Alpha Blockers  6627001500F810  Humira  Adaflmumab Prefilled Syringe Kit 20 MG/0.4Ml  16.75%  Tumor Necrosis Factor Alpha
            Blockers  6627001500F820  Humira  Ada!imumab Prefllled Syringe Kit 40 MG/0.SML  16.7S%  Tumor Necrosis Factor Alpha Blockers  66290030006420  Enbrel  Etanercept For Subcutaneous Jnj Kit 25 MG  16.75%  Tumor Necrosis Factor Alpha
            Blockers  6627001500F805  Humira  Adalimumab Prefilled Syringe Kit 10 MG/0.2Ml  16.75%  Viscosupplements  7580006000e515  Hymovis  Hya!uronan Intra-articular Soln Ptefilled Syringe 24
            MG/3Ml  15.50%  (blank)  96544244002900  Gabapentin  Gabapentin Powder  15.50%  (blank)  30201010102030  DDAVP  Desmopressin Acetate lnj 4 MCG/Ml  15.50%  (blank)  30089902506420  lupaneta Pack  leuproltde (1 Mon) lnj 3.75 MG &
            Norethindrone Tab 5 MG Kit  15.50%  {blank)  21700030000105  Hydroxyurea  Hydroxyurea Cap 500 MG  15.50%  (blank)  85153060101310  Aggrastat  Tlroflban HCI IV Cone 3.75 MG/lSML {250 MCG/ML) (Base Equiv)  15.50% 

      

    

     

    
      
        


    

    
      
        

      

      
                         Anexo 1: Lista de Descuentos para Medicamentos de Alto Cosio que sean despachados por las
            Farmacias Jndependlentes y Cadenas Locales {2017)  Category  GPI  Drug Name  GP! Name  Actual Discount  Agents for Gaucher Disease  82700020002020  Ceredase  A!glucerase IV Soln 80 Unit/ML  16.00%  Agents for Gaucher
            Disease  82700085102120  Vptiv  Ve!aglucerase Alfa For lnj 400 Unit  16.00%  Agents for Gaucher Disease  82700040600120  Cerdelga  Elig!ustat Tartrate Cap 84 MG {Base Equivalent)  16.00%  Agents for Gaucher
            Disease  82700050002110  Cerezyme  lmiglucerase For lnj 200 Unit  16.00%  Agents for Gaucher Disease  82700070000120  Zavesca  Miglustat Cap 100 MG  16.00%  Agents for Gaucher Disease  82700080102120  Elelyso  Taliglucerase Alfa For lnj 200
            Unit  16.00%  Agents for Gaucher Disease  82700050002120  Cerezyme  lmiglucerase For lnj 400 Unit  16.00%  ANALGESICS -ANTI-INFLAMMATORY  6620003000201S  Gold Sodium Thiomalate  Gold Sodium Thiomalate lnj 50 MG/ML    ANALGESICS -
            NonNarcotic  64154090102020  Prialt  Zlconotide Acetate lntrathecal lnj 100 MCG/Ml  16.00%  ANALGESICS- NonNarcotic  64154090102030  Malt  Ziconotide Acetate Jntrathecal Jnj 500 MCG/SML  16.75%  ANALGESICS -
            NonNarcotic  64154090102010  Prialt  Ziconotlde Acetate lntrathecal lnj 500 MCG/20ML {25 MCG/ML)  16.75%  ANDROGENS-ANABOLIC  23100030802030  Aveed  Testosterone Undecanoate IM Jnj In Oil 750 MG/3ML
            (250MG/ML)  16.75%  ANTIARRHYTHM!CS  35400025000110  Tikosyn  Dofeti1ide Cap 125 MCG (0.125 MG)  16.00%15.50%  ANTIARRHYTHMICS  35400025000120  Tikosyn  Dofetilide Cap 250 MCG (0.25
            MG)  15.50%  ANTIARRHYTHM!CS  35400025000130  Tikosyn  Dofetilide cap 500 MCG {0.5 MG)  15.50%  ANTIASTHMATICAND BRONCHODILATORAGENTS  44603060002120  Xolalr  Omalizumab For In] 150 MG  16.25%  ANTIB!OTICS-
            AMINOGlYCOStDES  07000070102030  Tobramycin Sulfate  TOBRAMVCIN SULFATE INJ 40 MG/ML  41.75%  ANTIBIOTICS-AMINOGLVCOStDES  07000070102020  Tobramycin Sulfate  Tobramycln Sulfate lnj 10
            MG/ML  41.75%  ANTIBIOTICS-AMINOGlVCOStDES  07000070102034  Tobramycin Sulfate  Tobramycin Sulfate In] 80 MG/2ML {40 MG/ML)  41.75%  ANTIBIOTICS-AMINOGLYCOSIDES  07000070102105  Tobramycin Sulfate  Tobramycin Sulfate For lnj 1.2
            GM  41.75%  ANTIBIOTICS-AMINOGLVCOSIDES  07000070102039  Tobramycin Sulfate  Tobramycin Sulfate lnj 2 GM/50Ml {40 MG/Ml}  41.75%  ANTIBIOTICS-AMINOGLVCOSIDES  07000070102022  Tobramycln Sulfate  Tobramycin Sulfate IV So!n 10
            MG/ML  41.75%  ANTIBIOTJCS-AMINOGLVCOSIDES  07000070102038  Tobramycln Sulfate  Tobramycin Sulfate lnj 1.2 GM/30ML{40 MG/ML)  41.75%  Anti-Catap!ect!c Agents  62450060202020  Xyrem  Sodium Oxybate Oral Solution 500
            MG/Ml  16.00%  ANTICOAGULANTS  83101010102020  Fragmin  Dalteparin Sodium lnj 2500 Unit/0.2Ml  16.00%  ANTICOAGULANTS  83101020102013  lovenox  Enoxap.irin Sodium lnj 40
            MG/0.4ML  16.00%  ANTICOAGULANTS  83103030102035  Arixtra  FondaparinuxSodium Subcutaneous lnj 5 MG/0.4ML  16.00%  ANTICOAGULANTS  83101010102065  Fragmin  Dalteparin Sodium In] 25000
            Unit/Ml  16.00%  ANTICOAGULANTS  83101020102050  Lovenox  Enoxaparin Sodium lnj 300 MG/3Ml  16.00%  ANTICOAGULANTS  83370060000340  Xarelto  Rivaroxaban Tab 20 MG  16.00%  ANTICOAGULANTS  83101010102040  Fragmin  Dalteparin Sodium lnj 5000
            Unit/0.2Ml  16.00%  ANTICOAGULANTS  83101020102014  lovenox  Enoxaparin Sodium In] 60 MG/0.6ML  16.00%  ANTICOAGULANTS  83103030102040  Arixtra  FondaparinuxSodlumSubcutaneous lnj 7.5
            MG/0.6Ml  16.00%  ANTICOAGULANTS  83101010102015  Fragmin  Da!teparin Sodium lnJ 10000 Unit/Ml  16.00%  ANTICOAGULANTS  83101020102012  Lovenox  Enoxaparin Sodium lnj 30 MG/0.3ML  16.00%  ANTICOAGULANTS  83103030102020  Arixtra  Fondaparinux
            Sodium Subcutaneous Jnj 2.5 MG/0.SML  16.00%  ANTICOAGULANTS  83101010102045  Fragmin  Dalteparin Sodium lnj 7500 Unit/0.3Ml  16.00%  ANTICOAGULANTS  83101020102015  lovenox  EnoxaparinSodlurn lnj 80
            MG/0.8ML  16.00%  ANTICOAGULANTS  83103030102045  Arixtra  Fondaparinux Sodium Subcutaneous JnJ 10 MG/0.8ML  16.00%  ANTICOAGULANTS  83101010102056  Fragmin  Dalteparin Sodium lnj 15000
            Unlt/0.6ML  16.00%  ANTICOAGULANTS  83101020102018  Lovenox  Enoxaparin Sodium lnj 120 MG/0.8ML  16.00%  ANTICOAGULANTS  83370060000320  Xarelto  Rivaroxaban Tab 10 MG  16.00%  ANTICOAGULANTS  83101010102060  Fragmin  Dalteparin Sodium lnj
            18000 Unit/0.72Ml _,,..·,,s·yi=.zrv'"' -.....:..•  16.00%  ANTICOAGULANTS  83101020102020  Lovenox  Enoxaparin Sodium lnj 150 MG/ML / t.\' ...<P·- i--.3⁄4'I..}...  16.00%  ANTICOAGULANTS  83370060000330  Xarelto  Rivaroxaban Tab 15 MG //(:',;Y
            -_v.r,\\  16.00%  /'t'"••·)"'  t '  1 ii  i, ! .l 9 ·  .  v•m  ' '  o, 5' 9/I  tu, - --vo  '  :'y  0, ''"'  \,;.,.,,·. '•.  /,,y_:S  \ ·,.-....:.:...,-:,:...,.:: ,_....,• . /. 

      

    

     

    
      
        


    

    
      
        

      

      
                                                                                                                                       ANTICOAGULANTS  ANTICOAGUlANTS  ANTICOAGULANTS  ANTICONVULSANTS  ANTICONVUL5ANTS  ANTICONVULSANTS  ANTICONVULSANTS  ANTICONVUL5ANTS  ANTICONVUISANTS  ANTICONVULSANTS  ANTICONVULSANTS  ANTICONVULSANTS  ANTICONVULSANTS  ANTIEMETICS  ANTIEMETICS  ANTIEMETICS  ANTIEMETICS  ANTIEMETJCS  ANTIEMETICS  ANTIEMET1CS  Antiemetics  ANTIEMETICS  ANTIEMETICS  Antiemetics  ANTIEMETICS  83101010102053




            Fragmin83101020102016 Lovenox83334050102120 Refludan72600043002020 Keppra72600043000340 Keppra72600043002060 Keppra72600043000350 Keppra72170085000320 Sabril72600043007520 Keppra XR72600043000320 Keppra72600043000330 Keppra72170085003020
            Sabril72600043007530 Keppra XR50250025200330 Anzemet50280035102130 Emend50280020000130 Emend50250025202020 Anzemet50250025200320 Anzemet50280020006320 Emend50250070102010 Aloxl50250065052030 Zofran50280020000110 Emend50280020000120
            Emend502S0065052024 Ondansetron HCI 50250070102020 Aloxi  ANTIFUNGALS  ANTIFUNGALS  11000010101920 Amphotec  11407060001820 Noxafil  Dalteparin Sodium lnj 12500 Unit/0.SML Enoxaparin Sodium lnj 100 MG/ML Lepirudin For IV So!n 50 MG
            Levetiracetam Oral Soln 100 MG/Ml levetiracetam Tab 750 MGlevetiracetam lnj 500 MG/SML{lOO MG/ML) Levetiracetam Tab 1000 MGVigabatrin Tab 500 MG levetiracetam Tab SR 24HR 500 MG levetiracetam Tab 250 MG levetiracetam Tab 500 MG Vigabatrin Powd
            Pack 500 MG levetiracetam Tab SR 24HR 750 MG Do!asetron Mesylate Tab 100 MGFosaprepitant Dirneglumlne For IV Infusion 150 MG (Base Eq) Aprepitant Capsule 125 MGDolasetron Mesylate IV lnj 20 MG/Ml Dolasetron Mesylate Tab SO MGAprepitant Capsule
            Therapy Pack 80 & 125 MGPalonosetron HCI IV Soln 0.075 MG/1.SML {Base Equiv) Ondansetron HCI lnj 40 MG/20ML {2 MG/ML) AprepltantCapsule 40 MGAprepitant Capsule 80 MGOndansetron HCI lnj 4 MG/2ML {2 MG/ML)Palonosetron HCI IV So!n 0.25 MG/SML
            {Base Equivalent}  Amphotericin B Cho!esteryl Sulfate Complex: For lnj 100 MG  ANTIFUNGALS  11500025102130 Cancidas  Posaconazole 5usp 40
            MG/ML  16.00%16.00%16.00%16.00%16.00%16.00%16.00%15.75%16.00%16.00%16.00%15.75%16.00%16.00%16.00%16.00%16.00%16.00%16.00%26.75%15.50",616.00%16.00%15.50%26.75%  16.00%  ANTIFUNGALS  Caspofungin Acetate For IV So!n 70 MG  16.00%  11000010002105
            Amphotericin B  16.00%  ANTIFUNGALS  11407015022020 Diflucan in Dextrose  Amphotericin B For lnj 50 MG  ftuconazole in Dextrose lnj 400 MG/200ML  16.00%  ANTIFUNGAlS  11500010002130 Eraxis  ANTIFUNGALS  11000010301820
            Abe!cet  ANTIFUNGALS  11407080000320 Vfend  Anidu!afungin For IV 5oln 100 MGAmphoterfcln B lipid lnjSusp {For IV Infusion) 5 MG/Ml  15.25%  Voriconazole Tab 50 MG  16.00%16.00%  ANTIFUNGALS  16.00%  ANTJFUNGALS  11500050102120 Mycamlne
            Micafungin Sodium For IVSoln 50 MG 11407015012020 Diflucan in Sodium Chlori Fluconazofe In NaCl 0.9% lnj 400 MG/200ML  16.00%  15.25%  ANTIFUNGALS ANTIFUNGAL5  11407080002120 Vfend IV  Voriconazo!e For Jnj 200
            MG  16.00%  ANTIFUNGALS  ANTIFUNGALS  11407015022010 Diflucan in Dextrose 11500010002120 Eraxis  Fluconazole in Dextrose lnj 200 MG/lOOMl Anidu!afungin For IVSoln 50
            MG  15.25%16.00%  ANTIFUNGALS  15.25%  ANTIFUNGALS  16.00%  ANTIFUNGALS  ANTIFUNGALS  11407015012010 Dif!ucan In Sodium Ch!ori Fluconazole in NaCl 0.9% lnJ 200 MG/100Ml 11407080001920 Vfend Voriconazole For Susp 40 MG/ML11000010101910 Amphotec
            Amphoterlcln B Cho!esteryl Sulfate Complex For lnj 50 MG 11407035002020 Sporanox Jtraconazole Oral Soln 10 MG/Ml  ANTJFUNGALS  11500025102120 Cancldas  Caspofungin Acetate For IV So!n 50 MG  ANTIFUNGALS  11000010401920 ArnBisome  Amphoter!cin B
            liposome IV For Susp 50 MG  11407080000340 Vfend  Voriconazole Tab 200 MG  16.00%  16.00%  16.00%  16.00%  ANTIFUNGALS  Antihemophi!ic Products  11500050102130 Mycamine  16.00%  Micafungin Sodium For JV So!n 100 MG  85100010002139 Hemofil
            M  16.00%  Antihemophific Products  85100010006460 Monodate-P  AntihemophiHc Factor {Human) For lnj 801-1700 Unit  Antihemophilic Products  85100010202145 Recomblnate  Antihemophilic Factor (Human) For lnj Kit 1000 Unit  Antihemophilic Factor
            {Recombinant) For lnj 1241-1800 Unit  42.00%30.00%  40.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                         Antihemoph!lic Products  85100010252150  Advate  Antihemophllic Factor rAHF-PFM For lnj
            1500 Unit  37.75%  Antihemophilic Products  85100028202150  BeneFIX  Coagulation Factor IX (Recombinant) For lnj 2000 Unit  21.00%  Antihemophilic Products  85100010266470  Xyntha So!ofuse  Antihemophillc Factor Recombinant PAF For lnj Kit 3000
            Unit  38.00%  Antihemophllic Products  85100010502130  Obizur  Antihemophilic Factor (Recomb Pore) rpFVJH For lnj 500 Unit  20.00%  Antihemophilic Products  85100015102139  Wilate  Antihemophilic Factor/VWF (Human) For lnj 1000-1000
            Unit  40.00%  Antihemophilic Products  85100020002100  Feiba NF  *Antiinhibitor Coagulant Complex For lnj**  40.00%  Antihemophllic Products  85100028002160  Mononine  Coagulation Factor IX For lnj 250 Unit  40.00%  Antihemophi1ic
            Products  85100030002115  Profilnine SD  Factor IX Complex For lnj 1500 Unit  19.75%  Antihemophi!ic Products  85100010002125  HemofilM  Antihemophflic Factor (Human) For lnj 401-800 Unit  42.00%  Antihemophi!ic
            Products  85100010006410  Monodate-P  Antihemophilic Factor {Human) For lnj Kit 250 Unit  30.00%  Antihemophific Products  85100010202135  Recomblnate  Antihemophi!ic Factor (Recombinant) For lnj 801-1240 Unit  40.00%  Antihemophilic
            Products  85100010252130  Advate  Antihemophl!lc Factor rAHF-PFM For lnj 500 Unit  37.75%  Antihemophllic Products  85100010266440  Xyntha  Antihemophilic Factor Recombinant PAF For lnJ Kit 1000 Unit  38.00%  Antihemophilic
            Products  85100010002140  HemofilM  Antihemophilic Factor (Human) For lnj 1000 Unit  42.00%  Antihemophillc Products  85100010006475  Monoclate-P  Antihemophilic Factor (Human) For lnj Kit 1500 Unit  30.00%  Antihemophilic
            Products  85100010302155  Eloctate  Antihemophi1ic Factor(Recomb) rFVIIIFc For lnj 2000 Unit  20.00%  Antihemoph'ilic Products  85100028202140  BeneFIX  Coagulation Factor IX (Recombinant) For lnj 1000 Unit  21.00%  Antihemophil!c
            Products  85100015102132  Humate•P  Antihemophi!ic Factor/WJF {Human) For lnj 500-1200 Unit  37.00%  Ant!hemophi!lc Products  85100015102190  Afphanate/VWF Complex  Antihemophilic Factor/VWF (Human) For fnj 1500 Unit  40.00%  Antihemophllic
            Products  85100026202145  NovoSeven RT  Coagulation Factor VIia {Recomb) For lnj 5 MG {5000 MCG)  31.75%  Antihemophilic Products  85100030002105  Profilnine SD  Factor IX Complex For lnj 500 Unit  19.75%  AntihemophJl!c
            Products  85100060106420  Kcentra  Prothrombin Complex Cone Human For lnj Kit 500 Unit  20.00%  AntihemophiHc Products  85100010202150  Novoeight  Antihemophillc Factor (Recombinant) For lnj 1500 Unit  20.00%  Antihemophilic
            Products  85100010252170  Advate  Antihemophllic Factor rAHF-PFM For lnj 2000 Unit  37.75%  Ant!hemophi!ic Products  85100028202160  BeneFIX  Coagulation Factor IX {Recombinant} For lnj 3000 Unit  21.00%  Antlhemophillc
            Products  85100010302120  Eloctate  Antihemophilic Factor {Recomb) rFVIIIFc For lnj 250 Unit  20.00%  Antihemoph!lic Products  85100015102120  Humate-P  Antihemophi!fc Factor/VWF (Human) For lnj 250-500 Unit  37.00%  Antihemophilic
            Products  85100015102140  Humate-P  Antihemophilic Factor/VWF (Human) For lnj 1000-2000 Unit  37.00%  Antihemophilic Products  85100026202117  NovoSeven RT  Coagulation Factor VIia {Recomb) For Jnj 1 MG {1000 MCG)  31.75%  Ant!hemophi!ic
            Products  85100028002185  AlphaN!ne SD  Coagulation Factor JX For lnj 1500 Unit  30.00%  Antihemophiltc Products  85100030002150  Bebu!in  Factor IX Complex For lnj 200-1200 Unit  20.00%  Antihemophllic Products  85100010206440  Helixate
            FS  Antlhemophl!ic Factor {Recombinant) For lnj Kit 1000 Unit  41.75%  Antihemophilic Products  85100010002130  Hemofil M  Antihemophilic Factor (Human) For lnj 500 Un!t  42.00%  Ant!hemophil!c
            Products  85100010006430  Monodate-P  Antihemophlllc Factor (Human) For lnj Kit500 Unit  30.00%  Antihemophific Products  85100010202140  BIOClATE  ANTJHEMOPHJUC FACTOR (RECOMBINANT) FOR INJ 1000 UNIT  20.00%  Antihemophilic
            Products  84100040002010  Cyk!okapron  TranexamicAcid lnj 100 MG/Ml  16.00%  Antihemophll!c Products  85100010002146  HemofilM  Ant!hemoph!lic Factor (Human) For lnj 1700 Unit  42.00%  Ant!hemophilic
            Products  85100010202115  Recombinate  Antlhemophll!c Factor (Recombinant) For lnj 220-400 Unit  40.00%  Antihemophilic Products  85100010252140  Advate  Antihemophi!ic Factor rAHF-PFM For lnj 1000 Unit  37.75%  Antihemophilic
            Products  85100010266460  Xyntha  Antihemophilic Factor Recombinant PAF For lnj Kit 2000 Unit  38.00%  Antihemophil!c Products  85100028202120  BeneFIX  Coagulation Factor IX (Recombinant) For lnj 250 Unit  21.00%  Ant!hemophi!ic
            Products  85100010302165  E[octate  AntihemophiHc Factor (Recomb) rFVIIIFc For lnj 3000 Unit  20.00%  Antihemoph!lic Products  85100015102138  Wilate  Antihemophi!ic Factor/VWF (Human) For lnj 900-900 Unit  40.00%  Antihemophilic
            Products  85100015102193  Alphanate/VWF Complex  Antlhemophinc Factor/VWF (Human) For lnj 2000 Unit  40.00%  Antihemophilfc Products  85100026202160  NovoSeven RT  Coagulation Factor Vila (Recomb) For lnj 8 MG (8000 MCG)  31.75%  Antihemophi!ic
            Products  85100030002110  Profilnine SD  Factor IX Complex For lnj 1000 Unit  19.75%  Antihemophilic Products  85100060106430  Kcentra  Prothrombin Complex Cone Human For lnj Kit 1000 Unit _, c•-Cf-.-7 /· - -'.  20.00%  Antihemoph'llic
            Products  85100028002170  AlphaNine SD  Coagulation Factor IX For lnJ 500 Unit ;,,•, :i• -;,-:-c---_-_;_'--l.-,'.-..,  40.00%  Antihemophl!ic Products  85100010202155  Recombinate  Antihemophi!ic Factor {Recombinant) For lnj 1801-2400 Unit -/
            :· .. P 's,.'1,....  40.00%  _ _:c: /4  r ) -  '{( Contrato Nlimoro.•.\,·•  ···•·  '·'  9 .,  .'I/.  ,,}. 2, 1'  u, >·---  .  '  , .  -------·' - 

      

    

     

    
      
        


    

    
      
        

      

      
                     Antihemophi!ic Products  85100010252180  Advate  Antihemophilic Factor rAHF-PFM For tnj 3000
            Unit      37.75%      Antihemophi!ic Products  85100010302125  Eloctate  Antihemophillc Factor {Recomb) rFVlllFc For lnj 500 Unit      20.00%      Antihemophil!c Products  85100015102122  Humate-P  Antihemoph!llc Factor/VWF (Human) For lnj
            250-600 Unit            Antihemophillc Products  85100015102144  Humate-P  Antihemoph!l!c Factor/VWF (Human) For lnj 1000-2400 Unit      37.00%      Antihemophillc Products  85100026202120  Novo5even  Coagulation Factor VIia (Recomb) For lnj
            1.2 MG {1200 MCG)      37.00%      Antihemophi11c Products  85100028402110  Alpro!ix  Coagulation Factor IX (Recomb) {rFIXFc) For lnj 500 Unit      31.75%22.00%      Antihemophillc Products  85100030002180  Profilnine SO  FACTOR IX COMPLEX FOR
            INJ 1000-1500 UNIT      20.05%      Antihemophilic Products  85100028002180  AlphaNine SD  Coagulation Factor IX For lnj 1000 Unit      40.00%      Antihemophilic Products  85100010206460  Helixate FS  Antihemophilic Factor (Recombinant) For
            lnj Kit 3000 Unit      41.75%      Antihemophilic Products  85100010002110  Hemof!I M  Antihemophilic Factor (Human) For fnj 250 Unit      42.00%      Antihemophilic Products  85100010002160  HemofilM  Antihemophilic Factor (Human) For lnj
            801-1500 Unit      42.00''/4      Antihemophllic Products  85100010202125  Recombinate  Antihemophilic Factor {Recombinant) For lnj 401-800 Unit      40.00%      Antihemophilic Products  85100010202170  Novoeight  Antihemophi!Jc Factor
            {Recombinant) For lnj 3000 Unit      20.00%      Antihemophi1ic Products  85100010266420  Xyntha  Antihemophi!ic Factor Recombinant PAF For lnj Kit 250 Unit      38.00%      Antihemophilic Products  85100010302135  Eloctate  Antihemophi!ic
            Factor {Recomb) rFVl!!Fc For lnj 1000 Unit      20.00%      Antihemophllic Products  85100015102129  Wilate  Antihemophilic Factor/VWF (Human) For lnj 500-500 Unit      40.00%      Antihemophilic Products  85100015102170  Alphanate/VWF
            Complex  Antihemophllic Factor/VWF (Human) For lnj 500 Unit      40.00%      Antlhemophilic Products  85100026202130  NovoSeven  Coagulation Factor Vila (Recomb) For lnj 2.4 MG {2400 MCG)      30.50%      Antihemophil!c
            Products  85100028402130  Alprolix  Coagulation Factor IX (Recomb) (rFIXFc) For lnj 2000 Unit      22.00%      Antihemophi1ic Products  85100033006440  Corifact  Factor XIII Concentrate (Human) For lnj Kit 1000-1600
            Unit      21.00%      Antihemophilic Products  85100010206420  Helixate FS  Antihemoph!llc Factor {Recombinant} For lnj Kit 250 Unit      41.75%      AntihemophiHc Products  85100010002112  ALPHANATE  ANTlHEMOPHILIC FACTOR (HUMAN) FOR INJ
            250-500 UNIT      41.75%      Antihemophilic Products  85100010002170  HemofilM  Antihemophi1!c Factor {Human) For Jnj 1501-2000 Unit      42.00%      Antihemophl!ic Products  85100010202130  B!OClATE  ANTIHEMOPHILICFACTOR {RECOMBINANT) FOR INJ
            500 UNIT      20.00%      Antihemophi!ic Products  85100010252120  Advate  Antihemophilic Factor rAHF-PFM For lnj 250 Unit      37.75%      Ant!hemophi!ic Products  85100010266430  Xyntha  Antihemophi!ic Factor Recombinant PAF For lnj Kit 500
            Unit      38.00%      Ant!hemophilic Products  85100010302145  Eloctate  Antihemophi!ic Factor {Recomb) rFVJIIFc For lnj 1500 Unit      20.00%      Antihemophilic Products  85100028202130  BeneFIX  Coagulation Factor IX (Recombinant) For lnj
            500 Unit      21.00%      Ant!hemoph!llc Products  85100015102130  Humate-P  Antihemophilic Factor/VWF {Human) For lnj 500-1000 Unit      37.001⁄4      Antihemophilic Products  85100015102180  Alphanate/VWF Complex  Antfhemophilic Factor/VWF
            (Human) For lnj 1000 Unit      40.00%      Antihemophi11c Products  85100026202140  NovoSeven  Co;;gulation FactorVUa {Recomb} For lnJ 4.8 MG (4800 MCG}      31.75%      AntihemophiHc Products  85100028402140  Alprollx  Coagulation Factor IX
            {Recomb) (rFIXFc) For lnj 3000 Unit      22.00%      Antihemophilic Products  85100035002120  RlaSTAP  FJbrinogen Cone (Human) lnj Approximately 1 GM (900-1300 MG)      21.00%      Antihemophi!ic Products  8S100010206430  Helixate
            FS  Antihemophi!ic Factor {Recombinant) For lnj Kit 500 Unit      41.75%      Ant!hemophi!ic Products  85100010002109  Hemofil M  Ant!hemophilic Factor {Human) For !nj 220-400 Unit      42.00%      Antihemophilic
            Products  85100010002147  HemofilM  Antihemophllic Factor (Human) For lnj 1701-2000 Unit      42.00%      Antihemophilic Products  85100010202120  BIOClATE  ANTIHEMOPHIL!CFACTOR {RECOMBINANT) FOR INJ 250 UNIT      20.00%      Antihemophilic
            Products  85100010202160  Novoeight  Antihemophilic Factor {Recombinant) For lnj 2000 Unit      20.00%      AntihemophiHc Products  85100010252185  Advate  Antihemophil!c Factor rAHF-PFM For lnj 4000 Unit      37.75%      Antihemophl!ic
            Products  85100010302130  Eloctate  Antihemophl!ic Factor (Recomb) rFVIIIFc For lnj 750 Unit      20.00%      Antihemophl!ic Products  85100015102128  Wilate  Antihemophllic Factor/VWF (Human} For lnj 450-450
            Unit      40.00%      Antlhemophi!ic Products  85100015102160  Alphanate/VWF Complex  Antihemoph!llc Factor/VWF {Human) For lnj 250 Unit      40.00%      Antihemophilic Products  85100026202126  NovoSeven RT  Coagulation Factor VIia (Recomb)
            For lnj 2 MG (2000 MCG)      31.75%      Antihemqphillc Products  85100028402120  Alpro11x  Coagulation Factor JX (Recomb) {rFIXFc) For !nj 1000 Unit      22.00%      Antihemophilic Products  85100032102130  Tretten  Coagulation Factor XIIf
            A+Subunit For tnj 2000-3125 Unit      16.00%      Antihemophi1ic Products  85100010206450  Helixate FS  Antihemophilic Factor (Recombinant) For lnj Kit2000 Unit      41.75%      ANTIHEMOPHILICS  30201010102015  Stimate  Desmopressin Acetate
            Nasal Soln 1.5 MG/ML    ,/, Nf--\C;',  "    15.75%  ANTIHISTAMINESANTlHYPERUPJDEMICS  412000301029003950004010ES20  DiphenhydrAMINE HCIKynamro  Diphenhydramine HC1 PowderMipomersen Sodium Soln Prefilled Syringe 200 MG/ML    ,,c-,- ·, ,_iYF  '
            :... . 16.00%'J"'t'' 16.00%              i\_I  :]:' f fontrato Numerol . "-· ._r • 7.''4··1 5?1. CJ    '  I  '.-,-  ,c•• ·•  ,,/ ..)  ,,, \l,>,,,..·,_  .  l,-...  \ Q .,., ..;., V  -- <...r. - ,.., """" <--Y·  , - . 

      

    

     

    
      
        


    

    
      
        

      

      
                     ANTIHYPERLIPIDEMICS  39480050200120  hixtapld  Lomitapide Mesylate Cap 5 MG (Base
            Equiv)  16.00%  ANTlHYPERLIPJDEMICS  39480050200130  Juxtapid  lomitapide Mesylate Cap 10 MG (Base Equiv)  16.00%  ANTlHYPERLIPIDEM!CS  39480050200140  Juxtapid  lomitap!de Mesylate Cap 20 MG {Base Equiv)  16.00%  ANTI-INFECTIVE AGENTS -
            MISC.  16000005402120  cayston  Aztreonam Lysine For lnha!Sofn 75 MG (Base Equivalent)  16.00%  ANTI-INFECTIVE AGENTS- MISC.  16000049000320  Xifaxan  Rifaximin Tab 200 MG  16.00%  ANTI-INFECTIVE AGENTS-
            MISC.  16000049000340  Xifaxan  Rifaximln Tab 550 MG  16.00%  Antineoplastics  21353045001360  Arzerra  Ofatumumab Cone for IV Infusion 1000 MG/SOML  16.75%  Antineoplastics  21353060002040  Rituxan  Rituximab For IV lnj Cone 10
            MG/ML  16.00%  Antineoplastics  21534007100120  Alecensa  Alectinib HCI Cap150 MG {Base Equivalent)  15.50%  Antineop!astics  21370060200120  Ddomzo  SONJDEGIB PHOSPHATE CAP 200 MG (BASE
            EQUIVALENT)  15.50%  Antineop!astics  2175S050102030  Levo!eucovorin Calcium  Levoleucovorin Calcium IV Sofn PF 250 MG/25ML {Base Equiv)  15.50%  Antineoplastics  21100010002020  Busulfex  Busu!fan lnj 6
            MG/ML  15.50%  Antineop[ast/cs  21574070401820  lmlyglc  Talimogene Laherparepvee lntralesional lnj1000000 Unit/ML  15.50%  Antineoplastlcs  21535570200320  Rubraca  Rucaparib Camsylate Tab 200 MG (Base
            Equivalent)  15.50%  Antineoplastics  21353060002040  Rltuxan  Rituximab For IV lnj Cone 10 MG/Ml  16.00%  Antineoplastlcs  21250010402125  Erwlnaze  Asparaginase Erwin!a Chrysanthemi for IM lnJ 10000
            Unit  16.00%  Antineoplastics  21353060002040  Rituxan  Ritux!mab For IV lnj Cone 10 MG/ML  16.00%  Antineoplastics  2147008000b720  Vendexta Starting Pack  Venetodax Tab Therapy Starter Pack 10 & 50 & 100
            MG  15.50%  Antfneoplastks  21755040102150  Leucovorin Cafdum  Leucovorin Calcium For lnj 200 MG  15.50%  Antineop!astics  21500012001325  PAClitaxel  Paditaxel IV Cone 30 MG/SML (6
            MG/ML)  15.50%  Antineoplastlcs  21300050100320  Trexall  Methotrexate Sodium Tab 5 MG {Base Equiv)  15.50%  Antineoplastics  21353027002030  Darzalex  Daratumumab IVSoln 400
            MG/20ML  15.50%  Antineoplastics  21534013100320  cabometyx  cabozantinib S-Malate Tab 20 MG {Base Equivalent)  15.50%  Antineoplastics  21990002750320  Lonsurf  TRIFLURlDINE-TIPlRACIL TAB 15-6.14
            MG  15.50%  Antlneoplastics  21708080000110  Vesanoid  Tret!noin Cap 10 MG  15.50%  Antineoplastlcs  21300050100350  Trexalf  MethotrexateSodium Tab15 MG (Base Equiv)  15.50%  Antineoplastics  21755040102130  Leucovorin Calcium  Leucovorin
            calcium For lnj 100 MG  15.50%  Antineoplastics  21100015002045  CARBOplatin  carboplatin JV Soln 600 MG/60ML  15.50%  Antineoplastlcs  21536045100140  Ninlaro  Jxazomib Citrate cap 4 MG {Base
            Equivalent)  15.50%  Antineoplastlcs  21100009102005  Bendeka  Bendamustine HCI IVSoln 100 MG/4Ml (25 MG/Ml)  15.50%  Antineoplastics  21700013001930  Tice BCG  BCG live lntraveslcal For Susp 50
            MG  15.50%  Antineoplastics  21700020002110  Dacarbazine  Dacarbazine For lnj 200 MG  15.50%  Antineoplastics  21200010102105  Bleomycln Sulfate  B!eomydn Sulfate for lnj15 Unit  15.50%  Antineoplastics  21100015002030  CARBOplatin  carboplatin
            IV Soln 50 MG/SML  15.50%  Antineoplastics  21574070401840  lmlyglc  Talimogene Laherparepvec lntralesional lnj100000000 Unit/Ml  15.50%  Antineoplastlcs  21353030002120  Emplidti  Etotuzumab For rvSoln 300
            MG  15.50%  Antineoplastics  21535570200330  Rubraca  Rucaparib Camsylate Tab 300 MG (Base Equivalent)  15.50%  Antineoplastics  21200050002120  Mitomycln  Mitomycln For lnj 40 MG  15.50%  Antineoplastics  21300007002015  Cladribine  Cladrlblne
            IVSofn 10 MG/lOML (1 MG/ML)  16.00%  Antineoplast!cs  21470080000320  Venclexta  VenetodaxTab 10 MG  15.50%  Antineoplastlcs  21534013100330  Cabometyx  cabozant!nib S-Malate Tab 40 MG (Base
            Equivalent)  15.50%  Antineoplastics  21990002750330  Lonsurf  TRIFLURIDINE-TIPlRAC!L TAB 20-8.19 MG  15.50%  Antineoptastic.s  21550040202220  Onl\.'yde  lrinotecan HCI Liposome IV lnj 43 MG/lOML (4.3
            MG/ML)  15.50%  Antineoplastlcs  21100020002020  CISplatin  Cisplatin lnj50 MG/SOML {1 MG/ML}  15.50%  Antineop!astics  21100015002040  CARBOplatin  carboplatin JV Sain 450
            MG/4SML  15.50%  Antineoplastic.s  21533530200320  Cotellie  Coblmetinlb fumarate Tab 20 MG {Base Equivalent)  15.50%  Antineoplastics  21353030002130  Empliciti  Elotuzumab For rv Soln 400 MG  15.50%  Antineoplastics  21500005002075  DOC£taxel
            (Non-Alcohol}  Docetaxel {Non-Alcohol Formula) IVSoln 80 MG/4Ml ., :,v..,·,--,· J c\ \·-:4";_;;._.,. , -  '1 ... 15.50%  Antineoplastics  21470080000340  Vendexta  Venetodax Tab 50 MG  ,._ /'! 15.50%  -"//i \, - \  ( rCorilrato N(rme1i"  ,,
            ..  "  ., ,.11:1-()5 JI 

      

    

     

    
      
        


    

    
      
        

      

      
                           Antineoplastic.s  21500012001350  Onxot  Paditaxe! IV Conc300 MG/SOML {6
            MG/ML)  15.50%  Antlneop!astic.s  21100020002025  CISplatin  Cisp!atin lnJ 100 MG/100Ml {1MG/Ml)  15.50%  Aotineoplastic.s  21500020102005  VinCRIStine Sulfate  Vinc.ristine Sulfate IV Soln 1
            MG/Ml  15.50'-'/4  Antineoplastks  21534065200330  Tagrisso  Osimertinlb Mesylate Tab 80 MG {Base Equivalent)  15.50%  Antineoplastks  21536045100120  Ninlaro  lxazomib Citrate Cap 2.3 MG {Base
            Equivalent)  15.50%  Antineoplastics  21500005002080  DOCEtaxel (Non-Alcohol)  Docetaxel {Non-Alcohol Formula} IV Soln 160 MG/8Ml  15.50%  Antineoplastic.s  21470080000360  Venclexta  Venetodax Tab 100
            MG  15.50%  Antineop!astics  21755050102020  levoleucovorln Calcium  levofeucovorin Calcium lnj 175 MG/17.SMl (Base Equiv)  15.50%  Antineoplastics  21755040102160  leucovorln Calcium  Leucovorin Calcium Forlnj350
            MG  15.50%  Antineoplastic.s  21755040102120  Leucovorin Calcium  Leucovorin Calcium For lnj 50 MG  15.50%  Antineop!astics  21100015002035  CARBOp!atin  Carboplatin JV So!n 150
            MG/lSML  15.50%  Antineop!ast!cs  21353027002020  Darzalex  Daratumumab IV Soln 100 MG/5Ml  15.50%  Antineoplastics  21536045100130  Ninlaro  lxazomib Citrate Cap 3 MG (Base Equivalent)  15.50%  Antineoplastics  21500005002070  DOCEtaxel
            {Non-Alcohol)  Docetaxel {Non-Alcohol Formula} IV Solo 20 MG/ML  15.50%  Antlneoplastics  21101040102115  Evome!a  Melphalan HCI For lnj 50MG {Propylene Glycol {PG) Free)  15.50%  Antineoplastics  21534013100340  Cabometyx  CabozantinibS-Malate
            Tab 60 MG (Base Equivalent)  15.50%  Antineoplastics  21107075002140  Yondelis  Trabectedin For lnj 1 MG  15.50%  Antineoplastic.s  21200010102115  B!eomycin Sulfate  Bleomycln Sulfate For fnj
            30Unit  15.50'-'/4  Antineoplastfcs  21500012001335  PAClitaxel  Pac!itaxe! IV Cone 100 MG/16.7ML (6 MG/Ml)  15.50%  Antineoplastics  21534065200320  Tagrisso  Osimertinib Mesylate Tab 40 MG (Base
            Equivalent)  15.50%  Antineoplastics  21353047002020  lartruvo  Ofaratumab Solo for IV Infusion 500 MG/SOML {10 MG/ML)  15.50%  ANTINEOPLASTJCS AND ADJUNCTIVE THERAPIES  21100009102010  Treanda  Bendamustine HCI IV So!n 45 MG/0,SML {90
            MG/ML)  16.75%  ANTINEOPlASTICS ANO ADJUNCTIVE THERAPIES  21100028002120  Dxallplatin  Oxalip!atin For IV lnj 50 MG  30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21101025002025  lfosfamide  lfosfamlde IV lnj 1 GM/20Ml {SO
            MG/ML)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21102020000110  CeeNU  Lomustine Cap 10 MG  16.£)0%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200030102210  DAUNOrubicin HCI  Daunorublcin HO lnj 5 MG/ML {Base
            Equiv)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200042102040  Epirublcln HCI  Epirubicin HCI lnj 150 MG/75ML (2 MG/ML)  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200055001325  Mftoxantrone HCI  Mitoxantrone HCI lnj Conc25
            MG/12.5Ml (2 MG/ML)  15.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300010002115  Cytarab!ne  Cytarabine For lnj 1 GM  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300034102040  Gemcitabine HCI  Gemcltabine HCl lnj 1 GM/26,3ML{38
            MG/ML) {Base Equiv)  30.00%  ANTINEOPLASTICS AND ADJUNCTJVE THERAPIES  21300054002025  Folotyn  Pra!atrexate IVlnj 40 MG/2ML  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21352020002120  Blincyto  Blinatumomab For IV Infusion 35
            MCG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21402430000120  Xtandi  Enzalutamide Cap 40 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  2140S010106410  lupron Depot  Leuprolide Acetate For lnj Kit 7.5
            MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405010256450  lupron Depot  leupro!ide Acetate (6Month} For lnj Kit45 MG  16.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21450080000115  Pomalyst  Pomalidomide Cap 2
            MG  18.25%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500005002040  DOCEtaxel  Docetaxel Solo for IV Infusion 80 MG/8ML  35.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500012201920  Abraxane  Paclitaxel Protein-Bound Particles For
            11/Susp 100 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21531060000130  lbrance  Palbociclib Cap 100 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21532025100120  Tafinlar  Dabrafenib Mesylate Cap SO MG (Base
            Equivalent)  16.00%  ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21532530007320  Afinitor Disperz  Evero!imus Tab for Oral Susp 3 MG  16.00%  ANTINEOPlA5TICS AND ADJUNCTIVE THERAPIES  21533070300140  Sutent  Sunitfnib Malate Cap 50 MG {Base
            Equlvalent)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534012000320  Bosulif  Bosutinlb Tab 100 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534020000320  Sprycel  Dasatinlb Tab 20 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21534025100360  Tarceva  Erlotinib HC/Tab 150 MG (Base Equivalent)  16.00%  ANTINEOPLASTIC$ AND ADJUNCllVE THERAPIES  21534054208240  Lenvima 14 MG Daily Do  Lenvatinlb Cap Therapy Pack 10 & 4 MG (14 MG Daily
            Dose)  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21536015002120  Velcade  Bortewmlb For lnj 3.5 MG .- •. \\ -:.,I _l'i:f-\  '.)-.''-. 16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21538040000330  Zydelig  /delalisib Tab 150 MG
            ,,\:-:,ye.- "'-  1;,., : ,;1.6.00%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21700020002105  Dacarbazine  Dacarbazlne For tnj100 MG t-r·Pr  "-, /.'l:(i.00%  Contrato N(unero \1h \  f1  ) J r  le\  '  ' . y f} s ?.i  '  ··-  p••·  \ti\·--;--  .
            ,,,  -  ,. \\\  ,./<§)  (;,,  , •. ''"  \,\,,\ 

      

    

     

    
      
        


    

    
      
        

      

      
                       ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES    21700060202135 lntron A    Interferon Alfa-2B
            For lnj 18000000 Unit              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21700075206420  Sylatron  Peginterferon alfa-2b For lnj Kit 300 MCG              16.75%  ANTINEOPLAST!CS AND ADJUNCTIVE
            THERAPIES    21755040100325  Leucovorin Calcium  Leucovorin Calcium Tab 10 MG              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21764065002140  Elitek  Rasburicase For IVSoln 7.5 MG              16.00%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES    21100020002030  CISplatln  Cisplatin lnj 200 MG/200ML {1 MG/ML)              20.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21101020002125  Cyclophosphamide  Cyclophosphamlde For lnj 1
            GM              32.30%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21101040102110  Alkeran  Me!phalan HCI For lnj 50 MG {Base Equiv)              16.00%  AmlNEOPLASTICSAND ADJUNCTIVE THERAPIES    212000300S2210  oaunoXome  Daunorubicin Citrate
            Uposome lnj 2 MG/ML              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21200042102025  Epirubkin HCI  Epirubicin HCI lnJ 10 MG/5ML (2 MG/ML}              16.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES    21200045102035  ldamycin
            PFS  ldarubkln HCI IV lnJ 20 MG/20ML (1 MG/ML)              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21300010002105  Cytarablne  Cytarabine For tnj 100 MG              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21300030002025  Fluorouracil  Fluorouracll fnj 1 GM/20ML {SO MG/Ml)              16.25%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21300053102120  Alimta  Pemetrexed Dlsodium For IV Soln 500 MG {Base
            Equiv)              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21335070002020  Cyramza  Ramucirumab tVSoln 100 MG/10ML (For Infusion)              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21353043002025  Gazyva  Ob!nutuzumab
            Soln for IV Infusion 1000 MG/40ML {25 MG/ML)              16.00%  ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES    21353054002020  Perjeta  Pertuzumab So!n for IV Infusion 420 MG/14ML {30 MG/ML)              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21402250000320  Lysodren  Mitotane Tab 500 MG              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21405007106450  vantas  H!stre!in Acetate Implant Kit 50 MG              15.75%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21405010206435  Eligard  leuprolide Acetate {4 Month} For Subcutaneous fnj Kit 30 MG              25.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21100009102030  Treanda  Bendamustine HCI IVSoln 180 MG/2ML {90
            MG/Ml}              16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21100028002130  Oxalip!atin  Oxalip!atin For IV lnj 100 MG              30.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21101025002030  Jfosfamlde  lfosfamide IV lnJ3
            GM/60Ml {SO MG/ML)              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21102020000115  CeeNU  Lomustine Cap 40 MG              16.00%  ANTINEOPLASTtCS AND ADJUNCTIVE THERAPIES    21200040102010  Adriamycln  Doxorubicin HCI lnj 2
            MG/ML              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21200042102045  Ellence  Epfrubidn HCI IV Sofn 200 MG/lOOML (2 MG/Ml)              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21200055001330  MitoxantroneHCI  Mitoxantrone HCI lnj Cone 30 MG/15Ml (2 MG/ML)              15.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21300010002120  Cytarabine  Cytarablne For lnJ 2
            GM              16.00%  ANTINEOPLASTICSAND ADJUNCTIVE THERAPIES    21300034102060  Gemcitab!ne HCI  Gemcltabine Hd lnj 2 GM/52.GML {38 MG/ML) (Base Equfv)              30.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21300060000305  Tabloid  Thfoguanine Tab 40 MG              16.00%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES    21353010002040  campath  A!emtuzumab IV lnj 30 MG/Ml(For Infusion)              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21353050002025  Vectibix  Panitumumab IV Soln 100 MG/SMl              16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21353070002120  Herceptln  Trastuzumab For lVSoln 440 MG              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21403020100105  Emcyt  Estramustine Phosphate Sodium Cap 140 MG              16.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES    21405010106415  E!igard  leuprolfdeAcetate For Subcutaneous lnj Kit 7.5
            MG              2S.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21100010000305  Myleran  Busulfan Tab 2 MG              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21101020000310  Cyclophosphamide  Cydophosphamide Tab 50
            MG              32.30%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21101030102105  Mustargen  Mechlorethamtne HCl For lnj 10MG              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21104070002120  Temodar  Temozo!omide For IV Soln
            100 MG              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21200040102115  Adriamycin  Doxorubicin HCI For lnj 50 MG              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21200045102025  ldamycin PFS  ldarubicin HCf IV
            lnj 5 MG/5Ml(1MG/Ml)              16.00%  ANT!NEOPlASTICS AND ADJUNCTIVE THERAPIES    21250060002020  Oncaspar  Pegaspargase lnj 750 Unit/Ml              16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21300025102020  Fludarabine
            Phosphate  Fludarabine Phosphate lnj 25 MG/ML              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21300052002020  Arranon  Ne!arabine IV So!n 5 MG/ML              16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21335020002025  Avastin  Bevaclzumab IV Soln100 MG/4Ml(For Infusion)              15.50%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21353032002020  Yervoy  lpilimumab Soln for IV Infusion 50 MG/10Ml (5
            MG/ML)              16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21353053002030  Keytruda  Pembro!izumab IV Soln 100 MG/4ML {25 MG/ML)              16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21355070302130  Kadcyla  Ado-Trastuzumab Emtansine For IV Soln 160 MG  />,\',_:7 '- -'\-..,'fl""''            16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    214050051023.10  Zoladex  Goserelin Acetate Implant 3.6
            MG  /t::,.··£;"'" ·::- i- \.,            16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21405010156432  E!igard  LeuprolfdeAcetate(3 Month) For Subcutaneous lnj Kit 22.SMG  /)'" //        .. ()    25.00%    -····      , q;·;t    fl Conhato
            N(1meroi l q (} ,51' (_j         \ \                        '                        v              -·-·\ \''        0                ·-              (_;,. 

      

    

     

    
      
        


    

    
      
        

      

      
                         ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES  21100015002120  CARBOplatin  Carboplatin JV For
            lnj 150 MG  16.25%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21101020002120  cyclophosphamide  Cyclophosphamide For lnj 500 MG  32.30%  ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES  21101040000305  Alkeran  Melphalan Tab 2
            MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21200020002105  Cosmegen  Dactfnomycin For lnj 0.5 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200040402210  Doxil  Doxorubicin HCI Liposomal lnj (For lV Infusion) 2
            MG/ML  16.00%  ANT!NEOPLASTICS AND ADJUNCTIVE THERAPIES  21200045102030  ldamycin PFS  ldarubicin HCI IV tnj 10 MG/lOML {1 MG/ML)  16.00%  ANT!NEOPLASTICS AND ADJUNCTIVE THERAPIES  21300007002010  Cladtibine  C!adriblne lnj 1
            MG/ML  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300025102120  Fludara  Fludarablne Phosphate For lnj 50 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300053102110  Alimta  Pemetrexed Disodium For IV Sofn 100 MG (Base
            Equiv)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21335020002030  Avastin  Bevacizumab IV Soln 400 MG/16ML {For Infusion)  15.50%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21353032002040  Yervoy  lpilimumab Soln for IV Infusion 200
            MG/40ML (5 MG/ML}  16.75%  ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES  21353053002120  Keytruda  Pembrolizumab For IV Sotn 50 MG  16.00%  ANTINEOPLASTICSAND ADJUNCTIVE THERAPIES  21370070000120  Erivedge  Vismodegib Cap 150
            MG  16.00%  ANTINEOPlASTJCS AND ADJUNCTIVE THERAPIES  21405005102330  Zoladex  Goserelin Acetate Implant 10.8 MG  16.00%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21405010206430  Lupron Depot  LeuprolideAcetate (4 Month) For Jnj Kit 30
            MG  16.00%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21104070000147  Temodar  Temozolomide Cap 180 MG  35.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  99392070000135  Tha!omid  Thalidomide C.ap 150 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21300034102140  Gemdtablne HCI  Gemcitabine HC\ For lnJ1 GM  30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21406010200320  Zytiga  Abiraterone Acetate Tab 250 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21500005001325  DOCEtaxe!  Docetaxel For lnj Cone 80 MG/2ML {40 MG/ML}  35.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500011002140  1xempra Kit  rxabepilone For IV Infusion 45 MG  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21500050802025  Navelbine  V!norelbine Tartrate lnj 50 MG/SML (10 MG/ML) (Base Equiv)  16.00%  !\NTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21531560002120  [stodax  Romidepsin For IV lnj 10 MG  16.75%  ANTINEOPLAST!CS AND ADJUNCTIVE
            THERAPIES  21532530000330  Afinitor  Everotimus Tab 10 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21533070300130  Sutent  Sunitinlb Malate Cap 25 MG {Base Equivalent)  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21534008000320  lnlyta  Axltinib Tab 1 MG  16.00%  ANTINEOPlAST/CS AND ADJUNCTIVE THERAPIES  21534015000120  Xalkori  Crizotinib cap 200 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534025100320  Tarceva  Er!otin!b HC!Tab
            25 MG (Base Equivalent}  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  2153405420B220  Lenvima 10 MG Dally Do  Lenvatinib cap Therapy Pack 10 MG {10 MG Daily Dose}  16.00%  ANTINEOPI.ASTICS AND ADJUNCTIVE
            THERAPIES  21534075100340  Jclus!g  Ponatinib HCI Tab 45 MG {Base Equiv)  22.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21537560200335  Jakafi  RuxoHtinib Phosphate Tab 25 MG (Base Equlvalent)  15.25%  ANTINEOPlASTlCS AND ADJUNCTIVE
            THERAPIES  21700008102020  Trisenox  Arsenic Trioxide lnj 10 MG/10Ml{1MG/ML}  16.()0%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21700060202030  lntron-A  lnterferonAlfa-28 Jnj 10000000 Unit/ML  16.00%  ANTINEOPI.ASTICS AND ADJUNCTIVE
            THERAPIES  21700060702020  Actlmmune  Interferon Gamma-1B lnj 100 MCG/0.5ML'(2000000 Unit/0.5ML)  16.75%  ANTINEOPLASTJCS AND ADJUNCTIVE THERAPIES  21707070102140  Photofrin  Porflmer Sodium For lnj 75 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21758050002010  Mesna  Mesna lnj 100 MG/ML  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405525102120  Firmagon  Degarelix:AcetateFor lnJ 80 MG {Base Equiv}  15.75%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21500005001317  DOCEtaxeJ  Docetaxel For !nj Cone 160 MG/8Ml (20 MG/ML)  35.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500010602120  Etopophos  Etoposlde Phosphate IV For lnj 100 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21500030102105  VinBlAStine Sulfate  Vinb!astine Sulfate For lnJ 10 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21531550100130  Farydak  Panobinostat Lactate cap 15 MG {Base Equivalent)  16.00%  ANTJNEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21532530000320  Afinitor  Evero!imus Tab 5 MG  16.00%  ANTINEOPI.ASTICS AND ADJUNCTIVE THERAPIES  21533060400320  NexAVAR  Sorafenib Tosylate Tab 200 MG {Base Equivalent)  16.00%  ANTINEOPI.ASTICS AND ADJUNCTIVE
            THERAPIES  21534006100330  Gilotrif  Afatinib Dimaleate Tab 30 MG (Base Equivalent)  16.00%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21534013106480  Cometriq (140 mg Daily I  cabozantin!b S-Mal cap 1 X 80 MG & 3 X 20 MG (140 Dose)
            Kit  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21534020000360  Sprycet  Dasatinib Tab 100 MG  16.00%  ANTINEOPLAST!CS AND ADJUNCTIVE THERAPIES  21534035100340  Gleevee  lmatfnib Mesylate Tab 400 MG {Base
            Equivalent}  17.25%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21534070100320  Votrient  Pazopan!b HCI Tab 200 MG {Base Equiv} c ..l, hi/_, -,.-.;_-} ' ~,r-, --  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21537560200325  Jakafi  Ruxotitinib Phosphate Tab 15 MG (Base Equivalent)  15.25%  /i'r1,·/'  ,, ()'  ,,,,-'  {( Contra to Numero\\ \\I'', 1- 9 - 1, fi '.a''  "'  U\ ;- - J/f),  , ...  f"•,,,, °"'···  \0 \ ,,  ,0 

      

    

     

    
      
        


    

    
      
        

      

      
                     ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21550080100140  Hycamtin  Topotecan HCI Cap 1 MG
            {Base Equiv)        16.00";,6  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21700050100105  Matulane  Prncarbazine HC/ cap 50 MG        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21700060206470  lntron-A  Interferon Atfa-28 lnj Kit
            10000000 Unit/0.2ML        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21700075206470  5ytatron  Peginterferon a!fa-2b For Jnj Kit4 X 600 MCG        16.75%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21755050102120  Fusilev  Levoleucovorin Calcium For IV lnj SO MG {Base Equiv)        16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21405050201920  Trelstar Depot  Triptorelin Pamoate For IM Susp 3.75
            MG        22.50%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21450080000120  Pomalyst  Pomalidomide Cap 3 MG        18.25%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES    21500005002050  DOCEtaxel  Docetaxel Soln for IVInfusion 160
            MG/16ML        35.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21500015002020  Teniposlde  Tenfposide IVSoln 10 MG/ML        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21531060000140  lbrance  Palbociclib Cap 125
            MG        16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21S32025100130  Tafinlar  Dabrafenib Mesylate cap 75 MG {Base Equivalent)        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21532530007340  Afinitor Disperz  Everolimus Tab
            for Oral Susp 5 MG        16.00%  ANTINEOPIASTICS AND ADJUNCTIVE THERAPIES    21533570100310  Mekinist  Trametin!b Dimethyl Sulfoxlde Tab 0.5 MG {Base Equivalent)        16.00",{;  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21534012000340  Bosulif  Bosutinib Tab 500 MG        16.00";,6  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21534020000340  Sprycel  Dasatinlb Tab 50 MG        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21534030000320  lressa  Gefrtfnlb Tab 250 MG        15.25%  ANTlNEOPLASTICS AND ADJUNCTIVE THERAPIES    2153405420B250  Lenv1ma 24 MG Daily Do  Lenvatinib cap Therapy Pack 10 (2) & 4 MG (24 MG Daily
            Dose)        16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21536025002120  Kyprol!s  Carfilzomib For lnj 60 MG        16.00%  ANTINEDPLASTICS AND ADJUNCTIVE THERAPIES    21550040102035  Camptosar  lrinotecan HCI lnj 300 MG/lSML (20
            MG/ML)        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21700024002020  Ontak  Denileukin Diftitox IV Soln 150 MCG/ML        16.00%  ANTINEDPlASTICSAND ADJUNCTIVE THERAPIES    21700060202160  lntron A  Interferon Alfa-2B For lnj
            50000000 Unit        16.00%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES    21700075206430  Sylatron  Peginterferon alfa-2b For lnj Kit 600 MCG        16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21755040100335  Leucovorin
            calcium  Leucovorin calcium Tab 15 MG        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21765060002120  Kepivance  Palifermin For IV lnj 6.25 MG        16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES    21405525102130  Flrmagon  Degarellx Acetate For Jnj 120 MG {Base Equiv)        lS.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES    21S00005001320  DOCEtaxel  Docetaxel For lnj Cone 20 MG/0.5ML (40
            MG/ML)        35.00%  ANTINEDPLASTICS AND ADJUNCTIVE THERAPIES    21500011002120  lxempra Kit  lxabepi!one For IV Infusion 15 MG        16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21500050802020  Navelb!ne  Vlnore!bine Tartrate lnj 10
            MG/ML {Base Equiv)        16.00%  ANTINEDPlASTICSAND ADJUNCTIVE THERAPIES    21531550100140  Farydak  Panoblnostat Lactate cap 20 MG (Base Equivalent)        16.00%  ANTINEOPlASTJCS AND ADJUNCTIVE
            THERAPIES    21532530000325  Aflnitor  Everolimus Tab 7.5 MG        16.00%  ANT!NEOPLASTICS AND ADJUNCTIVE THERAPIES    21533070300120  Sutent  Sunitinib Malate Cap 12.S MG {Base Equivalent)        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21534006100340  Gilotrif  Afatinib Dimaleate Tab 40 MG (Base Equivalent)        16.00%  ANTINEOPlASTICSAND ADJUNCTIVE THERAPIES    21S34014000130  Zykadia  Ceritinib Cap 150 MG        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21534020000380  Sprycel  Dasatinib Tab 140 MG        16.00%  ANTINEDPLASTICS AND ADJUNCTIVE THERAPIES    21534050100320  Tykerb  Lapatinfb Ditosy!ate Tab 250 MG (Base Equiv)        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21534075100320  lclusig  Ponatlnib HCI Tab 15 MG (Base Equiv)        22.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21537560200330  Jakafl  Ruxolitinib Phosphate Tab 20 MG (Base Equivalent)        lS.25%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES    21550080102020  Topotecan Hd  Topotecan HCl lnj 4 MG/4ML(Base Equlv) (For Infusion)        17.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21700060202022  lntron•A  Interferon A!fa-2B lnJ 6000000
            Unit/ML        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21700060302020  Alferon N  Interferon Alfa-n3 lnj 5000000 Unit/ML        15.75%  ANTINEOPLASTIC$ AND ADJUNCTIVE THERAPIES    21703020002120  Proleukln  Aldes!eukin For IV Soln
            22000000 Unit        16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21758050000320  Mesnex  Mesna Tab 400 MG        16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21100009102120  Treanda  Bendamustine HC1 For IV Soln 100
            MG        16.75%  ANTINEOPlASTICSAND ADJUNCTIVE THERAPIES    21101020000305  Cydophosphamlde  Cyc!ophosphamide Tab 25 MG        32.30%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES    21101025002130  lfex  ffosfamide For lnj 3
            GM        16.00%  ANTINEDPLA5TICS AND ADJUNCTIVE THERAPIES    21102030002105  Zanosar  Streptozodn Forlnj 1 GM    - - ·---..,    16.00%  ANTINEDPLASTICS AND ADJUNCTIVE THERAPIESANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    2120004010211021200042102170  Adr!amycinEpirubicln HCI  Doxorubicin HCI For lnj 20 MGEp!rubicin HCI For lnj 200 MG    /< \\:JI l'<i:i'--\f'\I"v . ·<_,,,,,:,A'\.\    16.00%16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES    21300025100320  Dforta  fludarablne Phosphate Tab 10MG    .0//    15.75%    ,- .        {I  If f Contrato NOmero f,\\I,",., 9 - () 5 :::C\ \.fl, ---f'     

      

    

     

    
      
        


    

    
      
        

      

      
               ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300040001830  Purixan  Merc.aptopurine Susp 2000
            MG/lOOML (20 MG/ML)  16.00%  ANTINEOPLASTJCS AND ADJUNCTIVE THERAPIES  21335010102030  Zaltrap  Ziv-Aflibercept IV Solo 200 MG/8ML {For Infusion)  16.00%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21353025002025  Erbitux  Cetuximab N Solo 200
            MG/lOOMl (2 MG/ML}  16.25%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21353050002035  Vectibix  Panitumumab IV Solo 400 MG/20Ml  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21355070302120  Kadcyla  Ado-Trastuzumab Emtans!ne For IVSoln 100
            MG  16.003⁄4  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21403530002024  Faslodex  Fulvestrant lnj 250 MG/5ML  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405010156430  Lupron Depot  leuprolide Acetate {3 Month) For lnj Kit 22.5
            MG  16.00%  ANTINEOPlASTICSAND ADJUNCTIVE THERAPIES  21100028002035  Eloxatin  Oxaliplatin IV Soln 200 MG/40ML  16.00%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21101020002130  Cyclophosphamide  Cydophosphamlde For lnj 2
            GM  32.30%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21102010002105  BiCNU  Carmustlne For lnj 100 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21200030102105  Cerubidine  Daunorubicin HCl For lnJ 20 MG  16.00%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21200042102030  Ellence  Epirubicin HCI IVSoln 50 MG/25Ml {2 MG/ML)  16.00%  ANTINEOPlAST\CS AND ADJUNCTIVE THERAPIES  21200055001320  Mitoxa ntrone HCI  Mitoxantrone HCI lnj Cone 20 MG/lOML {2
            MG/ML)  15.75%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21300010002110  Cytarabine  Cytarabine For lnj 500 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300034102020  Gemcitablne HCl  Gemcitabine HCI lnJ 200 MG/5.26ML {38 MG/Ml)
            {Base Equiv)  30.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21300054002020  Folotyn  Pra!atrexate IV lnj 20 MG/Ml  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21335070002040  Cyramza  Ramucirumab IV Sohl 500 MG/50ML (For
            Infusion)  16.00%  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21353045001320  Arzerra  Ofatumumab Cone For IV Infusion 100 MG/5Ml  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21402420000320  Casodex  Blcalutamide Tab 50
            MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21100009102110  Treanda  Bendamustine Hd For JV So!n 25 MG  16.75%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21101010000305  leukeran  Chlorambucil Tab 2 MG  16.00%  ANTJNEOPlASTICS AND
            ADJUNCTIVE THERAPIES  21101025002110  lfex  lfosfamide For lnj 1 GM  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21102020000120  CeeNU  lomustine Cap 100 MG  16.00%  ANTINEOPLASTICSAND ADJUNCTIVE
            THERAPIES  21200040102105  Adriamycin  Doxorublcin HCI Forlnj10 MG  16.00%  ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES  21200042102140  Epirubicin HCI  Epirubidn HCI For lnj 50 MG  16.00%  ANTJNEOPlASTICS ANO ADJUNCTIVE
            THERAPIES  21200080002020  Valstar  Va!rubicln Solo For lntraveslcal Instillation 40 MG/ML  16.75%  ANTJNEOPlASTICS AND ADJUNCTIVE THERAPIES  21300010301825  DepoCyt  Cytarabine Llposome lnj SO MG/SML  16.00%  ANTINEOPlASTlCS AND ADJUNCTIVE
            THERAPIES  21300034102160  Gemdtabine HCI  Gemcitabine HCI For lnj 2 GM  30.00%  ANTlNEOPlASTlCS AND ADJUNCTIVE THERAPIES  2133S010102020  Zaltrap  Ztv-Aflibercept IV Solo 100 MG/4ML {For Infusion)  16.00%  ANTlNEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21353025002020  Erbitux  Cetwcimab N Solo 100 MG/50ML (2 MG/ML}  16.25%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21353050002030  Vectibix  Panitumumab IV So!n 200 MG/10ML  16.75%  ANTJNEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21355020202120  Adcetris  Brentuximab Vedotin For IV So[n SO MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21403530002022  Faslodex  Fulvestrant Jnj 125 MG/2.SML  16.00%  ANTINEOPI.ASTICS AND ADJUNCTIVE
            THERAPIES  21405050201930  Tre!star LA  Triptorelln Pamoate For IM Susp 11.25 MG  22.50%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21104070000140  Temodar  Temozolomide Cap 100 MG  35.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21S00005001310  DOCEtaxel  Docetaxel For lnJ Cone 20 MG/Ml  35.00%  ANT!NEOPlASTICS AND ADJUNCTIVE THERAPIES  99392070000120  Thalomid  Thalidomide Cap 50 MG  16.00%  ANTJNEOPlASTICS AND ADJUNCTIVE
            THERAPIES  99394050000145  Revlim!d  lenalidomide Cap 20 MG  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405010256445  Eligard  leuprotide Acetate (6Month) For Sul?cutaneous fnj Kit45 MG  25.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21450080000110  Pomalyst  Pomalidomide Cap 1 MG  18.25%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500005002030  DOCEtaxel  DocetaxelSoln for IV Infusion 20 MG/2ML  35.00%  ANTINEOPLASTJCS AND ADJUNCTIVE
            THERAPIES  21500012001340  PACUtaxel  Paditaxel IV Cone 150 MG/25ML {6 MG/ML)  16.00%  ANTlNEOPlASTICS AND ADJUNCTIVE THERAPIES  21531060000120  lbrance  Pa!bociclib Cap 75 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21531575000120  Zolinza  VorinostatCap 100 MG  16.00%  ANT/NEOPlASTICS AND ADJUNCTIVE THERAPIES  21532530007310  Afinitor Disperz  Evero!Jmus Tab for Ora! Susp 2 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21533070300135  Sutent  Sunitinib Malate Cap 37.5 MG {Base Equivalent)  16.00%  ANT!NEOPLASTICS AND ADJUNCTIVE THERAPIES  21534008000340 lnlyta    Axitinib Tab 5 MG , .,,.----  16.00%  ANTlNEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21534015000125 !Xa!kori    Crizotinib Cap 250 MG /• _1\-l> _;, I•\,,(',  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534025100330 (Tarceva    Erlotinib HCI Tab 100 MG {Base Equivalent) ·,:-;-•·. """<'('\
            ·.  16.00%  '/  J r ",,  \ ,,.  .  {ContratoI . " ·'  \ ()  {  : J 1,1  '"n ero : rn  ·.  ri:12·  ... (.() - ----  P.  .,..  --    •-=  ~·,      \\ \ici;,_ .-  ---------,j•i 

      

    

     

    
      
        


    

    
      
        

      

      
                             ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  215340S4208230  Lenvima 20 MG Daily
            Do  Lenvatinib Cap Therapy Pack 10 (2) MG {20 MG Daily Dose)  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21535560000120  Lynparza  Olaparib Cap 50 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21538040000320  Zydelig  ldela!isib
            Tab 100 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700013001940  TheraCys  BCG Live lntravesical For Susp 81 MGNIAL  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21700060202130  lntron A  Interferon Alfa-28 For lnj 10000000
            Unit  16.001⁄4  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21700075206410  Sylatron  Peginterferon a!fa-2b For lnJ Kit 200 MCG  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21708220000120  rargretin  Bexarotene Cap 75
            MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21764065002120  Elitek  Rasbur!case For IV Soln 1.5 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21104070000150  Temodar  Temozolomide cap 250 MG  35.00%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  99392070000140  Thalomid  Thalidomide Cap 200 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21405010106407  Leuprolide Acetate  Leupro!ide Acetate lnj Kit S MG/ML  52.25%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21300015002120  Dacogen  Dedtablne For Jnj SO MG  25.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21500010002025  Etopos!de  Etoposlde I nj 100MG/5ML (20 MG/ML)  27.55%  ANTINEOPLAST!CS AND ADJUNCTIVE
            THERAPIES  21500010002030  Etoposide  Etoposide lnj 500MG/25ML {20 MG/ML)  27.55%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21450080000125  Pomalyst  Pomalidomlde Cap 4 MG  18.25%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21500009202020  Halaven  Eribulln Me::.y!ate lnj 1 MG/2ML {0.5 MG/ML)  16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500020201820  Marqibo  Vincristine Sulfate Liposome IV Susp S MG/31ML (0.16 MG/ML)  16.00%  ANTINEOPLASTICS
            AND ADJUNCTIVE THERAPIES  21531520002120  Beleodaq  Bellnostat For IV lnj 500 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21532080000320  Ze!boraf  Vemurafenib Tab 240 MG  16.(){)%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21532570002020  Torlsel  Temsirolimus Soln For JV Infusion 25 MG/ML  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21533570100330  Mekinist  Trametinib Dimethyl Sulfoxide Tab 2 MG (Base Equivalent)  16.00%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21534013106460  Cometriq (60 mg Daily 0(  cabozantinib 5-Malate Cap 3 X 20 MG (60 MG Dose) Kit  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21534020000350  Sprycel  Dasat!nib Tab 70 MG  16.00%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21534033000120  lmbruvica  lbrutinib Cap 140 MG  16.00%  ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES  21534060200115  Tasigna  Nllotinib HCI Cap 150 MG {Base Equivalent)  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21537560200310  Jakafi  Ruxolitinlb Phosphate Tab 5 MG {Base Equivalent)  15.25%  ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES  21550040102040  trinotecan HCI  lrinotecan HCI lnj 500 MG/25ML {20 MG/ML)  30.00%  ANTINEOPLAST!CS AND
            ADJUNCTIVE THERAPIES  21700040102120  Synribo  Omacetaxine Mepesuccinate For lnj 3.5 MG  16.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21700060206450  lntron-A  lnterferonAlfa-2B lnj Kit 3000000 Unit/0.2ML  16.00%  ANTINEOPLASTlCS AND
            ADJUNCTIVE THERAPIES  21700075206450  Sylatron  Peginterferon alfa-2b For lnj Kit 4X 200 MCG  16.75%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21755040102030  Leucovorin Calcium  Leucovorin Calcium lnj 10 MG/ML  16.00%  ANTINEOPLASTICS AND
            ADJUNCTIVE THERAPIES  21104070000143  Temodar  Temozolomlde Cap 140 MG  35.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21500005001315  DOCEtaxel  Docetaxel For lnj Cone 80 MG/4ML {20 MG/ML)  35.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  99392070000130  Thalomid  Thalidomide Cap 100 MG  16.00%  ANTINEOPLASTlCS AND ADJUNCTIVE THERAPIES  99394050000150  Revlimid  Lenalidomide Cap 25 MG  16.75%  ANTINEOPLASTICS AND ADJUNCTIVE
            TI-IERAPIES  21100028002030  Eloxatin  Oxa!iplatin IV Soln 100 MG/20ML  30.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  99394050000110  Revlim!d  Lenalidomide Caps 2.5 MG  16.75%  ANTINEOPLASTIC$ AND ADJUNCTIVE
            THERAPIES  21534085000320  Caprelsa  Vandetanlb Tab 100 MG  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21550040102025  Camptosar  lrinotecan HCI lnj 40 MG/2ML {20 MG/ML)  30.00%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21550080102120  Hycamtin  Topotecan HCI For Jnj 4 MG  17.00%  ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES  21300034102110  Gemdtablne HCI  Gemcitabine HCI For lnj 200 MG  30.00%  ANTINEOPLASTJCS AND ADJUNCTIVE
            THERAPIES  21500010002040  Etoposide  Etoposfde lnj 1 GM/SOML (20 MG/ML)  27.55%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21550040102030  Camptosar  lrinotecan HCI lnj 100 MG/5ML {20 MG/ML)  30.00%  ANTfNEOPLAST!CS AND ADJUNCTIVE
            THERAPIES  21250010402120  Erwinaze  Asparaginase Erwinia Chrysanthemi For !nj 10000 Unit  16.00%  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21104070000110  Temodar  Temozo!om!de Cap 5 MG  35.00%  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES  21300005000350  Capecitabine  Capedtabine Tab 500 MG  40.00%  ANT!NEOPLASTICS AND ADJUNCTIVE THERAPIES  99394050000130  Revlimid  Lenalidomide Cap 10 MG  16.75%  ANTINEOPlASTICS AND ADJUNCTIVE
            THERAPIES  21300030002030  Adrucil  Ftuorouracil Jnj 2.5 GM/SOML {SO MG/ML) ....'-\'-l\;:, I iY.<-.  16.25%  ANTINEOPlASTJCS AND ADJUNCTIVE THERAPIES  21104070000120  Temodar  Temozolomide Cap 20 MG / f '.,_.?,.V-= , . - , ,.
            \.  35.00%  v,  I ••,,.,  '0  / ,-  Vurr,r::1 i _  ' ,',J  -ro Ill  ,,,,,  ((1_· if::  1(1, 2,  ,- ,,,,  0,,' -:;  " "',,,,  (,;'.'(<,, ,Ch', "'='=_/ \v9,  ----- oc. st:-..;,,  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                                                       21300030002020 Adrucil  ANTINEOPLASTICS AND ADJUNCTIVE
            THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  99394050000140 Revnmid  21300030002035 Adrucil21300003001920 AzaCITIDlne21405050201940 Trelstar Mb:ject21500003002020 Jevtana21500010000120 Etoposide21500030102020 VinBlAStine
            Sulfate21531550100120 Farydak21532530000310 Afinitor21533050000320 Stivarga21534006100320 Gilotrif  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPlASTlCS AND ADJUNCTIVE THERAPIES ANTJNEOPlASTICS AND
            ADJUNCTIVE THERAPIES ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTJNEOPlASTICS
            AND ADJUNCTIVE THERAPIES ANTINEOPlASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS ANO ADJUNCTIVE THERAPIES  21534020000354 Sprycel21534035100320
            Gleevec21534060200125 Tasigna  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21537560200320 Jakafi  ANTJNEOPLASTICS AND ADJUNCTIVE THERAPIES  21550080100120 Hycamtin  ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES  21700045002120 Nipent  ANTINEOPlASTICS
            AND ADJUNCTIVE THERAPIES ANTINEDPlASTlCS ANO ADJUNCTIVE THERAPIES ANTINEDPlASTICS AND ADJUNCTIVE THERAPIES ANTINEDPlASTICS AND ADJUNCTIVE THERAPIES ANTINEDPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
            ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ANTINEOPLAST!CS TOPICALSANTINEDPlASTICS TOP!CALSAntiparasitics ANTIPARKINSON AGENTSAntipsychotics Antipsychotics Antipsychotics AntipsychoticsAntipsychotics Antipsychotics Antipsychotics Antipsychotfcs
            Antipsychotics Antipsychotks Antipsychotics Antipsychotks Antipsychotks Antipsychotics Antipsychot!cs  21700060206460 lntron-A21700075206460 Sylatron21755040102170 leucovorin Calcium21100028002025 Eloxatin21300005000320
            Capecitabine99394050000120 Revlimid21534085000340 Caprelsa90371050204030 Valchlor90376015004020 Panretin13000040000310 Daraprim73203010102020 Apokyn59070070101930 RisperDAL Consta59250015001930 Abilify Maintena59070070101920 RlsperOAL
            Consta59070070101910 R!sperDAL Consta59070050101837 fnvega Sustenna59070070101940 RisperDAl Consta59070050101845 lnvega Sustenna 590700S0101838 lnvega Sustenna 59070050101850 lnvega Trinza59250015001920 Abllify Malntena5925001520E430 Aristada
            59070050101839 lnvega Sustenna59070050101870 lnvega Trinza5925001520E440 Aristada 59070050101880 lnvega Trinza    Antipsychotics  5925001520E420 Aristada  3⁄4  Antipsychotics  59070050101840 lnvega Sustenna  Ant/psychotics  59070050101860 lnvega
            Trinza  :,  ANTJPSYCHOTICS/ANTIMANICAGENTS  59157060101950 ZyPREXA Relprew  ····•  .•.  , ..,  Fluorouracil lnj 500 MG/lOMl {SO MG/Ml)  lenalidomide Cap 15 MG  16.25%  16.75%  Ffuorouracll lnj 5 GM/lOOML {SO MG/ML) Azadtidine For lnj 100
            MGTriptorelln Pamoate For 1M Susp 22.5 MGCabazitaxel lnj 60 MG/1.5Ml (For IV Infusion) Etoposlde Cap 50 MGVlnblastine Sulfate lnj 1 MG/MlPanoblnostat lactate Cap 10 MG (Base Equivalent) Everolimus Tab 2.5 MGRegorafenib Tab 40 MGAfatin!b
            Dimaleate Tab 20 MG {Base Equivalent)  21534013106470 Cometriq (100 mg Daily Cabozantinlb S-Mal Cap lX 80 MG & 1 X 20 MG (100 Dose) Kit  Dasatinib Tab 80 MGlmatinib Mesylate Tab 100 MG {Base Equivalent)  Nilotinib HCI Cap 200 MG {Base
            Equivalent)  16.25%25.00%22.50%16.75%27.55%16.00%16.00%16.00%16.00%16.00%16.00%16.00%17.25%16.00%  Ruxolitinib Phosphate Tab 10 MG {Base Equivalent) Topotecan HCI Cap 0,25 MG (Base Equiv)  15.25%16.00%  Pentostat!n For lnj 10MG  Interferon
            Alfa-2B lnj Kit 5000000 Unit/0.2ML Peginterferon alfa-2b For lnJ Kit 4X 300 MCG  leucovorin Calcium For lnj 500 MG  Oxaliplatin IV Soln 50 MG/lOML Capecitabine Tab 150 MG  lena!idomide Cap 5 MG Vandetanib Tab 300 MGMech!orethamine HCI Gel
            0.016% (Base Equivalent) Alitretlnoin Gel 0.1%Pyrimethamine Tab 25 MGApomorphine Hydrochloride lnj 10 MG/Ml  Risper/done Mlcrospheres For lnj 37.5 MG  Aripiprazole IM For Extended Release Susp 400 MG Risperidone Mlcrospheres For rnJ 25
            MG  Risperidone Mfcrospheres For Jnj 12.5 MG  Pa!iperidone Palmitate IM Extended-Release Susp 39 MG/0,25ML Risper/done Mlcrospheres For !nj SO MGPaliperidone Palmitate IM Extended-Release Susp 234 MG/1.SML Pafiperidone PalmitatelM
            Extended-Release Susp 78 MG/0.SMl Paliperidone Palmitate IM Extend-Release Susp 273 MG/0.875Ml Arlplprazole !M For Extended Release Susp 300 MGARIPIPRAZOLE lAUROXILIM ERSUSP PREFlllED SYR 662 MG/2.4MlPaliperidone Palmitate IM Extend-Release
            Susp 117 MG/0.75ML Pa!!peridone Palmltate IM Extend-Release Susp 546 MG/1.75MlARIPIPRAZOLE lAUROXU 1M ERSUSP PREFILLED SYR 882 MG/3.2MlPalipericfone Palmitate IM Extend-Release Susp 819
            MG/2.625Ml  16.00%16.00%16.75%16.00%30.00%40.00%16.75%16.00%16.00%16.00%15.50%15.75%15.50%15.50%15.50%15.50%15.50%15.50%15.50%15.50%15.50%15.50%15.50%15.50%15.50%15.50%15.50%  ARIPIPRAZOLE lAUROXIL lM ER SUSP PREFILLEO SYR
            441MG/1.6ML  15.50%  Paliperidone Palmitate IM Extended-Release Susp 156 MG/ML  Paliperidone Palmltate IM Extend-ReleaseSusp 410 MG/1.315ML  Olanzap!ne Pamoate For Extended Rel JM Susp210 MG (Base Eq)  15.50%15.50%  16.00%  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                             \ ''··  ANTIPSYCHOTICS/ANTIMANICAGENTS      59157060101970  ZyPREXA
            Relprew  Olanzapine Pamoate For Extended Rel IM Susp 405 MG {Base Eq)    16.00%    ANTIPSYCHOTICS/ANTIMANICAGENTS      59157060101960  ZyPREXA Relprew  OJanzapine Pamoate For Extended Rel IM susp 300 MG (Base
            Eq)    16.00%    Antivirals      12200020102030  Foscavir  FoscarnetSodium tnj 6000 MG/2SOML {24 MG/Ml)    16.00%    Antivirals      12359902300320  Zepatier  Elbasvlr-Grazoprevir Tab 50-100
            MG    15.50%    Antivirals      12200020102040  FoscametSodium  Foscarnet Sodium lnj12000 MG/500ML (24 MG/ML)    16.00%    ANTIVIRALS INFLUENZA      12504065002020  Rapivab  Peramlvir Jnj 200 MG/20Ml {10
            MG/ML)    16.00%    Bisphosphonates      300420481D0360  Boniva  fbandronate Sodium Tab 150 MG (Base Equivalent}    16.00%    BLEEDING DISORDERS      84100010000320  Amicar  AminocaproicAcid Tab 1000 MG    16.00%    BLEEDING
            DISORDERS      84100010001205  Amicar  Aminocaproic Acid Syrup 25%    16.00%    BLEEDING DISORDERS      8410001000030S  Amicar  Aminotaprolc Add Tab 500 MG    16.00%    Blood Products/ Modifiers/Volume Expanders      8240101510ES56  Aranesp
            (Albumin Free)  Darbepoetln Affa-Polysorbate 80 Soln lnj 60 MCG/Ml    16.00%    Blood Products/ Modifiers/Volume Expanders      8240101510E575  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate80 Soln lnj150 MCG/0.3Ml    16.00%    Blood
            Products/ Modifiers/ Volume Expanders      82401015102080  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 500 MCG/ML    16.00%    Blood Products/ Modifiers/Volume Expanders      8240102000E545  Epogen  Epoetin Alfa lnj10000
            Unit/Ml    16.00%    Blood Products/ Modifiers/ Volume Expanders      8240104010E515  Mircera  Methoxy Polyethylene Glycol-Epoetin Beta lnj 50 MCG/0.3Ml    16.00%    Blood Products/ Modifiers/Volume
            Expanders      8240152000ES45  Neupogen  Fl!grastlm lnj 300 MCG/0.5ML{600 MCG/MLJ    16.00%    Blood Products/ Modifiers/ Volume Expanders      85100028402105  Alprolix  Coagulation Factor IX {Recomb) {rFIXFc} For lnj 250
            Unit    15.50%    Blood Products/ Modifiers/ Volume Expanders      85100015106440  Wi/ate  Antihemophilic Factor/V\VF {Human) For lnj 1000-1000 Unit Kit    15.50%    Blood Products/ Modifiers/ Volume
            Expanders      85100028202145  lxinity  Coagulation Factor IX (Recombinant) For lnj1500 Unit    15.50%    Blood Products/Modifiers/Volume E:icpanders      85100010402130  Adynovate  Antihemophilic Factor Recomb Pegylated For lnj 500
            Unit    15.50%    Blood Products/ Modifiers/ Volume Expanders      85100031002140  Coagadex  Coagulation Factor X (Human} For lnj500 Unit    15.50%    Blood Products/ Modifiers/ Volume Expanders      8240101510E543  Aranesp {Albumfn
            Free)  Darbepoetin Alfa-Po!ysorbate 80 Soln lnj 40 MCG/0.4Ml    16.00%    Blood Products/ Modifiers/ Volume Expanders      8240101510E560  Aranesp (Albumin Free)  Darbepoetin A!fa-Polysorbate 80 So!n lnj100 MCG/0.SML    16.00%    Blood
            Products/ Modifiers/Volume Expanders      8240101510E582  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 200 MCG/0.4ML    16.00%    Blood Products/ Modifiers/Volume Expanders      85100028206430  BeneFIX  Coagulation Factor IX
            (Recombinant) For lnj Kit 500 Unit    21.00%    Blood Products/ Modifiers/Volume Expanders      8240101510E543  Aranesp (Albumin Free)  Darbepoetin A!fa-Polysorbate 80 Sain lnJ 40 MCG/0.4Ml    16.00%    Blood Products/ Modifiers/ Volume
            Expanders      8240101510ES60  Aranesp (Albumin Free)  Darbepoetin Atfa-Polysorbate 80 Soln lnj100 MCG/0.SML    16.00%    Blood Products/ Modifiers/ Volume Expanders      82401015102070  Aranesp {Albumin Free)  Oarbepoetln Alfa-Pofysorbate 80
            Sain lnj 300 MCG/ML    16.00%    Blood Products/ Modifiers/ Volume Expanders      8240102000E54S  Epogen  Epoetin Alfa lnj10000 Unit/ML    16.00%    Blood Products/ Modifiers/ Volume Expanders      8240102000E575  Epogen  Epoetin Alfa lnj 40000
            Unit/Ml    16.00%    Blood Products/ Modifiers/ Volume Expanders      8240152000E525  Neupogen  Fifgrastim lnJ 300 MCG/Ml    16.00%    Blood Products/ Modifiers/Volume Expanders      82401015102010  Aranesp (Albumin Free)  Darbepoetln
            Alfa-Polysorbate 80 Sain lnJ 25 MCG/Ml    16.00%    Blood Products/ Modifiers/Volume Expanders      8240101510E552  Aranesp (Albumin Free)  Darbepoetin Alfa-Po!ysorbate 80 Soln lnJ 60 MCG/0.3Ml    16.00%    Blood Products/ Modifiers/Volume
            Expanders      8240101510ES58  Aranesp (Albumin Free)  Darbepoetln Alfa-Polysorbate 80 So!n lnj 200 MCG/ML    16.00%    Blood Products/ Modifiers/ Volume Expanders      82401015102080  Aranesp (Albumin Free)  Darbepoetln Alfa-Po!ysorbate80 Soln
            lnj 500 MCG/Ml    16.00%    Blood Products/ Modifiers/Volume Expanders      8240102000£545  Epogen  EpoetinAlfa lnj 10000 Unit/Ml    16.00%    Blood Products/ Modifiers/ Volume Expanders      8240104010E520  Mircera  Methoxy Polyethylene
            G!ycol-Epoetin Beta lnj 75 MCG/0.3Ml    16.00%    Blood Products/ Modifiers/ Volume Expanders      8240152000E550  Neupogen  Fi!grastim lnJ 480 MCG/0.8Ml (600 MCG/ML)    16.00%    Blood Products/ Modifiers/ Volume
            Expanders      85100028352130  ldetvion  Coagulation Factor IX{Retomb} (r!X-FP) For lnj1000 Unit    15.50%    Blood Products/ Modifiers/Volume Expanders      85100028402150  Alprolix  Coagulation Factor IX{Recomb) (rFlXFc) For lnj 4000
            Unit    15.503⁄4    Blood Products/ Modifiers/Volume Expanders      8240104010E525  Mlrcera  Methoxy Potyethylene Glycol-Epoetin Beta lnj100 MCG/0.3Ml    16.00%    Blood Products/ Modifiers/Volume Expanders      82401015102020  Aranesp {Albumin
            Free)  O:arbepoetin Alfa-Polysorbate80 Soln lnj 40 MCG/Ml    16.00%    Blood Products/ Modifiers/ Volume Expanders      82401015102040  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Sain lnj100 MCG/Ml    16.00%    Blood Products/
            Modifiers/ Volume Expanders      8240101510E558  Aranesp (Albumin Free)  Darbepoetln Alfa-Polysorbate 80 Sain lnj 200 MCG/Ml    16.00%    Blood Products/ Modifiers/ Volume Expanders      85100028206420  BeneFIX  Coagulation Factor IX
            (Recombinant) For !nj Kit 250 Unit    21.00%    Blood Products/ Modifiers/ Volume Expanders      8240101510E556  Aranesp (Albumin Free)  Darbepoetin Affa-Polysorbate 80 Sein lnj60 MCG/ML    16.00%    Blood Products/ Modifiers/Volume
            Expanders      82401015102050  Aranesp (Albumin Free)  DarbepoetfnAlfa-Po!ysorbate80 5oln JnJ 150 MCG/0.75Ml  ,r.\\8Tf?.c:-, '  16.00%    Blood Products/ Modifiers/ Volume Expanders      8240101510E588  Aranesp (Albumin Free)  Darbepoetin
            Alfa-Polysorbate 80 So!n lnj 300 MCG/0.6Ml ,;,-,--l'<•: p:'"'*TI:.:Z-{?"-."...f,    16.00%    Blood Products/ Modifiers/ Volume Expanders      8240102000E545  Epogen  Epoetin Alfa lnj 10000 Unit/Ml  _:;,_/
            _(,r'    16.00%  ,,,~···,:v  ,  ..        •c! !Ir ontmro Nu.ine\ro·0mt! , .f • r, I!}_((} ·._ ./ /i {'\\\\ ', ---------------1·.-o    ,'  ,-./0DES!" / 

      

    

     

    
      
        


    

    
      
        

      

      
                   ".-, \\)i\  ..:c_ ·,J) \-,, I  ,,1  'I'  I::'"'•\  lctd Prod cts/ Modifiers/ Volume
            Expanders    8240102000ES75  Epogen  Epoetin A!fa Jnj 40000 Unit/ML  16.00%  Bloo  rod.l1cts/ Modifiers/ Volume Expanders  8240101510ES28  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Sein fnj 25 MCG/0.42Ml  16.00%  s,~  Pfoducts/
            Modifiers/ Volume Expanders  82401015102040  Aranesp (Albumin Free}  Darbepoetln Alfa-Polysorbate 80 Sein lnj100 MCG/ML  16.00%  tfffc19 I-Products/ Modifiers/Volume Expanders    8240101510ES58  Aranesp (Albumin Free)  Darbepoetin
            A!fa-Polysorbate 80Solo lnj 200 MCG/ML  16.00%  §1obd Products/ Mod'rfiers/ Volume Expanders    8240102000E510  Epogen  Epoetin Alfa Jnj 2000 Unit/ML  16.00%  BtOod Products/ Modifiers/ Volume Expanders    8240102000E545  Epogen  Epoetin Alfa
            lnj10000 Unit/ML  16.00%  Blood Products/ Modifiers/ Volume Expanders    8240104010E525  Mircera  Methoxy Polyethylene Glycol-Epoetin Beta lnj100 MCG/0.3Ml  16.00%  Blood Products/ Modifiers/Volume
            Expanders    85100028352140  ldelvion  Coagulation Factor IX{Recomb) {rlX-FP) For lnj 2000 Unit  15.50%  Blood Products/ Modifiers/ Volume Expanders    85100015106430  Wi!ate  Antihemophilic Factor/VWF (Human) For lnJ 500-500 Unit
            Kit  15.50%  Blood Products/ Modifiers/Volume Expanders    85100010402140  Adynovate  Antihemophilic Factor Recomb Pegylated Forlnj1000 Unit  15.50%  Blood Products/ Modifiers/ Volume Expanders    8240157000E520  Neulasta  Pegfi!grastim lnj6
            MG/0.6Ml  16.00%  Blood Products/ Modifiers/ Volume Expanders    82401015102070  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj300 MCG/ML  16.00%  Blood Products/ Modifiers/Volume Expanders    8240104010E520  Mircera  Methoxy
            Polyethylene Glycol-Epoetin Beta lnj 75 MCG/0.3Ml  16.00%  Blood Products/ Modifiers/Volume Expanders    85100028206450  BeneFIX  Coagulation Factor IX{Recombinant) For lnj Kit 2000 Unit  21.00%  Blood Products/ Modifiers/ Volume
            Expanders    85100010402150  Adynovate  Antihemophi!fc Factor Recomb Pegylated For lnJ 2000 Unit  15.50%  Blood Products/ Modifiers/Volume Expanders    82401015102010  Aranesp (Albumin Free)  Darbepoetin Alfa-Po!ysorbate 80 Soln lnj 25
            MCG/Ml  16.00%  Blood Products/ Modifiers/Volume Expanders    8240101510E556  Aranesp {Albumin Free)  Darbepoetin A!fa-Po[ysorbate 80Sain lnj 60 MCG/Ml  16.00%  Blood Products/ Modifiers/ Volume Expanders    82401015102050  Aranesp (Albumin
            Free)  Darbepoetln Alfa-Polysorbate 80 So!n lnJ 150 MCG/0.75ML  16.00%  Blood Products/ Modifiers/ Volume Expanders    85100010402120  Adynovate  Antihemophilic Factor Recomb Pegylated For lnj 250 Unit  15.50%  Blood Products/ Modifiers/Volume
            Expanders    85100031002120  Coagadex  Coagulation FactorX {Human) For Jnj 250 Unit  15.50%  Blood Products/ Modifiers/ Volume Expanders    8240102000ES45  Epogen  Epoetin Alfa lnJ 10000 Unit/Ml  .16.00%  Blood Products/ Modifiers/ Volume
            Expanders    8240152000E545  Neupogen  F!lgrastim lnj300 MCG/0.SML {600 MCG/ML)  16.00%  Blood Products/ Modifiers/Volume Expanders    8240102000E575  Epogen  Epoetin Alfa fnj 40000 Unit/Ml  16.00%  Blood Products/ Modifiers/ Volume
            Expanders    85100028206460  BeneFIX  Coagulation Factor IX {Recombinant) For lnJ Kit 3000 Unit  21.00%  Blood Products/ Modifiers/Volume Expanders    82401015102020  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 40
            MCG/Ml  16.00%  Blood Products/ Modifiers/ Volume Expanders    82401015102040  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 So!n Jnj100 MCG/ML  16.00%  Blood Products/ Modifiers/ Volume Expanders    8240101510E558  Aranesp (Albumin
            Free}  Darbepoetin Alfa-Polysorbate 80Soln lnJ 200 MCG/ML  16.00%  Blood Products/ Modifiers/ Volume Expanders    8240102000E520  Epogen  Epoetin Alfa Jnj 4000 Unit/Ml  16.00%  Blood Products/ Modifiers/Volume
            Expanders    8240102000E575  Epogen  Epoetin Alfa Jnj 40000 Unit/ML  16.00%  B!ood Products/ Modifiers/Volume Expanders    8240157000E520  Neulasta  Pegfllgrastim lnj6 MG/0.6Ml  16.00%  Blood Products/ Modifiers/ Volume
            Expanders    85100028352110  ldelvlon  Coagulation Factor IX (Recomb) {rlX-FP) For lnj 250 Unit  15.50%  Blood Products/ Modifiers/ Volume Expanders    85100010402145  Adynovate  Antihemophillc Factor Recomb Pegylated For fnj1500
            Unit  15.50%  Blood Products/ Modifiers/Volume Expanders    8240101510E528  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnJ 25 MCG/0.42Ml  16.00%  Blood Products/ Modifiers/ Volume Expanders    8240101510E552  Aranesp (Albumin
            Free}  Darbepoetin Alfa-Polysorbate 80Soln Jnj 60 MCG/0.3Ml  16.00%  Blood Products/ Modifiers/ Volume Expanders    8240101510E575  Aranesp {Albumin Free)  Darbepoetin Affa-Polysorbate 80 So!n fnj150 MCG/0.3Ml  16.00%  Blood Products/
            Modifiers/Volume Expanders    82401015102020  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Soln lnj 40 MCG/Ml  16.00%  Blood Products/ Modifiers/ Volume Expanders    82401015102040  Aranesp (Albumin
            free)  DarbepoetinAlfa-Polysorbate80 Soln lnj100 MCG/Ml  16.00%  Blood Products/ Modifiers/Volume Expanders    8240101510E582  Aranesp(Albumin free)  Darbepoetin Alfa-Polysorbate 80 So!n fnj 200 MCG/0.4Ml  16.00%  Blood Products/ Modifiers/
            Volume Expanders    8240102000ES45  Epogen  Epoetin Alfa lnj10000 Unit/ML  16.00%  Blood Products/ Modifiers/Volume Expanders    8240102000E575  Epogen  Epoetin Alfa Jnj40000 Unit/Ml  16.00%  81000 Products/ Modifiers/Volume
            Expanders    8240157000E520  Neulasta  Pegfllgrastim lnj 6 MG/0.6ML  16.00%  Blood Products/ Modifiers/Volume Expanders    83334030002120  lprivask  Desirudln For lnj15 MG  15.50%  B!ood Products/ Modifiers/ Volume
            Expanders    85100028352120  ldelvion  Coagulation Factor IX{Recomb) (rlX-FP) For lnj500 Unit  15.50%  Blood Products/ Modifiers/ Volume Expanders    8240152000E525  Neupogen  F!lgrast!m lnj300 MCG/Ml  16.00%  Blood Products/ Modifiers/ Volume
            Expanders    8240101510E588  Aranesp {Albumin free)  Darbepoetin Alfa-Po!ysorbate 80 Soln lnj 300 MCG/0.6Ml  16.00%  Blood Products/ Modifiers/Volume Expanders    8240104010E515  Mircera  Methoxy Polyethylene Glycol-Epoetin Beta lnj50
            MCG/0.3ML  16.00%  Blood Products/ Modifiers/ Volume Expanders    8240102000E520  Epogen  Epoetin Alfa lnj 4000 Unit/Ml  16.00%  Blood Products/ Modifiers/Volume Expanders    8240152000E550  Neupogen  Fi!grastim lnj 480 MCG/0.8Ml (600
            MCG/ML)  16.00%  Blood Products/ Modifiers/ Volume Expanders    85100028206440  BeneFIX  Coagulation Factor IX (Recombinant) For lnj Kit 1000 Unit  21.00%  ( 

      

    

     

    
      
        


    

    
      
        

      

      
                 '  ·•. · •.·.,'\<,,,)\'- . "iJ)  .  "I·,  IBUiod.  rodutts/ Modifiers/Volume
            Expanders  82401015102020  Aranesp (Albumin Free)  Darbepoetin Alfa-Po!ysorbate 80 Soln lnj 40 MCG/ML  16.00%  Hlnnd.-' rodu'tts/ Modifiers/ Volume Expanders    82401015102040  Aranesp {Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Sofn lnj
            100 MCG/ML  16.00%  Bl otleffldllcts/ Modifiers/ Volume Expanders    8240101510E558  Aranesp (Albumin Free)  Darbepoetin Alfa-Polysorbate 80 Solo lnJ 200 MCG/Ml  16.00%  w69ieroducts/ Modifiers/Volume
            Expanders    8240104010E545  Mlrcera  Methoxy Polyethylene G!ycol-Epoetin Beta lnj 200 MCG/0.3ML  16.00%  _ruQ d-Products/ Modifiers/Volume Expanders    85100010402135  Adynovate  Antihemophilic Factor Recomb Pegylated For lnj 750
            Unit  15.50%  Blood Products/ Modifiers/Volume Expanders    84100040002025  Cyklokapron  TranexamlcAcid IV Soln 1000 MG/lOML {100 MG/ML)  16.00%  Blood Products/ Modifiers/ Volume Expanders    8240102000ES10  Epogen  Epoetin Alfa lnj 2000
            Unit/ML  16.00%  Blood Products/ Modifiers/Volume Expanders    8240101S102080  Aranesp (Albumin Free)  DarbepoetinAlfa-Polysorbate80 Sain lnj 500 MCG/ML  16.00%  Blood Products/ Modifiers/ Volume Expanders    8240104010ES45  Mircera  Methoxy
            Polyethylene Gtycol-Epoetin Beta lnj 200 MCG/0.3ML  16.00%  Bone Density Regulators    30044530002020  Prolia  Denosumab lnj 60 MG/ML  15.75%  Bone Density Regulators    3004405510E140  Natpara  Parathyroid Hormone (Recombinant) For lnj
            Cartridge 100 MCG  16.00%  Bone Density Regulators    3004405510E110  Natpara  Parathyroid Hormone (Recombinant) For tnj Cartridge 25 MCG  16.00%  Bone Density Regulators    30044070002020  Forteo  Teriparatide (Recomblnant) lnj 600
            MCG/2.4ML  16.00%  Bone Density Regulators    30044530002030  Xgeva  Denosumab lnJ 120 MG/1.7ML  16.00%  Bone Density Regulators    3004405S10E120  Natpara  Parathyroid Hormone (Recombinant) For lnJ Cartridge 50 MCG  16.00%  Bone Density
            Regulators    3004405510E130  Natpara  Parathyroid Hormone {Recombinant) For lnj Cartridge 75 MCG  16.00%  cardiovascular APents    37100020000305  Keveyfs  Dichlorphenamide Tab SO MG  15.50%  CASTLEMAN
            DISEASE    99473080002120  Sylvant  Siltuxlmab For IV Infusion 100 MG  16.00%  CASTLEMAN DISEASE    99473080002140  Sylvant  Si!tuximab For 1V Infusion 400 MG  16.00%  Central Nervous System Agents    624030604SDS60  Rebif Rebidose
            Titration  Interferon Beta-la lnj6X 8.8 MCG/0.2ML& 6 X 22 MCG/0.SML  16.50%  Central Nervous System Agents    624030604SE540  Rebif  Interferon Beta-la lnj44 MCG/0.SML (24MU/ML) {88 MCG/ML)  16.50%  Central Nervous System
            Agents    62403060450560  Rebff Rebidose Titration  Interferon Beta-la lnJ 6 XS.8 MCG/0.2ML & 6X 22 MCG/0.SML  16.50%  Central Nervous System Agents    74400020202140  Xeomin  lncobotu!inumtoxinA For IM lnj 200 Unit  15.50%  Central Nervous
            System Agents    6240306045E540  Rebif  Interferon Beta-la lnj 44 MCG/0.5ML {24MU/ML) (88 MCG/ML)  16.50%  Central Nervous System Agents    624030604SD520  Rebif Rebidose  Interferon Beta-la lnj 22 MCG/0,SML (12MU/Ml) {44
            MCG/ML)  16.50%  Central Nervous System Agents    6240306045D520  Reblf Rebidose  Interferon Beta-la lnj22 MCG/0.SML {12MU/ML) (44 MCG/ML)  16.50%  Central Nervous System Agents    6240306045D560  Rebif Rebidose Titration  Interferon Beta-la
            lnj 6X 8.8 MCG/0.2ML & 6 X 22 MCG/0.SML  16.50%  Central Nervous System Agents    6240306045DS20  Rebif Rebidose  Interferon Beta-la lnj 22 MCG/0.SML (12MU/ML) {44 MCG/ML)  16.50%  Central Nervous System
            Agents    6240306045FS30  AvonexPen  Interferon Beta-la IM lnj Kit30 MCG/0.5ML  16.75%  Central Nervous System Agents    62609902300120  Nuedexta  Dextromethorphan HBr-Quinldine Sulfate Cap 20-10 MG  15.50%  Central Nervous System
            Agents    624030604SF530  AvonexPen  Interferon Beta-la IM lnj Kit30 MCG/0.SML  16.75%  Central Nervous System Agents    624030604SES40  Rebif  Interferon Beta-la lnj 44 MCG/0.SML (24MU/ML) {88 MCG/ML)  16.50%  Central Nervous System
            Agents    62403060450520  Rebif Rebidose  Interferon Beta-la lnj 22 MCG/0.SML {12MU/ML) {44 MCG/Ml)  16.50%  Central Nervous System Agents    624030604SF530  AvonexPen  Interferon Beta-la IM lnj Kit 30 MCG/0.SML  16.75%  Central Nervous System
            Agents    624030604SE540  Rebif  Interferon Beta-la lnj44 MCG/0.5ML(24MU/ML){88 MCG/ML)  16.50%  CMV Agents    12200010002020  Vistide  Cidofovir IV lnj 75 MG/ML  16.00%  CMV Agents    12200020102020  FoscarnetSodium  Foscarnet Sodium lnj 24
            MG/ML  16.00%  CMV Agents    12200066102120  Valcyte  Valganciclovlr HCI For Soln SO MG/ML (Base Equiv)  16.00%  CMV Agents    12200066100320  Vafcyte  Vafgandc!ovir HC1 Tab 450 MG (Base
            Equivalent)  16.00%  CMVAgents    12200030102110  Cytovene  Gandclovir Sodium For lnj 500 MG  60.00%  CONGESTIVE HEART FAILURE    40180050002120  Natrecor  Nesiritlde For lnj 1.5 MG  16.00%  CORTICOSTEROIDS    22100020202011  Dexamethasone Sod
            Pho  Dexamethasone Sod Phosphate Preservative Free lnj 10 MG/ML  16.00%  CORTICOSTEROIDS    22100030202115  Solu-MEDROL  Methylprednisolone Sodium Sucdnate For lnj 500 MG  16.00%  CORTICOSTEROIDS    22100020002900  Dexamethasone  Oexamethasone
            Powder  16.00%  CORTICOSTEROIDS    2210003020210S  Solu-MEDROL  Methylprednlsolone Sodium Succinate For lnj 40 MG  16.00%  CORTICOSTEROIDS    22100020001320  Dexamethasone lntensol  Dexamethasone Cone 1
            MG/ML  16.00%  CORTICOSTEROIDS    22100025402161  Solu-CORTEF  Hydrocortisone Sodium Succinate PF For Jnj 500 MG  16.00%  CORTICOSTEROIDS    221000S0101810  Kenalog  Triamcinolone Acetonide lnj Susp 40
            MG/ML  16.00%  CORTICOSTEROIDS    22100020202900  Dexamethasone Sodium  Dexamethasone Sodium Phosphate Powder  16.00% 

      

    

     

    
      
        


    

    
      
        

      

      
               _:, ,<,J) "\  l  wa·    COSi'EROIDS  22100030202120  Solu-MEDROL  Methylprednisotone Sodium
            Sucdnate For lnj 1000 MG  16.00%  co"    COSlEROIDS  22100020002005  Dexamethasone  Dexamethasone Solo 0.5 MG/SML  16.00%    9R l(i.OSTEROIDS    22100025402165  Sofu-CORTEF  Hydrocortisone Sodium Sucdnate PF For lnj 1000
            MG  16.00%    l\ll,COSTEROIDS    22100020102900  Dexamethasone Acetate  DexamethasoneAcetate Powder  16.00%  <.; lAiJCOSTEROIDS      22100030202110  Solu-MEDROL  Methylprednisolone Sodium Sucdnate For lnj 125
            MG  16.00%  orticosteroids      22100017001830  Emflaza  Deflazacort Susp 22.75 MG/ML  15.50%  CORTICOSTEROIDS      22100020000325  Dexamethasone  Dexamethasone Tab 1
            MG  16.00"76  CORTICOSTEROIDS      22100025402150  Solu-CORTEF  HydrocortisoneSodfumSucdnate PF For Jnj100 MG  16.00%  CORTICOSTEROIDS      22100030202130  Solu-MEDROL  Methylprednisolone Sodium Succinate For Jnj 2000
            MG  16.00%  Corticosteroids      22100017000340  Emflaza  Deflazacort Tab 6MG  15.50%  corticosteroids      22100017000360  Emftaza  DeflazacortTab 30 MG  15.50%  Corticosteroids      22100017000365  EmfJaza  Deftazacort Tab 36
            MG  15.50%  CORTICOSTEROIDS      22100020000335  Dexamethasone  Dexamethasone Tab 2 MG  16.00%  CORTICOSTEROIDS      22100025402155  So]u.CQRTEF  Hydrocortisone Sodium Sucdnate PF For lnj 250
            MG  16.00%  CORTICOSTEROIDS      22100050101805  Kenalog  Triamdno!one Acetonfde Jnj Susp 10 MG/Ml  16.00%  Corticosteroids      22100017000350  Emflaza  Def!azacortTab 18 MG  15.50%  CYSTIC FIBROSIS AGENTS      07000070000120  Tobi
            Podhaler  Tobramydn lnha! Cap 28 MG  17.10%  CYSTIC FIBROSIS AGENTS      45302030003030  Kalydeco  lvacaftor Packet75 MG  15.75%  CYSTIC FIBROSIS AGENTS      07000070002530  Bethkis  Tobramycin Nebu Sofn 300 MG/4Ml  16.00%  CYSTIC FIBROSIS
            AGENTS      45302030000320  Ka!ydeco  lvacaftorTab 150 MG  15.75%  CYSTIC FIBROSIS AGENTS      45304020002010  PulmoJ..yme  Dornase Alfa lnhal So!n 1 MG/ML  16.00%  CYSTIC FIBROSIS AGENTS      07000070002520  Kltabis Pak  Tobramycin Nebu So/n
            300 MG/5ML  41.75%  CYSTIC FIBROSIS AGENTS      45302030003020  Kalydeco  lvacaftor Packet 50 MG  15.75%  Cystfnosls Agents      56400030106530  Procysbi  Cysteamine Bitartrate Cap Delayed Release 75 MG {Base Equiv)  16.00%  Cystinosls
            Agents      56400030100140  Cystagon  Cysteam!ne Bitartrate Cap 150 MG  15.25%  Cystinosls Agents      56400030106520  Procysbi  Cysteamfne Bitartrate Cap Delayed Release 25 MG (Base Equiv)  16.00%  Cystfnosis
            Agents      564-00030100120  Cystagon  Cyst amine Bltartrate Cap 50 MG  15.25%  DERMATOLOG\CAl5      90890020002110  Botox Cosmetic  OnabotulinumtoxinA {Cosmetic) For lnj SO Unit  16.75%  DERMATOLOG!CAl5      90890020002120  Botox
            Cosmetic  OnabotulinumtoxinA (Cosmetic) For lnj 100 Unit  16.75%  DERMATOlOGICAl5      90890018002120  Dysport (Glabellar lines)  Abobotu!inumtoxinA (Glabellar Lines) For lnj 300
            Unit  16.75%  DERMATOlOGICAl5      90550085103400  Kenalog  Triamcinolone Acetonlde Aerosol Solo  16.00%  DIAGNOSTIC PRODUCTS      94200037002105  Cortrosyn  Cosyntropin For lnj 0.25 MG  16.00%  DIAGNOSTIC
            PRODUCTS      94200090102120  Thyrogen  Thyrotropin Alfa For lnj 1.1 MG  16.75%  Digestive Enzymes      51200024006760  Creon  Pancrelipase (llp-Prot-Amyl) DR Cap 24000-76000-120000Unit  16.00%  Digestive
            EnJ..ymes      51200024006750  Pancreaze  Pancrelipase {llp-Prot-Amyl) DR Cap 16800-40000-70000 Unit  16.00%  Digestive Enzymes      51200024006705  Creon  Pancrelipase {Lip-Prot-Amyl) DR Cap 3000-9500-15000 Unit  16.00%  Dlgest!Ve
            Enzymes      51200024006780  Creon  Pancrel!pase (Lip-Prot-Amyl) DR Cap 36000-114000-180000 Unit  16.00%  Digestive Enzymes      51200024006754  Pancreaze  Pancre!ipase {Lip-Prot-Amyl) DR Cap 21000-37000-61000 Unit  16.00%  Digestive
            Enzymes      51200024006710  Pancreaze  Pancrellpase (Up-Prot-Amyl) DR Cap 4200-10000-17500Unit  16.00%  Digestive Enzymes      51200060002030  Sucraid  Sacrosidase Soln 8500 Unit/Ml  16.00%  Digestive
            Enzymes      51200024006734  Pancreaze  Pancrellpase {Up-Prot-Amyl) DR Cap 10500-25000-43750 Unit  16.00%  Digestive Enzymes      51200024006740  Creon  Pancrelipase {Lip-Prat-Amyl) DR Cap 12000-38000-60000 Unit  16.00%  Digestive
            Enzymes      51200024006720  Creon  Pancrelipase {Up-Prot-Amyl) DR Cap 6000-19000-30000 Unit  16.00%  Direct Muscle Relaxants      75200010101920  Ryanodex  Dantro!ene Sodium For JV Susp 250 MG  16.0D%  ENDOCRINE AND METABDUCAGENTS-
            MISC.      30080050106440  Lupron Depot-Ped  leuprofide Acetate For lnj Pediatric Kit 15 MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.      30170070106420  SandoSTATJN lAR Depot  Octreotide Acetate For IM lnj Kit 20 MG  16.50%  ENDOCRINE
            ANO METABOLIC AGENTS - MISC.      30180060002120  Somavert  PegvisomantFor lnj 10 MG (As Protein)  15.75%  ENDOCRINE AND METABOUCAGENTS- MISC.      30454060000330  Samsca  Tolvaptan Tab 30 MG  16.75%  ENDOCRINE AND METABOLIC AGENTS-
            MISC.      30905070000120  Zemplar  Paricafcitol Cap 2 MCG  16.00% 

      

    

     

    
      
        


    

    
      
        

      

      
               ,- '---..,/).  ,,,, '\')..  '• ,,\ .  -/U.4ti  --'.6·  (J)'          r:N , · CRlNE AND METABOLIC
            AGENTS- MISC.    30906550002020  Aldurazyme  Laronidase Soln For IV Infusion 2.9 MG/SML  15.75%  E IJOtRlNE AND METABOLIC AGENTS- MISC.    30908565107320  Kuvan  Sapropterin Dlhydroch!orlde Soluble Tab 100 MG  16.75%  Q'9CRINE AND
            METABOUCAGENTS- MISC.    30908060002950  Buphenyl  Sodium Phenylbutyrate Oral Powder 3 GM/Teaspoonful  24.00%  DOCRINE AND METABOLIC AGENTS- MISC.    30080050106420  lupron Depot-Ped  leuprol!de Acetate For lnJ Pediatric Kit 7.5
            MG  16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30170050102040  Somatu!ine Depot  lanreotide Acetate Extended Release lnj 120 MG/0.SMl  16.75%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30170075401930  Signifor lAR  Pasireotide Pamoate
            For IM ERSusp 40 MG (Base Equiv)  16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30904520002920  Cystadane  "'Betaine Powder For Oral Solution**•  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30905225100340  Senslpar  Cinaca!cet HCI Tab
            90 MG (Base Equiv)  16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30908230000320  Carbaglu  Carg!umicAcidTab 200 MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30090040102020  Ganirefix Acetate  Ganirellx Acetate lnj 250
            MCG/0.SMl  15.25%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30170050102025  Somatu!ine Depot  lanreotideAcetate Extended Release lnj 60 MG/0.2Ml  16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30170075202040  Signifor  Pasireotide
            Diaspartate lnj 0.9 MG/Ml(Base Equiv)  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30180060002160  Somavert  Pegvlsomant For lnj 30 MG (As Protein)  15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30904045000120  Orfadln  Nitisinone Cap 5
            MG  16.00%  ENDOCRINE AND METABOUCAGENTS- MISC.    30905225100320  Senslpar  Cinacalcet HCI Tab 30 MG {Base EqulV)  16.75%  ENDOCRINE AND METABOUCAGENTS- MISC.    30908030000920  Ravicti  Glycerol Phenylbutyrate Liquid 1.1
            GM/Ml  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    300800501S6420  lupron Depot-Ped  leupro!JdeAcetate (3 Month) For lnj Pediatric Kit 11.25 MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30150085102120  Egrifta  Tesamorelin Acetate
            For Jnj1 MG {Base Equiv)  16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30170070106430  SandoSTATIN lAR Depot  Octreotide Acetate For IM lnj Kit 30 MG  16.50%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30180060002130  Somavert  Pegvisomant
            For lnJ 15 MG (As Protein)  15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC,    30903610102110  Fabrazyme  Agalsidase beta For IV Soln 5 MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30905070000140  Zemplar  Paricaldtol Cap 4
            MCG  16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30906850002020  Elaprase  ldursulfase Soln for JV Infusion 6 MG/3ML (2 MG/Ml)  15.75%  ENDOCRINE AND METABOUCAGENTS- MISC.    30080045106450  Supprelin lA  Histrelin Acetate (CPP) Implant
            Kit SO MG  15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30170050102030  SomatuHne Depot  lanreot!de Acetate Extended Release lnj 90 MG/0.3Ml  16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC,    30170075401920  Signifor lAR  Pasireotide Pamoate
            For IM ER Susp 20 MG {Base Equiv)  16.00%  ENDOCRINE AND METABOLIC AGENTS· MISC.    30904045000130  Oriadin  Nitisinone Cap 10 MG  16.00%  ENDOCRINE AND METABOUCAGENTS- MISC.    30905225100330  Sensipar  Cinaca!cet HC!Tab 60 MG {Base
            Equiv)  16.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30908060000320  Buphenyl  Sodium Phenylbutyrate Tab 500 MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30080050106430  Lupron Depot-Ped  leuprolideAcetate For lnj Pediatric Kit
            11.25 MG  16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.    301700701064-10  SandoSTATIN LAR Depot  Octreotide Acetate For IM lnj Kit 10 MG  16.50%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30170075401940  Sign!for LAR  Paslreotide Pamoate For
            IM ER Susp 60 MG {Base Equiv)  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC,    30454060000320  Samsca  Tolvaptan Tab 15 MG  16.75%  ENDOCRINE ANO METABOLIC AGENTS- MISC.    30905070000110  Zemplar  Paricalcltol Cap 1 MCG  16.00%  ENDOCRINE AND
            METABOLIC AGENTS- MISC.    30906050002120  Myalept  Metre!eptin For Subcutaneous lnJ 11.3 MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30908565103020  Kuvan  Sapropterin Dihydrochloride Powder Packet 100 MG  16.75%  ENDOCRINE AND
            METABOUCAGENTS-MISC,    30170070102030  Octreotide Acetate  Octreotide Acetate lnj 1000 MCG/Ml (1MG/Ml)  52.25%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30080050156440  lupron Depot-Ped  Leuprofide Acetate (3 Month) For lnj Pediatric Kit 30
            MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30150085102130  Egrifta  Tesamorelin Acetate Forlnj 2 MG (Base Equiv)  16.75%  ENDOCRINE AND METABOllCAGENTS- MISC.    30170075202020  Signifor  Pasfreotide Dlaspartate lnj 0.3 MG/ML {Base
            Eauiv)  16.00%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30180060002140  Somavert  Pegvisomant Forlnj 20 MG (As Protein}  15.75%  ENDOCRINE AND METABOLIC AGENTS- MJSC.    30903610102120  Fabrazyme  Agalsidase beta For IV So!n 35
            MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30905070002010  Zemp!ar  Parlca!dtol JV Soln 2 MCG/Ml  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30907030052020  vtmizim  Elosu)fase Alfa So!n For JV Infusion S MG/SML (1
            MG/Ml}  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30170070102005  Octreotide Acetate  Octreotide Acetate lnj 50 MCG/Ml (0.05 MG/Ml)  52.25%  ENDOCRINE AND METABOLIC AGENTS- MISC,    30907715002120  lumi2.yme  Alglucosidase Alfa For IV
            Sain 50MG  15.75%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30170070102015  Octreotide Acetate  Octreotide Acetate !nj 200 MCG/Ml (0.2 MG/Ml)  52.25%  ENDOCRINE AND METABOLIC AGENTS - MISC.    30170070102020  Octreotide Acetate  Octreotide
            Acetate lnj 500 MCG/ML (0.5 MG/ML)  52.25%  ENDOCRINE AND METABOLIC AGENTS- MISC.    30080055102020  Synarel  NafareHn Acetate Nasal So!n 2 MG/Ml  16.00% 

      

    

     

    
      
        


    

    
      
        

      

      
               ',d,  ,,I  Ul!)OC:RINE AND METABOLIC AGENTS- MISC.  30160045002020  lncre!ex  Mecaserm!n lnj 40
            MG/4ML {10 MG/ML)  16.00%  i.N1 QCRINE AND METABOLIC AGENTS- MISC.  30170075202030  Signifor  Pasireotide Diaspartate lnj 0,6 MG/Ml (Base Equiv)  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30180060002150  Somavert  Pegvisomant For lnj 25
            fy'!G (As Protein)  15.75%  ENDOCRINE AND METABOLIC AGENTS - MISC.  30904045000110  Orfadin  Nitisinone Cap 2 MG  16.00%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30905070002020  zemplar  Paricaldtol IV Soln 5 MCG/ML  16.00%  ENDOCRINE AND
            METABOLIC AGENTS- MISC.  30907535002020  Nagla2.yme  Galsu!fase So!n For IV Infusion 1 MG/Ml  15.75%  ENDOCRINE AND METABOLIC AGENTS- MISC.  30170070102010  Octreotide Acetate  Octreotide Acetate lnj 100 MCG/ML {0.1MG/ML)  52.25%  ENZVME
            REPLACEMENT  2ooooos000202s  Adagen  Pegademase Bovine lnj 250 Unit/Ml  16.00%  Enzyme Replacements/Modifiers  30903875203020  Xuriden  Uridine Triacetate Oral Granules Packet 2 GM  15.50%  Enzyme
            Replacements/Modifiers  30905610002040  5trenslq  Asfotase Alfa Subcutaneous lnj 40 MG/ML  15.50%  Enzyme Replacements/Modifiers  30906360002020  Kanuma  SebeHpase Alfa IVSoln 20 MG/lOML {2 MG/ML)  15.50%  Enzyme
            Replacements/Modifiers  30905610002050  Strensiq  AsfotaseAlfa Subcutaneous lnj 80 MG/0.8ML  15.50%  Enzyme Replacements/Modifiers  30905610002020  Strensiq  Asfotase Alfa Subcutaneous lnJ18 MG/0.45ML  15.50%  Enzyme
            Replacements/Modifiers  30905610002030  Strensiq  AsfotaseAlfa Subcutaneous Jnj 28 MG/0.7Ml  15.50%  Enzymes  99350035002120  Xiaflex  Collagenase Clostridium Histolyticum For lnj 0.9 MG  16.75%  Enzymes  99350040102020  Hylenex  Hyaluronidase
            Human lnj 150 Unit/ML  16.00%  Fertility Regulators  30062030052020  Gonal-f RFF Pen  Follitropin Alfa lnj 300 Unit/0.5Ml  15.25%  Fertility Regulators  30062030102030  Fol!istimAQ  Folfitropln Beta lnj 600 Unit/0.72Ml  22.80%  Fertilfty
            Regulators  30062030102006  Follistim AQ  Follitropin Beta lnj 150 Unit/0.SML  22.80%  Fertility Regulators  30062030052150  Gonal-f  Fo!litropin Alfa For In] 1050 Unit  15.25%  Fertility Regulators  30062090102112  Bravel!e  Urofo!litropin
            Purified For lnj 75 Unit  15.25%  Fertility Regulators  30062030052040  Gonal-f RFF Pen  Fol!itropin Alfa Jnj 900 Unlt/1.5ML  15.25%  Fertility Regulators  30062030102040  FolfisflmAQ  Foltitropin Beta lnj 900 Unit/1.0SMl  22.80%  Fertility
            Regulators  30062030102003  FollistimAQ  Folfltropin Beta Jnj 75 Unit/0.SML  22.80%  Fertility Regulators  30062030102020  FoltistlmAQ  Follitropin Beta lnj 300 Unit/0.36ML  22.80%  Fertilfty Regulators  30062030052115  Gonal-f RFF  Fol!itrop!n
            Alfa For lnj 75 Unit  15.25%  Fertility Regulators  30062050002155  Repronex  Menotropins For lnj 75 Unit  15.25%  Fertility Regulators  30062030052140  Gonal-f  Fo!litropin Alfa For lnJ 450 Unit  15.25%  Fertility
            Regulators  30062050002175  Menopur  Menotropins For Subcutaneous lnj 75 Unit  15.25%  GASTROINTESTINALAGENTS- MISC.  52300020112900  Metoclopramide HCI Mo  Metodopramide HCl Monohydrate Powder  16.003⁄4  GASTROINTESTINAL AGENTS-
            MISC.  52700025000140  Cholbam  Cho!ic Acid Cap 250 MG  16.00%  GASTROINTESTINAL AGENTS - MISC.  52300020102900  Metoclopramide HCI  Metoclopramide HCI Powder  16.00%  GASTROINTESTJNALAGENTS- MISC.  52700025000120  Cholbam  Chol!cAcid Cap 50
            MG  16.00%  Genitourinary Agents  99200030000110  Cuprimine  Penicillam!ne Cap 250 MG  15.50%  GENITOURINARY AGENTS - MISCEllANEOUS  56500010002010  Rimso-50  Dimethyl Sulfoxide So!n 50%  16.00%  GOUT
            AGENTS  68000050002020  Krystexxa  Peglotlcase lnj 8 MG/Ml {For IV Infusion)  16.75%  Growth Hormones  30100020002066  Norditrop!n FlexPro  Somatropin lnJ 30 MG/3ML  17.25%  Growth Hormones  30100020002140  Nutropin  Somatropin For lnj 10
            MG  16.75%  Growth Hormones  30100020002178  Genotropin MiniQuick  Somatropln For lnj 1.4 MG  16.75%  Growth Hormones  30100020102130  Saizen  Somatropin (Non-Refrigerated) For lnj 8.8 MG  16.25%  Growth
            Hormones  30100020002050  Norditropin  Somatropin lnj 5 MG/1.SML  17.25%  Growth Hormones  30100020002062  Norditropin  Somatropin lnj 15 MG/1.SML  17.25%  Growth Hormones  30100020002132  Humatrope  Somatropln Forlnj 12 MG (36
            Unit)  16.75%  Growth Hormones  30100020002174  Genotropin MiniQulck  Somatropln For Jnj 1 MG  16.75%  Growth Hormones  30100020102121  Serostim  Somatropin (Non-Refrigerated} For Subcutaneous lnj 5 MG  16.00%  Growth
            Hormones  30100020002125  Humatrope  Somatropln For Jnj 6 MG (18 Unit)  16.75%  Gro\-vth Hormones  30100020002170  Genotropin MiniQulck  Somatropln For Jnj 0.6 MG  16.75%  Growth Hormones  30100020102118  serostim  Somatropin {Non-Refrigerated)
            For Subcutaneous lnJ 4 MG  16.00%  Growth Hormones  30100020002118  Nordltropin  SOMATROPIN FOR INJ 4 MG (12 UNIT)  16.50% 

      

    

     

    
      
        


    

    
      
        

      

      
                 h•      (J) l          Gr,i-u,t    Hon'hones  30100020002150  Humatrope  Somatropin For lnJ 24
            MG  16.75%  "''  wt  Hor(nones  30100020002180  Genotropin MlniQuick  Somatropin For lnJ 1.6 MG  16.75%  G  :_vf(h)Mofmones    3010002000201S  Nutropin AQ NuSpin 5  Somatropin lnj 5 MG/2Ml  16.75%  G«  "
            •ef.1-Hormones    30100020002127  Norditropin  SOMATROPIN FOR INJ 8 MG  16.50%  , Gr'C\ifth Hormones      30100020002172  Genotropin Min!Qulck  Somatropin For lnJ 0.8 MG  16.75%  GrO\;lth Hormones      30100020102120  Saizen  Somatropin
            {Non-Refrigerated) For lnj 5 MG  16.25%  Growth Hormones      30100020102132  Serostim  Somatropin (Non-Refrigerated) For Subcutaneous lnj 8.8 MG  16.25%  Growth Hormones      30100020002064  Nutropin AQNuSpin 20  Somatropin lnj 20
            MG/2Ml  16.75%  Growth Hormones      30100020002134  Genotropln  Somatropln For lnj 12 MG {13.8 MG overfill)  16.75%  Growth Hormones      30100020002176  Genotropin MiniQuick  Somatropin For Jnj 1.2 MG  16.75%  Growth
            Hormones      3010002010212S  Serostirn  Somatropin (Non-Refrigerated) For Subcutaneous lnj 6 MG  16.00%  Growth Hormones      30100020002121  Genotropln  Sornatrop!n For Subcutaneous lnj s MG  16.75%  Growth
            Hormones      30100020002120  Humatrope  Somatropin For lnj S MG  16.75%  Growth Hormones      30100020002166  Genotrop!n MlniQuick  Sornatropin For lnj 0.2 MG  16.75%  Growth Hormones      30100020002182  Genotrop!n M!niQuick  Sornatropin For
            lnj 1.8 MG  16.75%  Growth Hormones      30100020002056  Nordltropln FlexPro  Somatropin tnj 10 MG/1.SMl  17.25%  Growth Hormones      30100020002020  NutropinAQ  Somatropin lnj 10 MG/2ML  16.75%  Growth
            Hormones      30100020002123  Omnitrope  Somatropin For lnj 5.8 MG  16.25%  Growth Hormones      30100020002168  Genotropin MiniQulck  Somatropin For lnj 0.4 MG  16.75%  Growth Hormones      30100020002184  Genotropin MiniQulck  Somatropin For
            lnj 2 MG  16.75%  H-2 Antagonists      49200030112020  Famotidine Premixed  Famotidine in NaCl 0.9% IV Soln 20 MG/SOML  16.00%  H-2 Antagonists      49200010002900  Cimetidine  Cimetidine Powder  16.00%  HEMATOLOGICAL AGENTS-
            MISC.      85550060102120  Ceprotin  Protein C Concentrate (Human} For IV Soln 500 Unit  16.00%  HEMATOLOGICAL AGENTS- MISC.      85550060102140  Ceprotin  Protein C Concentrate {Human) For IVSoln 1000 Unit  16.00%  HEMATOLOGICALAGENTS-
            MISC.      85800050002020  Soliris  Eculizumab IVSoln 10 MG/ML (For Infusion)  15.75%  Hematopoietic Growth Factors      82403060002120  Neumega  Oprelvek!n For fnj 5 MG  16.25%  Hematopoietic Growth
            Factors      8240205000202S  Leukfne  Sargramostim lnj 500 MCG/Ml  16.75%  Hematopoietic Growth Factors      82405060002130  Np!ate  Romlplostlm For lnj 500 MCG  16.75%  Hematopoletic Growth Factors      82405030100310  Promacta  Eltrombopag
            O!amine Tab 12.5 MG {Base Equiv)  16.75%  Hematopoietic Grovtth Factors      82401520002012  Neupogen  Fi!grastim lnj 480 MCG/1.6Ml (300 MCG/ML)  16.00%  Hematopoletic Growth Factors      82402050002120  Leukine  Sargramostim Lyophi!ized For
            lnj 250 MCG  16.75%  Hematopoietic Growth Factors      8240152070ES30  Granix  Tbo-Fifgrastim Soln Prefilled Syringe 300 MCG/0.5ML  16.00%  Hematopoletic Growth Factors      82405030100320  Promacta  EltrombopagOlamine Tab 25 MG {Base
            Equiv)  16.75%  Hematopo!etic Growth Factors      82401060102050  Omontys  Peginesat!de Acetate Soln Jnj 10 MG/ML  16.00%  Hematopoietic Growth Factors      82405030100340  Promacta  Eltrombopag Olamine Tab 75 MG {Base
            Equiv)  16.75%  Hematopoietic Growth Factors      82401060102055  Omontys  Peginesatide Acetate Soln lnJ 20 MG/2Ml  16.00%  Hematopoietic Grovil:h Factors      82405060002120  Nplate  Rom!p!ostim For lnj 250 MCG  16.75%  Hematopoietic Growth
            Factors      82401020002015  Epogen  Epoetin Alfa lnj 3000 Unit/Ml  16.00%  Hematopoietic Growth Factors      82401020002050  Epogen  Epoetin Alfa lnj 20000 Unit/Ml  16.00%  Hematopoietic Growth
            Factors      8240152070E540  Granix  Tbo-Fflgrastim Soln Prefil!ed Syringe 480 MCG/0.8ML  16.00%  Hematopoietic Growth Factors      82405030100330  Promacta  Eltrombopag Olamine Tab 50 MG (Base Equiv)  16.75%  HEREDITARY
            ANGIOEDEMA      85820040102020  Firazyr  lcatibant Acetate lnj 30 MG/3Ml {Base Equivalent)  15.75%  HEREDITARY ANG!OEDEMA      85840030002020  Kalbitor  Eca!lantlde lnj 10 MG/ML  16.00%  HEREDITARY
            ANGIOEDEMA      85802022006420  Berinert  C1Esterase Inhibitor (Human) For IV lnj Klt500 Unit  16.25%  HEREDITARY ANGIOEDEMA      85802022102130  Ruconest  Cl Esterase Inhibitor (Recombinant) For JV lnj 2100 Unit  16.00%  HEREDITARY
            ANGIOEDEMA      85802022002120  Cinryze  Cl £sterase Inhibitor (Human) For IV lnj 500 Unit  15.25%  Hormonal Agents, Stimulant/Replacement/Modifying      30062022052220  Ovidrel  Choriogonadotropin Alfa lnJ 250 MCG/0.5Ml  15.50%  Hormonal
            Agents, StfmulanVReplacement/Modifying      30062020002140  Chorionic Gonadotropin  ChorionicGonadotropin for lnj 10000 Unit  15.50%  Hormonal Agents, Suppressant {Pituitary)      21404010101840  Depo-Provera  Medroxyprogesterone Acetate IM
            Susp 400 MG/ML  15.50% 

      

    

     

    
      
        


    

    
      
        

      

      
                 'S,o, 'Y,.)  ', \')  ' ,1\. iJ)ii' ...  .  I    If  .Nonts/SEDATIVES/SLEEP DISORDER
            AGENTS  60250070000130  HetliOl  Tasfmelteon Capsule 20 MG  16.00%  'lllJo I""    ;INOGLOBULINS  19100020102046  Octagam  Immune Globul!n (Human) IV Sofn 25 GM/SOOML  24.25%  ,w\    mNOGLOBUUNS  1910002010212S  CARIMUNE  Immune Globulfn {Human)
            IV For So!n 6 GM  25.00%    UNOGLOBULINS    19100020302080  Gammagard  Immune Globulin {Human) JV or Subcutaneous Soln 30 GM/300ML  27.55%    MUNOGLOBULINS    19100020102020  Flebogamma  Immune Globulin {Human) IV So!n 0.5
            GM/10ML  18.00%  --  IMMUNOGLOBULINS    19100020102113  Gammagard 5/D  Immune Globulin {Human) IV For Soln 0.5 GM  27.55%  \IMMUNOGLOBUUNS      19100020202058  Hizentra 20%  Immune Globulin (Human) Subcutaneous lnj 4
            GM/20ML  24.50%    IMMUN6GLOBULINS    191000SOO0ES40  RhoGAM Ultra-Filtered P  Rho D Immune Globulin IM Sein PrefSyr 1500 Unit (300MCG)  16J)0%    IMMUNOGLOBULINS    19990002356450  Hyqvia  1lmmun Glob lnJ 30 GM/300Ml-Hyaluron lnJ 2400 Unt/15
            Ml Kit  20.00%    IMMUNOGLOBUUNS    19100020102060  Gamunex  \Immune Globulin (Human) IV Soln 1 GM/10Ml  24.25%    IMMUNOGLOBULINS    19100020102130  Gammagard 5/D  Immune Globulin {Human) IV For Soln 10
            GM  27.55%    IMMUNOGLOBULINS    19100020302084  Gamunex-C  1 l mmuneGlobulfn {Human) IV or Subcutaneous Soln 40 GM/400ML  23.00%    IMMUNOGLOBULINS    19100020102090  Privigen  IImmune Globulin (Human) IV Soln 40
            GM/400Ml  19.00%    IMMUNOGLOBULINS    19100020202050  Hizentra 20%  Immune Globulin (Human) Subcutaneous !nj 1 GM/SML  24.50%    IMMUNOGLOBULINS    19100050002060  WinRhoSOF  Rho D Immune Globulin (Human} lnj 1500
            Unit/1.3Ml  17.75%    IMMUNOGLOBULINS    19990002356430  Hyqvla  lmmun Glob lnj 10 GM/lOOML-Hyaluron lnj 800 Unt/5 Ml Kit  20.00%    IMMUNOGlOBULINS    19100005002200  Cytogam  cytomegalovirus Immune Globulin {Human)
            !VlnJ  18.00%    IMMUNOGLOBULINS    19100020102112  GAMMAR-P I.V.  IMMUNE GLOBULIN {HUMAN) IV FOR SOLN 1 GM  31.25%    IMMUNOGLOBUUNS    19100020202054  Hizentra 20%  Immune Globulin (Human) Subcutaneous fnj 2
            GM/10Ml  24.50%    IMMUNOGLOBULINS    19100050002065  WinRhoSDF  Rho D Immune Globulin {Human) lnj 15000 Unlt/13Ml  17.75%    IMMUNOGLOBULINS    19990002356440  Hyqvla  lmmun Glob lnj 20 GM/200Ml-Hyafuron lnj 1600 Unt/10 Ml
            Kit  20.00%    IMMUNOGLOBULINS    19100020102120  Gammagard S/D  Immune Globu!!n (Human) IVFor Soln S GM  27.55%    IMMUNOGlOBUUNS    19100020102034  Flebogamma  Immune Globul!n (Human) IV Soln 2.5
            GM/50Ml  25.00%    lMMUNOGLOBULINS    19100020102068  Bivigam  Immune Globulin {Human) IV Soln 5 GM/SOML  24.25%    IMMUNOGLOBUUNS    19100020302068  Gammagard  Immune Globulin (Human} IV or Subcutaneous Sein 5
            GM/50Ml  27.55%    IMMUNOGLOBUUNS    19100020102064  Gamunex  Immune GlobuUn (Human) IVSoln2.5 GM/25Ml  24.25%    lMMUNOGLOBULINS    19100020202020  Vivaglobin  Immune Globulln {Human) Subcutaneous lnj 160 MG/Ml
            {16%}  23.75%    IMMUNOGLOBULINS    19100050002055  WinRhoSOF  Rho D Immune Globulfn {Human) lnj 5000 Unit/4.4Ml  17.75%    IMMUNOGLOBULINS    19990002356425  Hyqvia  Immun Glob lnj 5 GM/50Ml-Hyaluron lnj 400 Unt/2.5 ML
            Kit  20.00%    IMMUNOGLOBULINS    19100020102030  Octagam  Immune Globulin (Human) IVSoln 1 GM/20Ml  24.25%    IMMUNOGLOBULINS    19100020102117  Carimune NF  Immune Globulin (Human) IV For So!n 3
            GM  25.00%    IMMUNOGLOBULINS    19100020202065  Hiientra  Immune Globulin (Human) Subcutaneous lnj 10 GM/SOMl  24.50%    IMMUNOGLOBULINS    1910005000E550  Rhophylac  Rho D Immune Globulin Sol PrefSyr 1500 Unt/2Ml
            {300MCG/2ML)  18.25%    IMMUNOGLOBULINS    19100020102063  Octagam  Immune Globulin (Human) IVSoln 2 GM/20Ml  24.25%    IMMUNOGLOBUUNS    19100020102135  Carimune NF  Immune Globulin (Human) IV For Sofn 12
            GM  25.00%    IMMUNOGLOBUUNS    19100050002050  WinRhoSDF  Rho D lmmuneGlobunn (Human} lnj 2500 Unlt/2.2ML  17.75%    IMMUNOGLOBULINS    19990002356420  Hyqvia  lmmun Glob Jnj 2.5 GM/25ML-Hya!uron lnj 200 Unt/1.25 ML
            Kit  20.00%    IMMUNOGLOBULINS    19100020002200  GamaSTAN S/D  Immune Globulin (Human) lnj  23.75%    JMMUNOGLOBUUNS    19100020102044  Flebogamma DIF  Immune Globulin (Human) IV Soln 20
            GM/400Ml  25.00%    IMMUNOGLOBUUNS    19100020302064  Gammagard  Immune Globulin (Human) IV or Subcutaneous Sein 2.5 GM/25ML  27.55%    IMMUNOGLOBULINS    19100020102115  Gammagard 5/D  Immune Globulin (Human) IV For So!n 2.5
            GM  27.55%    IMMUNOGLOBULINS    19100020102205  GAMIMUNEN  IMMUNE GLOBULIN (HUMAN) JV SOLN 5%  47.75%    lMMUNOGLOBUUNS    19100020302060  Gammagard  Immune Globulin (Human) IV or Subcutaneous Soln 1
            GM/10Ml  27.55%    IMMUNOGLOBULINS    19100020102034  F!ebogamma  Immune Globulin (Human) IVSoln 2.5 GM/SOML  25.00%    IMMUNOGLOBULINS    19100020102072  Blvigam  Immune Globulin (Human) IV Solo 10
            GM/100Ml  24.25%    IMMUNOGLOBULINS    19100020302072  Gammagard  Immune Globulin (Human) IV or Subcutaneous Soln 10 GM/lOOMl  27.55%    IMMUNOGLOBUUNS    19100020102038  Flebogamma  Immune Globulin (Human) IVSoln 5
            GM/lOOML  25.00%    JMMUNOGLOBULINS    19100020102072  Bivigam  Immune Globulin (Human) N Soln 10 GM/100Ml  24.25%    IMMUNOGLOBULINS    19100020302072  Gammagard  Immune Globulin (Human) IV or Subcutaneous Soln 10 GM/lOOMl  27.55% 

      

    

     

    
      
        


    

    
      
        

      

      
                 lU  0  l y,_-::----._  " ',\\ t-  I  ' l  (, '.r' , ,,1 \            j
            UUAJll·INQG[OBUUNS    19100020102068  Bivigam  Immune Globulin (Human) IV Soln 5 GM/SOML  24.25%  01 UJl)N O/e_ IMMl1NOG!OBUUNS0    19100020302068  Gamrnagard  Immune G!obulln {Human) IV or Subcutaneous So!n 5 GM/SOML  27.55%  \: ,'JJ!
            fMMUN,OG'LOBUUNS., ·._    19100020102042  Flebogamma  Immune Gfobul!n (Human) IVSoln 10 GM/200ML  25.00%  t1NoGLOBULINS    19100020102076  Flebogamma DIF Immune Globulin {Human) IVSoln 20 GM/200Ml    24.25%  \.)..• "• -. _._,_ v
            iMM(JNOGlOBULINS    19100020302076  Gammagard  Immune Globulin (Human) IV or Subcutaneous Soln 20 GM/200Ml  27.55%  . : t,,- LtSW IMMUNOGLOBULINS    19100020102042  Flebogamma  Immune Globulin (Human) IV So!n 10
            GM/200ML  25.00%    IMMUNOGLOBULINS  19100020302064  Gammagard  Immune Globulin {Human) IV or Subcutaneous Soln 2.5 GM/25ML  27.55%    IMMUNOGLOBULINS  19100020102038  F!ebogamma  Immune Globulin (Human) IV Solri 5
            GM/100Ml  25.00%    [MMUNOGlOBULINS  19100020102076  Flebogamma DIF  Immune Globulin (Human) IV Soln 20 GM/200Ml  24.25%    IMMUNOGlOBULINS  19100020302076  Gammagard  Immune Globulin (Human) IV or Subcutaneous Soln 20
            GM/200Ml  27.55%  Immunological Agents    902S055400e520  Taltz  lxekizumab Subcutaneous Solo Prefilled Syringe 80 MG/Ml  15.50%    Immunological Agents  44604055002120  Nucala  Mepollzumab For lnj 100 MG  15.50%  l1mmuno!oglcal
            Agents    19200040002100  Antivenin Micrurus FulviL  Antivenin Micrurus Fu!vius For JV Sain  15.50%    lmmunofoglcal Agents  99450060203030  Veltassa  Patiromer Sorbitex Calcium For Susp Packet 16.8 GM {Base Eq)  15.50%    Immunological
            Agents  52505040202120  rnflectra  lnflbdmab-dyyb For IV lnj 100 MG  15.50%    Immunological Agents  99450060203040  Veltassa  Patiromer SorbitexCalcium For Susp Packet 25.2 GM (Base Eq}  15.50%    Immunological
            Agents  66290030002120  Enbrel  Etanercept For Subcutaneous lnj 25 MG  16.75%    Immunological Agents  99450060203020  Veltassa  Patiromer Sorbitex Calcium For Susp Packet 8.4 GM {Base Eq)  15.50%    lmmunosuppressive
            t1°ents  99402020000110  SandlMMUNE  Cyc!osporine Cap 25 MG  16.00%    !mmunosuppresslve Agents  99402540102220  Atgam  Lymphocyte Immune Globulin Anti-Thymocyte G lnj 50 MG/Ml(Eq)  16.00%    Immunosuppressive
            Agents  99404035000325  Zortress  Everolimus Tab 0.5 MG  16.00%    lmmunosuppressive11.oents  99404080000120  Prograf  Tacrolimus Cap 5 MG  16.00%    rmmunosuppressive Agents  99402020300150  Neoral  Cyc!osporine Modified Cap 100
            MG  16.00%    lmmunosuppressive Agents  99403030300630  Myfortic  Mycophenolate Sodium Tab DR 360 MG (MycophenolicAcldEquiv)  16.00%    lmmunosuppressive Agents  99404080000105  Prograf  Tacrolfmus Cap 0.5 MG  16.00%    lmmunosuppressive
            Agents  99402020000140  SandlMMUNE  Cyclosporine Cap 100 MG  16.00%    lmmunosuppressive Agents  99403030100120  CellCept  Mycopheno!ate Mofetil Cap 250 MG  16.00%    lmmunosuppressive Agents  99404035000330  Zortress  Evero!Jmus Tab 0.75
            MG  16.00%    lmmunosuppresslve Agents  99404080002010  Prograf  Tacrolimus Jnj 5 MG/Ml  1600%    Immunosuppressive Agents  99402020302020  Neoral  Cyclosporine Modified Oral Solo 100 MG/ML  16.00%    Im munosuppresslve
            Agents  99404035000320  Zortress  Everolimus Tab 0.25 MG  16.00%    lmmunosuppressive Agents  99404080000110  Prograf  Tacrolimus Cap 1 MG  16.00%    [mmunosuppressive Agents  99402020002005  SandlMMUNE  Cyclosporine IV Soln 50
            MG/Ml  16.00%    lmmunosuppressive Agents  99403030100330  Ce!ICept  Mycopheno!ate Mofetil Tab 500 MG  16.00%    Im munosuppressive Agents  99404070000310  Rapamune  Sirolimus Tab 0.5 MG  16.00%    lmmunosuppressive
            Agents  99405015002110  Simu!ect  Basiliximab For IV So!n 10 MG  16.00%    lmmunosuppressive Agents  99402020300120  Neoral  Cyclosporine Modified Cap 25 MG  16.00%    ImmunosuppresslveAgents  99403030202120  CelJCept Intravenous  Mycophenolate
            Mofetil HCI For IV Solo 500 MG {Base Equiv)  16.00%    Jmmunosuppressive Agents  99404070000330  Rapamune  Sirolimus Tab 2 MG  16.00%    lmmunosuppressive Agents  99406010000305  lmuran  Azath!oprine Tab SO MG  16.00%    (mmunosuppressive
            Agents  99402020300130  CycloSPORINE Modified  Cyc!osporine Modified Cap 50 MG  16.00%    Im munosuppressive Agents  99403030300620  Myfortlc  Mycophenolate Sodium Tab DR 180 MG {MycophenolicAcid Equiv)  16.00%    Jmmunosuppressive
            Agents  99404070002020  Rapamune  Sirolimus Oral So!n 1 MG/ML  16.00%    lmmunosuppressive Agents  99408020002120  Nulojix  Be!atacept For IV Infusion 250 MG  16.00%    l mmunosuppressive Agents  99402020002010  5andlMMUNE  Cyclosporine Oral
            So!n 100 MG/ML  1600%    /mmunosuppressive Agents  99403030101920  CellCept  Mycopheno!ate Mofetil For Oral Susp 200 MG/ML  16.00%    lmmunosuppressive Agents  99404070000320  Rapamune  Sirolfmus Tab 1 MG  16.00%    Jmmunosuppres.sive
            Agents  99405015002120  S!mulect  Basmx!mab For IV So!n 20 MG  16.00%    Inflammatory Bowel Agents  52503080002120  Entyvio  Vedolizumab For IV Solution 300 MG  16.00%  (  ,"°"'- 

      

    

     

    
      
        


    

    
      
        

      

      
                       :,, '0.,  ,o,-·\,,  ,-  elJl<i  -1 Blockers  66450060002120  Arcalyst  Rilonacept For
            lnj 220 MG  16.75%  Int£::  euki  -1 Receptor Antagonist{ll-lRa) RHEUtv1AT  6626001000ES20  Kineret  Anakinra Subcutaneous So!n Prefilled Syringe 100 MG/0.67Ml  16.00%  11{9  OVI  RLOAD-ANTIDOTES  93000020102110  Desferal  Deferoxamlne Mesylate
            For lnj 500 MG  16.75%  1Rbμ.o,VERLOAD-ANTIDOTES      93100028000320  Ferriprox  Deferiprone Tab 500 MG  16.00%  &'- OVERLOAD-ANTIDOTES      93100025007330  Exjade  DeferaslroxTab For Oral susp 250 MG  15.25%  (({ON
            OVERLOAD-ANTIDOTES      93000020102130  Desferal  Deferoxamine Mesy!ate For lnj 2 GM  16.75%  IRON OVERLOAD-ANTIDOTES      93100025007340  Exjade  DeferasiroxTab For Oral susp 500 MG  15.25%  IRON
            OVERLOAD-ANTIDOTES      93100025000320  Jadenu  DeferaslroxTab 90 MG  16.00%  IRON OVERLOAD-ANTIDOTES      9310002S000340  Jadenu  DeferasiroxTab 360 MG  16.00%  IRON OVERLOAD-ANTIDOTES      93100025007320  Exjade  DeferaslroxTab For Oral susp
            125 MG  15.25%  IRON OVERLOAD-ANTIDOTES      93100025000330  Jadenu  DeferaslroxTab 180 MG  16.00%  IRON REPlACEMENTS      82300085102020  Ferrlecit  Sod Ferric Gluc Cmpix fn Sucrose IV Soln 12.5 MG/Ml {Fe Eq)  16.00%  IRON
            REPLACEMENTS      82300048002020  Venofer  Iron Sucrose lnj 20 MG/Ml {Fe Equiv)  16.00%  LHRH Analogs      21405010106405  lupron Depot  leupro!ide Acetate For lnj Kit 3.75 MG  16.00%  LHRH Analogs      21405010156420  lupron
            Depot  leuprolideAcetate (3 Month) For lnj Kit 11.25 MG  16.00%  local Anesthetics - Topical      90850025306420  Qutenza  Capsaicin Patch 8% & Cleansing Gel Kit  16.00%  MEDICAL DEVICES      97051050106300  Omnitrope Pen 10 lni
            De  "-Injection Device - Misc***  16.25%  MOUTH/rHROAT/DENTALAGENTS      88501000002000  caphosot  *Artificial Saliva - Solution•"'*  16.00%  Movement Disorder Drug Therapy      62380070000310  Xenazlne  Tetrabenazine Tab 12.5
            MG  16.75%  Movement Disorder Drug Therapy      62380070000320  Xenazine  Tetrabena2ine Tab 25 MG  16.75%  MULTIPLE SCLEROSIS      30300010004010  Acthar HP  Corticotropin lni Gel 80Unit/Ml  16.00%  MULTIPLE SCLEROSIS
            AGENTS      6240003010E520  Copaxone  Glatiramer Acetate Soln Prefil!ed Syringe 20 MG/Ml  16.75%  MULTIPLE SCLEROSIS AGENTS      6240307530D250  Plegridy Starter Pack  Peginterferon Beta-la Soln Pen-inj 63 & 94MCG/0.SML
            Pack  16.00%  MULTlPLE SCLEROSIS AGENTS      62405525006520  Tecfidera  Dimethyl Fumarate Capsule Delayed Release 120 MG  16.00%  MULTIPLE SCLEROSIS AGENTS      62403060506420  Betaseron  Interferon Beta-lb For lnj Kit0.3 MG  16.25%  MULTIPLE
            SCLEROSIS AGENTS      62405050001320  Tysabri  Natalizumab for IV lnj Cone 300 MG/15Ml  18.00%  MULTIPLE SCLEROSIS AGENTS      6240003010E540  Copaxone  Glatiramer Acetate Soln Prefilled Syringe 40 MG/Ml  16.75%  MULTIPLE SCLEROSIS
            AGENTS      6240307530E520  Plegridy  Peglnterferon Beta-la Soln Prefilfed Syringe 125 MCG/0.SML  16.00%  MULTIPLE SCLEROSIS AGENTS      62405525006540  Tecfidera  Dimethyl Fumarate Capsule Delayed Release 240 MG  16.00%  MULTIPLE SCLEROSIS
            AGENTS      6240307530D220  Plegrldy  Peginterferon Beta-la Soln Pen-injector 125 MCG/0.SMl  16,00%  MULTIPLE SCLEROSIS AGENTS      62405525006320  Tetfidera  Dimethyl Fumarate Capsule DR Starter Pack 120 MG & 240 MG  16.00%  MULTIPLE
            SCLEROSIS AGENTS      62403060456420  Avonex  Interferon Beta-la For IM lnj Kit30MCG (33MCG{6.6 MU),N!a\)  16.75%  MULTIPLE SCLEROSIS AGENTS      6240307530ESSO  PlegridyStarter Pack  Peginterferon Beta-la Sofn Pref Syr 63 & 94 MCG/0.SML
            Pack  16.00%  MULTIPLE SCLEROSIS AGENTS      62406030007420  Ampyra  Dalfamprldine Tab SR 12HR 10MG  15.25%  MULTIPLE SCLEROSIS AGENTS      62404070000330  Aubagio  Teriflunomide Tab 14 MG  23.75%  MULTIPLE SCLEROSIS
            AGENTS      62403060S02120  Betaseron  Interferon Beta-lb For lnj 0.3 MG  16.25%  MULTIPLE SCLEROSIS AGENTS      62405010002020  lemtrada  Alemtuzumab IV lnj 12MG/1.2ML(10 MG/Ml)  16.00%  MULTIPLE SCLEROSIS
            AGENTS      62404070000320  Aubagio  Teriflunomide Tab 7 MG  23.75%  MULTtPLE SCLEROSIS AGENTS      62407025100120  Gilenya  Fingolimod HCl Cap 0.5 MG (Base Equ·1v)  16.50%  MUSCULOSKELETAL THERAPY
            AGENTS      75840015002300  Carticel  *Autologous Cultured Chondrocytes for Implantation""*  16.00%  Neurogenic Orthostatic Hypotension (NOH)-Agents      38700030000150  Northera  Droxldopa cap 300 MG  16.00%  Neurogenic Drthostatic Hypotension
            (NOH)-Agents      38700030000130  Northern  Droxidopa Cap 100 MG  16.00%  NeurogenicOrthostatic Hypotenslon (NOH)-Agents      38700030000140  Northera  Droxidopa cap 200 MG  16.00%  NEUROMUSCULAR
            AGENTS      74400020052140  Botox  OnabotullnumtoxinA For lnj 200 Unit  16.75%  NEUROMUSCULAR AGENTS      74400020032120  Dysport  AbobotulinumtoxinA For lnj 500 Unit  16.75%  NEUROMUSCULAR AGENTS      74503070000320  Rifutek  Riluzo!e Tab SO
            MG  16.00%  NEUROMUSCULAR AGENTS      74400020102018  Myobloc  RimabotulinumtoxinB lnj 2500 Unit/0.SML  16.25%  NEUROMUSCULAR AGENTS      74400020052120  Botox  OnabotulinumtoxinA For lnj 100 Unit  16.75%  NEUROMUSCULAR
            AGENTS      74400020102020  Myobloc  RimabotulinumtoxinB lnj 5000 Unit/ML  16.25% 

      

    

     

    
      
        


    

    
      
        

      

      
                   '\\ .,.  \)\\  -\, !J)  :,J/{  EUR  . MU
            ULARAGENTS  74400020202120  Xeomln  lncobotulinumtoxinA For Jnj SO Unit  16.25%    NIH  MU$CULAR AGENTS  74400020032115  Dysport  AbobotultnumtoxinA For lnj 300 Unit  16.75%    M
            :Ufl!tMUSCULARAGENTS    74400020202130  Xeomin  lncobotulinumtoxinA For lnj 100 Unit  16.25%    IN{LJJi;0MUSCUlAR AGENTS    74400020102022  Myobloc  RimabotulinumtoxinB lnj 10000 Unit/2ML  16.25%  ,w  10
            ·sbLETO    90250515002120  AMEVNE  ALEFACEPT FPR IV INJ 7.5 MG  15.50%    OPHTHALMIC AGENTS    86300010002320  Ozurdex  Dexamethasone lntravitreal Implant 0.7 MG  16.00%    OPHTHALMIC AGENTS    86700065002120  Visudyne  Verteporfin For IVSoln
            15 MG {2 MG/ML)  16.25%    OPHTHALMIC AGENTS    86300017102320  Retisert  Fluocinolone Acetonlde lntravitreal Implant 0.59 MG  16.00%    OPHTHALMIC AGENTS    86801060002020  Jetrea  Ocrip!asmin lntravitreal lnj 0.5 MG/0.2ML (2.5
            MG/ML)  16.00%    OPHTHALMIC AGENTS    86655010002020  Eylea  Aflibercept lntravitreal lnj 2 MG/0.05Ml (40 MG/ML)  15j5%    OPHTHALMIC AGENTS    86655060002012  Lucentis  Ranibizumab lntravJtreal lnj 0.3 MG/0.05ML {6
            MG/ML)  16.75%    OPITTHALMIC AGENTS    86655060002020  Lucentis  Ranibizumab lntravltreal lnj 0.5 MG/0.05ML (10 MG/ML)  16.75%    OPHTHALMIC AGENTS    86655050302020  Macugen  Pegaptanib Sodium lntravitreouslnj0.3 MG/90
            Micronter  16.25%    Ophthalmic Agents    86300080101820  Triesence  Triamcinolone Acetonide Ophth lnj 40 MG/ML  15.50%    OSTEOARTHRITIS OF THE KNEE    7580004000E530  Synvisc  Hylan Intra-articular Solution Prefllled Syringe 16
            MG/2Ml  16.75%    OSTEOARTHRITIS OF THE KNEE    7580004000E560  Synvlsc One  Hylan Intra-articular Solution Prefilled Syringe48 MG/6Ml  16.75%    OSTEOARTHRITIS OF THE KNEE    7580006000E520  OrthoVisc  Hyaluronan Intra-articular Solo Prefilled
            Syringe 30 MG/2ML  16.75%    OSTEOARTHRITIS OF THE KNEE    7580007010E520  Euflexxa  Sodium Hyaluronate Intra-articular Soln PrefSyr 20 MG/2ML  16.75%    OSTEOARTHRITIS OF THE KNEE    7580007010ES25  Supartz  Sodium Hyaluronate Intra-articular
            Soln Pref Syr 25 MG/2.SML  16.25%    OSTEOARTHRITIS OF THE KNEE    75800070102024  Hyalgan  Sodium Hyaluronate Intra-articular lnj 20 MG/2ML  16.75%    OSTEOPOROSIS-- BISPHOSPHONATES    30042090002120  Zoledronic Acid  Zoledronic Acid For IV
            So!n 4 MG  35.00%    OSTEOPOROSIS- BISPHOSPHONATES    30042090001320  Zoledron!c Acid  Zoledronic Acid lnj Cone For N Infusion 4 MG/SML  34.20%    OSTEOPOROSIS- BlSPHOSPHONATES    30042060102012  Pamldronate Disodium  Pamidronate Dlsodium JV
            Soln 9 MG/ML  16.00%    OSTEOPOROSIS-- BISPHOSPHONATES    30042060102006  Pamidronate Disodium  Pamidronate Disodium IV Soln 3 MG/ML  16.00%    OSTEOPOROSIS-- BlSPHOSPHONATES    30042060102009  Pamidronate Dlsodium  Pam!dronate Disodium IV Soln
            6 MG/ML  16.00%    OSTEOPOROSIS- BISPHOSPHONATES    30042090002016  ZoledronicAcid  Zo!edronic Acid IV Soln 4 MG/lOOML  35.00%    OSTEOPOROSIS- BISPHOSPHONATES    30042060102120  Aredia  Pamidronate Dlsodium For lnj 30
            MG  16.00%    OSTEOPOROSIS- BISPHOSPHONATES    30042090002020  Rec!ast  Zoledronic Acid IV Soln 5 MG/lOOML  35.00%    OSTEOPOROSIS- BISPHOSPHONATES    30042060102140  Aredia  Pamidronate Disodium For lnj 90MG  16.00%    OSTEOPOROSIS-
            BISPHOSPHONATES    30042048102030  Boniva  lbandronate Sodium IV Soln 3 MG/3ML {Base Equivalent)  16.00%    Progesterone Receptor Antagonists ANTIDIABET!CS    27304050000330  Korlym  Mifepristone Tab 300 MG  16.00%    Progestin Contraceptives-
            IUD    25200050005320  Mirena  levonorgestrelReleas!ng IUD 20 MCG/24HR (52 MG Total)  15.50%    Progestin Contraceptives- IUD    25300005002320  lmplanon  Etonogestrel Subdermal Implant 68
            MG  15.25%    PROGESTINS    26000010101710  Makena  HydroYVprogesterone Caproate IM In Oil 250 MG/ML  16.75%    PSORIASIS    9025058500ES20  Stelara  Ustekinumab So!n Prefi!led Syringe 45
            MG/0.5ML  16.00%    PSORIASIS    66700015000330  Otezla  ApremilastTab 30 MG  16.00%    PSORIASIS    9025058500ES40  Stelara  Usteklnumab Soln Prefilled Syringe 90MG/ML  16.00%    PSORIASIS    90250515002130  AMEVIVE  Alefacept For IM lnj 15
            MG  15.50%    PSORIASIS    9025057500E520  Cosentyx  Secukinumab Subcutaneous Soln Prefil!ed Syringe 150 MG/ML  16.00%    PSORIASIS    90250S85002020  Stelara  USTEKINUMAB INJ 45
            MG/0.SML  16.oo%    PSORIASIS    66700015008720  Otezla  ApremilastTab Starter Therapy Pack 10 MG & 20 MG & 30 MG  16.00%    PSORIASIS    9025057500D52  0 Cosentyx Sensoready Pei  Secukfnumab Subcutaneous Soln Auto-Injector 150
            MG/ML  16.00%    PULMONARY ARTERIAL HYPERTENSION    40134050000340  Adempas  Riociguat Tab 2 MG  16.00%    PULMONARY ARTERIAL HYPERTENSION    40160015000330  Tracleer  Bosentan Tab 125 MG  16.00%    PULMONARY ARTERIAL
            HYPERTENSION    40170080050415  Orenltram  Treprostinil Dio!amfne Tab CR 0.25 MG (Base Equiv)  16.00%    PULMONARY ARTERIAL HYPERTENSION    40134050000320  Adempas  RiociguatTab 1 MG  16.00%    PULMONARY ARTERIAL
            HYPERTENSION    40160007000320  Letairis  Ambr!sentan Tab 10MG  16.00%    PULMONARY ARTERIAL HYPERTENSION    40170080002020  Tyvaso  Treprostinil Inhalation Solution 0.6 MG/Ml  16.00%    PULMONARY ARTERIAL
            HYPERTENSION    40134050000350  Adempas  RiociguatTab 2.5 MG  16.00% 

      

    

     

    
      
        


    

    
      
        

      

      
                   <!,'.).  -S'o... -,-  .  '  -'-'()'' \_\\'-, U) ,'' l'i              fpal  ;:iNA  ARTERIAL
            HYPERTENSION  40160050000320  Opsumit  Macitentan Tab 10 MG  16.00"76  P.Ul  NAS  v ARTERIAL HYPERTENSION  40134050000310  Adempas  RiociguatTab 0.5 MG  16.00%  ""y(  3N 1W ARTERIAL HYPERTENSION    40160007000310  Letairis  Ambrisentan Tab 5
            MG  16.00%  f!II.  r lNARY ARTERIAL HYPERTENSION    40170080102040  Remodulin  Treprostlnil Sodium lnj 10 MG/ML(Base Equiv)  16.00%  P_LILMONARY ARTERIAL HYPERTENSION      40170080050420  Orenitram  Treprostinil Diolamine Tab CR 1 MG (Base
            Equiv)  16.00%  PULMONARY ARTERIAL HYPERTENSION      40134050000330  Adempas  RiociguatTab 1.5 MG  16.00%  PULMONARY ARTERIAL HYPERTENSION      40160015000320  Tracleer  Bosentan Tab 62.5 MG  16.00%  PULMONARY ARTERIAL
            HYPERTENSION      40143060101920  Revatio  Sildenafil Citrate For Suspension 10 MG/Ml  16.75%  PULMONARY ARTERIAL HYPERTENSION      40170080050410  Orenitram  Treprostln!I Diolamine Tab CR 0.125 MG (Base Equiv)  16.00%  PULMONARY ARTERIAL
            HYPERTENSION      40170040102110  Epoprostenol Sodium  Epoprostenol Sodium For lnj 0.5 MG  16.00%  PULMONARY ARTERIAL HYPERTENSION      40170080050425  Orenitram  Treprostinil Oio!amlne Tab CR 2.5 MG {Base Equiv)  16.00%  PULMONARY ARTERIAL
            HYPERTENSION      40143060100320  Revatlo  S!ldenafil Citrate Tab 20 MG  40.00%  PULMONARY ARTERIAL HYPERTENSION      40143080000320  Adcirca  Tada!afil Tab 20 MG {PAH}  15.75%  PULMONARY ARTERIAL
            HYPERTENSION      40170060002020  Ventavls  lloprostlnhalation Solution 10 MCG/ML  16.00%  PULMONARY ARTERIAL HYPERTENSION      40170080102020  Remodulin  Treprostinll Sodium lnj 2.5 MG/Ml(Base Equiv)  16.00%  PULMONARY ARTERIAL
            HYPERTENSION      40170060002040  Ventavis  lloprost Inhalation Solution 20 MCG/ML  16.00%  PULMONARY ARTERIAL HYPERTENSION      40170080102030  Remodulin  Treprostinil Sodium lnJ 5 MG/Ml (Base Equiv)  16.00%  PULMONARY ARTERIAL
            HYPERTENSION      40143060102020  Revatio  Sitdenafll Citrate IV Soln 10 MG/12.5Ml {Base Equivalent)  16.75%  PULMONARY ARTERIAL HYPERTENSION      40170040102130  Epoprostenol Sodium  Epoprostenol Sodium For lnj 1.5 MG  16.00%  PULMONARY
            ARTERIAL HYPERTENSION      40170080102010  Remodulin  Treprostinll Sodium lnj 1 MG/ML(Base Equiv}  16.00%  Pulmonary Fibrosis Agents      45550060000120  Esbrlet  Pirfenldone Cap 267 MG  16.00%  Pulmonary Fibrosis
            Agents      45554050200130  Ofev  Nintedanib Esylate cap150 MG (Base Equivalent)  16.00%  Pulmonary Fibrosis Agents      45554050200120  Ofev  Nintedanib Esylate Cap 100 MG (Base EQuivalent)  16.00%  RESPIRATORY AGENTS-
            MISC.      45100010102110  Aralast NP  A!phal-Protelnase Inhibitor {Human) For IV Soln 500 MG  16.00%  RESPIRATORY AGENTS- MISC.      45000070001820  Surfaxln  lucinactant Jntratracheal Susp 30 MG/ML  16.00%  RESPIRATORY AGENTS-
            MISC.      45100010102108  Aralast  Alphal-Proteinase Inhibitor (Human) For IV Soln 400 MG  15.50%  RESPIRATORY AGENTS- MISC.      45100010102118  Aralast  Alpha1-ProtelnaseInhibitor {Human) For IV Sofn 800 MG  15.50%  RESPIRATORY AGENTS -
            MISC.      45100010102020  G!assia  Alpha1-ProteinaseInhibitor (Human) lnj 1000 MG/SOML  15.75%  RESPIRATORY GENTS- MISC.      45100010102120  AralastNP  Alphal-Proteinase lnh!bitor(Human) For IV Soln 1000 MG  16.00%  RespiratorySyncytial Virus
            (RSV) Agents      19502060002015  Synag!s  Palivizumab JM Soln 50 MG/0.SML  15.75%  Respiratory Syncytial Virus (RSV) Agents      19502060002020  Synagis  Pa!ivizumab IM So!n 100 MG/Ml  15.75%  Respiratory Syncytial Virus {RSV)
            Agents      12604075002120  Virazole  Ribavifin For lnhal Soln 6 GM  16.003⁄4  Respiratory Tract Agents      40120070000310  Uptravi  Selexipag Tab 200 MCG  15.50%  Respiratory Tract Agents      40120070000340  Uptravi  SelexipagTab 1400
            MCG  15.50%  Respiratory Tract Agents      40120070000315  Uptravi  SelexipagTab 400 MCG  15.50%  Respiratory Tract Agents      40120070000320  Uptravi  SelexipagTab 600 MCG  15.50%  Respiratory Tract
            Agents      40120070008720  Uptravi  SelexipagTab Therapy Pack 200 MCG (140) & 800 MCG (60)  15.50%  Respiratory Tract Agents      40120070000345  Uptravi  SelexipagTab 1600 MCG  15.50%  Respiratory Tract
            Agents      40120070000330  Uptravi  Selexipag Tab 1000 MCG  15.50%  Respiratory Tract Agents      40120070000335  Uptravi  SelexipagTab 1200 MCG  15.50%  Respiratory Tract Agents      40120070000325  Uptrav/  SelexipagTab 800
            MCG  15.50%  RHEUMATOID ARTHRITIS MISC      6650007000£520  Actemra  Tocilizumab Subcutaneous So!n Prefilled Syringe 162 MG/0.9ML  15.50%  RHEUMATOID ARTHRITIS MISC      66500070002035  Actemra  Toci!izumab IV lnj 200
            MG/lOML  15.50%  RHEUMATOID ARTHRITIS MISC      66400010002120  Orencia  Abatacept For JV Soln 250 MG  16.25%  RHEUMATOID ARTHRITIS MISC      66603065100320  Xeljanz  Tofacitinib Citrate Tab 5 MG (Base Equivalent)  16.00%  RHEUMATOID ARTHR/TIS
            MISC      66500070002040  Actemra  Tociliwmab /VlnJ 400 MG/20Ml  15.50%  RHEUMATOID ARTHRITIS MISC      6640001000E520  Orencia  AbataceptSubcutaneous Soln Prefifled Syringe 125 MG/ML  16.25%  RHEUMATOID ARTHRITIS
            MISC      66280050000320  Arava  Leflunomlde Tab 20 MG  16.00%  RHEUMATOID ARTHRITIS MISC      66460020002120  llaris  Canakinumab For lnj 180 MG  16.75% 

      

    

     

    
      
        


    

    
      
        

      

      
                     66S0007000203066280050000310525330700064208250206000202099422015002120    ActemraArava
            GattexMozobl1 Ben!ysta Benlysta ferriprox SlrturoCimzia Starter Kit SimponiEnbrelCimzia Simponi ArlaEnbrel 5ureClick RemicadeSimponi Cimzia Simponi Enbrel Humira Pen Simponi Humira Humira Enbrel Humira Hymovls Gabapentin DDAVPLupaneta Pack
            HydroxyureaAggrastat  ToclHzumab IV lnj 80 MG/4MlLeflunomide Tab 10 MG Teduglutide (rDNA) For lnj Kit 5 MGPlerixaforSubcutaneous lnj 24 MG/1.2ML(20 MG/ML) Belimumab For IV Sein 120 MGBe!imumab For IV So!n 400 MG Deferiprone Oral So!n 100
            MG/MLBedaqu!lfne Fumarate Tab 100 MG (Base Equiv) Certoli2umab Pegol Jnj Kit 6X 200 MG/MLGolimumab Subcutaneous Sein Auto-injector 100 MG/MLEtanerceptSubcutaneous Sein Prefilled Syringe SO MG/ML Certolizumab Pegol For lnj Kit 2 X 200
            MGGolimumab JV Soln 50 MG/4MlEtanerceptSubcutaneous Solution Auto-injector 50 MG/ML lnfliximab For IV lnj 100 MGGolimumab Subcutaneous Sein Prefi!led Syringe SO MG/0.SML Certoli2umab Pegol lnj Kit 2X 200 MG/MlGolimumab Subcutaneous Sein
            Auto-injector SO MG/0.SMLEtanerceptSubcutaneous Solo Prefilled Syringe 25 MG/0.5Ml Ada!fmumab Pen-injector Kit 40 MG/0.8MlGolimumab SubcutaneousSoln Prefilfed Syringe 100 MG/Ml Adalfmumab Prefil!ed Syringe Kit 20 MG/0.4MLAdallmumab PrefiHed
            Syringe Kit40 MG/0.BML Etanercept For Subcutaneous lnJ Kit 25 MG AdaHmumab Prefilled Syringe Kit 10 MG/0.2MLHyaluronan lntra-articularSoln Prefi!led Syringe 24 MG/3ML Gabapentin PowderDesmopressinAcetate lnj 4 MCG/MLLeuprollde {1 Mon) lnj 3.75
            MG & Norethlndrone Tab 5 MG Kit Hydroxyurea Cap 500 MGTirofiban HCI IV Cone 3.75 MG/15ML (250 MCG/ML) (Base
            Equiv)  15.50%16.00%16.00%16.75%16.75%16.75%15.50%16.00";>'616.75%16.25%16.75%16.75%16.25%16.75%16.00%16.25%16.75%16.25%16.75%16.75%16.25%16.75%16.75%16.75%16.7S%15.50%15.50%15.50%15.50%15.50%15.50%  Systemic Lupus Erythematosus
            Agents  9942201500214093100028002.02009000015100320525050201064606627004000D5406629003000ES305250502010642066270040002.0156629003000D53052SOS0400021206627004000ES20525050201064406627004000DS206629003000E5256627001500F4206627004000ES406627001500F8106627001500F820662900300064206627001500F80S7580006000e5159654424400290030201010102030300899025064202170003000010585153060101310        Therapeutic




            Nutrients/Minerals/Electrolytes          TUBERCULOSIS          Tumor Necrosis Factor Alpha Blockers Tumor Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha Blockers          Tumor
            Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha Blockers Tumor Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha
            Blockers          Tumor Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha Blockers          Tumor Ne<:rosis Factor Alpha Blockers Tumor Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha
            Blockers          Tumor Necrosis Factor Alpha Blockers          Tumor Necrosis Factor Alpha Blockers          Viscosupplements          (blank)          (blank)          (blank)          {blank}          (blank)         

      

    

     

     

    

     

    







  
    Attachment 7

    

  

  

    Special Coverage

     

    

    Attachment 7

     

      

    Version 10.1.18

     

      

    
      
        


    

    
    

    

    

    Mandated and Uniform Protocol for Conditions Included in Special Coverage

    

    

    Initiation:

    

    

    Any primary or specialist physician who have evaluated a patient may submit a request for Register subject to having available all
        required documentation for said condition. The insurer shall make a determination of approval or denial of registration and inform this decision in writing to the insured and the physician requesting the registration. If the physician requesting
        the registry is not the primary physician of the insured, the insurer shall send a copy of the determination to the primary care physician. The insurance company will make a final determination on the application for special coverage in a 72-hour
        period, after receiving the complete documentation as required by this Protocol for each condition.

    

    

    Once a Provider supplies all the required information for the Contractor to process a registration and the Contractor processes such
        information, Special Coverage shall take effect retroactively as of the date the Provider reaches a diagnosis, including documentation of test results, for any condition included in Special Coverage. In case Information is submitted to the
        Contractor after the diagnosis was reached, coverage can be made retroactive up to sixty (60) Calendar Days before the date on which Provider submitted the registration request. (Contract Section 7.7.5)

    

    

    Reactivation: Any insured who have lost eligibility for PSG
        for over one year period, will be required a new certification by the primary care physician that evidence current treatment plan to be reactivated in the special coverage. Any insured that loses its eligibility for a period less than 12 months,
        will be register without documents or additional certifications, unless there is any other limit for the specific condition.

    

    

    Risk allocation*: the distribution of the special coverage
        between insurer and primary medical groups risk is defined in the following table. The same may be modify at the request of the insurance company subject to prior review and approval by ASES.

    

    

    Note: Covered medications are those included in the pharmacy benefit and ASES drug formulary (FMC).

     

      

    
      1

      
        


    

    	 	
            Special Condition

          	 	
            Definitive diagnosis criteria for

            inclusion in the coverage

          	 	
            Special Coverage Effectiveness

            and Duration

          	 	
            Services included in Special

            Coverage

          	 	
            Risk Allocation*

          
	 	
            1.   Aplastic Anemia

              

          	 	
            1-Diagnosis certification by a hematologist/oncologist with treatment plan

            2- Evidence of:

            a.    Absolute
                Neutrophils Count

              

            b.    Platelets
                Counts

            c.    Reticulocytes
                Counts

            d.    Results of
                bone Marrow aspiration or biopsy

          	 	
            Effectiveness = From the date of the diagnosis by the
                hematologist/oncologist or date the biopsy was performed if its reading establishes the definitive diagnosis.

             

            Duration= Special coverage will begin from the date the
                definitive diagnosis is established. Special cover will be in effect as long as the insured is eligible in the PSG

          	 	
            1.    All hospital
                services, emergency room or medical specialist services provided with primary diagnosis of Aplastic Anemia.

            2.    All medical
                services provided or ordered by the hematologist/oncologist

            3.    Medication prescribed by the oncologist/hematologist and specific to treat the condition.

          	 	
            Insurer:

            Medical services and

            medications as defined

            for the special coverage

            condition in this

            document.

             

            GMP/PCP:

            Will receive the monthly

            capitation corresponding

            to the insured.

          
	 	 	 	 	 	 	 	 	 	 
	 	
             2.  Rheumatoid
                Arthritis

          	 	
            1-Diagnosis certification by the rheumatologist in accordance with the criteria established by the American College of Rheumatology.

            (The insurance company will provide a sheet with the criteria and treatment plan to be fill by the specialist.)

             

            2-Evidence of laboratory tests:

            ESR, ANA Test, CRP, RA

            Factor.

            3- Evidence of relevant radiologic studies

            4-Evidence of treatment with a DMARD medication.

          	 	
            Effectiveness = From the date of the diagnosis by the
                rheumatologist.

             

            Duration = Special cover will be in effect as long as the
                insured is eligible in the PSG

          	 	
            1. All hospital services, emergency room or medical specialist services provided with primary diagnosis of Rheumatoid Arthritis.

            2. All medical services provided or ordered by the rheumatologist.

            3. Medication prescribed by the rheumatologist and specific to treat the condition, including DMARD.

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP – Will receive the monthly capitation corresponding
                to the insured.

          


    

    

    
      2

      
        


    

    	 	
            4.   Autism

            a.    Provisional
                Coverage

          	 	
             

            a.    Certification
                of risk by the primary care physician and evidence of the screening tool utilized.

          	 	
            Provisional Special Coverage:

            a. Effectiveness:

            If the risk of developing the condition is confirm using the instruments established in the Protocol of Autism from the Department of Health, the
                primary care physician will complete the registration form for provisional special coverage and send it to the insurer. Once the provisional special coverage for autism is activate, a referral or authorization from the primary care
                physician to access the services of a qualified provider for the diagnostic evaluation process will not be required.

            Duration: The provisional coverage will last for six months.
                If the evaluation process is not completed, the provisional coverage may be renew for six additional months.

          	 	
            Provisional Special Coverage:

            a.    Diagnostic evaluation according to the Protocol of the Dept. of Health that includes family history, development and health, interview with tutors on the skills, behavior, communication and social interactions of the person,
                observation of the conduct of the person in interaction with others and own age play and socialization activities and the results of the most recent version of at least one instrument to document current behaviors.

          	 	
             

              

            a. Insurer – All services rendered by providers qualified
                for diagnostic evaluation.

                

              

            GMP/PCP – Will receive the monthly capitation corresponding
                to the insured.

          


    

    

    
      3

      
        


    

    	 	
            b.    Permanent Special
                Coverage

          	 	
            b.1. Diagnosis certification by a clinical psychologist,
                school psychologist, counselor psychologist, neurologist, psychiatrist or a pediatrician development specialist. Professionals should have training or experience in the area of Autism, as required by the Protocol of Autism from the
                Department of Health of PR.

             

            b. 2 Evidence of the relevant

            screening tests according to the Protocol of Autism from the Department of Health of PR.

          	 	
            b. Effectiveness:

            From the date of the diagnosis certification by one of the listed professionals, the effective date will be the earliest certification date.

             

            Duration:

            Special coverage will be valid, provided the insured eligibility to the PSG, until 21 years of age. After 21 years, to continue in the special
                coverage, a certification by a neurologist or psychiatrist establishing the need for the condition management and treatment as an adult is required.

          	 	
            b. Medical services rendered or ordered by the psychiatrist,
                psychologist, neurologist, or any other qualified provider according to the Protocol of Autism from the Department of Health of PR will not require referral from the primary physician.

            Medicines for the specific management of the condition, prescribed by a qualified provider, will not require PCP authorization.

          	 	
            b. Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

             

            GMP/PCP – Will receive the monthly capitation corresponding
                to the insured.

          


    

    

    
      4

      
        


    

    	 	
            5.    Cancer

          	 	
            1.    Diagnostic
                certification with stage, by a hematologist/ oncologist or specialist physician in charge of the management of the condition, treatment plan with estimated start and completion dates.

            The insurer shall provide a specific form to be used as the Registry Application and Cancer Certification to be
                completed by the specialist.

             

              

            2-Evidence of diagnosis by biopsy result.

             

            3- In cases where the diagnosis cannot be confirmed by a pathology study, evidence of diagnostic studies of CT, MRI, PET Scan, ultrasonography
                supporting diagnosis or stage will be taken into consideration.

          	 	
            Effectiveness = from the date of certification of the
                diagnosis by the hematologist/oncologist or the biopsy date if its results establishes the definitive diagnosis.

             

            Duration = until the end of active treatment of the
                condition with radiotherapy or chemotherapy. All insured will receive a certification of registration until the date in which the insured meets their surgical treatment, chemotherapy and/or radiation therapy. The insured will have the
                benefit of covered visits to his oncologist/hematologist to a maximum of one year. At the end of the year, if needed, the hematologist/oncologist may perform a request for extension of registration documenting the condition stage and the
                treatment plan for next year. A temporary register up to a maximum of 30 days shall be granted to receive documentation on the Cancer Registration Extension form provided by the insurer. If this process is not completed, the insured will
                automatically lose its registration for special coverage.

             

            In cases of prostate cancer, treatment with hormonal chemotherapy will qualify the member to continue active in the cancer registry. Their visits to
                the urologist and medical orders and treatment ordered by this specialist (urologist) will be cover.

             

            In the cases of breast cancer, once active treatment with radiotherapy and chemotherapy ends, they will no longer remain in the registry. However,
                patients receiving treatment with antiestrogens will continue being consider under cancer special coverage.

          	 	
            1. All hospital services, emergency room or medical specialist services provided with primary diagnosis of Cancer.

             

            2-All medical services provided or ordered by the hematologist/oncologist. .

             

            3- Medications prescribed by the hematologist/oncologist specific to treat the cancer condition.

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP – – Will receive the monthly capitation
                corresponding to the insured

          


    

    

    
      5

      
        


    

    	 	
            6.    Skin Cancer:

            Carcinoma IN SITU

          	 	
            -      Positive Biopsy Report

          	 	
            Effectiveness: Special coverage in skin cancer and carcinoma
                in situ will only apply to the surgery day.

             

            Duration: the day or days for surgical removal and all
                services on said day and any other radiotherapy treatment used any time.

          	

          	
            Surgical removal and all related services on said day and any other subsequent radiotherapy/chemotherapy treatment.

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP – – Will receive the monthly capitation
                corresponding to the insured.

          
	 	 	 	 	 	 	 	 	 	 
	 	
            7. Skin Cancer such as
                Invasive Melanoma or squamous cells with evidence of metastasis.

          	 	
            -      Positive
                biopsy or pathology

            -      Special
                studies like CT Scan, MRI, Sonogram

            -      Registry
                certification completed by a dermatologist or a hematologist/oncologist.

          	 	
            Effectiveness: From the date the diagnosis is established.

             

            Duration = until the end of the active treatment of the
                condition with radiotherapy or chemotherapy. All insured will receive a certification of registration for up to a year. At the end of the year, if needed, the dermatologist or hematologist/oncologist may request an extension of registration
                documenting the condition stage and the treatment plan for next year. A temporary register up to a maximum of 30 days shall be granted to receive documentation on the Cancer Registration Extension form provided by the insurer. If this
                process is not completed, the insured will automatically lose its registration for special coverage.

          	 	
            1. All hospital services, emergency room or medical specialist services provided with primary diagnosis of indicated Skin Cancer.

             

            2-All medical services provided or ordered by the dermatologist or hematologist/oncologist.

             

            3- Medications prescribed by the dermatologist or hematologist/oncologist specific to treat the cancer condition.

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP:

            Will receive the monthly

            capitation corresponding

            to the insured.

             

          


    

    

    
      6

      
        


    

    	 	
            8.   Chronic Renal

            Disease

          	 	
            The Glomerular Filtration Rate (GFR) is used. Evidence of recent results of Creatinine in blood and age, sex and race of the insured.

             

              

          	 	 	 	 	 	 
	 	
            Level 1 and 2

          	 	
            Level 1:    GFR over 90,

             ICD-10-N18.1

             

              

            Level 2:    GFR between 60 to 89,

            ICD-10-N18.2

          	 	
            Level 1 and 2: Does not qualify for registry under special
                coverage.

          	 	
            GMP/PCP: Levels 1and 2 are total risk of GMP.

          	 	
            GMP/PCP: Levels 1and 2

            are total risk of GMP.

          


    

    

    
      7

      
        


    

    	 	Level 3 and 4	 	
            Level 3:    GFR between 30 to 59, ICD-10-N18.3   

             

              

            Level 4:    GFR between 15 to 29,  

              ICD-10-N18.4

          	 	
            Level 3 and 4: Qualifies for special coverage registry.

             

            Effectiveness: From the date the diagnosis is established.

             

            Duration = As long as the insured is eligible in the PSG.

             

          	 	Level

                3 and 4-The insurer assumes the nephrologist visits (without referrals), renal laboratory and diagnostic studies ordered by this specialist, peripheral vascular studies to document hemodialysis access and drugs ordered by the
              nephrologist, related to the condition and limited to immunosuppressants, erythrocytes stimulants, Megace, renal antidotes and systemic corticosteroids	 	
            Level 3 and 4:

            Insurer: All medical services provided or ordered by
                nephrologist from the date of effectiveness of the coverage. Additionally including: -insertion of catheters for dialysis

            - surgeries for arteriovenous (AV) fistulas

            -Administration of hematopoietic agents

            - blood transfusions

            GMP/PCP

            Level 3 and 4:

            Will receive the monthly capitation corresponding to the insured.

             

          
	 	Level 5	 	
            Level 5:   GFR less than 15

            ICD-10-N18.5

            ICD-10-N18.6 (ESRD)

          	 	
            Effectiveness: From the date the diagnosis is established.

             

            Duration = As long as the insured is eligible in the PSG

          	 	
            Level 5-All services covered by the PSG as long as the

            insured is active in the Special Coverage Registry.

          	 	
            Level 5: Insurer:

            Once the registration for chronic kidney condition is authorized, the insured received a notice by mail, indicating the changes in the coverage or the
                change of the GMP to one of the Renal-GMP (Dialysis Center).

            The change of GMP will be effective the month in which the change request is done. From this moment, the monthly capitation to the GMP for this
                insured is discontinued.

            The risk of the services received by the insured prior to the exchange of GMP or registration of the insured will be at the risk of the GMP, except
                those dealing directly with dialysis. Outpatient services, except emergency, provided to the insured in the Renal GMP have to be coordinated by the nephrologist, who will become the primary physician of the insured.

             

            GMP/PCP:

            Level 5 – Will not receive monthly capitation for the
                insured.

          


    

    

    
      8

      
        


    

    	 	
            8.   Scleroderma

          	 	
            1. Diagnosis certification by the rheumatologist including signs and symptoms supporting the diagnosis.

            2. Evidence of a positive ANA Test > or equal to1:80 dil

            3. Positive skin biopsy

             

            The insurer will develop a Registry form for this condition to be completed by the specialist certifying the condition, the criteria used to establish
                the diagnosis and the treatment plan.

             

              

          	 	
            Effectiveness: From the diagnosis certification date by the
                rheumatologist.

             

            Duration = As long as the insured is eligible in the PSG

             

          	 	
            1.    All hospital
                services, emergency room or medical specialist services provided with primary diagnosis of Scleroderma.

            2.    All medical
                services provided or ordered by the rheumatologist.

            3.    Medication
                prescribed by the rheumatologist and specific to treat the condition.

             

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP:

            Will receive the monthly capitation corresponding to the insured.

             

          
	 	
            9.    Multiple Sclerosis
                (MS) and Amiotrophic Lateral Sclerosis (ALS)

          	 	
            1.    Certification
                of the diagnosis by a neurologist confirming condition and plan of treatment

            2.    Evidence of
                relevant diagnostic studies performed to reach diagnosis such as:

            MRIs, EMG, Evoked potentials, NCS, lumbar punction, Genetic studies, etc.

          	 	
            Effectiveness: From the date a definitive diagnosis is
                certified and a treatment plan is established by the neurologist.

             

            Duration = As long as the insured is eligible in the PSG

          	 	
            1.    All hospital
                services, emergency room or medical specialist services provided with primary diagnosis of MS or ALS.

            2.    All medical
                services provided or ordered by the neurologist.

            3.    Medication
                prescribed by the neurologist and specific to treat the condition.

             

              

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP:

            Will receive the monthly capitation corresponding to the insured.

          
	 	
            10. Cystic Fibrosis

          	 	
            1.    Sweat test

            2.    Evidence of treatments

            3.    Diagnosis
                certification by a pneumologist.

             

          	 	
            Effectiveness: From the date a definitive diagnosis is
                certified and a treatment plan is established by the pneumologist.

             

            Duration = As long as the insured is eligible in the PSG

             

          	 	
            All services covered by the PSG as long as the insured is active in the Special Coverage Registry.

             

          	 	
            Insurer- All medically necessary services cover by the PSG.

             

            GMP/PCP:

            Monthly capitation does

            not apply for this

            insured.

             

          


    

    

    
      9

      
        


    

    	 	
            11.  Hemophilia

          	 	
            1.    Certification
                of diagnosis by a hematologist

            2.    Evidence of
                relevant studies and test

          	 	
            Effectiveness: From the date a definitive diagnosis is
                certified and a treatment plan is established by a hematologist.

             

            Duration = As long as the insured is eligible in the PSG

             

          	 	
            1- All hospital services, emergency room or medical specialist services provided with a diagnosis of hemophilia.

             

            2-All medical services provided by the hematologist.

             

            3-Medications prescribed by the hematologist specifics to treat the condition and antihemophilic drugs administered to the insured.

             

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP:

            Will receive the monthly capitation corresponding to the insured.

             

          
	 	
            12. Leprosy

          	 	
            1. Evidence of skin biopsy result

            2. Infection positive cultures

            3. Diagnosis certification by an infectologist or a dermatologist.

             

          	 	
            Effectiveness = starts from the date of certification, which
                establishes the definitive diagnosis by the infectious disease specialist or a dermatologist.

             

            Duration= It ends when the treatment is complete.

             

          	 	
            1.    All hospital
                services, emergency room or specialist, cultures, and biopsies of follow-up, provided with a diagnosis of leprosy. (ICD-10 A30)

            2.    All medical
                services provided by the infectious disease specialist or dermatologist.

            3.    Medications
                prescribed by the infectious disease specialist or dermatologist.

             

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP:

            Will receive the monthly capitation corresponding to the insured.

             

          


    

    

    
      10

      
        


    

    	 	
            13.  Systemic Lupus Erythematosus (SLE)

             

          	 	
            1-Diagnosis certification by a rheumatologist with evidence of the following tests: ANA Test, DS-DNA, Anti Sm y Anti

            Phospholipids.

          	 	
            Effectiveness = from the date of certification establishing
                the definitive diagnosis by the rheumatologist

             

            Duration = As long as the

            insured is eligible in the PSG

             

          	 	
            1.    All hospital
                services, emergency room or medical specialist services provided with primary diagnosis of SLE.

             

            2.    All medical
                services provided or ordered by the rheumatologist.

             

            3.    Medication
                prescribed by the rheumatologist and specific to treat the condition of SLE.

             

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP:

            Will receive the monthly capitation corresponding to the insured.

             

             

          
	 	
            14. Children with
                Special Health Needs

             

          	 	
            Complete the Registration Form for children with special health care needs by the primary care physician with evidence of the condition according to
                the list of diagnoses included by ASES as an attachment to the contract, entitled "Conditions to include patients in the Register of Children with Special Health Needs", revision of June 2015. Medical evidence will consist of relevant
                laboratories or tests, evidence of current treatment, diagnosis certifications by specialist physicians consulted and others.

             

          	 	
            Effectiveness= From the diagnosis certification date

             

            Duration = depends on whether the condition is temporary or
                permanent. The case manager will determine based on the Protocol established by the insurer the Registry duration, provided that the insured is under 21 years old.

             

          	 	
            As defined in the Conditions List revised on June 2015.

          	 	
            Refer to the listing of diagnosis codes of the conditions for Children with Special Needs Registry.

             

          


    

    

    
      11

      
        


    

    	 	
            15. Obstetric

          	 	
            Obstretic Registry Form Certification of pregnancy by the obstretric gynecologist

          	 	
            Effectiveness: After registration, a certification of the
                special coverage will be mail to the insured.

             

            Duration: Registration will be effective since the estimated
                day of conception according to certification provided by the obstetrician and will continue to be effective until 56 days after the delivery date, provided this occur after the 20th week. If pregnancy ends in miscarriage before week 20,
                will only granted 30 days after the event.

          	 	
            All services covered by the PSG as long as the insured is active in the Special Coverage Registry.

             

            Sterilization: Sterilization carried out in a separate
                admission, after childbirth or caesarean section, will be responsibility of the primary medical group, therefore it will require referral from the PCP

             

            Newborn: newborn children will be cover as long as the
                mother have eligibility for the PSG, and until the Obstetrics Registration in in effect (56 days of the date of birth) at risk of the insurance company. Under the Obstetric Registry coverage, the assistance of the pediatrician during
                delivery by caesarean section or high risk and routine care for the newborn in the hospital (nursery room) are part of the obstetrics special coverage.

             

          	 	
            Insurer:

            All cover medical services and medications as long as the insured is active under this special coverage category.

             

            GMP/PCP:

            Will not receive monthly capitation for the insured.

             

            Newborn: per capita payment shall be paid for the newborn
                once the mother is out of the registration or the newborn is certified by the mother, whichever occurs first.

             

             

             

          


    

    

    
      12

      
        


    

    	 	
            16. Tuberculosis (Tb)

          	 	
            Pneumologist Certification with treatment plan and evidence of:

            1-    Tb test result

            2-    Chest
                radiology findings

            3-    Samples of
                sputum or bronchial wash for Acid-Fast Basillus (AFB) and culture for Mycobacterium tuberculosis.

            4-    Biopsies of
                the affected area, if applicable.

            5-    HIV test
                results

          	 	
            Effectiveness = from the date of certification establishing
                the definitive diagnosis by the pneumologist.

             

            Duration: Coverage will be variable, depending on the
                duration of the treatment, which can fluctuate between six (6) months to (1) year, depending on the plan of treatment certified by the pulmonologist. After the first year, if the patient requires continuing treatment, a re-evaluation of the
                case by the pulmonologist will be requested and according to the new plan of treatment, special coverage may be extended.

             

          	 	
            -Medical services related to the condition, follow-up, complications, complications of the diagnostic procedure and treatment shall be at the risk of
                the insurer from the date of effectiveness of the special coverage.

            -Special coverage includes medications to treat or control the special condition or conditions that may arise as part of diagnostic studies performed
                or from complications of the disease.

            -Chest radiology for follow up until the treatment is completed will be responsibility of the insurer.

             

            Department of Health of PR

            covers:

            -    Tuberculin

            -     Culture

            -     Bronchial washing

            -     Medical treatment

             

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP:

            Will receive the monthly capitation corresponding to the insured.

          


    

    

    
      13

      
        


    

    	 	
            17.  HIV/AIDS

          	 	
            Evidence of the result of any of the following laboratories;

             

            1-Western Blot positive

            2- positive HIV Viral load

            3- positive 4th generation test with validation of the subtypes of antibody or Antigen for acute infection.

             

            The registration may be requested by one of the following providers:

            -Primary Care Physician

            -HIV/AIDS Clinics Physician

            -VIH/AIDS Clinics Case Manager

             

              

          	 	
            Effectiveness = from the date of certification establishing
                the definitive diagnosis

             

            Duration = As long as the insured is eligible in the PSG

             

          	 	
            1. All hospital services, emergency room or medical specialist services provided with primary diagnosis of HIV/AIDS.

             

            2-All medical services provided or ordered by HIV/AID treaters.

             

            3- Medications prescribed by the HIV/AID treaters specific to treat the HIV/AID condition.

             

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP – Will receive the monthly capitation corresponding
                to the insured.

             

          
	 	
            18.  Adults with phenylketonuria (PKU)

             

          	 	
            When the special coverage is a continuation to the coverage under children with special conditions, once the beneficiary reaches age 21, no additional
                evidence is required. The evidence that qualifies he/she as a child, serves the purpose for the continuation of coverage under the category of adult PKU.

             

            If it is not a continuation of coverage, the registry has to be request by the geneticist and shall include a treatment history and evidence of the
                result of the genetic study.

          	 	
            Effectiveness: it is a continuation of the registry under
                children with special conditions, after the beneficiary reaches age 21.

             

            Duration = As long as the insured is eligible in the PSG

             

          	 	
            1.     All hospital services,
                emergency room or medical specialist services provided with primary diagnosis of PKU.

             

              

            2.     All medical services
                provided or ordered by the geneticist.

             

            3.     Medication prescribed by
                the geneticist and specific to treat the condition of PKU.

             

          	 	
            Insurer:

            Medical services and medications as defined for the special coverage condition in this document.

             

            GMP/PCP:

            Will receive the monthly capitation corresponding to the insured.

             

          


    

    

    
      14

      
        


    

    	 	
            19.  Pulmonary Hypertension

             

          	 	
            Diagnosis certification and treatment plan by the Pneumologist or Cardiologist and evidence of supporting test(s).

             

          	 	
            Effectiveness = from the date of certification establishing
                the definitive diagnosis by the pneumologist or cardiologist.

             

            Duration = As long as the insured is eligible in the PSG

             

          	 	
            1.    All hospital services, emergency room or medical specialist services
                provided with primary diagnosis of Pulmonary Hypertension or its complications.

            2.    All medical services provided or ordered by the pneumologist or
                cardiologist to treat the condition or its complications.

            3.     Medication prescribed by pneumologist or cardiologist to treat the
                condition or its complications.

             

          	 	
            Insurer:

            Medical services and

            medications as defined

            for the special coverage

            condition in this

            document.

             

            GMP/PCP:

            Will receive the monthly capitation corresponding to the insured.

          


    

    

    

    

    15

     

  








  
  
    Attachment 8

    

    

    

    
      		


      

      

      PUERTO RICO MEDICAID PROGRAM

      

      

      Cost Sharing Policy (Copayments) for Medicaid and CHIP Beneficiaries

      

      

      Introduction

      

      

      On July 15, 2013, the Centers for Medicare and Medicaid Services (CMS) published the final rule to update and simplify the Medicaid premium and cost
          sharing requirements, to promote the most effective use of services, and to assist states in identifying cost sharing flexibilities, (78 Federal Register page 42,100).

      

      

      The federal regulation defines "cost sharing" as any
          copayment, coinsurance, deductible, or other similar charge. Copayment is a fixed amount (for example, $1) that the beneficiary pays directly to a provider for each covered health care service, usually when he or she receives at the time of the
          service.

      

      

      The Puerto Rico Medicaid State Plan dictates that Medicaid beneficiaries may pay cost sharing. The Puerto Rico Department of Health (PRDoH), through the
          Puerto Rico Medicaid Program (Medicaid Program), and the Puerto Rico Health Insurance Administration (PRHIA, Administración de Seguros de Salud de Puerto Rico,
          or ASES, from its acronym in Spanish) have issued this "Cost Sharing Policy (Copayments) for Medicaid and CHIP Beneficiaries" to establish copayment rules,
          as required by:

      

      

      
        	
                1.

              	
                The Social Security Act (SSA), Sections 1916 and 1916A.

              


      

      

      

      
        	
                2.

              	
                The federal regulation, 42 CFR §§447.50-447.57 (excluding 42 CFR §447.55) of the federal regulation.

              


      

      

      

      
        	
                3.

              	
                The Puerto Rico State Plan Amendment (SPA) for Cost Sharing.

              


      

      

      

      
        	
                4.

              	
                The New Cost Sharing (Copayment) Structure for Medicaid and CHIP Beneficiaries.

              


      

      

      

      The federal regulation addresses the following topics:

      

      

      Medicaid Premiums and Cost Sharing

      

      

      42 CFR §447.50 Premiums and cost sharing: Basis and purpose.

      

      

      42 CFR §447.51 Definitions.

      

      

      42 CFR §447.52 Cost sharing.

      

      

      
        Page 1

        
          


      

      42 CFR §447.53 Cost sharing for drugs.

      

      

      42 CFR §447.54 Cost sharing for services furnished in a hospital emergency department.

      

      

      42 CFR §447.55 Premiums.

      

      

      42 CFR §447.56 Limitations on premiums and cost sharing.

      

      

      42 CFR §447.57 Beneficiary and public notice requirements.

      

      

      The Policy establishes the following copayments rules, among others:

      

      

      
        	
                1.

              	
                Medicaid beneficiaries are only subject to copayments and to no other form of cost sharing, such as coinsurances or deductibles.

              


      

      

      

      
        	
                2.

              	
                CHIP beneficiaries (Children Health Insurance Program or Medicaid Optional Targeted Low-Income Children) do not pay cost sharing or any other
                    form of cost sharing, such as coinsurances or deductibles.

              


      

      

      

      
        	
                3.

              	
                Certain beneficiaries and services are exempt from any cost sharing, which mean that no copayment will be charged in these instances.

              


      

      

      

      
        	
                4.

              	
                Copayment amounts can vary by coverage codes and by the type of covered health care service.

              


      

      

      

      
        	
                5.

              	
                This Policy does not apply to individuals eligible for the Government Health Plan (GHP) as State or Commonwealth beneficiary.

              


      

      

      

      Medicaid and CHIP Cost Sharing (Copayments) Structure Prior to July 1, 2016

      

      

      Cost Sharing (Copayments) Policy for Medicaid and CHIP Beneficiaries:

      

      

      
        	
                1.

              	
                The Cost Sharing (Copagos) Structure, coverage codes, and copayment amounts applied to all Medicaid and CHIP beneficiaries, were effective from
                    November 1, 2011 through June 30, 2016.

              


      

      

      

      
        	
                2.

              	
                The coverage codes were determined on the basis of the beneficiary Eligibility Monthly Income and the number of Members in the Family Unit. For
                    example: if the Eligibility Income of a Medicaid beneficiary is $300 per month and the Members in the Family Unit is two (2), the coverage code assigned is 110. The evaluation uses Table I as follows:

              


      

      

      

      
        	
                a.

              	
                Eligibility Monthly Income = $300;

              


      

      

      

      
        	
                b.

              	
                Members in Family Unit = 2;

              


      

      

      

      
        Page 2

        
          


      

      
        	
                c.

              	
                Position on the row for Members in Family Unit of 2;

              


      

      

      

      
        	
                d.

              	
                Determine in which column of Coverage Codes on the row the Eligibility Monthly Income of $300 fits;

              


      

      

      

      
        	
                e.

              	
                The eligibility monthly income of $300 fits in range $249-UP which is under column 110; and

              


      

      

      

      
        	
                f.

              	
                Therefore, the beneficiary is assigned coverage code 110.

              


      

      

      

      
        	
                3.

              	
                It does not apply to anyone who is eligible as a State or Commonwealth beneficiary.

              


      

      

      

      The following three (3) tables illustrate the Cost Sharing (Copayments) Structure for Medicaid and CHIP Beneficiaries prior July 1, 2016:

      

      

      
        	
                1.

              	
                Table I - Medicaid Coverage Codes, determined on the basis of eligibility monthly income and the number of members in the beneficiary’s family
                    unit.

              


      

      

      

      
        	
                2.

              	
                Table II - CHIP Coverage Codes, determined on the basis of eligibility monthly income and the number of members in the beneficiary’s family
                    unit.

              


      

      

      

      
        	
                3.

              	
                Table III - Medicaid and CHIP Coverage Codes and the applicable copayment amounts for each service.

              


      

      

      

      	
              TABLE TABLE I

            
	
              Medicaid Cost Sharing (Copayments) Structure Prior to July 1st, 2016

              Coverage Codes and Its Determination

            
	
              Members in Family Unit

            	
              Eligibility Monthly Income Range by Coverage Code

            
	
              100

            	
              110

            
	
              1

            	
              $0-$200

            	
              $201-UP

            
	
              2

            	
              $0-$248

            	
              $249-UP

            
	
              3

            	
              $0-$295

            	
              $296-UP

            
	
              4

            	
              $0-$343

            	
              $344-UP

            
	
              5

            	
              $0-$390

            	
              $391-UP

            
	
              6

            	
              $0-$438

            	
              $439-UP

            
	
              7

            	
              $0-$485

            	
              $486-UP

            
	
              8

            	
              $0-$533

            	
              $534-UP

            
	
              9

            	
              $0-$580

            	
              $581-UP

            
	
              10

            	
              $0-$628

            	
              $629-UP

            
	
              11

            	
              $0-$675

            	
              $676-UP

            
	
              12

            	
              $0-$723

            	
              $724-UP

            
	
              13

            	
              $0-$770

            	
              $771-UP

            
	
              14

            	
              $0-$818

            	
              $819-UP

            
	
              15

            	
              $0-$865

            	
              $866-UP

            


      

      

      
        Page 3

        
          


      

      	
              TABLE TABLE II

            
	
              CHIP Cost Sharing Structure (Copayments) Prior to July 1st, 2016

              Coverage Codes and Its Determination

            
	
              Members in Family Unit 

            	
              Eligibility Monthly Income Range by Coverage Code

            
	
              230

            
	
              1

            	
              $551-$1,100

            
	
              2

            	
              $551-$1,300

            
	
              3

            	
              $551-$1,500

            
	
              4

            	
              $551-$1,700

            
	
              5

            	
              $551-$1,900

            
	
              6

            	
              $551-$2,100

            
	
              7

            	
              $551-$2,300

            
	
              8

            	
              $551-$2,500

            
	
              9

            	
              $551-$2,700

            
	
              10

            	
              $551-$2,900

            
	
              11

            	
              $551-$3,100

            
	
              12

            	
              $551-$3,300

            
	
              13

            	
              $551-$3,500

            
	
              14

            	
              $551-$3,700

            
	
              15

            	
              $551-$3,900

            


      

      

      
        Page 4

        
          


      

      	
              TABLE III

            
	
              Medicaid and CHIP Cost Sharing (Copayments) Structure Prior to July 1st, 2016

              Applicable Copayment Amounts for Each Service by Coverage Code

            
	
              Service

            	
              Coverage Codes and

               Copayments Amounts

            
	
              Medicaid

            	
              CHIP

            
	
              100

            	
              110

            	
              230

            
	 	
              Hospital Admission, (per entire stay)

            	
              $0.00

            	
              $3.00

            	
              $0.00

            
	 	
              Non-emergency Services Provided in a Hospital Emergency Room (ER), (per visit)

            	
              $3.80

            	
              $3.80

            	
              $0.00

            
	 	
              Visit to Primary Care Physician (PCP), (per visit)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              Visit to Specialist, (per visit)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              Visit to Sub-Specialist, (per visit)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              High-Tech Laboratories, (per procedure)

            	
              $0.00

            	
              $0.50

            	
              $0.00

            


      

      

      
        Page 5

        
          


      

      	
              TABLE III

            
	
              Medicaid and CHIP Cost Sharing (Copayments) Structure Prior to July 1st, 2016 

              Applicable Copayment Amounts for Each Service by Coverage Code

            
	
              Service

            	
              Coverage Codes and Copayments Amounts

            
	
              Medicaid

            	
              CHIP

            
	
              100

            	
              110

            	
              230

            
	 	
              Clinical Laboratories, (per procedure)

            	
              $0.00

            	
              $0.50

            	
              $0.00

            
	 	
              X-Rays, (per procedure)

            	
              $0.00

            	
              $0.50

            	
              $0.00

            
	 	
              Special Diagnostic Test, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              Therapy - Physical, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              Therapy - Respiratory, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              Therapy - Occupational, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              Dental - Preventative, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              Dental - Restorative, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $0.00

            
	 	
              Pharmacy - Generic, (per drug)

            	
              $1.00

            	
              $1.00

            	
              $0.00

            
	 	
              Pharmacy - Brand, (per drug)

            	
              $3.00

            	
              $3.00

            	
              $0.00

            
	 	
              All Other Services or Items Not Specified Above

            	
              $0.00

            	
              $0.00

            	
              $0.00

            


      

      

      Medicaid and CHIP Cost Sharing (Copagos) Structure to be Effective On and After July 1, 2016

      

      

      The New Cost Sharing Structure (Copayments) will apply to all Medicaid and CHIP beneficiaries and:

      

      

      
        	
                1.

              	
                Be effective on July 1st, 2016; except for those Medicaid dual
                    beneficiaries with Medicare Part A and B and who are enrolled in a Medicare Advantage (MA) Plan contracted with ASES, commonly known as Platino Plan. In Platino Plans, the New Cost Sharing Structure will be implemented on January 1st, 2017.

              


      

      

      

      
        	
                2.

              	
                Assign the Medicaid and CHIP Coverage Codes on the basis of:

              


      

      

      

      
        	
                a.

              	
                MAGI: Obamacare provides a new method for determining eligibility of individuals for Medicaid and CHIP, based on what is called Modified
                    Adjusted Gross Income (MAGI).

              


      

      

      

      
        	
                b.

              	
                At July 1, 2016 and until implementation of MAGI Methodologies for determining Medicaid and CHIP eligibility, the Medicaid Program will
                    continue assigning Medicaid and CHIP Coverage Codes for a beneficiary on the basis of the eligibility monthly income and the number of members in the family unit of the beneficiary, as illustrates on Tables I and II.

              


      

      

      

      
        Page 6

        
          


      

      
        	
                c.

              	
                On and after implementation of MAGI Methodologies for determining Medicaid and CHIP eligibility:

              


      

      

      

      
        
          
            	 	
                    (1)

                  	
                    The Medicaid Program will be assigned the Medicaid and CHIP Coverage Codes for an individual on the basis of MAGI Monthly Income and MAGI
                        Household Size of the individual.

                  


          

        

      

      

      

      
        
          
            	 	
                    (2)

                  	
                    Coverage Codes vary by household monthly income ranges.

                  


          

        

      

      

      

      
        
          
            	 	
                    (3)

                  	
                    Medicaid and CHIP Coverage Codes are based on ranges of MAGI Monthly Income as a percentage of the Puerto Rico Poverty Level (PRPL) in
                        effect.

                  


          

        

      

      

      

      
        
          
            	 	
                    (4)

                  	
                    Example: if the MAGI Monthly Income of a Medicaid beneficiary is $300 per month with a MAGI  household  size of two (2) the coverage code
                        assigned is 110. The evaluation uses Table IV as follows:

                  


          

        

      

      

      

      
        
          
            	 	
                    (a)

                  	
                    MAGI Monthly Income = 300;

                  


          

        

      

      

      

      
        
          
            	 	
                    (b)

                  	
                    MAGI household size = 2;

                  


          

        

      

      

      

      
        
          
            	 	
                    (c)

                  	
                    Position on the row for MAGI Household Size of 2;

                  


          

        

      

      

      

      
        
          
            	 	
                    (d)

                  	
                    Determine in which column of Coverage Code 100, 110, 120 ó 130 on the row, the MAGI Monthly Income of $300 fits;

                  


          

        

        

      

      
        
          
            	 	
                    (e)

                  	
                    MAGI Monthly Income of $300 fits in range $272-$542 which is under column 110; and,

                  


          

        

      

      

      

      
        
          
            	 	
                    (f)

                  	
                    Therefore, the beneficiary is assigned coverage code 110.

                  


          

        

      

      

      

      
        	
                3.

              	
                Expand the number of coverage codes:

              


      

      

      

      
        	
                a.

              	
                The new coverage codes 120, 130, and 220 and the copayments amounts associate with these codes will be implemented on and after MAGI
                    eligibility evaluation system go-lives.

              


      

      

      

      
        	
                b.

              	
                The new coverage codes will be assigned on the basis of MAGI Monthly Income and MAGI Household Size of the individual.

              


      

      

      

      
        	
                4.

              	
                Revise some copayments amounts on existing coverage codes and establish copayment amounts on new coverage codes.

              


      

      

      

      
        	
                a.

              	
                Starting on July 1st, 2016:

              


      

      

      

      
        Page 7

        
          


      

      
        	
                (1)

              	
                All Medicaid beneficiaries with the coverage codes 100 or 110 will pay the new the copayments amounts associate with these codes, as illustrate
                    on Table VI.

              


      

      

      

      
        	
                (2)

              	
                All CHIP beneficiaries with the coverage code 230 will continue paying the copayments amounts associate with this code, which remains as zero
                    ($0) as illustrate on Table VI.

              


      

      

      

      
        	
                b.

              	
                On and after the implementation of MAGI methodologies for determining Medicaid or CHIP eligibility:

              


      

      

      

      
        	
                (1)

              	
                All Medicaid beneficiaries assigned the new coverage codes 120 and 130 will pay the copayment amounts associate with these codes, as illustrate
                    on Table VI.

              


      

      

      

      
        	
                (2)

              	
                All CHIP beneficiaries with the coverage code 220 will pay the copayments amounts associate with these codes, which is zero ($0) as illustrate
                    on Table VI.

              


      

      

      

      
        	
                5.

              	
                Copayment amount vary by coverage codes and by service.

              


      

      

      

      The following three (3) tables illustrate the Cost Sharing (Copayments) Structure for Medicaid or CHIP Beneficiaries to be effective on and after July 1st, 2016:

      

      

      
        	
                1.

              	
                Table IV - Medicaid Coverage Codes, determined on the basis of MAGI Monthly Income and the MAGI Household Size of the individual. Coverage
                    codes are assigned according to monthly income ranges defines as a percentage of the PRPL.

              


      

      

      

      
        	
                2.

              	
                Table V - CHIP Coverage Codes, determined on the basis of MAGI Monthly Income and the MAGI Household Size of the individual. Coverage codes are
                    assigned according to income ranges defines as a percentage of the PRPL.

              


      

      

      

      
        	
                3.

              	
                Table VI - Medicaid and CHIP Coverage Codes and the applicable copayment amounts for each service.

              


      

      

      

      
        Page 8

        
          


      

      	
              TABLE IV

            
	
              Medicaid Cost Sharing Structure (Copayments) to be Effective On and After July 1, 2016

              Coverage Codes and Its Determination

            
	
              MAGI  

              Household Size

            	
              Puerto Rico

              Poverty Level

              (PRPL)

            	
              MAGI Monthly Income Range by Coverage Code

            
	
              100

            	
              110

            	
              120

            	
              130

            
	
              Percentage of PRPL

            
	
              0%-50%

            	
              51%-100%

            	
              101%-150%

            	
              151%-UP

            
	
              1

            	
              $0-$459

            	
              $0-$230

            	
              $231-$459

            	
              $460-$689

            	
              $690-UP

            
	
              2

            	
              $0-$542

            	
              $0-$271

            	
              $272-$542

            	
              $543-$813

            	
              $814-UP

            
	
              3

            	
              $0-$626

            	
              $0-$313

            	
              $314-$626

            	
              $627-$939

            	
              $940-UP

            
	
              4

            	
              $0-$709

            	
              $0-$355

            	
              $356-$709

            	
              $710-$1,064

            	
              $1,065-UP

            
	
              5

            	
              $0-$792

            	
              $0-$396

            	
              $397-$792

            	
              $793-$1,188

            	
              $1,189-UP

            
	
              6

            	
              $0-$876

            	
              $0-$438

            	
              $438-$876

            	
              $877-$1,314

            	
              $1,315-UP

            
	
              7

            	
              $0-$959

            	
              $0-$480

            	
              $481-$959

            	
              $960-$1,439

            	
              $1,440-UP

            
	
              8

            	
              $0-$1,043

            	
              $0-$522

            	
              $523-$1,043

            	
              $1,044-$1,565

            	
              $1,566-UP

            
	
              9

            	
              $0-$1,126

            	
              $0-$563

            	
              $564-$1,126

            	
              $1,127-$1,689

            	
              $1,690-UP

            
	
              10

            	
              $0-$1,210

            	
              $0-$605

            	
              $606-$1,210

            	
              $1,211-$1,815

            	
              $1,816-UP

            
	
              11

            	
              $0-$1,293

            	
              $0-$647

            	
              $648-$1,293

            	
              $1,294-$1,940

            	
              $1,941-UP

            
	
              12

            	
              $0-$1,377

            	
              $0-$689

            	
              $690-$1,377

            	
              $1,378-$2,066

            	
              $2,067-UP

            
	
              13

            	
              $0-$1,460

            	
              $0-$730

            	
              $731-$1,460

            	
              $1,461-$2,190

            	
              $2,191-UP

            
	
              TABLE IV

            
	
              Medicaid Cost Sharing Structure (Copayments) to be Effective On and After July 1, 2016

              Coverage Codes and Its Determination

            
	
              MAGI

               Household Size

            	
              Puerto Rico

              Poverty Level

              (PRPL)

            	
              MAGI Monthly Income Range by Coverage Code

            
	
              100

            	
              110

            	
              120

            	
              130

            
	
              Percentage of PRPL

            
	
              0%-50%

            	
              51%-100%

            	
              101%-150%

            	
              151%-UP

            
	
              14

            	
              $0-$1,544

            	
              $0-$772

            	
              $773-$1,544

            	
              $1,545-$2,316

            	
              $2,317-UP

            
	
              15

            	
              $0-$1,627

            	
              $0-$814

            	
              $815-$1,627

            	
              $1,628-$2,441

            	
              $2,442-UP

            


      

      

      
        Page 9

        
          


      

      	
              TABLE V

            
	
              CHIP Cost Sharing Structure (Copayments) to be Effective On and After July 1, 2016

              Coverage Codes and Its Determination

            
	
              MAGI

               Household Size

            	
              Puerto Rico Poverty Level (PRPL)

            	
              MAGI Monthly Income Range by  

              Coverage Code

            
	
              220

            	
              230

            
	
              Percentage of PRPL

            
	
              0%-150%

            	
              151%-UP

            
	
              1

            	
              $0-$459

            	
              $0-$689

            	
              $690-UP

            
	
              2

            	
              $0-$542

            	
              $0-$813

            	
              $814-UP

            
	
              3

            	
              $0-$626

            	
              $0-$939

            	
              $940-UP

            
	
              4

            	
              $0-$709

            	
              $0-$1,064

            	
              $1,065-UP

            
	
              5

            	
              $0-$792

            	
              $0-$1,188

            	
              $1,189-UP

            
	
              6

            	
              $0-$876

            	
              $0-$1,314

            	
              $1,315-UP

            
	
              7

            	
              $0-$959

            	
              $0-$1,439

            	
              $1,440-UP

            
	
              8

            	
              $0-$1,043

            	
              $0-$1,565

            	
              $1,566-UP

            
	
              9

            	
              $0-$1,126

            	
              $0-$1,689

            	
              $1,690-UP

            
	
              10

            	
              $0-$1,210

            	
              $0-$1,815

            	
              $1,816-UP

            
	
              11

            	
              $0-$1,293

            	
              $0-$1,940

            	
              $1,941-UP

            
	
              12

            	
              $0-$1,377

            	
              $0-$2,066

            	
              $2,067-UP

            
	
              13

            	
              $0-$1,460

            	
              $0-$2,190

            	
              $2,191-UP

            
	
              14

            	
              $0-$1,544

            	
              $0-$2,316

            	
              $2,317-UP

            
	
              15

            	
              $0-$1,627

            	
              $0-$2,441

            	
              $2,442-UP

            


      

      

      
        Page 10

        
          


      

      	
              TABLE VI

            
	
              Medicaid and CHIP Cost Sharing Structure (Copayments) to be Effective On and After July 1, 2016

              Applicable Copayment Amounts for Each Service by Coverage Code

            
	
              Service

            	
              Coverage Codes and Copayments Amounts

            
	
              Medicaid

            	
              CHIP

            
	
              100

            	
              110

            	
              120

            	
              130

            	
              220

            	
              230

            
	 	
              Hospital Admission, (per entire stay)

            	
              $0.00

            	
              $4.00

            	
              $5.00

            	
              $8.00

            	
              $0.00

            	
              $0.00

            
	 	
              Non-Emergency Services Provided in a Hospital Emergency Room, (per visit)

            	
              $0.00

            	
              $4.00

            	
              $5.00

            	
              $8.00

            	
              $0.00

            	
              $0.00

            
	 	
              Non-Emergency Services Provided in a non-Hospital / Freestanding Emergency Room, (per visit)

            	
              $0.00

            	
              $2.00

            	
              $3.00

            	
              $4.00

            	
              $0.00

            	
              $0.00

            
	 	
              Visit to Primary Care Physician (PCP), (per visit)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              Visit to Specialist, (per visit)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              Visit to Sub-Specialist, (per visit)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              High-Tech Laboratories, (per procedure)

            	
              $0.00

            	
              $0.50

            	
              $1.00

            	
              $1.50

            	
              $0.00

            	
              $0.00

            
	 	
              Clinical Laboratories, (per procedure)

            	
              $0.00

            	
              $0.50

            	
              $1.00

            	
              $1.50

            	
              $0.00

            	
              $0.00

            
	 	
              X-Rays, (per procedure)

            	
              $0.00

            	
              $0.50

            	
              $1.00

            	
              $1.50

            	
              $0.00

            	
              $0.00

            
	 	
              Special Diagnostic Test, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              Therapy - Physical, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              Therapy - Respiratory, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              Therapy - Occupational, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              Dental - Preventative, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              Dental - Restorative, (per procedure)

            	
              $0.00

            	
              $1.00

            	
              $1.50

            	
              $2.00

            	
              $0.00

            	
              $0.00

            
	 	
              Pharmacy - Preferred Drugs, (per drug)

            	
              $0.00

            	
              $1.00

            	
              $2.00

            	
              $3.00

            	
              $0.00

            	
              $0.00

            
	 	
              Pharmacy - Non-Preferred Drugs, (per drug)

            	
              $0.00

            	
              $3.00

            	
              $4.00

            	
              $6.00

            	
              $0.00

            	
              $0.00

            
	 	
              All Other Services or Items Not Specified Above

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            


      

      

      
        Page 11

        
          


      

      Contracts between ASES and Managed Care Organizations (MCOs), Medicare Advantage Organizations (MAOs), Pharmacy Benefit Managers (PBMs), Managed
          Behavioral Healthcare Organizations (MBHOs), and Third Party Administrators (TPAs), among others, shall include this Cost Sharing Policy. Each entity is required by contract to make this Cost Sharing (Copayments) Policy known to beneficiaries and
          providers. Compliance with this Cost Sharing Policy will be monitored by ASES.

      

      

      Medicaid Beneficiaries Enrolled in a Platino Plan

      

      

      The Medicaid dual beneficiaries with Medicare Part A and B have the option to be enrolled in a Medicare Advantage (MA) Plan contracted with ASES,
          commonly known as Platino Plan. For Platino Plans, the New Cost Sharing Structure will be implemented on January 1, 2017.

      

      

      MAO contracts, or Platino Plan contracts, are based on calendar year, from January 1st to






          December 31st of each year. The January 1st, 2017 implementation date will allow the changes in
          copayments to be incorporated under premiums and contract negotiation with each MAO, which will take effect in 2017.

      

      

      Therefore, from July 1st to December 31s, 2016, MAOs will continue using the Cost Sharing Structure as indicated in Table I, II and III for the Platino Plans. The beneficiary will continue using his/her Platino ID Card up to December 31, 2016. If during
          the period from July 1st to December 31st. 2016 the Medicaid Program:

      

      

      
        	
                1.

              	
                Performs a Medicaid beneficiary determination or redetermination on a beneficiary who enrolls in, or is enrolled in, a Platino Plan, and

              


      

      

      

      
        	
                2.

              	
                The beneficiary is assigned a coverage 120 or 130,

              


      

      

      

      
        	
                3.

              	
                The MAO will treat that beneficiary as if the coverage code was assigned as 110.

              


      

      

      

      On January 1st, 2017:

      

      

      
        	
                1.

              	
                The MAOs will implement the New Cost Sharing Structure, as indicated in Tables IV, VI, and VI.

              


      

      

      

      
        	
                2.

              	
                The MAOs will issue to each beneficiary a new ID Card with (i) the coverage code assigned by the Medicaid Program and (ii) copayments amount
                    applicable to such code, as indicated in Table VI.

              


      

      

      

      
        	
                4.

              	
                The beneficiary will discard the old ID Card and use the new ID Card.

              


      

      

      

      
        	
                5.

              	
                The beneficiary will only be liable to pay the Table VI's copayments amount as a maximum.

              


      

      

      

      
        Page 12

        
          


      

      A Platino beneficiary can submit a reimbursement request as soon as he/she believes he/she has exceeded the 5% limit per quarter as it is described under
          the section "Five Percent (5%) Limit or Cap Per Quarter on all Copayments".

      

      

      MAOs cannot impose cost sharing requirements on specified Medicaid beneficiary with a Platino Plan that would exceed the amounts permitted under the
          Medicaid State Plan for Medicaid beneficiaries not enrolled in a Platino Plan. Therefore, MAOs are not allowed to charge any other cost sharing for Medicaid covered services except for the copayment amounts establish in the Puerto Rico Medicaid
          State Plan, as described in this "Cost Sharing Policy for Medicaid and CHIP Beneficiaries".

      

      

      Contracts between ASES and MAOs shall include this Cost Sharing Policy. The MAOs are required by contract to make this Cost Sharing Policy knows to
          beneficiaries, providers, and any other person that provides health care services to beneficiaries. Compliance with this Cost Sharing Policy will be monitored by ASES.

      

      

      Beneficiaries Copayments Exemptions

      

      

      Pursuant to the federal regulation, 42 CFR §447.56(a)(1), Puerto Rico Medicaid State Plan states that certain groups of individuals are exempted from any
          copayments. No copayment will be charged to the following Medicaid or CHIP beneficiaries:

      

      

      
        	
                1.

              	
                Children from 0 to less than 21 years of age.

              


      

      

      

      
        	
                2.

              	
                Pregnant women, during pregnancy and the post-partum period. The post-partum period begins on the last day of pregnancy and extends through the
                    end of the month in which a 60-day period following the last day of pregnancy ends. Example: If March 3 is the last day of pregnancy, May 2 is the end of the 60-days, and May 31 is the last day of the month in which post-partum ends.

              


      

      

      

      
        	
                3.

              	
                Institutionalized Individuals, such as a nursing home.

              


      

      

      

      
        	
                4.

              	
                Beneficiaries receiving hospice care. As defined in Section 1905(o) of the Social Security Act, hospice care means the care furnished by a
                    hospice program to a terminally ill individual who has voluntarily elected to have payment made for hospice care.

              


      

      

      

      
        	
                5.

              	
                American Indians and Alaskan Natives (AI/AN).

              


      

      

      

      Contracts between ASES and MCOs, MAOs and PBMs include the requirement to exempt these group of beneficiaries, as defined at 42 CFR §447.56(a)(1). MCOs,
          MAOs, and PBMs are required by contract to make these exemptions known to beneficiaries, providers, and any other person that provides health care services to beneficiaries. Compliance with these cost sharing exemptions will be monitored by ASES.

      

      

      
        Page 13

        
          


      

      Health Care Services Copayments Exemptions

      

      

      Pursuant to the federal regulation, 42 CFR §447.56(a)(2), Puerto Rico Medicaid State Plan establishes that certain health care services are exempted from
          any copayments. All Medicaid and CHIP beneficiaries are exempt from copayments for the following services:

      

      

      
        	
                1.

              	
                Emergency services, (including ambulatory, hospital, and post-stabilization services), as defined at Section 1932(b)(2) of the Social Security
                    Act and in the federal regulation, 42 CFR §438.114(a).

              


      

      

      

      
        	
                2.

              	
                Family planning services and supplies as described in Section 1905(a)(4)(C) of the Social Security Act, including contraceptives and
                    pharmaceuticals for which the Puerto Rico claims or could claim Federal match at the enhanced rate under Section 1903(a)(5) of the Social Security Act for family planning services and supplies.

              


      

      

      

      
        	
                3.

              	
                Preventive services provided to children under 18 years of age, as described in the federal regulation at 42 CFR §457.520 of chapter D.

              


      

      

      

      
        	
                4.

              	
                Pregnancy-related services, including those services as defined in the federal regulation, 42 CFR §440.210(a)(2) and 42 CFR §440.250(p), and
                    counseling services and drugs for cessation of tobacco use. All services provided to pregnant women, during pregnancy and the 60-day post-partum period, will be considered as pregnancy-related.

              


      

      

      

      
        	
                5.

              	
                Provider-preventable services as defined in the federal regulation, 42 CFR §447.26(b).

              


      

      

      

      Contracts between ASES and MCOs, MAOs and PBMs include the requirement to exempt these services, as defined in 42 CFR §447.56(a)(2). MCOs, MAOs, and PBMs
          are required by contract to make these exemptions known to beneficiaries, providers, and any other person that provides health care services to beneficiaries. Compliance with these cost sharing exemptions will be monitored by ASES.

      

      

      Other Copayments Exemptions

      

      

      Preferred Provider Network (PPN) Copayment Exemption:

      

      

      
        
          
            	
                    1.

                  	
                    The Preferred Provider Network is a subset of providers within the MCO General Network of Providers. The objectives of the Preferred
                        Provider model are to:

                  


          

        

      

      

      

      
        
          	

                	a.	
                  Increase access to Providers and needed services;

                


        

      

      

      

      
        
          	

                	b.	
                  Improve timely receipt of services;

                


        

      

      

      

      
        	
                c.

              	
                Improve the quality of beneficiary care;

              


      

      

      

      
        	
                d.

              	
                Enhance continuity of care; and

              


      

      

      

      
        	
                e.

              	
                Facilitate effective exchange of personal health information between providers and the MCO.

              


      

      

      

      
        Page 14

        
          


      

      
        
          	2.	
                  Copayments do not apply to any service provided to a Medicaid beneficiary by a provider participating in the Preferred Provider Network.

                


        

      

      

      

      
        
          
            	
                    3.

                  	
                    A provider who is a member of the Preferred Provider Network provides services to beneficiaries without the requirement for referrals and
                        copayments.

                  


          

        

      

      

      

      
        
          
            
              	
                      4.

                    	
                      The MCO’s contracts with a provider who is a member of the Preferred Provider Network shall prohibit the provider from collecting copayments from Medicaid
                          beneficiary.

                    


            

          

        

      

      

      

      
        
          
            	
                    5.

                  	
                    The Medicaid beneficiary is not required to use the Preferred Provider Network. But, if the Medicaid beneficiary chooses a provider from
                        the MCO General Network of Providers, he/she is subject to the applicable copayments amount.

                  


          

        

      

      

      

      
        
          
            	
                    6.

                  	
                    If the Medicaid beneficiary needs a covered service and cannot have access to a specialist within the Preferred Provider Network within
                        thirty (30) calendar days, the beneficiary shall have access to the specialist within the MCO General Network of Providers, without the imposition of copayments, but shall return to the PPN specialist once the PPN specialist is
                        available to treat the beneficiary.

                  


          

        

      

      

      

      
        
          
            	
                    7.

                  	
                    Dentists and Pharmacies are not part of the Preferred Provider Network.

                  


          

        

      

      

      

      
        
          
            	
                    8.

                  	
                    For a Platino Plan, MAOs have to be in compliance with this exemption, if they operate a Preferred Provider Network model.

                  


          

        

      

      

      

      Medical Advice Service Line Copayment Exemption:

      

      

      
        	
                1.

              	
                The Puerto Rico Medicaid State Plan does not allow charging copayment for non-emergency services provided in a hospital emergency room to a
                    Medicaid or CHIP beneficiary when the beneficiary:

              


      

      

      

      
        
          	

                	a.	
                  Calls the MCO Medical Advice Service Line, prior to visiting the hospital emergency room;

                


        

      

      

      

      
        
          	

                	b.	
                  Receives a code or an identification number;

                


        

      

      

      

      
        
          	

                	c.	
                  Presents such number at the time of the visit to the hospital emergency room; and

                


        

      

      

      

      
        
          	

                	d.	
                  The hospital emergency room will waive the beneficiary copayment for non-emergency  services provided in a hospital emergency room.

                


        

      

      

      

      
        	
                2.

              	
                Regardless of whether the beneficiary uses or does not use the MCO Medical Advice Service Line, under no circumstance will a copayment be
                    imposed on a Medicaid or CHIP Beneficiary for the treatment of an Emergency Medical Condition or Psychiatric Emergency provided.

              


      

      

      

      
        Page 15

        
          


      

      
        	
                3.

              	
                For a Platino Plan, MAOs will comply with the "Medical Advice Service Line Copayment Exemption", as described herein.

              


      

      

      

      Preventive Services:

      

      

      All Medicaid beneficiaries do not pay copayments for the following diagnostics tests when these services are required as part of a preventive service.

      

      

      
        	
                1.

              	
                High-Tech Laboratories.

              


      

      

      

      
        	
                2.

              	
                Clinical Laboratories.

              


      

      

      

      
        	
                3.

              	
                X-Rays.

              


      

      

      

      
        	
                4.

              	
                Special Diagnostic Test.

              


      

      

      

      Contracts between ASES and MCOs, MAOs, and PBMs include the requirement to exempt Medicaid beneficiaries from these copayments when he/she complies with
          the rules as described under this section. MCOs, MAOs, and PBMs are required by contract to make these exemptions known to beneficiaries, providers, and any other person that provides health care services to the beneficiaries. Compliance with
          this Policy Cost Sharing section will be monitored by ASES.

      

      

      Copayment for Non-Emergency Services Provided in a Hospital Emergency Room (ER)

      

      

      Pursuant the federal regulation, 42 CFR §447.51, Non-Emergency
            Services means any care or services that are not considered emergency services, as it concept is defined and described in 42 CFR §438.114 (Emergency and Post-Stabilization Services). Non-Emergency Services do not include any services
          furnished in a hospital emergency department that are required to be provided as an appropriate medical screening examination or stabilizing examination and treatment under Section 1867 of the Social Security Act, (Examination and Treatment for
          Emergency Medical Conditions and Women In Labor, also known as EMTALA).

      

      

      Emergency and Post-Stabilization Services are defined as follows:

      

      

      
        
          	1.	
                  Emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who
                      possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

                


        

      

      

      

      
        
          	

                	a.	
                  Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;

                


        

      

      

      

      
        
          	

                	b.	
                  Serious impairment to bodily functions; and

                


        

      

      

      

      
        Page 16

        
          


      

      
        
          	

                	c.	
                  Serious dysfunction of any bodily organ or part.

                


        

      

      

      

      
        	
                2.

              	
                Emergency services means covered inpatient and outpatient services that are:

              


      

      

      

      
        
          	

                	a.	
                  Furnished by a provider that is qualified to furnish these services under 42 CFR §438.114 and

                


        

      

      

      

      
        
          	

                	b.	
                  Needed to evaluate or stabilize an emergency medical condition.

                


        

      

      

      

      
        	
                3.

              	
                Post-Stabilization care services means covered services, related to an emergency medical condition that are provided after an enrollee is
                    stabilized in order to maintain the stabilized condition, or to improve or resolve the enrollee's condition.

              


      

      

      

      The Puerto Rico Medicaid State Plan allows charging cost sharing for non-emergency services provided in the hospital emergency room. It is
          expected that all participating hospital emergency rooms will charge the applicable copayment amount to all non-exempt Medicaid beneficiaries for the non-emergency services provided in a hospital emergency room.

      

      

      The Puerto Rico Medicaid State Plan does not allow charging cost sharing for non-emergency services provided in the hospital emergency room in
          the following instances:

      

      

      
        	
                1.

              	
                To Medicaid beneficiary when he/she:

              


      

      

      

      
        
          	

                	a.	
                  Calls the MCO Medical Advice Service Line, previous to visit the hospital emergency room,

                


        

      

      

      

      
        
          	

                	b.	
                  Receives a code or an identification number, and

                


        

      

      

      

      
        
          	

                	c.	
                  Presents such number at the time of the visit to the hospital emergency room. In this instance, the copayment is waived.

                


        

      

      

      

      
        	
                2.

              	
                To Medicaid exempted groups of individuals listed in this Cost Sharing Policy under section "Copayments Are Not Charged To The Following
                    Beneficiaries".

              


      

      

      

      
        	
                3.

              	
                Copayments do not apply to any service provided to a Medicaid beneficiary by a hospital emergency room participating in the Preferred Provider
                    Network (PPN).

              


      

      

      

      
        	
                4.

              	
                For Medicaid beneficiaries with a Platino Plan, MAOs have to be in compliance with the "Preferred Provider Network (PPN) Copayment Exemption"
                    and the "Medical Advice Service Line Copayment Exemption", as described under section "Other Copayments Exemptions".

              


      

      

      

      If the beneficiary does not follow the copayment exemption describes under section "Medical Advice Service Line Copayment Exemption" of this Cost Sharing
          Policy, the non-preferred hospital's emergency room may charge the applicable copayment for this service only if, before providing non-emergency services and imposing the applicable copayment for such services, the hospital's emergency room must
          complies with the following requirements:

      

      

      
        Page 17

        
          


      

      
        	
                1.

              	
                First, conducts an appropriate medical screening to determine

              


      

      

      

      
        
          	

                	a.	
                  Whether or not an emergency medical condition exists as required under 42 CFR §489.24 subpart G and

                


        

      

      

      

      
        
          	

                	b.	
                  That the individual does not need emergency services.

                


        

      

      

      

      
        	
                2.

              	
                Second, if not an emergency medical condition exists and before providing non-emergency services and imposing cost sharing for such services,
                    the hospital's emergency room:

              


      

      

      

      
        
          	

                	a.	
                  Informs the beneficiary of the amount of his or her copayment obligation for non-emergency services provided in the hospital emergency room;

                


        

      

      

      

      
        
          	

                	b.	
                  Provides the beneficiary with the name and location of an available and accessible alternative non-emergency services provider;

                


        

      

      

      

      
        
          	

                	c.	
                  Determines that the alternative provider can provide services to the individual in a timely manner with the imposition of a lesser copayment amount or no copayment if the
                      beneficiary is otherwise exempt from copayment; and

                


        

      

      

      

      
        
          	

                	d.	
                  Provides a referral to coordinate scheduling for treatment by the alternative provider.

                


        

      

      

      

      
        	
                3.

              	
                The federal regulation, 42 CFR §447.51, defines Alternative
                      Non-Emergency Services Provider as a Medicaid provider, such as a physician's office, health care clinic, community health center, hospital outpatient department, or similar provider that can provide clinically appropriate
                    services in a timely manner.

              


      

      

      

      
        	
                4.

              	
                Therefore, the hospital emergency room cannot charge the copayment if it does not follow and comply with the process as described herein.

              


      

      

      

      The Puerto Rico Medicaid Program and ASES ensure that:

      

      

      
        	
                1.

              	
                Before providing non-emergency services and imposing the applicable copayment for such services the hospital's emergency room will comply with
                    the above mentioned requirements.

              


      

      

      

      
        	
                2.

              	
                There is a process in place to identify hospital emergency room services as non-emergency's room services for purposes of imposing cost
                    sharing. This process does not:

              


      

      

      

      
        
          	

                	a.	
                  Limit hospital's obligations for screening and stabilizing treatment of an emergency medical condition under section 1867 of the Social Security Act (EMTALA); or

                


        

      

      

      

      
        Page 18

        
          


      

      
        
          	

                	b.	
                  Modify any obligations under either state or federal standards relating to the application of a prudent-layperson standard for payment or coverage of emergency medical
                      services by any MCO (MAO for a Platino Plan).

                


        

      

      

      

      
        	
                3.

              	
                As part of the New Cost Sharing Structure, all participating hospital emergency rooms located in Puerto Rico will have their payments reduced
                    by the copayment amount for non-emergency services provided at the hospital emergency room.

              


      

      

      

      
        	
                4.

              	
                Contracts between ASES and MCOs and MAOs include the non-emergency hospital emergency room copayment rules. MCOs and MAOs are required by
                    contract to make these rules know to beneficiaries and providers. Compliance with these cost sharing rules will be monitored by ASES.

              


      

      

      

      The Puerto Rico Medicaid State Plan does not allow charging the copayment for "Non-Emergency Services Provided in a Hospital Emergency Room" when the
          non-emergency services is provided in a nonhospital/freestanding emergency room. In non-hospital/freestanding emergency room facilities, the provider can only charge, per visit, the copayment applicable for "Non-Emergency Services Provided in a
          non-Hospital/Freestanding Emergency Room", as indicated in "TABLE VI".

      

      

      The List of Hospital Emergency Rooms by MCO, that may charge the copayment for
            non-emergency services provided in the hospital emergency room, is available in any of the Medicaid Local Offices throughout the Island or at the ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto
            Rico 00926-2712). Additionally, the list of MCO's Hospital Emergency Rooms can be downloaded, reviewed, and printed from the Medicaid Program website (https://www.medicaid.pr.gov/) or the ASES website (http://www.asespr.org/ or http://ases.pr.gov/).

      

      

      The List of Hospital Emergency Rooms by MCO may be changed to add or remove its participating Hospital Emergency Rooms at any time. ASES will notify and
          post such changes through its ASES website.

      

      

      Each MCO will post its Hospital Emergency Rooms List through its website, as well as any change to add or remove its participating Hospital Emergency
          Rooms at any time.

      

      

      Each MAO will post its Hospital Emergency Rooms List through its website not later than January 1st, 2017, as well as any change to add or remove its participating Hospital Emergency Rooms at any time.

      

      

      Contracts between ASES and MCOs, MAOs, and PBMs include these copayment rules. MCOs, MAOs, and PBMs are required by contract to make these rules known to
          beneficiaries, providers, and any other person that provides health care services to the beneficiaries. Compliance with these copayment rules will be monitored by ASES.

      

      

      
        Page 19

        
          


      

      Preferred Drug List

      

      

      Pursuant to the federal regulation, 42 CFR §447.51, preferred drugs means






          drugs that the state has identified on a publicly available schedule as being determined by a pharmacy and therapeutics committee for clinical efficacy as the most cost effective drugs within each therapeutically equivalent or therapeutically
          similar class of drugs.

      

      

      The Medicaid Program and ASES differentiate between preferred and non-preferred drugs. The Preferred Drug List (PDL) was revised to produce a new Drugs
          Formulary (“Formulario de Medicamentos en Cubierta del Plan de Salud del Gobierno de PR”). The review was performed by ASES’ Pharmacy Administrative
          Committee, composed of a clinical pharmacist, an epidemiology analyst, a medical doctor from the Pharmacy Program Administrator (PPA), two clinical pharmacists, a system implementation manager from the contracted PBM, ASES Clinical Medical Doctor
          Representative, and ASES Clinical Department Manager. All drugs included have been previously approved by the ASES Pharmacy and Therapeutics Committee, composed of thirteen (13) voluntary community representatives, community medical doctors, and
          pharmacist representatives. All decisions have been managed and documented under the contracted PBM for such purposes.

      

      

      For the determination of which medication will be covered as preferred or non-preferred drug, the Pharmacy Administrative Committee evaluated each
          therapeutic category based on the amount of alternatives available with similar efficacy, utilization frequency, and total cost impact. As a result of such analysis the majority of the generic drugs were considered as preferred drugs, with some
          exceptions where other more cost-effective drugs were available within the same therapeutic category. All branded products with contracted rebates were considered preferred drugs, but depending on availability on a class category, some
          non-rebatable, branded drugs were also considered preferred drugs.

      

      

      The drugs in the Formulary are divided into two categories (Tiers): Preferred and Non-preferred drugs, as permitted by the federal regulation applicable
          to Medicaid. The criteria used for the drug classifications were based on their safety profile, established efficacy (cost-effectiveness), generic drug availability, and treatment cost. The Medicaid Program and ASES define both categories as
          follows:

      

      

      Preferred Drugs means:

      

      

      
        	
                1.

              	
                All generic drugs, except for:

              


      

      

      

      
        
          	

                	a.	
                  Those with a significantly higher cost compared to their therapeutic alternatives, in which case they are classified as non-preferred drugs.

                


        

      

      

      

      
        
          	

                	b.	
                  Those with a low safety profile compared to their therapeutic alternatives, in which case they are classified as non-preferred drugs.

                


        

      

      

      

      
        	
                2.

              	
                Branded drugs that:

              


      

      

      

      
        
          	

                	a.	
                  Have no generic available and their net cost does not exceed a certain limit, otherwise they are classified as non-preferred.

                


        

      

      

      

      
        Page 20

        
          


      

      
        
          	

                	b.	
                  Their generic drug alternative is more expensive.

                


        

      

      

      

      
        
          	

                	c.	
                  Are contracted by ASES.

                


        

      

      

      

      
        
          	3.	
                  Specialty drugs contracted by ASES.

                


        

      

      

      

      Non-Preferred Drugs means:

      

      

      
        
          	1.	
                  Branded drugs, except for:

                


        

      

      

      

      
        
          	

                	a.	
                  Those that have no generic drug available and their cost does not exceed a certain limit, in which case they are classified as preferred drug.

                


        

      

      

      

      
        
          	

                	b.	
                  Those with a more expensive generic (net cost), in which case they are classified as preferred drug.

                


        

      

      

      

      
        
          	

                	c.	
                  Are contracted by ASES, in which case they are classified as preferred drugs.

                


        

      

      

      

      
        
          	2.	
                  Generic drugs that their established safety, efficacy, and cost profile (cost-effectiveness) are low compared to their therapeutic alternatives.

                


        

      

      

      

      
        	
                3.

              	
                Specialty drugs not contracted by ASES.

              


      

      

      

      The Puerto Rico Medicaid State Plan allows charging copayments for preferred and non-preferred drugs. However, the Medicaid State Plan does not allow
          charging those copayments in the following instances:

      

      

      
        	
                1.

              	
                To Medicaid beneficiaries exempted groups of individuals listed in this Cost Sharing (Copayments) Policy under section Beneficiaries Copayments
                    Exemptions

              


      

      

      

      
        	
                2.

              	
                To Medicaid exempted services as described in this Cost Sharing (Copayments) Policy under section Health Care Services Copayments Exemptions,
                    such as contraceptives for family planning services and drugs for cessation of tobacco use.

              


      

      

      

      
        	
                3.

              	
                For Platino Plans, MAOs will comply with this rule on January 1st, 2017.

              


      

      

      

      The Puerto Rico Medicaid State Plan requires charging the applicable copayment for preferred drug instead of the non-preferred drug copayment in the
          following instances:

      

      

      
        	
                1.

              	
                The beneficiary's prescribing provider determines based on medical necessity that:

              


      

      

      

      
        Page 21

        
          


      

      
        
          	

                	a.	
                  A Formulary non-preferred drug can be covered when a Formulary preferred drug for treatment of the same health condition either: (i) is less effective for the beneficiary
                      health condition, (ii) has adverse effects for the beneficiary, or (iii) both.

                


        

      

      

      

      
        
          	

                	b.	
                  A non-Formulary drug can be covered when a Formulary preferred or non-preferred drug for treatment of the same health condition either: (i) is less effective for the
                      beneficiary health condition, (ii) has adverse effects for the beneficiary, or (iii) both.

                


        

      

      

      

      
        
          	2.	
                  The MCOs and the provider follow the usual pre-authorization procedure to consider these cases.

                


        

      

      

      

      
        
          	

                	a.	
                  The exception process is utilized when there is an indication that there is a medically necessary reason to cover a non-preferred drug or non-Formulary drug.

                


        

      

      

      

      
        
          	

                	b.	
                  When an exception is requested by the beneficiary, the MCO will do a clinical evaluation to consider and review the justification given by the prescribing provider,
                      beneficiary's medical records, and any other relevant documentation to determine medical necessity based on the following criteria:

                


        

      

      

      

      
        
          	

                	(1)	
                  Contraindications to the medication listed in the Formulary.

                


        

      

      

      

      
        
          	

                	(2)	
                  History of adverse reactions to the medication listed in the Formulary.

                


        

      

      

      

      
        
          	

                	(3)	
                  Therapeutic failure of all available alternatives in the Formulary.

                


        

      

      

      

      
        
          	

                	(4)	
                  Non-existence of alternative therapy in the Formulary.

                


        

      

      

      

      
        
          	

                	c.	
                  If the documents and information provided supports the exception, the preauthorization is granted.

                


        

      

      

      

      
        
          	

                	d.	
                  The beneficiary has the right to file an appeal and request a fair hearing to review the determination that has been notified by the MCO.

                


        

      

      

      

      
        
          	3.	
                  If the authorization is granted, the Medicaid Program and ASES have a timely process in place in which the pharmacy only charges to the Medicaid beneficiary the copayment
                      applicable to a preferred drug, which is:  $1 to beneficiaries with coverage code 110, $2 with coverage code 120, and $3 with coverage code 130.

                


        

      

      

      

      
        	
                4.

              	
                According with the federal regulation, 42 CFR §447.53(e), the Medicaid Program and ASES certify that in such cases the reimbursement to the
                    pharmacy is based on the appropriate copayment amount.

              


      

      

      

      
        	
                5.

              	
                For Platino Plans, MAOs will comply with this rule on January 1st, 2017.

              


      

      

      

      In addition to, the Puerto Rico Medicaid State Plan indicates that:

      

      

      
        Page 22

        
          


      

      
        	
                1.

              	
                In the event a beneficiary needs a drug or medicine that is not included in Puerto Rico Medicaid Formulary, the MCOs and providers will follow
                    the usual pre-authorization procedure to allow beneficiaries to obtain drugs not included in the Formulary.

              


      

      

      

      
        	
                2.

              	
                The use of bioequivalent medications and drugs approved by the FDA and local regulations is authorized, unless contraindicated for the
                    beneficiary by the physician or dentist who prescribed the medication.

              


      

      

      

      
        	
                3.

              	
                The absence of bioequivalent medications and drugs in stock does not exonerate the pharmacist from dispensing the medication nor does it entail
                    the payment of additional surcharges by beneficiaries.

              


      

      

      

      
        	
                4.

              	
                Brand name drugs will be dispensed if the bioequivalent is not available at the pharmacy.

              


      

      

      

      
        	
                5.

              	
                All prescriptions shall be filled and dispensed at a participating pharmacy properly licensed under the laws of Puerto Rico freely chosen by
                    the beneficiary.

              


      

      

      

      
        	
                6.

              	
                Pharmacies and Dentists are not part of the Preferred Provider Network.

              


      

      

      

      
        	
                7.

              	
                The MCO and/or provider cannot establish a different drug formulary nor limit in any way the drugs and medications included in the Puerto Rico
                    Medicaid Formulary.

              


      

      

      

      The Drugs Formulary is available in any of the Medicaid Local Offices throughout the
            Island or at ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico 00926-2712). Additionally, the Drugs Formulary can be downloaded, reviewed, and printed from the Medicaid Program website
            (https://www.medicaid.pr.gov/) or the ASES website (http://www.asespr.org/ or http://ases.pr.gov/).

      

      

      The Drugs Formulary may be amended to add or remove drugs, as well as to classify a drug as a preferred or non-preferred, at any time according to the
          ASES' Pharmacy Administrative Committee. ASES will notify and post such changes through its ASES website.

      

      

      Each MCO and PBM will post the“Formulario de Medicamentos en Cubierta
            del Plan de Salud del Gobierno de PR”, as well as any amendment approved by the ASES' Pharmacy Administrative Committee to add or remove drugs or to classify a drug as a preferred or non-preferred, through its website.

      

      

      Each MAO has its own drugs formulary that has to be in compliance with Medicare and Medicaid federal regulation. The Medicaid beneficiaries with a
          Platino Plan will use the MAO's Drugs Formulary. The MAO's Drugs Formulary, as well as any amendment, will be posted through the MAO's website. Pursuant the federal regulation, each MAO must be in compliance with the copayment rules state under
          the Puerto Rico Medicaid State Plan and this Cost Sharing Policy.

      

      

      Contracts between ASES and MCOs, MAOs, and PBMs include these copayment rules. MCOs, MAOs, and PBMs are required by contract to make these rules known to
          beneficiaries, providers, and any other person that provides health care services to the beneficiaries. Compliance with these copayment rules will be monitored by ASES.

      

      

      
        Page 23

        
          


      

      Five Percent (5%) Limit or Cap Per Quarter on all Copayments

      

      

      The federal regulation, 42 CFR §447.56(f), provides that Medicaid or CHIP copayments incurred by all eligible beneficiary in his/her Medicaid and CHIP
          household may not exceed an aggregate limit of five percent (5%) of the household's income applied on a quarterly basis. The 5% cap on total copayments per quarter is determined on the basis of:

      

      

      
        	
                1.

              	
                At July 1st, 2016 and until implementation of MAGI Methodologies for
                    determining Medicaid & CHIP eligibility, the Medicaid Program will continue determining the 5% cap on total copayments per quarter for a beneficiary on the basis of the eligibility monthly income and the number of members in the
                    family unit of the beneficiary.

              


      

      

      

      
        	
                2.

              	
                On and after implementation of MAGI Methodologies for determining Medicaid & CHIP eligibility, the Medicaid Program will determine the 5%
                    cap on total copayments per quarter for a beneficiary on the basis of his/her MAGI Monthly Income and his/her MAGI Household Size.

              


      

      

      

      
        	
                3.

              	
                For example: if a beneficiary Monthly Income is $300 per month, his/her quarterly copayment limit will be $45 ($300 x 3 months = $900 x 5% =
                    $45).

              


      

      

      

      Each beneficiary has his/her own quarters, which are based on the eligibility month. For example, if the Medicaid Program determines that the individual
          is eligible starting in February, he/she's quarters are: February, March, and April (first quarter); May, June, and July (second quarter); August, September and October (third quarter); and November, December, and January (fourth quarter).

      

      

      Any Medicaid beneficiary can request to the Medicaid Program a reassessment of his/her aggregate limit of 5 percent (5%) if he/she has a change in
          circumstances, such as:

      

      

      
        	
                1.

              	
                Increase or decrease in income.

              


      

      

      

      
        	
                2.

              	
                Increase or decrease in household size.

              


      

      

      

      A beneficiary's 5% cap or limit will be reached, if copayments paid in a quarter by his/her family unit or MAGI household members who are Medicaid and
          CHIP are summed together and the result exceeds the calculated 5% cap amount per quarter.

      

      

      The New Cost Sharing Structure does not place beneficiaries at risk of reaching the copayment aggregate limit of 5% per quarter of the family unit or
          MAGI household income applied on a quarterly basis. The Medicaid Program and ASES have a "Process for Requesting Reimbursement of Excess Cost Sharing Payments" for individuals that believe they have incurred cost sharing over the aggregate limit
          for a quarterly cap period, which includes an explanation of his/her right to appeal any decision and request a fair hearing.

      

      

      
        Page 24

        
          


      

      If, over the course of a period of Medicaid or CHIP eligibility, a Medicaid or CHIP beneficiary believes that copayments in a quarter have been paid in
          excess of the 5% cap, he/she can submit a Cost Sharing Reimbursement Request, which will be evaluated by ASES. The Process for Requesting Reimbursement of Excess Cost Sharing Payments establishes that:

      

      

      
        	
                1.

              	
                The reimbursement requests must be submitted no later than two (2) calendar months after the end of the quarter.

              


      

      

      

      
        	
                2.

              	
                Reimbursement requests must include all minimum mandatory information, as instructed on the  reimbursement request form, and can be submitted:

              


      

      

      

      
        
          	

                	a.	
                  In person: at ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico 00926-2712) or in any of the Medicaid Local Offices
                      throughout the Island;

                


        

      

      

      

      
        
          	

                	b.	
                  By mail, to following postal address: ASES Client Services, PO Box 195661, San Juan, PR, 00919-5661; or

                


        

      

      

      

      
        
          	

                	c.	
                  By Facsimile (Fax), to ASES Fax number: 787-474-3347.

                


        

      

      

      

      
        	
                3.

              	
                ASES will conduct an investigation to evaluate reimbursement requests which will be completed no later than four (4) months from the end of the
                    quarter for which the reimbursement request is made. The results of the investigation of any reimbursement request will be notified to the beneficiary no later than fifteen (15) calendar days from the limit date for the investigation.
                    ASES will send a written communication to the beneficiary explaining the results of the reimbursement process investigation, and:

              


      

      

      

      
        
          	

                	a.	
                  If the amount to be reimbursed is five dollars ($5) or more, ASES will issue a reimbursement and will send a written communication to the beneficiary explaining the
                      results of the reimbursement process investigation.

                


        

      

      

      

      
        
          	

                	b.	
                  If the amount to be reimbursed is less than five dollars ($5), the amount will be kept as a credit for a two (2) years period and can be added to the result of
                      reimbursement request for another quarter.

                


        

      

      

      

      
        	
                4.

              	
                The individual has the right to file an appeal and request a fair hearing to review the determination that has been notified by ASES. The
                    appeal must be presented in writing and within a period of thirty (30) days, counting from the date of the ASES' notice. The appeal may be submitted:

              


      

      

      

      
        
          	

                	a.	
                  In person: at the ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico, 00926-2712);

                


        

      

      

      

      
        
          	

                	b.	
                  By mail, to following postal address: ASES Client Services, PO Box 195661, San Juan, PR, 00919-5661; or

                


        

      

      

      

      
        
          
            
              	 	
                      c.

                    	
                      By Facsimile (Fax), to ASES Fax number: 787-474-3347.

                    


            

          

        

      

      

      

      
        Page 25

        
          


      

      
        	
                5.

              	
                The determination will be final if the individual does not appeal within the term of thirty (30) days.

              


      

      

      

      The "Process for Requesting Reimbursement of Excess Cost Sharing Payments" and the
            reimbursement request form (in English or Spanish) are available in any of the Medicaid Local Offices throughout the Island or at the ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico
            00926-2712). These documents can also be downloaded, reviewed, and printed from the Medicaid Program website (https://www.medicaid.pr.gov/) or the ASES website (http://www.asespr.org/ or http://ases.pr.gov/).

      

      

      The Consequences for a Beneficiary Who Does Not Pay a Cost Sharing Charge

      

      

      A Medicaid beneficiary is expected to pay a copayment at the time of receiving the health care service. Therefore, the provider may request and collect
          the copayment amount each time a beneficiary receives a service.

      

      

      A beneficiary does not have to pay copayments for any service provided by a provider participating in the Preferred Provider Network. The MCO’s (MAO for
          a Platino Plan) contracts with a provider who is a member of the Preferred Provider Network shall prohibit the provider from collecting copayments from Medicaid beneficiary.

      

      

      The Medicaid beneficiary, who chooses a provider from MCO's General Network of Providers (MAO for a Platino Plan) and with coverage code 110, 120 or 130,
          is subject to the applicable copayments amount.

      

      

      Pursuant the federal regulation, 42 CFR §447.52(e), the Puerto Rico Medicaid State Plan dispone:

      

      

      
        	
                1.

              	
                Beneficiaries with an eligibility monthly income at or below 100 percent (100%) of the PRPL:

              


      

      

      

      
        
          	

                	a.	
                  When copayment charge is allowed or the beneficiary is not part of an otherwise exempt group, the provider, including a pharmacy or dentist, may request the applicable
                      copayment amount, but cannot not deny services to a beneficiary on account of the his/her inability to pay the copayment amount at the time of receiving a service.

                


        

      

      

      

      
        
          	

                	b.	
                  The beneficiary will receive the health care service without paying the cost sharing at the time of receiving the service.

                


        

      

      

      

      
        
          	

                	c.	
                  Although services may not be denied, the beneficiary is still obligated to pay the cost sharing unless it is waived by the provider.

                


        

      

      

      

      
        
          	

                	d.	
                  If the copayment is not waived, the provider may ask the beneficiary for outstanding copayments amount the next time the beneficiary comes in for a service and/or send a
                      bill to the beneficiary.

                


        

      

      

      

      
        Page 26

        
          


      

      
        
          	

                	e.	
                  In these cases, a hospital can charge the applicable copayment for non-emergency services furnished in its emergency room, if the conditions under 42 CFR 447.54(d) and
                      the copayment rules for this service have been satisfied.

                


        

      

      

      

      
        
          	

                	f.	
                  Nothing prohibits a provider from choosing to reduce or to waive the copayment on a case-by-case basis.

                


        

      

      

      

      
        
          	

                	g.	
                  Medicaid beneficiaries identified by coverage code 100:

                


        

      

      

      

      
        	
                (1)

              	
                Prior MAGI Implementation and as illustrate on Table VII, all Medicaid beneficiaries identified by coverage code 100 have an Eligibility
                    Monthly Income unit below 100% of the PRPL.

              


      

      

      

      
        	
                (2)

              	
                On and After MAGI Implementation and as illustrate on Table VIII, all Medicaid beneficiaries identified by coverage code 100 have a MAGI
                    household monthly income below 100% of the PRPL.

              


      

      

      

      
        
          	

                	h.	
                  Medicaid beneficiaries identified by coverage code 110:

                


        

      

      

      

      
        	
                (1)

              	
                Prior MAGI Implementation and as illustrate on Table VII, there are some Medicaid beneficiaries identified by coverage code 110 have an
                    Eligibility Monthly Income at or below 100% of the PRPL.

              


      

      

      

      
        	
                (2)

              	
                On and After MAGI Implementation and as illustrate on Table VIII, all Medicaid beneficiaries identified by coverage code 110 have a MAGI
                    household monthly income at or below 100% of the PRPL.

              


      

      

      

      
        	
                2.

              	
                Beneficiaries with MAGI household monthly income above 100 percent (100%) of the PRPL:

              


      

      

      

      
        
          	

                	a.	
                  When copayment charge is allowed or the beneficiary is not part of an otherwise exempt group, the provider, including a pharmacy and a dentist, may request the applicable
                      copayment amount as a condition for receiving the service.

                


        

      

      

      

      
        
          	

                	b.	
                  In these cases, a hospital can charge the applicable copayment for non-emergency services furnished in its emergency room, if the conditions under 42 CFR 447.54(d) and
                      the copayment rules for this service have been satisfied.

                


        

      

      

      

      
        
          	

                	c.	
                  Nothing prohibits a provider from choosing to reduce or to waive the copayment on a case-by-case basis.

                


        

      

      

      

      
        
          	

                	d.	
                  Medicaid beneficiaries identified by coverage code 110: Prior MAGI Implementation and as illustrate on Table VII, there are some Medicaid beneficiaries identified by
                      coverage code 110 have an Eligibility Monthly Income above 100% of the PRPL.

                


        

      

      

      

      
        
          	

                	e.	
                  Medicaid beneficiaries identified by coverage code 120 or 130: On and After MAGI Implementation and as illustrate on Table VIII, all Medicaid beneficiaries identified by
                      coverage code 120 or 130 have a MAGI household monthly income above 100% of the PRPL.

                


        

      

      

      

      
        Page 27

        
          


      

      
        	
                3.

              	
                The following tables show Puerto Rico Poverty Level (PRPL) for Medicaid and CHIP and the coverage codes:

              


      

      

      

      
        
          	

                	a.	
                  Table VII: Puerto Rico Poverty Level (PRPL) Prior MAGI Implementation.

                


        

      

      

      

      
        
          	

                	b.	
                  Table VIII: Puerto Rico Poverty Level (PRPL) On and After MAGI Implementation.

                


        

      

      

      

      	
              TABLE VII

            	 
	 	
              Puerto Rico Poverty Level (PRPL) Prior MAGI Implementation

            
	
              Member in

              Family Unit

            	
              Puerto Rico 

              Poverty Level 

              (PRPL)

            	
              Eligibility Monthly Income Ranges by Coverage Codes

            
	
              At or Below 100% of the PRPL

            	
              Above 100% of the PRPL

            
	
              100

            	
              110

            	
              Ranges Above 100% PRPL

            	
              110

            
	
              1

            	
              $0-$413.53

            	
              $0-$200

            	
              $201-$413.53

            	
              $413.54-UP

            	
              $413.54-$550

            
	
              2

            	
              $0-$488.72

            	
              $0-$248

            	
              $249-$488.72

            	
              $488.73-UP

            	
              $488.73-$650

            
	
              3

            	
              $0-$563.91

            	
              $0-$295

            	
              $296-$563.91

            	
              $563.92-UP

            	
              $563.92-$750

            
	
              4

            	
              $0-$639.10

            	
              $0-$343

            	
              $344-$639.10

            	
              $639.11-UP

            	
              $639.11-$850

            
	
              5

            	
              $0-$714.29

            	
              $0-$390

            	
              $391-$714.29P

            	
              $714.30-UP

            	
              $714.30-$950

            
	
              6

            	
              $0-$789.47

            	
              $0-$438

            	
              $439-$789.47

            	
              $789.48-UP

            	
              $789.48-$1,050

            
	
              7

            	
              $0-$864.66

            	
              $0-$485

            	
              $486-$864.66

            	
              $864.67-UP

            	
              $864.67-$1,150

            
	
              8

            	
              $0-$939.85

            	
              $0-$533

            	
              $534-$939.85

            	
              $939.86-UP

            	
              $939.86-$1,250

            
	
              9

            	
              $0-$1,015.04

            	
              $0-$580

            	
              $581-$1,015.04

            	
              $1,015.05-UP

            	
              $1,015.05-$1,350

            
	
              10

            	
              $0-$1,090.23

            	
              $0-$628

            	
              $629-$1,090.23

            	
              $1,090.24-UP

            	
              $1,090.24-$1,450

            
	
              11

            	
              $0-$1,165.41

            	
              $0-$675

            	
              $676-$1,165.41

            	
              $1,165.42-UP

            	
              $1,165.42-$1,550

            
	
              12

            	
              $0-$1,240.60

            	
              $0-$723

            	
              $724-$1,240.60

            	
              $1,240.61-UP

            	
              $1,240.61-$1,650

            
	
              13

            	
              $0-$1,315.79

            	
              $0-$770

            	
              $771-$1,315.79

            	
              $1,315.79-UP

            	
              $1,315.79-$1,750

            
	
              14

            	
              $0-$1,390.98

            	
              $0-$818

            	
              $819-$1,390.98

            	
              $1,390.98-UP

            	
              $1,390.98-$1,850

            
	
              15

            	
              $0-$1,466.17

            	
              $0-$865

            	
              $866-$1,466.17

            	
              $1,466.17-UP

            	
              $1,466.17-$1,950

            


      

      

      
        Page 28

        
          


      

      	
              TABLE VIII

            
	
              Puerto Rico Poverty Level (PRPL) To Be Effective Implemented On and After MAGI Implementation

            
	
              MAGI Household

              Size

            	
              Puerto Rico

              Poverty Level

              (PRPL)

            	
              MAGI Monthly Income Range by Coverage Code

            
	
              100

            	
              110

            	
              120

            	
              130

            
	
              At or Below 100% of the PRPL

            	
              Above 100% of the PRPL

            
	
              0%-50%

            	
              51%-100%

            	
              101%-150%

            	
              151%-UP

            
	
              1

            	
              $0-$459

            	
              $0-$230

            	
              $231-$459

            	
              $460-$689

            	
              $690-UP

            
	
              2

            	
              $0-$542

            	
              $0-$271

            	
              $272-$542

            	
              $543-$813

            	
              $814-UP

            
	
              3

            	
              $0-$626

            	
              $0-$313

            	
              $314-$626

            	
              $627-$939

            	
              $940-UP

            
	
              TABLE VIII

            
	
              Puerto Rico Poverty Level (PRPL) To Be Effective Implemented On and After MAGI Implementation

            
	
              MAGI Household

              Size

            	
              Puerto Rico

              Poverty Level

              (PRPL)

            	
              MAGI Monthly Income Range by Coverage Code

            
	
              100

            	
              110

            	
              120

            	
              130

            
	
              At or Below 100% of the PRPL

            	
              Above 100% of the PRPL

            
	
              0%-50%

            	
              51%-100%

            	
              101%-150%

            	
              151%-UP

            
	
              4

            	
              $0-$709

            	
              $0-$355

            	
              $356-$709

            	
              $710-$1,064

            	
              $1,065-UP

            
	
              5

            	
              $0-$792

            	
              $0-$396

            	
              $397-$792

            	
              $793-$1,188

            	
              $1,189-UP

            
	
              6

            	
              $0-$876

            	
              $0-$438

            	
              $438-$876

            	
              $877-$1,314

            	
              $1,315-UP

            
	
              7

            	
              $0-$959

            	
              $0-$480

            	
              $481-$959

            	
              $960-$1,439

            	
              $1,440-UP

            
	
              8

            	
              $0-$1,043

            	
              $0-$522

            	
              $523-$1,043

            	
              $1,044-$1,565

            	
              $1,566-UP

            
	
              9

            	
              $0-$1,126

            	
              $0-$563

            	
              $564-$1,126

            	
              $1,127-$1,689

            	
              $1,690-UP

            
	
              10

            	
              $0-$1,210

            	
              $0-$605

            	
              $606-$1,210

            	
              $1,211-$1,815

            	
              $1,816-UP

            
	
              11

            	
              $0-$1,293

            	
              $0-$647

            	
              $648-$1,293

            	
              $1,294-$1,940

            	
              $1,941-UP

            
	
              12

            	
              $0-$1,377

            	
              $0-$689

            	
              $690-$1,377

            	
              $1,378-$2,066

            	
              $2,067-UP

            
	
              13

            	
              $0-$1,460

            	
              $0-$730

            	
              $731-$1,460

            	
              $1,461-$2,190

            	
              $2,191-UP

            
	
              14

            	
              $0-$1,544

            	
              $0-$772

            	
              $773-$1,544

            	
              $1,545-$2,316

            	
              $2,317-UP

            
	
              15

            	
              $0-$1,627

            	
              $0-$814

            	
              $815-$1,627

            	
              $1,628-$2,441

            	
              $2,442-UP

            


       

      

      
        Page 29

        
          


      

      ASES requires that the MCOs, MAOs, and PBMs inform providers whether the copayment for a specific service may be imposed on a beneficiary and whether the
          provider may require the beneficiary to pay the copayment, as a condition for receiving the service, through an indicator:

      

      

      
        	
                1.

              	
                In the Eligibility and Enrollment System;

              


      

      

      

      
        	
                2.

              	
                In the Eligibility Verification System; and

              


      

      

      

      
        	
                3.

              	
                On the Beneficiary Identification Card.

              


      

      

      

      Contracts between ASES and MCOs, MAOs, and PBMs include this copayment rule. MCOs, MAOs, and PBMs are required by contract to make these rules known to
          beneficiaries, providers, and any other person that provides health care services to the beneficiaries. Compliance with these copayment rules will be monitored by ASES.

      

      

      Mechanisms for Required Cost Sharing Charges and Payments to Providers

      

      

      The MCOs, MAOs, and PBMs contracted by ASES may impose copayments on beneficiaries up to the amounts specified under the Puerto Rico Medicaid State Plan,
          and the requirements set forth in 42 CFR 447.50 through 447.57”as presented in this Policy.

      

      

      Therefore, the ASES' contract with these entities will provide that any copayment charges the MCO, MAO or PBM impose on Medicaid and CHIP beneficiaries
          are implemented and administered in accordance with:

      

      

      
        	
                1.

              	
                The Social Security Act (SSA), Sections 1916 and 1916A.

              


      

      

      

      
        	
                2.

              	
                The federal regulation, 42 CFR §§447.50-447.57 (excluding 42 CFR §447.55) of the federal regulation.

              


      

      

      

      
        	
                3.

              	
                The Puerto Rico Medicaid and CHIP State Plans.

              


      

      El Plan Estatal Medicaid y el de CHIP de Puerto Rico.

      

      

      
        	
                4.

              	
                Cost Sharing Policy (Copayments) for Medicaid and CHIP Beneficiaries.

              


      

      

      

      
        Page 30

        
          


      

      
        	
                5.

              	
                The New Cost Sharing (Copayment) Structure for Medicaid and CHIP Beneficiaries.

              


      

      

      

      Payments to MCOs and MAOs:

      

      

      
        	
                1.

              	
                ASES has contracted with more than one MCO (MAO for a Platino Plan) to deliver the health care services establish under Puerto Rico Medicaid
                    State Plan.

              


      

      

      

      
        	
                2.

              	
                ASES provides assurance that it calculates the payments to MCOs (MAOs for a Platino Plan) to take into account the copayments established under
                    the Medicaid State Plan for beneficiaries or services not exempt from copayment, regardless of whether the MCO (MAO for a Platino Plan) imposes the copayment or the copayment is collected by the providers.

              


      

      

      

      
        	
                3.

              	
                Any MCO, MAO, or PBM contracted by ASES is allowed to impose copayments on beneficiaries up to the amounts specified in this Cost Sharing
                    (Copagos) Policy, but such MCO, MAO, or PBM cannot exceed the copayment amounts established under the Puerto Rico Medicaid State Plan, as shown in this Policy.

              


      

      

      

      
        	
                4.

              	
                Contracts between ASES and MCOs, MAOs, and PBMs shall include this Cost Sharing Policy.

              


      

      

      

      
        	
                5.

              	
                MCOs and PBMs are required by contract:

              


      

      

      

      
        
          	

                	a.	
                  To make these rules know to beneficiaries and providers.

                


        

      

      

      

      
        
          	

                	b.	
                  To comply with this Cost Sharing Policy and the Puerto Rico Medicaid State Plan.

                


        

      

      

      

      
        	
                6.

              	
                For Platino Plans, MAOs have to be in compliance with this rule on January 1st,
                    2017.

              


      

      

      

      
        	
                7.

              	
                ASES will monitor the compliance with this Cost Sharing Policy.

              


      

      

      

      Payments to Providers:

      

      

      
        	
                1.

              	
                Except as provided under federal regulation 42 CFR §§447.56(c)(2) and (c)(3), each MCO must reduce the payment it makes to a provider by the
                    amount of a beneficiary's copayment obligation, regardless of whether the provider has collected the copayment or has waived the copayment. Where the MCO contracts a provider on a capitated basis, the beneficiary’s copayment obligation
                    is taken into account in calculating capitated rates.

              


      

      

      

      
        	
                2.

              	
                Contracts between ASES and MCOs shall include this Cost Sharing (Copagos) Policy. ASES will monitor the MCOs compliance with this Cost Sharing
                    Policy's requirement.

              


      

      

      

      
        	
                3.

              	
                Contracts between ASES and MCOs and providers shall include this Cost Sharing Policy. MCOs will monitor the providers' compliance with this
                    Cost Sharing Policy's requirement.

              


      

      

      

      
        Page 31

        
          


      

      
        	
                4.

              	
                For Platino Plans, MAOs have to be in compliance with this rule on January 1st,
                    2017. ASES will monitor the MCOs compliance with this Cost Sharing Policy's requirement.

              


      

      

      

      Notice of the Results of Coverage Code and Cost Sharing (Copayments) Determination

      

      

      The Medicaid or CHIP Beneficiary is notified to his/her coverage code and copayments amount through:

      

      

      
        	
                1.

              	
                The Medicaid Program notifies the beneficiary the "Results of Cost Sharing Determination" through the MA-10 Form (Notification of Action Taken
                    on Application and/or Recertification), which is provided after a determination or redetermination of eligibility or when the Results of Cost Sharing Determination is revised.

              


      

      

      

      
        	
                2.

              	
                ASES notifies to the beneficiary the assign coverage code and the copayments amounts through the ID Card, which is provided by the MCO (MAO for
                    a Platino Plan).

              


      

      

      

      Before July 1st, 2016, each MCO contracted by ASES will send a certification
          coverage letter to the beneficiary to notify the coverage code assigned by the Medicaid Program and the copayments amount applicable to such code for each service. The beneficiary will use said letter as his/her ID Card up to his/her eligibility
          redetermination, when the MCO will issue a new ID Card. ASES will monitor the MCOs compliance with this Cost Sharing Policy's requirement.

      

      

      For Platino Plans, the MAOs will implement the New Cost Sharing (Copayments) Structure on January 1st, 2017.

      

      

      The MAOs will issue to each beneficiary a new ID Card with the coverage code assigned by the Medicaid Program and copayments amount, as applicable to
          such code. The beneficiary will discard the old ID Card and use the new ID Card. ASES will monitor the MCOs compliance with this Cost Sharing Policy's requirement.

      

      

      ASES requires that the MCOs, MAOs, and PBMs inform providers whether the copayment for a specific service may be imposed on a beneficiary and whether the
          provider may require the beneficiary to pay the copayment, as a condition for receiving the service, through an indicator:

      

      

      
        	
                1.

              	
                In the Eligibility and Enrollment System;

              


      

      

      

      
        	
                2.

              	
                In the Eligibility Verification System; and

              


      

      

      

      
        	
                3.

              	
                On the Beneficiary Identification Card.

              


      

      

      

      Right to Appeal Coverage Code and Cost Sharing (Copayments) Determination

      

      

      The beneficiary is entitled to file an appeal and to request a fair hearing to the Medicaid Program to review the "Results of Cost Sharing Determination"
          that it is notified through the MA-10 Form (Notification of Action Taken on Application and/or Recertification) when he/she is not in agreement with the decision made in his/her case.

      

      

      
        Page 32

        
          


      

      The request for review must be presented in writing and within a period of thirty (30) days, counting from the Certification Date shown on the MA-10.
          This request for review can be submitted:

      

      

      
        	
                1.

              	
                In person: at any Puerto Rico Medicaid Program Local Office throughout the Island;

              


      

      

      

      
        	
                2.

              	
                By mail, to the following postal address: Medicaid Program, Puerto Rico Department of Health, P.O. Box 70184, San Juan, P.R. 00936-8184; or

              


      

      

      

      
        	
                3.

              	
                By Facsimile (Fax) to: (787) 759-8361.

              


      

      

      

      Access to the Cost Sharing (Copayment) Policy

      

      

      The Medicaid and CHIP Beneficiaries have access to the New Cost Sharing Structure (Copayments) through the Enrollee Handbook or Guide, which is provided
          by the MCO (MAO for a Platino Plan).

      

      

      The Cost Sharing Policy and the Puerto Rico Medicaid SPA for a New Cost Sharing Structure
            are available in any of the Medicaid Local Offices throughout the Island or at the ASES Central Office (physical address: #1549 Calle Alda, Urbanización Caribe, Río Piedras, Puerto Rico, 00926-2712). These documents can also be downloaded,
            reviewed, and printed from the Medicaid Program website (https://www.medicaid.pr.gov/) or the ASES website (http://www.asespr.org/ or http://ases.pr.gov/).

      

      

      In compliance with the federal regulation, 42 CFR §435.905(b), the Medicaid Program will provided access to this Policy, upon request, to individuals
          living with disabilities through the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act.

      

      

      Attestation

      

      

      The Medicaid Program and ASES assure that:

      

      

      
        	
                1.

              	
                They administer the Medicaid and CHIP Cost Sharing (Copagos) Policy in accordance with:

              


      

      

      

      
        
          	

                	a.	
                  The Social Security Act (SSA), Sections 1916 and 1916A

                


        

      

      

      

      
        
          	

                	b.	
                  The federal regulation, 42 CFR §§447.50-447.57 (excluding 42 CFR §447.55) of the federal regulation,

                


        

      

      

      

      
        
          	

                	c.	
                  The Puerto Rico Medicaid and CHIP State Plan.

                


        

      

      

      

      
        	
                2.

              	
                The cost sharing amount established for each service is always less than the amount that is paid for the service.

              


      

      

      

      
        Page 33

        
          


      

      
        	
                3.

              	
                The contracts with the MCOs, MAOs, and PBMs provide that any copayment charges imposes on Medicaid or CHIP beneficiaries are in accordance with
                    the Puerto Rico Medicaid State Plan and this Cost Sharing (Copayments) Policy.

              


      

      

      

      The Medicaid Program and ASES, as required by the federal regulation (42 CFR 447.57):

      

      

      
        	
                1.

              	
                Issued a Public Notice, in English and Spanish, to inform the beneficiaries, applicants, providers, and general public of the Cost Sharing SPA
                    that specifies, among other topics:

              


      

      

      

      
        
          	

                	a.	
                  The copayment amounts for each service by coverage code.

                


        

      

      

      

      
        
          	

                	b.	
                  The beneficiaries who are subject to the copayment charges.

                


        

      

      

      

      
        
          	

                	c.	
                  The consequences, if any, for a beneficiary who does not pay a copayment amount.

                


        

      

      

      

      
        	
                2.

              	
                Have provided a reasonable opportunity for stakeholder comments about the Medicaid SPA for the New Cost Sharing Structure.

              


      

      

      

      Effective Date

      

      

      This Cost Sharing (Copagos) Policy is effective on July 1st, 2016.

      

      

      
        Page 34

        
          


      

      	
              CO-PAYS & CO-INSURANCE - effective on July 1st 2016

            
	 	
              Federal

            	
              CHIPs

            	
              Commonwealth

            	
              *ELA

            
	
              SERVICES

            	
              100

            	
              110

            	
              120

            	
              130

            	
              220

            	
              230

            	
              300

            	
              310

            	
              320

            	
              330

            	
              400

            
	 	
              HOSPITAL

            	 	 	 	 
	 	
              Admissions

            	
              $0

            	
              $4

            	
              $5

            	
              $8

            	
              $0

            	
              $0

            	
              $15

            	
              $15

            	
              $15

            	
              $20

            	
              $50

            
	 	
              Nursery

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            
	 	
              EMERGENCY ROOM (ER)

            	 	 	 	 
	 	
              Emergency Room (ER) Visit

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $2

            	
              $10

            	
              $15

            	
              $20

            	
              $20

            
	 	
              Non-Emergency Services Provided in a Hospital Emergency Room, (per visit)

            	
              $0

            	
              $4

            	
              $5

            	
              $8

            	
              $0

            	
              $0

            	
              $20

            	
              $20

            	
              $25

            	
              $30

            	
              $20

            
	 	
              Non-Emergency Services Provided in a Freestanding Emergency Room, (per visit)

            	
              $0

            	
              $2

            	
              $3

            	
              $4

            	
              $0

            	
              $0

            	
              $20

            	
              $20

            	
              $25

            	
              $30

            	
              $20

            
	 	
              Trauma

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            
	 	
              AMBULATORY VISITS TO

            	 	 	 	 
	 	
              Primary Care Physician (PCP)

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              $3

            
	 	
              Specialist

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              $7

            
	 	
              Sub-Specialist

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              $10

            
	 	
              Pre-natal services

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            
	 	
              OTHER SERVICES

            	 	 	 	 
	 	
              High-Tech Laboratories**

            	
              $0

            	
              50¢

            	
              $1

            	
              $1.50

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              20%

            
	 	
              Clinical Laboratories**

            	
              $0

            	
              50¢

            	
              $1

            	
              $1.50

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              20%

            
	 	
              X-Rays**

            	
              $0

            	
              50¢

            	
              $1

            	
              $1.50

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              20%

            
	 	
              Special Diagnostic Tests**

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $6

            	
              40%

            
	 	
              Therapy – Physical

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              $5

            
	 	
              Therapy – Respiratory

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              $5

            
	 	
              Therapy – Occupational

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $5

            	
              $5

            
	 	
              Vaccines

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            
	 	
              Healthy Child Care

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            
	 	
              DENTAL

            	 	 	 	 
	 	
              Preventive (Child)

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            
	 	
              Preventive (Adult)

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $3

            	
              $5

            	
              $3

            
	 	
              Restorative

            	
              $0

            	
              $1

            	
              $1.50

            	
              $2

            	
              $0

            	
              $0

            	
              $2

            	
              $2

            	
              $5

            	
              $6

            	
              $10

            
	 	
              PHARMACY***

            	 	 	 	 
	 	
              Preferred (Children 0-21)

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $5

            
	 	
              Preferred (Adult)****

            	
              $0

            	
              $1

            	
              $2

            	
              $3

            	
              N/A

            	
               N/A

            	
              $3

            	
              $3

            	
              $5

            	
              $5

            	
              $5

            
	 	
              Non-Preferred (Children 0-21)

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $0

            	
              $10

            
	 	
              Non-Preferred (Adult)****

            	
              $0

            	
              $3

            	
              $4

            	
              $6

            	
              N/A

            	
               N/A

            	
              $8

            	
              $8

            	
              $10

            	
              $10

            	
              $10

            
	 	 	
              Federal

            	
              CHIPs

            	
              Ommonwealth Populati

            	
              ELA

            
	 	
              SERVICES

            	
              100

            	
              110

            	
              120

            	
              130

            	
              220

            	
              230

            	
              300

            	
              310

            	
              320

            	
              330

            	
              400

            


      

      

      
        Page 35

        
          


      

      APROVED: JUNE 16, 2016

      NOTAS

      1. Independiente del código de cubierta, los siguientes beneficiarios a Medicaid / CHIP están exentos del pago de copagos –

      · Niños y niñas menores de 21 años de edad (0-20 años, inclusive);

      · Mujeres embarazadas (durante el embarazo y el período de los 60 de post parto);

      · Indios Americanos o Nativos de Alaska (AI/AN, por sus siglas en inglés);

      

      

      · Beneficiarios que reciben servicios de hospicio.

      2. Los beneficiarios a Medicaid / CHIP están exentos del pago de copagos cuando reciban alguno de los siguientes servicios –

      · Planificación familiar, servicios y materiales o suministros médicos (supplies);

      · Servicios Preventivos a menores de 18 años de edad (0-17 años, inclusive);

      · Servicios relacionados con el embarazo; y

      · Servicios prestados por condiciones de salud que se pudieron evitar, “Provider
          Preventable Conditions”.

      · Servicios de Emergencia, incluye servicios ambulatorios, hospitalarios y de post
          estabilización según se indica en la reglamentación federal 42 CFR §438.114(a);

      3. Los beneficiarios no pagaran copago alguno por los servicios provistos por un proveedor participante de la Red Preferida de
          Proveedores (RPP). Las farmacias y los dentistas no son parte de la Red Preferida de Proveedores (RPP). 

      4. El beneficiario no tendrá que pagar el copago por visita a sala de emergencia cuando no existe una emergencia si antes de visitar
          la sala de emergencia llama al centro de llamadas (call center) de la línea de orientación médica, el call center le provee un código y éste presenta el
          código numérico al momento de visitar la sala de emergencia.

      

      

      

      

      Page 36 

       

    

  








  
    
      
        
          Attachment 9

          

          

          

        

        GHP ENROLLMENT MANUAL
          


      

      

      
      	 	
              ENROLLMENT MANUAL

            
	 	
              GHP

            


      

      

      	 	
              Creation Date:

            	
              May 2017

            
	 	
              Last Revised:

            	
              August 2018

            
	 	
              Version:

            	
              2.0

            


      

      
        
          


      

      
        GHP ENROLLMENT MANUAL

        
          


        

        

      

      
        1

        
          


      

      GHP ENROLLMENT MANUAL

       

        

      
        
          TABLE OF CONTENTS

        

         

      
        


      

      

      	
              TABLE OF CONTENTS

            	
              2

            
	
              I.

            	
              INTRODUCTION

            	
              4

            
	
              II.

            	
              DEFINITIONS

            	
              5

            
	
              III.

            	
              MEDICAID ELIGIBILITY PROCESSES

            	
              11

            
	
              A.

            	
              ELIGIBILITY DETERMINATION

            	
              11

            
	
              B.

            	
              MA-10

            	
              11

            
	
              C.

            	
              EFFECTIVE DATE





                  OF ELIGIBILITY

            	
              12

            
	
              D.

            	
              EFFECTIVE DATE





                  OF ELIGIBILITY IN THE CASE OF DEEMED





                  NEWBORN

            	
              13

            
	
              E.

            	
              MEDICAID/CHIP RETROACTIVE





                  ELIGIBILITY

            	
              15

            
	
              TABLE 2:RETROACTIVE





                  ELIGIBILITY PERIOD SCENARIOS

            	
              15

            
	
              F.

            	
              ENROLLEE RECERTIFICATION

            	
              16

            
	
              G.

            	
              TERMINATION OF ELIGIBILITY (ELIGIBILITY CANCELLATIONS)

            	
              16

            
	
              H.

            	
              APPEALS PROCESSES

            	
              17

            
	
              I.

            	
              ELIGIBILITY EXTENSIONS

            	
              18

            
	
              IV.

            	
              ENROLLMENT IN GHP CONTRACTORS

            	
              19

            
	
              A.

            	
              GENERAL ENROLLMENT





                  REQUIREMENTS

            	
              19

            
	
              B.

            	
              AUTO-ENROLLMENT





                  ALGORITHM

            	
              20

            
	
              C.

            	
              EFFECTIVE DATE





                  OF ENROLLMENT

            	
              20

            
	
              D.

            	
              TERM OF ENROLLMENT

            	
              21

            
	
              E.

            	
              CONTRACTOR NOTIFICATION





                  PROCEDURES RELATED TO REDETERMINATION

            	
              21

            
	
              F.

            	
              ENROLLMENT PROCEDURES

            	
              21

            
	
              G.

            	
              INITIAL MEMBERSHIP





                  DISTRIBUTION

            	
              22

            
	
              H.

            	
              INITIAL OPEN





                  ENROLLMENT PERIOD

            	
              23

            
	
              I.

            	
              ENROLLEE SELECTION





                  OF CONTRACTOR

            	
              23

            
	
              FIGURE 1 ILLUSTRATION





                    OF INITIAL AUTO ENROLLMENT





                  OPERATIONS

            	
              25

            
	
              FIGURE 2 ILLUSTRATION





                    OF NEW ENROLLEE ENROLLMENT

            	
              26

            
	
              V.

            	
              ENROLLMENT COUNSELOR OPERATIONS

            	
              28

            
	
              VI.

            	
              DATA EXCHANGE BETWEEN MEDICAID, ASES AND CONTRACTORS

            	
              28

            
	
              A.

            	
              DATA EXCHANGE





                  BETWEEN MEDICAID, ASES AND
                  THE CONTRACTORS

            	
              28

            
	
              FIGURE 3 MEDICAID/ASES/CONTRACTORS DATA FLOW

            	
              31

            
	
              B.

            	
              ENROLLMENT FILES

            	
              32

            
	
              C.

            	
              GHP ENROLLMENT

            	
              33

            
	
              FIGURE 4 MEMBERS





                  RECERTIFICATION & ENROLLMENT MAINTENANCE (COVERAGE CODE / PLAN VERSION CHANGE) PROCESS

            	
              34

            
	
              D.

            	
              LATE ENROLLMENT





                  DUE TO DELAYED ELIGIBILITY

            	
              35

            
	
              E.

            	
              RETROACTIVE ELIGIBILITY





                  PERIOD ENROLLMENT

            	
              35

            
	
              F.

            	
              ENROLLMENT RECORD

            	
              35

            
	
              G.

            	
              ENROLLMENT RECORD FIELDS

            	
              36

            
	
              TABLE 3: HIERARCHY TABLE

            	
              38

            
	
              TABLE 4: REGION CODES

            	
              40

            
	
              H.

            	
              REJECTION OF AN ENROLLMENT RECORD

            	
              43

            
	
              I.

            	
              REJECTED ENROLLMENT MANAGEMENT

            	
              43

            
	
              VII.

            	
              ERROR CODES TABLE

            	
              44

            
	
              VIII.

            	
              GHP DISENROLLMENT (CANCELLATION/TERMINATION OF ELIGIBILITY)

            	
              44

            
	
              A.

            	
              DISENROLLMENT FROM THE GHP

            	
              44

            
	
              TABLE 6: CANCELLATIONS





                  CODE & CASES DESCRIPTION

            	
              44

            
	
              B.

            	
              GHP DISENROLLMENT EFFECTIVE DATE

            	
              45

            
	
              IX.

            	
              CONTRACTOR DISENROLLMENT

            	
              45

            
	
              A.

            	
              DISENROLLMENT FROM THE CONTRACTOR

            	
              45

            
	
              B.

            	
              DISENROLLMENT INITIATED





                  BY THE ENROLLEE

            	
              45

            


       

      

      
        2

        
          


      

      	
              C.

            	
              EFFECTIVE DATE





                  OF TEMPORARY PAYMENT SUSPENSION

            	
              47

            
	
              X.

            	
              CONTRACTORS RESPONSIBILITIES IN THE ENROLLMENT PROCESS

            	
              47

            
	
              TABLE 7: ENROLLMENT





                  TRANSACTION CONTRACTORS RESPONSIBILITIES

            	
              47

            
	
              XI.

            	
              PREMIUM PAYMENTS

            	
              48

            
	
              TABLE 8: RATE
                  CELLS

            	
              49

            
	
              A.

            	
              TYPES OF PAYMENTS

            	
              50

            
	
              B.

            	
              ASES REASONS FOR NOT EXECUTING A PREMIUM PAYMENT

            	
              53

            
	
              C.

            	
              EDI 820 PAYMENT FILE

            	
              53

            
	
              XII.

            	
              SYSPREM: ENROLLMENT IN HISTORICAL DATA

            	
              54

            
	
              A.

            	
              SYSPREM FUNCTIONALITY

            	
              54

            
	
              B.

            	
              CONTRACTORS ELIGIBILITY





                  FILE

            	
              54

            
	
              FIGURE 5: VALIDATION





                  PROCESS UNDER SYSPREM

            	
              55

            
	
              C.

            	
              PREMIUM PAYMENTS





                    FOR SYSPREM

            	
              55

            
	
              D.

            	
              SYSPREM ERROR CODES

            	
              56

            
	
              TABLE 9: PRIMARY





                  ERROR CODES FOR SYSPREM

            	
              56

            
	
              TABLE 10: SECONDARY





                  ERROR CODES FOR SYSPREM

            	
              56

            
	
              TABLE 11: SYSPREM ERROR CODES

            	
              56

            
	
              XIII.

            	
              REFERENCES

            	
              57

            
	
              XIV.

            	
              APPROVALS

            	
              57

            
	
              REVISION SHEET

            	
              57

            


       

      

      
        3

        
          


      

      I. INTRODUCTION

      
        

        

        
          


      

       

        

      The Puerto Rico Health Insurance Administration, hereinafter known as PRHIA or ASES, is a government corporation created in accordance with the Act No.
          72 of September 7, 1993 as amended, also known as the “Puerto Rico Health Insurance Administration Act”. PRHIA is created with the purpose of managing, negotiating and contracting of health plans that enable it to obtain, for its beneficiaries,
          particularly the medically needy, quality hospital and other medical services.

      

      

      This document constitutes a reference manual, which establishes the requirements in the development of the systems, between the Information Systems
          Office of PRHIA and GHP Contractors, in accordance to the Government Health Plan (GHP) contract (Contract). This includes processes of eligibility, enrollment and premium payment. Any conflicts between this document and the applicable statutes,
          regulations and guidance from the Centers for Medicare and Medicaid Services (CMS) or Contracts for the Provision of Physical and Behavioral Health Services under the GHP as between PRHIA and the GHP Contractors shall be resolved in favor of CMS
          guidance and such contracts, as amended.

      

      

      Previously, a Contractor was assigned to each of the ASES regions and beneficiaries in each region could not select a Contractor or change Contractors
          unless they moved to another region. Beginning November 1, 2018, managed care organizations (MCOs) contracted with ASES under the GHP will cover enrollees island-wide, and enrollees will have choice of Contractors. To support implementation of
          the GHP program, all GHP enrollees up until September 30, 2018 will be auto-enrolled by ASES in Contractors based on an algorithm that considers the existing enrollee-provider relationships and household composition, among other factors.
          Enrollees will be notified of the Contractor’s assignment. Those enrollees, along with New Enrollees certified during October 2018 which will have the opportunity to select a Contractor of their preference, will have the opportunity to change the
          Contractor assignment for any reason for the ninety (90) calendar day period between November 1, 2018, and January 31, 2019. New enrollees certified on or after November 1, 2018 will have the opportunity to select a Contractor of their preference
          and ninety (90) days from the certification date to opt for another selection.

       

        

      
        4

        
          


      

      II. DEFINITIONS

      
        

        

        
          


      

      

      

      
        
          	1.	
                  Adjusted Payment: Reversal of a payment that has been adjudicated during the
                      payment process of a previous premium payment cycle.

                


        

      

      

      

      
        
          	2.	
                  ASES: Administración de Seguros de Salud de Puerto Rico (the Puerto Rico Health
                      Insurance Administration (PRHIA)), the entity within the Government of Puerto Rico responsible for oversight and administration of the Government Health Plan (GHP) or its Agent.

                


        

      

      

      

      
        
          	3.	
                  Auto-Assignment: The assignment of an Enrollee to a PMG and a PCP by ASES,
                      Contractor or Medicaid.

                


        

      

      

      

      
        
          	4.	
                  Auto-Enrollment Process: The Enrollment of a Potential Enrollee in a GHP Plan
                      without any action by the Potential Enrollee, as provided in Article 5 of this Contract.

                


        

      

      

      

      
        
          	5.	
                  Business Day: Traditional workdays, including Monday, Tuesday, Wednesday,
                      Thursday and Friday. Puerto Rico’s holidays, as defined in the Law for Compliance with the Fiscal Plan, Act No. 26 of April 29, 2017, or any other law enacted during the duration of this Contract regarding this subject, are excluded.

                


        

      

      

      

      
        
          	6.	
                  Calendar Days: All seven days of the week.

                


        

      

      

      

      
        
          	7.	
                  Cancellation Date: Is the date in which a member loses his or her eligibility
                      for the GHP Program. The Medicaid Office is the only entity with the authority to cancel an enrollee’s eligibility.

                


        

      

      

      

      
        
          	8.	
                  Centers for Medicare and Medicaid Services (“CMS”): The agency within the U.S.
                      Department of Health and Human Services which is responsible for the Medicare, Medicaid and the Children’s Health Insurance Program (CHIP).

                


        

      

      

      

      
        
          	9.	
                  Certification: A decision by the Puerto Rico Medicaid Office, that a person is
                      eligible for services under the GHP because the person is Medicaid Eligible, CHIP Eligible, or a member of the State Population.

                


        

      

      

      

      
        
          	10.	
                  Certification Date: As provided in Section 5.1.3 of this Contract, a decision by
                      the Puerto Rico Medicaid Program that a person is eligible for services under the GHP Program because the person is Medicaid Eligible, CHIP Eligible, or a member of the State Population. Some public employees and pensioners may enroll
                      in GHP without first receiving a Certification.

                


        

      

      

      

      
        
          	11.	
                  Children’s Health Insurance Program (“CHIP”): The Children’s Health Insurance
                      Program established pursuant to Title XXI of the Social Security Act.

                


        

      

      

      

      
        
          	12.	
                  CHIP Eligible: A
                        child eligible to enroll in the GHP Program because he or she is eligible for CHIP.

                


        

      

      

      

      
        5

        
          


      

      
        
          	13.	
                  Contractor: The Managed Care Organization that is a Party of this Contract,
                      licensed as an insurer by the Puerto Rico Commissioner of Insurance (“PRICO”), which contracts hereunder with ASES under the GHP program for the provision of Covered Services and Benefits to Enrollees on the basis of PMPM Payments.

                


        

      

      

      

      
        
          	14.	
                  Coverage Code: Code assigned by the Puerto Rico Medicaid Office to eligible
                      beneficiaries, according to Federal, CHIP and State indigence criteria. Under GHP, the coverage code will coincide with the Plan Version.

                


        

      

      

      

      
        
          	15.	
                  Covered Services: Those Medically Necessary health care services (listed in
                      Article 7 of this Contract) provided to Enrollees by Providers, the payment or indemnification of which is covered under this Contract.

                


        

      

      

      

      
        
          	16.	
                  Daily Basis: Each Business Day.

                


        

      

      

      

      
        
          	17.	
                  Deemed Newborns: Children born to a mother with Medicaid or CHIP eligibility on
                      the date or delivery and are eligible from the date of birth. They will be granted an eligibility period of thirteen (13) months.

                


        

      

      

      

      
        
          	18.	
                  Disenrollment: The termination of an individual’s enrollment in GHP or a
                      Contractor. In the latter, the Enrollee will maintain their eligibility but will not be affiliated to any contractor.

                


        

      

      

      

      
        
          	19.	
                  Domestic Violence Population: Certain survivors of domestic violence referred by
                      the Office of the Women’s Advocate

                


        

      

      

      

      
        
          	20.	
                  Dual Eligible Enrollee: An Enrollee or potential enrollee eligible for both
                      Medicaid and Medicare.

                


        

      

      

      

      
        
          	21.	
                  Effective Date of Disenrollment: The date on which an Enrollee ceases to be
                      covered under the Contractor’s plan, either because of an eligibility termination (cancellation) or because of a request for disenrollment coming from the MCO or from the Enrollee.

                


        

      

      

      

      
        
          	22.	
                  Effective Date of Eligibility: It is the start date of an eligibility period. It
                      is assign by the Medicaid Office according to the evaluation performed and eligibility program determined (CHIP, Medicaid, State population).

                


        

      

      

      

      
        
          	23.	
                  Effective Date of Contractor Change: It is the start date of the enrollment of
                      an enrollee in a selected Contractor. For changes made in the first twenty days of the month the Contractor enrollment will become effective in the first day of the month following the Contractor selection. For Contractor changes made
                      after the first twenty days of the month the Contractor enrollment will be effective on the first day of the subsequent month (20 Days Rule).

                


        

      

      

      

      
        6

        
          


      

      
        
          	24.	
                  Enrollment Effective Date (Contractor Effective Date): The date in which the
                      eligible enrollee is enrolled in the contracted Contractor. This date considers the eligibility effective date or the Contractor change effective date.

                


        

      

      

      

      
        
          	25.	
                  Enrollee Seed Sets: These are groups of the GHP eligible by the auto-assignment
                      algorithm execution date which are classified by their eligibility expiration date and Medicaid cancellation date. These groups are assigned to the contracted Contractors and define the delivery packages sent to the Contractors during
                      the auto-assignment maintenance period.

                


        

      

      

      

      
        
          	26.	
                  Eligibility: Eligibility is determined by the Medicaid Office of the Puerto Rico
                      Department of Health.

                


        

      

      

      

      
        
          	27.	
                  Eligible Person: A person eligible to enroll in the GHP Program, as provided in
                      Section 1.3.1 of this Contract, by virtue of being Medicaid Eligible, CHIP Eligible, or an Other Eligible Person.

                


        

      

      

      

      
        
          	28.	
                  Enrollee: A person who is enrolled in a Contractor’s GHP Plan, as provided in
                      this Contract, and who, by virtue of relevant Federal and Puerto Rico laws and regulations, is an Eligible Person listed in Section 1.3.1 of the Contract.

                


        

      

      

      

      
        
          	29.	
                  Enrollment: The process by which an Eligible Person becomes an Enrollee of the
                      Contractor’s Plan.

                


        

      

      

      

      
        
          	30.	
                  Federal Category: Classification established by the Puerto Rico Medicaid Office
                      for an Enrollee, according to established criteria of indigence levels. This category includes the population that benefits from the Medicaid and CHIP programs.

                


        

      

      

      

      
        
          	31.	
                  Foster Care Population: Children who are in the custody of the Department of
                      Family’s ADFAN Program and enrolled in the GHP.

                


        

      

      

      

      
        
          	32.	
                  Government Health Insurance Plan (GHP): The government health services program
                      (formerly referred to as “La Reforma” or “MI Salud”) offered by the Government, and administered by ASES, which serves a mixed population of Medicaid Eligible, CHIP Eligible, and Other Eligible Persons, and emphasizes integrated
                      delivery of physical and Behavioral Health services.

                


        

      

      

      

      
        
          	

                	33.	
                  GHP Welcome Package: The first welcome package that a Contractor sends to
                      Enrollees upon enrollment.

                


        

      

      

      

      
        
          	34.	
                  Health Insurance Claim Number (HICN): Previously it was a Medicare enrollee’s
                      identification number and appeared in the enrollee’s insurance card. A new Medicare Enrollee Identifier (MBI) replaced the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like
                      billing, eligibility status, and claim status.

                


        

      

      

      

      
        7

        
          


      

      
        
          	35.	
                  Identification Card (ID): A card bearing an Enrollee’s name, contract number,
                      and co-payment amounts, and a customer service telephone number, which is used to identify the Enrollee in connection with the provision of services.

                


        

      

      

      

      
        
          	36.	
                  Initial Auto-Enrollment: The process by which an Eligible Person enrolled with a
                      GHP contractor prior to November 1, 2018 is Auto-Enrolled with a contractor by ASES with an effective date of November 1, 2018.

                


        

      

      

      

      
        
          	37.	
                  Initial Auto-Enrollment Enrollee: An Eligible Person enrolled prior to November
                      1, 2018 with a GHP contractor who is Auto-Enrolled with a contractor by ASES with an effective date of November 1, 2018.

                


        

      

      

      

      
        
          	38.	
                  Managed Care Organization (MCO): An entity that is organized for the purpose of
                      providing health care and is licensed as an insurer by the Puerto Rico Commissioner of Insurance (“PRICO”), which contracts with ASES for the provision of Covered Services and Benefits Island-wide on the basis of PMPM Payments, under
                      the GHP program.

                


        

      

      

      

      
        
          	

                	39.	
                  MA-10: Form issued by the Puerto Rico Medicaid Office, entitled “Notice of
                      Action Taken or Application and/or Recertification” containing the Certification decision (whether a person was determined eligible or ineligible for Medicaid, CHIP, or the State Population).

                


        

      

      

      

      
        
          	40.	
                  Medicaid: The medical assistance federal/state joint government program
                      established by Title XIX of the Social Security Act.

                


        

      

      

      

      
        
          	41.	
                  Medicaid Eligible: An individual eligible to receive services under Medicaid,
                      who is eligible, on this basis, to enroll in the GHP Program.

                


        

      

      

      

      
        
          	42.	
                  Medically Necessary Services: Those services that meet the definition found in
                      Section 7.2 of this Contract.

                


        

      

      

      

      
        
          	43.	
                  Medicare: The Federal Program of medical assistance for persons over sixty-five
                      (65) and certain disabled persons under Title XVIII of the Social Security Act.

                


        

      

      

      

      
        
          	44.	
                  Medicare Beneficiaries: People older than sixty-five (65) years of age or
                      disabled or people who have end state renal disease (ESRD), who are eligible for Medicare Part A coverage which covers hospital services or Parts A and B, which cover hospital, ambulatory and medical care services.

                


        

      

      

      

      
        
          	45.	
                  Medicare Part A: The part of the Medicare program that covers inpatient hospital
                      stays, skilled nursing facilities, home health and hospice care.

                


        

      

      

      

      
        
          	46.	
                  Medicare Part B: The part of the Medicare program that covers physician,
                      laboratories, outpatient, and preventive services.

                


        

      

      

      

      
        8

        
          


      

      
        
          	47.	
                  Medicare Part C: The part of the Medicare program that permits Medicare
                      recipients to select coverage among various private insurance plans.

                


        

      

      

      

      
        
          	48.	
                  Medicare Part D: The Medicare prescription outpatient drug benefit.

                


        

      

      

      

      
        
          	49.	
                  National Provider Identifier (“NPI”): The 10-digit unique-identifier numbering
                      system for Providers created by the Centers for Medicare & Medicaid Services (CMS), through the National Plan and Provider Enumeration System.

                


        

      

      

      

      
        
          	50.	
                  Newborn: A child born during the GHP eligibility period of his/her mother. For
                      Federal beneficiaries the eligibility effective date corresponds to the date of birth or up to tree retroactive eligibility periods. For Commonwealth beneficiaries, the eligibility effective date corresponds to the certification date.
                      It is required that the mother submit the newborn for Medicaid eligibility certification no later than ninety (90) days after the date of birth.

                


        

      

      

      

      
        
          	51.	
                  New Enrollee: An Eligible Person who became a Potential Enrollee after November
                      1, 2018..

                


        

      

      

      

      
        
          	52.	
                  Open Enrollment: A period of ninety (90) Calendar Days in which Enrollees have
                      one (1) opportunity to select a different contractor, without cause, as set forth in Section 5.2.5 of the Contract.

                


        

      

      

      

      
        
          	53.	
                  PCP Effective Date: Date on which a PCP1 or PCP2 enrollment becomes effective.

                


        

      

      

      

      
        
          	54.	
                  Plan Type: Code 01 to identify members with GHP.

                


        

      

      

      

      
        
          	55.	
                  Plan Version: Product identification number that corresponds with the Plan Type.
                      For GHP, the Plan Version will be the same as the code assigned to the beneficiaries by the Medicaid Office.

                


        

      

      

      

      
        
          	56.	
                  PMPM Premium (“Per Member Per Month (PMPM)” Payment): The fixed monthly amount
                      that the Contracted Contractor is paid by ASES for each Enrollee to ensure that benefits under this contract are provided. This payment is made regardless of whether the enrollee receives benefits during the period covered by the
                      payment.

                


        

      

      

      

      
        
          	57.	
                  Potential Enrollee: A person who has been certified by the Puerto Rico Medicaid
                      Office as eligible to enroll in the GHP (whether on the basis of Medicaid Eligibility, CHIP eligibility or eligibility as a member of the Commonwealth Population), but who has not been yet enrolled with the Contracted Contractor.

                


        

      

      

      

      
        
          	58.	
                  Primary Care Physician (PCP): A licensed medical doctor (MD) who is a Provider
                      and who, within the scope of practice and in accordance with Puerto Rico Certification and licensure requirements, is responsible for providing all required Primary Care to Enrollees. The PCP is responsible for determining services
                      required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary. A PCP may be a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, or
                      pediatrician.

                


        

      

      

      

      
        9

        
          


      

      
        
          
            	59.	
                    Primary Medical Group (PMG): A grouping of associated Primary Care Physicians
                        and other Providers for the delivery of services to GHP Enrollees using a coordinated care model. PMGs may be organized as Provider care organizations, or as another group of Providers who have contractually agreed to offer a
                        coordinated care model to GHP Enrollees under the terms of this Contract.

                  


          

        

        

        

        
          
            	60.	
                    Process Date: For the export file (.exp) it is the date related to the daily
                        run process. For the enrollment files (.sus) it is the date in which the changes in the enrollment records were processed at the Contractor.

                  


          

        

        

        

        
          
            	61.	
                    Prorated Payment: A back payment that covers a fraction of the month prior to
                        the month in which the premium payment is made. The prorated payments only apply to the Contractors specifically during the first eligibility month of the Commonwealth Population and newborns. The concept of prorated payments also
                        applies to the adjusted payments considering the different reasons that trigger cancellations.

                  


          

        

        

        

        
          
            	62.	
                    Provider: Any physician, hospital, facility, or other Health Care Provider who
                        is licensed or otherwise authorized to provide physical or Behavioral Health Services in the jurisdiction in which they are furnished.

                  


          

        

        

        

        
          
            	63.	
                    Puerto Rico Medicaid Office (or “Medicaid Office”): The subdivision of the
                        Health Department that conducts eligibility determinations and offer a Contractor selection after a favorable outcome of such determination under GHP for Medicaid, CHIP, and the State Population programs.

                  


          

        

        

        

        
          
            	64.	
                    Recertification: A determination by the Puerto Rico Medicaid Program that a
                        person previously enrolled in the GHP subsequently received a Negative Redetermination Decision, is again eligible for services under the GHP Program..

                  


          

        

        

        

        
          
            	65.	
                    Redetermination: The periodic Redetermination of eligibility of an individual
                        for Medicaid, CHIP, or the State Population, conducted by the Puerto Rico Medicaid Program.

                  


          

        

        

        

        
          
            	66.	
                    Retroactive Payment: Refers to a payment that corresponds to a period prior to
                        the month in which the PMPM Payment is made.

                  


          

        

        

        

        
          
            	67.	
                    State Population (or “Commonwealth Population”): A group eligible to
                        participate in the GHP as Other Eligible Persons, with no Federal participation supporting the cost of their coverage, which is comprised of low-income persons and other groups listed in Section 1.3.1.2.1 of the contract.

                  


          

        

        

        

        
          
            	68.	
                    SYSPREM: System that provides for the enrollment of an enrollee in historical
                        data. It allows the update and/or enrollment of data that corresponds to eligibility periods prior to the cancellation period of the eligibility of an enrollee or before an enrollment to a different Contractor comes into effect.

                  


          

        

        

        

        
          10

          
            


        

        III. MEDICAID ELIGIBILITY PROCESSES

         

          
          


        
          

          

        

        
          
            A. Eligibility Determination

          

        

        

        

        The Medicaid Office, which administers the Puerto Rico Medicaid Assistance Program, is the state plan agency with authority
            to determine whether a person is eligible to receive covered services under the GHP. Enrollees may be determined eligible to participate in the GHP as either a Federally-funded Medicaid beneficiary (Federal), Federally-funded CHIP beneficiary
            (CHIP), or be determined eligible as a State Population beneficiary (State). For both Medicaid and CHIP populations, eligibility criteria are established in the State Plan and in cooperation with CMS. For State beneficiaries, eligibility
            requirements are established by the Medicaid Program, except for public employees and pensioners included in Other Eligible Populations, which are determined by separate ASES policies.

        

        

        
          
            B. MA-10

          

        

        

        

        Pursuant to Section 5.1.2 of the Contract, the Puerto Rico Medicaid Program’s determination that a person is eligible for
            the GHP is contained on Form MA-10, titled “Notification of Action Taken on Application and/or Recertification.” A person who has received an MA-10 is referred to as a “Potential Enrollee.”

        

        

        The Potential Enrollee may access Covered Services using the MA-10 as a temporary Enrollee ID Card from the first day of
            the eligibility period specified on the MA-10 even if the person has not received an Enrollee ID Card. Only Medicaid, CHIP, and State Enrollees receive an MA-10 and may access Covered Services with the MA-10 as a temporary Enrollee ID Card. A
            Form MA-10 will be provided for each Household Potential Enrollee included in the Application and the authorized contact member.

        

        

        The MA-10 form is valid for the eligibility period identified on Form MA-10 and may be used for a period of thirty (30)
            calendar days from the date of Certification for the purpose of demonstrating eligibility. See Attachment 9, MA-10 Form.

        

        

        
          11

          
            


        

        C. Effective Date of Eligibility

        

        

        1.   Federal Program Enrollee (Medicaid or CHIP)

        

        

        The Effective Date of Eligibility for purposes of a Medicaid or CHIP Potential Enrollee is the first day of the month in which the
            Medicaid Office determines eligibility. This should be the same date indicated as the eligibility period on the Form MA-10.

        

        

        The eligibility period specified on Form MA-10 may be a retroactive eligibility period which is up to three (3) months before the
            first day of the month in which the Potential Enrollee submits its eligibility application with the Medicaid Office for the Medicaid and CHIP populations only during which services can be retroactively covered. Retroactivity on the Effective
            Date of Eligibility is granted when the Potential Enrollee indicates that he/she incurred medical expenses prior to the current eligibility period, including any Medicaid or CHIP covered service(s) that is related to medications or services
            that elicit pharmacy expenses and that has not been paid for. The Effective Date of Eligibility will be within three (3) months before the month in which the Potential Enrollee is applying. If the Potential Enrollee is Medicaid or CHIP eligible
            in the month in which the service was eligible, the Potential Enrollee will be granted retroactive eligibility. The retroactive benefit does not apply to eligible State beneficiaries. Retroactive eligibility is evaluated to all Medicaid and
            CHIP Potential Enrollees that notify the Medicaid Office of their medical expenses and/or services utilization during the allowable three (3) month period. Note, a Potential Enrollee could be classified as a State Enrollee for their current
            eligibility period but be classified as a Federal Enrollee for any of the retroactive eligibility periods. The Medicaid Office will evaluate each retroactive month separately which may result, with different coverage code(s) or eligibility
            classification(s) from one retroactive month to another.

        

        

        When an Enrollee re-certification is filed, and the Enrollee is again eligible, as determined by the Medicaid Office, the
            Effective Date of Eligibility for the subsequent period is generally the 1st of the month after eligibility expires from the previous eligibility period. If an Enrollee does not apply for Re-certification at the Medicaid Office once his/her
            eligibility period has expired, the eligibility for the GHP is lost. This will happen even in cases in which the Enrollee’s eligibility was lost for at least one (1) day. The Effective Date of Eligibility for a new eligibility period for these
            cases will be the first (1st) day of the month of the new application for certification.

        

        

        A person may apply for Medicaid/CHIP on behalf of a person who has died during the same month in which they apply or up to three
            (3) months retroactively in the event the person would have been eligible in those months. The eligibility period will be from the first (1st) day of the month of the application until the date of death. This provision does not apply to State
            beneficiaries.

         

          

        
          12

          
            


        

        All Federal, CHIP and State pregnant women may have an eligibility period greater than twelve (12) months when adding the required
            sixty (60) days of postpartum coverage. The expiration date will be the last day of the month at the end of these sixty (60) days.

        

        

        2.   State Enrollees (State Category Beneficiaries)

        

        

        The Effective Date of Eligibility for the State Population (see Section 1.3.1.2.1 of the Contract) is the eligibility period
            specified on the Form MA-10, and Potential Enrollees are eligible to be enrolled as of that date. Note, a Potential Enrollee could be classified as a State Enrollee for their current eligibility period but be classified as a Federal Enrollee
            for any of the retroactive eligibility periods. The Medicaid Office will evaluate each retroactive month separately which may result, with different coverage code(s) or eligibility classification(s) from one retroactive month to another.

        

        

        Recertification for State Enrollees in which the Enrollee is found eligible again, the Effective Date of Eligibility is the first
            (1st) day of the month after the current eligibility expires. The date of certification for State beneficiaries will be when the certification is completed. If a State Enrollee’s eligibility period expires before re-certification, the State
            Enrollee’s eligibility will be processed as a new case and the Effective Date of Eligibility will be the new Effective Date of Eligibility provided in Form MA-10. The State Enrollee may request a Contractor in the Medicaid Office for the new
            eligibility period at the time of certification.

        

        

        All Federal, CHIP and State pregnant women may have an eligibility period greater than twelve (12) months when adding the required
            sixty (60) days of postpartum coverage. The expiration date will be the last day of the month at the end of these sixty (60) days.

        

        

        D. Effective Date of Eligibility in the Case of Deemed Newborn

        

        

        Table 1 Deemed Newborn’s Eligibility Guidelines

         

        	 	
                Mother’s Medicaid

                Classification

              	 	
                Child’s

                Medicaid

                Classification

              	 	
                Child’s

                Evaluation

                Outcomes

              	 	
                Eligibility Outcomes

              	 
	 	
                Federal at the time of birth

              	 	
                Deemed Newborn

              	 	
                Federal Deemed Newborn

              	 	
                Retroactive Eligibility from the date of birth or from twelve (12) months back, whichever begins later

              	 
	 	
                Evaluated and determined to be

              	 	
                Federally Evaluated

              	 	
                Federal/CHIP

              	 	Retroactive Eligibility from the date of
                  birth	 


        

        

        
          13

          
            


        

        	 	
                Mother’s Medicaid

                Classification

              	 	
                Child’s

                Medicaid

                Classification

              	 	
                Child’s

                Evaluation

                Outcomes

              	 	
                Eligibility Outcomes

              	 
	 	
                Federal at the time of birth

              	 	
                

                

              	 	
                

                

              	 	
                or from three (3) months back, whichever begins later

              	 
	 	 	 	
                Federal Deemed Newborn

              	 	
                Retroactive Eligibility from the date of birth or from twelve (12) months back, whichever begins later

              	 
	 	
                Not Eligible or State or Evaluated and determined to be State at the time of birth

              	 	
                Independently Evaluated

              	 	
                Federal/CHIP

              	 	
                Retroactive Eligibility from the date of birth or from three (3) months back, whichever begins later

              	 
	 	 	 	
                State

              	 	
                Eligible from the Effective Date of Eligibility as noted on Form MA-10

              	 


        

        

        As described in Table 1, if a mother is Federal at the time of birth
              the newborn is classified as a Deemed Newborn, enrolled in the mother’s MCO and granted retroactive eligibility from the date of birth up to twelve (12) months. These
              cases will be identified in the eligibility record by including a letter ‘N’ (Deemed Newborn) in the second position in the Group Code field.

        

        

        In the event that the mother is not currently eligible but is evaluated and found to be Federal at the time of the newborn’s birth,
            the newborn will be evaluated for Federal eligibility and could be classified as either Federal, which would provide retroactive eligibility from the date of birth or from three (3) months back, whichever begins later, or Federal Deemed Newborn
            which would provide retroactive eligibility from the date of birth or from twelve (12) months back, whichever begins later.

        

        

        If the mother, on the other hand, is not eligible or either State or Evaluated and determined to be State at the time of birth, the
            child will be evaluated independently. If the evaluation of the child results in federal classification, he or she will be granted retroactive eligibility from the date of birth or from three (3) months back, whichever begins later. If the
            result is State funded enrollment in the program, the child will be granted eligibility from the certification date.

        

        

        
          14

          
            


        

        E. Medicaid/CHIP Retroactive Eligibility

        

        

        1.  Medicaid/CHIP Retroactive Eligibility Period Effective Date

        

        

        Under Medicaid or CHIP, the Effective Date of Eligibility corresponds to a retroactive period determined month by month. Each
            retroactive period or record shall correspond to one (1) calendar month. The Medicaid Office may grant up to four (4) eligibility periods for the same enrollee which may be comprised of three (3) retroactive periods and one (1) record for the
            current period. Each record of retroactivity will mark the beginning and end of the eligibility in relation to the period to which it corresponds. That is, each of the retroactive periods of eligibility granted will determine the start and
            completion of the Eligibility Effective Date for that particular period. See Table 1.

        

        

        Retroactive eligibility periods prior to November 1, 2018 will correspond to the contracted MCO for the appropriate region
            according to the previous contract.

        

        

        Retroactive Eligibility periods with effective date before Go Live will not be assigned a Contractor. For these cases, the
            Carrier, Carrier_eff_date, PCP, PCP_eff_date, PMG y PMG_eff_eff_date data fields will be left blank.

        

        

        Table 2: Retroactive Eligibility Period Scenarios

         

        	 	
                Eligibility Period

              	
                X = indicates included period of each eligibility scenario

              
	 	
                Current Period

              	
                X

              	
                X

              	
                X

              	
                X

              	 	 	 
	 	
                Retroactive Period 1

              	 	
                X

              	
                X

              	
                X

              	
                X

              	
                X

              	
                X

              
	 	
                Retroactive Period 2

              	 	
                X

              	
                X

              	 	
                X

              	
                X

              	 
	 	
                Retroactive Period 3

              	 	
                X

              	 	 	
                X

              	 	 


        

        

        2.  Group of Records of Retroactive Periods

         

          

        Each retroactive eligibility period involves a group of records. This information is sent to the Contractor on a daily basis in an Export (.exp) file. ASES could receive, for a single enrollee labeled as Federal (Medicaid, CHIP), up to
              three (3) retroactive eligibility enrollment records and one (1) current eligibility enrollment record in an enrollments file. A member may be eligible for one (1) to three (3) retroactive periods and not be eligible for the current term. In
              this case, sets of records for the retroactive periods may be received but none for the current eligibility period. Retroactive eligibility period will be from the first day of the month of retroactive eligibility until the last day of the
              month of retroactivity. An exception to this, will be first retroactive month for a newborn, which will begin with the date of birth.

         

            

        
          15

          
            


        

        
        Each retroactivity period is evaluated separately. That is the
              evaluation of the retroactive eligibility period is independent from that of the current period. A member can have retroactive eligibility periods and not be currently eligible. Therefore, there can be a change in coverage from one
            period to the next.

        

        

        Retroactive eligibility periods will be confirmed and sent to the Contractors in the daily eligibility file (.exp). Each period
            will have a group of records labeled with the ‘1’, ‘2’, ‘3’ indicators in the Tran_id column. The indicators are unrelated to the order of the periods;
            they are only used to unify the group of records. These retroactive eligibility periods do not necessarily correspond to consecutives eligibility periods.

        

        

        F. Enrollee Recertification

        

        

        After a period of eligibility is granted to an Enrollee, two (2) or
              three (3) months in advance of the Eligibility Expiration Date, the Enrollee will undergo a Recertification Process, for a new eligibility period, that will be carried out by the Medicaid Office. This will allow the renewal of the covered
              services for the next period of twelve (12) months. The Re-certification Effective Date refers to the date Medicaid re-evaluates an Enrollee’s eligibility. This date is provided on the Form MA-10. The Eligibility Expiration Date refers to the
              expiration date of the eligibility period granted to the enrollee by the Medicaid Office. A Federal and State enrollee which is recertified, will have its current
              eligibility period observed and will have a future Effective Date of Eligibility in the MA-10 for its next eligibility period which will start the next day after the current eligibility period expires.

         

        

        G. Termination of Eligibility (Eligibility Cancellations)

        

        

        Only the Medicaid Office may cancel and provide notice of the cancellation of an enrollee’s eligibility. In the recertification
            process, all the beneficiaries that receive a negative eligibility determination for GHP will continue to be eligible to receive services under the GHP until the eligibility expiration date has been reached. The cancellation of health services
            transaction due to the expiration of the eligibility period will be notified by the Medicaid Office and will be reflected in the ASES databases on the last day of each month.

        

        

        On a daily basis, ASES receives from Medicaid a file with the eligibility status of the beneficiaries. In such cases, ASES will send
            to the Contractors the contents of the files of those beneficiaries who have received a Negative Redetermination Decision within a period of twenty-four (24) hours or one (1) business day from the time it receives the file from the Medicaid
            Office. Note timeframes are subject to change at ASES, in the event of extraordinary circumstances, periods of maintenance or other unforeseen circumstances.

         

          

        
          16

          
            


        

        The termination of the eligibility period is marked by either the
              Expiration Date or the Medicaid Cancellation Date. At the moment of a certification or recertification of a member, an Expiration Date is established. If the eligibility of a member is extended for any of the reasons explained later in this
              document, the expected termination of such extension will be expressed through the Medicaid Cancellation Date. Also, if the eligibility period of a member, extended or not, is terminated before the Expiration Date (for example, by the
            death of an enrollee, members identified in the PARIS file, or by voluntary resignation) or a previously stated Medicaid Cancellation Date (for example, by a pregnancy that ended prematurely), the date for the real cancellation of the
            eligibility period of a member will be stated in the Medicaid Cancellation Date. The ASES System identifies the cancellations, in the export file, with the letter “I” in the transaction_id field.

         

        

        H. Appeals Processes

        

        

        1.  Appeals Process for Re-Certification

        

        

        When an enrollee does not qualify during his/her re-certification process, he/she has the right to appeal his/her eligibility’s
            negative redetermination within a term of fifteen (15) days. If a previously eligible Medicaid or CHIP member appeals within fifteen (15) days of an adverse eligibility determination, content “A” (In Appeal) or “X” will be sent to the insurance
            Contractor in the Extension_flag field. The member may not be cancelled during the appeals process even if the expiration date passes. When the
            appealing process is completed, Medicaid will send an update of the member’s status to ASES. If the appeal is presented after the first fifteen (15) calendar days after the adverse eligibility determination, no extension will be issued. In this
            case, a cancellation will be received from Medicaid.

         

        

        The following are the possible outcomes of the appeal process:

        

        

        (a)       If the appeal is found to be in favor of the
            enrollee: the expiration date will be updated to the appropriate one. He/she will be identified as eligible and the record marking the termination of the appeals process will be labeled with a “U” and will reflect a new eligibility period. If
            there were to be a change in coverage, a new enrollment with the new plan version must be sent, just as is currently done.

        

        

        (b)       If the appeal is found to be against the enrollee
            the Medicaid Office will send a cancellation with the original expiration date. He/she will be identified as ineligible, the termination of the appeals process will be labeled with an “N” and the Medicaid Cancellation Date will contain the
            corresponding cancellation date. The Contractor will keep offering services to the enrollee until it receives the cancellation in the eligibility file sent by ASES. ASES will continue paying premiums until the cancellation is received from
            Medicaid Office. Only Medicaid Office may cancel an enrollee. The cancellation’s effective date will reflect the date that Medicaid specifies in the Medicaid Cancellation Date field if it differs from the eligibility expiration date.

         

          

        
          17

          
            


        

        (c)       If the appeal is resolved only after a
            cancellation, the Contractor will receive the eligibility information only if the appeal is in favor of the enrollee and with updated dates with the new eligibility period.

        

        

        2.  Appealing at a Certification (either new or not active at the time)

        

        

        If a person who is not active in the Medicaid Program requests eligibility and he/she does not qualify, he/she has the right to
            appeal the result of the evaluation. This type of appeal is an internal Medicaid Office process. The Medicaid Office will not send to ASES records of these processes unless the appeal is decided in the person’s favor. In the case of Medicaid or
            CHIP eligible beneficiaries, a group of records will arrive with an effective date that may be retroactive to the first day of the month corresponding to the certification date. If more than three (3) months has passed, the Contractor will
            treat the enrollment as an emergency (special enroll = ‘E’). For these cases, Medicaid will not send the retroactive eligibility in separate
            transactions. In the event the person is certified as a state funded State enrollee, the date of eligibility after a favorable appeal shall be prospective from the date of the favorable determination.

        

        

        
          
            I. Eligibility Extensions

          

        

        

        

        When Medicaid grants an eligibility extension, the date in
            which the extension expires is included in the Medicaid Cancellation Date field at the Family Eligibility table. For these cases, the Eligibility Expiration Date field is not updated since it encompasses the end of the original eligibility
            period granted by Medicaid before the extension.

        

        

        1.  Eligibility Extension Due to Pregnancy

        

        

        If a pregnant woman is undergoing re-certification and she is determined to be ineligible, she cannot be terminated the last day
            of the month in which postpartum coverage expires. These cases will be labeled with the letter “P” in the Extension flag field. The Medicaid Office will
            send ASES a cancellation transaction at the appropriate point.

        

        

        2.  Eligibility Extension Due to Natural Disaster

        

        

        If a natural disaster occurs, a determination will be made by the Department of Health’s Medicaid Program to extend the
            eligibility of the population affected. The eligibility extension for natural disasters grants the extension period approved by CMS to the affected member. These cases will be labeled with the letter “H” in the Extension flag field. The Medicaid Office will send ASES an update transaction at the appropriate date. The granted extension’s expected expiration date will be held in the Medicaid
            Cancellation Date field. The eligibility effective date and expiration date will not change because of the extension granted.

         

          

        
          18

          
            


        

        3.  Beneficiaries With More Than One Extension Type

        

        

        If an enrollee qualifies for more than one (1) type of extension, the extensions will be combined applying the extension with the
            longest eligibility period extension stated through the Medicaid Cancellation Date and the extension that grants the most benefits stated through the Extension Flag containing the appropriate Extension Code. For example, if an enrollee is
            granted the extension due to pregnancy and the extension due to a natural disaster, the extensions will be combined and his or her eligibility will be extended because of the natural disaster extension and will have the coverage benefits of the
            pregnancy extension.

        

        

        4.  Eligibility Extension Codes

        

        

        N –Member eligibility period not extended

        A – Member is amid an appeal process

        U – Update to a member amid an appeal process. This states that the process has reached an outcome.

        H – Member eligibility extended due to the occurrence natural disaster

        P – Member eligibility extended due to pregnancy status

        

        

        5.  Member Eligibility Period Not Extended (N)

        

        

        The enrollee does not have any type of extension. For these cases the Medicaid Cancellation Date cannot have a future date.

        

        

        
          IV. ENROLLMENT IN GHP CONTRACTORS

           
            


        

        

        

        A.  General Enrollment Requirements

        

        

        The Contractor must coordinate with ASES, the Medicaid Office and the Enrollment Counselor, as applicable, for all Enrollment and
            Disenrollment functions, as required under Section 5.2.1 of the Contract.

        

        

        The Contractor must guarantee the maintenance, functionality, and reliability of all systems necessary for Enrollment and
            Disenrollment, pursuant to the Contract and this Manual.

         

          

        
          19

          
            


        

        B.  Auto-Enrollment Algorithm

        

        

        ASES developed an Auto-Enrollment algorithm, in accordance
            with the requirements in 42 CFR 438.54, designed to distribute the GHP population groups among GHP Contractors, with the goal of preserving the relationship of the Enrollees with their main healthcare providers. The algorithm prioritizes the
            enrollment of the High Cost High Need population, followed by the Dual Eligible Enrollees, Special Coverage Enrollees and the Non-Chronic Enrollees. The algorithm also seeks to keep Enrollees sharing a dwelling place with the same Contractor.
            The algorithm also takes into account Contractor capacity in order to accommodate enrollment changes and fluctuations during the initial enrollment periods. These considerations were factored in order to minimize Enrollee disruption as the GHP
            moves to an Island-wide delivery system while maintaining an equitable distribution of enrollment for all Contractors.

        

        

        The Foster Care Population and Domestic Violence Population will be Auto-Enrolled in one contractor’s plan and are not eligible to
            enroll into another contractor’s plan.

        

        

        C.  Effective Date of Enrollment

        

        

        The Effective Date of Enrollment for all Initially Auto-Enrolled Enrollees is November 1, 2018. Except as provided below,
            Enrollment, whether selected or automatic, will be effective as of the same date as the date demarking the beginning of the period of eligibility specified on Form MA-10 set forth in Section 5.2.6 of the Contract.

        

        

        The Effective Date of Enrollment for a newborn whose mother is Medicaid or CHIP Eligible on the date of delivery (Deemed Newborn) is
            the date of his or her birth. The Effective Date of Enrollment for a newborn whose mother is a State Population Enrollee is the Effective Date of Eligibility established by the Puerto Rico Medicaid Program. A newborn shall be Auto-Enrolled
            pursuant to the procedures set forth in Section 5.2.7 of the Contract.

        

        

        Changes in Enrollment requested by the Enrollee received during the first twenty (20) Calendar Days of the month will be effective
            the first Calendar Day of the following month (e.g., requests received January 10 will be effective February 1).

        

        

        Changes in Enrollment received after the first twenty (20) Calendar Days of the month will be effective the first Calendar Day of
            the second month following the request to change Enrollment (e.g., requests received January 25 will be effective March 1).

        

        

        
          20

          
            


        

        D.  Term of Enrollment

        

        

        The Term of Enrollment with the Contractor shall be a period of twelve (12) consecutive months for all GHP Enrollees, unless a
            different contractor is selected during the applicable Open Enrollment Period described in Section 5.2.5 of the Contract, and except in cases in which the Puerto Rico Medicaid Program has designated an eligibility period shorter than twelve
            (12) months for an Enrollee who is a Medicaid or CHIP Eligible or a member of the State Population, in which case that same period shall also be considered the Enrollee’s Term of Enrollment.

        

        

        Such a shortened eligibility period may apply, at the discretion of the Puerto Rico Medicaid Program, when an Enrollee is pregnant,
            is homeless, or anticipates a change in status (such as receipt of unemployment benefits or in family composition). Section 5.3.3 of the Contract controls the Effective Date of Disenrollment.

        

        

        Deemed Newborns have a Term of Enrollment of up to thirteen (13) months.

        

        

        Pregnant Enrollees with a Term of Enrollment that expires during pregnancy or within sixty (60) Calendar Days of the post-partum
            period have an extended Term of Enrollment that expires on the last day of the month after sixty (60) Calendar days counted from the beginning of the post-partum period.

        

        

        Except as otherwise provided in Section 5.2 of the Contract, and notwithstanding the Term of Enrollment provided in Section 5.2.3 of
            the Contract, Enrollees remain enrolled with the same contractor until the occurrence of an event listed in Section 5.3 of the Contract (Disenrollment).

        

        

        E.  Contractor Notification Procedures Related to Redetermination

        

        

        The Contractor must inform Enrollees who are Medicaid and CHIP Eligible and members of the State Population of an impending
            Redetermination through written notices. Such notices shall be provided ninety (90) Calendar Days, sixty (60) Calendar Days, and thirty (30) Calendar Days before the scheduled date of the Redetermination pursuant to Section 5.2.8 of the
            Contract.

        

        

        F.  Enrollment Procedures

        

        

        For all Enrollees except Newborns, the Contractor must comply with the Auto-Enrollment process and issue to the Enrollee a notice
            informing the Enrollee of the PMG and PCP they are assigned to and their rights to change the PMG or PCP without cause during the applicable Open Enrollment Period.

         

          

        
          21

          
            


        

        Following, the Effective Date of Enrollment, the Enrollee has 90 Calendar Days to change his/her Auto-Assigned or Selected PMG and
            PCP without cause through the Contractor. The Contractor can offer counseling and assistance to the Enrollee in selecting a different PCP and PMG.

        

        

        Enrollees under the Foster Care Population and Domestic Violence Population classification are not assigned to a PCP or PMG.

        

        

        The Contractor must issue the Enrollee ID Card and a notice of Enrollment, as well as an Enrollee Handbook and Provider Directory
            either in paper or electronic form, within five (5) Business Days of Enrollment pursuant to Section 5.2.6.2 of the Contract. The notice of enrollment must clearly state the Effective Date of Enrollment. The notice of Enrollment will explain
            that the Enrollee is entitled to receive Covered Services through the Contractor.

        

        

        All Enrollees must be notified at least annually of their disenrollment rights as set forth in Section 5.3 of the Contract and 42
            CFR 438.56.

        

        

        The Contractor must comply with 5.2.7 of the Contract regarding Procedures for Auto-Enrollment of Newborns.

        

        

        G.  Initial Membership Distribution

        

        

        The Initially Auto-Enrolled Enrollees will be classified into Enrollee Seed Sets using the Eligibility Expiration Date and Medicaid
            Cancellation Date as the classification parameters.

        

        

        This whole population will be processed for Contractor Auto-Enrollments, PMG and PCP Auto-Assignments. These Seed Sets will be
            included then in Delivery Packages that will contain the corresponding Enrollee Seed Set and Maintenance Set. The Maintenance Set will be constituted by any existing Enrollee seed set updates or new Enrollee information relayed by Medicaid
            before the Go-Live Date.

        

        

        The period that begins on the Auto-Enrollment Algorithm Execution Date and finishes the day before the GHP Go-Live Date is known as
            the Auto-Enrollment Maintenance Period.

         

        

        As Contractors receive these delivery packages with their corresponding membership (enrollment), Contractors are expected to issue
            GHP Welcome Packages to enrolled Enrollees and send the completed enrollment records to ASES as a confirmation of that action.

         

          

        
          22

          
            


        

        H.  Initial Open Enrollment Period

        

        

        In the first year of GHP, Enrollees certified as GHP eligible (Federal and State) and enrolled in the GHP prior to November 1, 2018,
            will be Auto-Enrolled in a Contractor (Initial Auto-Enrollment Enrollees). ASES will determine a Contractor’s initial enrollment by applying the auto-enrollment algorithm described above.

        

        

        As of day one of GHP Go-Live (November 1, 2018), Initially Auto-Enrolled Enrollees will have one (1) opportunity to change
            contractors without cause during their Open Enrollment Period, which shall begin on November 1, 2018 and end on January 31, 2019.

         

        

        I. Enrollee Selection of Contractor

        

        

        1.  Initial Open Enrollment Period

        

        

        Initially Auto-Enrolled Enrollees will have one (1) opportunity to change (select) contractors without cause during their Open
            Enrollment Period, which shall begin on November 1, 2018 and end on January 31, 2019. ASES will determine a Contractor’s initial enrollment by applying the Auto-Enrollment algorithm described above. If the Enrollee does not make a change in
            contractor during the Initial Open Enrollment Period, the Enrollee will remain enrolled with his/her Auto-Enrolled contractor until Annual Open Enrollment Period described in Section 5.2.5.3 of the Contract, unless the Enrollee disenrolls from
            the contractor due to for cause disenrollment reasons as specified in Section 5.3.5 of the Contract.

        

        

        2. Open Enrollment Period for New Enrollees

        

        

        New Enrollees to the GHP will have the opportunity to select a contractor during the Medicaid eligibility process with the Puerto
            Rico Medicaid Program. If the New Enrollee does not select a Contractor, the Puerto Rico Medicaid Program will select a Contractor on behalf of the New Enrollee using an algorithm based on a Round-Robin order arrangement. New Enrollees shall be
            permitted to select a different Contractor once without cause, regardless of how the initial selection of the Contractor was made, during their Open Enrollment Period, which shall begin on the New Enrollee’s Eligibility Certification Date and
            will extend for a period of ninety (90) days.

        

        

        3. Annual Open Enrollment Periods

         

          

        Each year, the GHP provides Enrollees with an Annual Open Enrollment Period. The Annual Open Enrollment Period consists of three
            (3) months from November 1 through January 31 of the following year. All Enrollees will have the opportunity to select a contractor without cause during the Annual Open Enrollment period. If the Enrollee does not make a change in contractor
            during the Annual Open Enrollment Period, the Enrollee will remain enrolled with his/her current contractor.

         

          

        
          23

          
            


        

        Annual Open Enrollment Periods:

         

          

        
          
            	 	·	
                    Year 1: November 1st 2018



                        through January 31st 2019 (Initial Year)

                  


          

        

         

        
          
            	

                  	·	
                    Year 2: November 1st 2019



                        through January 31st 2020

                  


          

        

         

        
          
            	

                  	·	
                    Year 3: November 1st 2020



                        through January 31st  2021

                  


          

        

         

        
          
            	

                  	·	
                    Year 4: November 1st 2021



                        through January 31st 2022 (Option Year)

                  


          

        

        

        

        During each Annual Open Enrollment Period, all Enrollees will have one (1) opportunity to change contractors without cause during
            their Annual Open Enrollment Period. If a New Enrollee’s Open Enrollment Period pursuant to Section 5.2.5.2 of the Contract coincides with the Annual Open Enrollment Period, the Open Enrollment Period in Section 5.2.5.2 controls.

        

        

        When an Enrollee ceases to be part of the Domestic Violence or Foster Care population but continues to be an Eligible Person, the
            Enrollee may select a new contractor during an Open Enrollment Period.

        

        

        When an Enrollee ceases to be eligible for the Platino Program but continues to be an Eligible Person, the Enrollee may select a
            new contractor during an Open Enrollment Period and must follow the for cause processes described in Section 5.3.5.4 of the Contract.

         

          

        
          24

          
            


        

        Figure 1 Illustration of Initial Auto Enrollment Operations

         

          

        

        Illustration of Initial Auto Enrollment Operations

        

        

        
          

          

        

        
          25

          
            


        

        Figure 2 Illustration of New Enrollee Enrollment Operations

        

        

        
          

          

        

        
          26

          
            


        

        Figure 3 Illustration of Open Enrollment Operations

        

        

        
          

          

        

        
          27

          
            


        

        
          V. ENROLLMENT COUNSELOR OPERATIONS
            


        

        

        

        ASES has procured Enrollment Counselor functions, available in-person at Medicaid Offices, by toll-free number and online, to help Enrollees understand
            the GHP and make informed choices for contractor enrollment. It is at the Enrollee’s option to receive the services of the Enrollment Counselor. If any Enrollee actively selects a contractor during the applicable Open Enrollment Period (or at
            point of eligibility application for New Enrollees), the Enrollment Counselor will record the selected contractor and such information will be provided to ASES, through an enrollment (.sus) file, to formalize the enrollment process.

        

        

        On an ongoing basis, Enrollees will have access to a Counselor to select a Contractor, PMG and PCP. New Enrollees and re-certified Enrollees will be
            able to select a Contractor taking into account the availability of an enrollment spot within the capacity of each Contractor and available PCPs. The Effective Date of Enrollment of the Contractor, PCP and PMG will coincide with the Effective
            Date of Eligibility pursuant to Section 5.2.2 of the Contract and as determined at the Medicaid Office. New and re-certified Enrollees are entitled to assistance by the Enrollment Counselor during the Open Enrollment Period applicable to each
            population regarding selection of a Contractor, PCP and PMG.

        

        

        
          VI. DATA EXCHANGE BETWEEN MEDICAID, ASES AND CONTRACTORS

        

        
          


         

          

        The following sections provides an overview of data exchange information between Medicaid, ASES and the Contractors. For specific data layout
            information, refer to Attachment 9 with the referenced layout files.

        

        

        A. Data Exchange Between Medicaid, ASES and the Contractors

        

        

        
          
            
              
                1.  Medicaid and ASES Data Exchange
                      (.ref file)

              

            

          

        

        

        

        Under GHP, at the end of the certification process at Medicaid, a
              New Enrollee will have the opportunity to select a Contractor and the Medicaid Office will relay the resulting selection to ASES. The information relayed to ASES will
              include any eligibility information resulting from the process and the Contractor selection or auto enrollment.

        

        

        
          
            
              
                2.  ASES and the Contractors Data Exchange (.exp file)

              

            

          

        

        

        

        The eligibility files from Medicaid (.ref) mentioned in the previous section are entered into the daily run cycle and are
            evaluated through an editing and verification program at the Information Systems Office at ASES. After receiving and processing the eligibility and Contractor data of each enrollee, ASES creates an electronic record that includes information
            which the Contractor can use to enroll the enrollee, such as information about the Plan Type (Federal or State) and Plan Version (coverage code) along with their respective effective dates and other related data elements. On a daily basis, ASES
            sends accepted enrollments, new eligibility, updates and cancellations data to Contractors in a file (.exp)

         

          

        
          28

          
            


        

        Following receipt of the contractor’s file, the contractor is required to send ID cards along with a GHP Welcome Package, to the
            new enrollees by postal mail in five (5) business days pursuant to Section 5.2.6.2 of the Contract.

        

        

        The Enrollee, in turn, has ninety (90) days to request a change of the MCO, PCP and or PMG. The Contractor then produces the
            electronic enrollment record and submits it to ASES in a file (.sus) that accounts for the enrollments made. If either the Coverage Code, PCP or PMG of the enrollee changes, the Contractor must send an enrollment record to ASES reflecting the
            change as a confirmation of issuing a new plan identification card and sending it to the enrollee.

        

        

        Generally, Contractors have a one business day to remit enrollment records to ASES. They must notify ASES of the information about
            the new Enrollees and send information about any changes performed on a record previously enrolled. Such notification must be sent on the next business day.

        

        

        When an enrollee’s data sent to a given Contractor is received with a different Contractor code than the one for the Contractor
            receiving the data, it means that the enrollee has been enrolled with a different Contractor. In this case, the previous Contractor must perform a disenrollment of the enrollee in its database. For these cases the Carrier Effective Date will be
            modified and the transaction will be sent to both contractors. The Tran_ID value for this transactions will be “E”.

        

        

        In the case that the Contractor has to update the information previously sent to ASES in relation to a new enrollment, or when it
            is appropriate to add a new enrollee that has been previously omitted, that update must occur the next business day after the information has been updated or that a new enrollee has been added. In these cases, ASES reserves the right not to
            accept new additions or corrections to the enrollment data after two (2) business days after the Effective Date of the Enrollment indicated in the Contractor’s notification to ASES. Likewise, he Enrollee’s PMG and/or PCP changes will take
            effect as stated in Section 5.4 of the Contract.

        

        

        Records that are accepted without errors during the editing process are updated in the databases at ASES and the beneficiaries are
            duly enrolled. Any record that is accepted during the editing and verification processes will be stored in the ASES database tables.

         

          

        
          29

          
            


        

        The records for the rejected enrollments are returned to the Contractor with the applicable reject codes in a file (.rjc) on a
            daily basis. The Contractor must correct any errors in the enrollment record and send the information back to ASES in a file (.sus) within two (2) business days. ASES will only pay the premiums related to those beneficiaries who are enrolled in
            the databases at ASES. Therefore, the execution of the payment of the corresponding premium for these rejected records will be delayed until the enrollment records are sent back with the correction of the indicated errors. It is important that
            the Contractor sends the corrected enrollment records within the timeframe specified no later than two (2) business days past the date on which ASES notifies the Contractor of the rejected subscriptions, after which the Contractor could start
            losing premium payments, as stated in Section 5.3.10 of the Contract.

        

        

        ASES will identify late transactions by comparing the date of the rejection and the date of the resubmission. If the rejected
            transaction is reconciled, resent and accepted within the timeframe specified at Section 5.3.10 of the Contract, no payment suspension will occur. If it does not occur within two (2) days, it will be included for prospective payment, which
            shall be prorated from the day the file is accepted. Applies to Trans_ID V, E, C, but not Special Enrolls N, E, T.

        

        

        During the premium payments process, the enrollments received during the month before the process run are considered.

        

        

        The exchange of data regarding eligibility and enrollment processes between the Medicaid Office, ASES and the contracted
            Contractors occurs on a daily basis. In Figure 4, which is provided below, the information exchange processes described in the previous subsections are presented.

         

          

        
          30

          
            


        

        Figure 4 Medicaid/ASES/Contractors Data Flow

        

        

        

        

        

        
          31

          
            


        

        B. Enrollment Files

        

        

        	 	
                ENROLLMENT FILE [CCYYMMDD.sus]

              	 
	 	
                a. CC = Contractor Code

              	 
	 	
                b. YY = Year

              	 
	 	
                c. MM = Month

              	 
	 	
                d. DD = Day

              	 
	 	
                e. .sus = Identifies the file as an enrollment file. The enrollment file may contain records belonging to any of the regions contracted
                    by the Contractor.

              	 
	 	
                Notes:

                ✓ Files received at 9:00 am are entered in
                    the ASES daily cycle.

                ✓ If a file is received after 9:00 am, it
                    will be entered in the next day’s cycle.

                See File Layout Attachment – Enrollment Record Layout (.sus)

              	 


        

        

        	 	
                ELIGIBILITY FILE [VYYMMDD.ref]

              	 
	 	
                a. V = indicates that it is an eligibility file

              	 
	 	
                b. YY = Year

              	 
	 	
                c. MM = Month

              	 
	 	
                d. DD = Day

              	 
	 	
                e. .ref = Indicates that it is a file containing the records of the beneficiaries’ eligibility.

              	 


        

        

        	 	
                DATA EXPORT FILE [CCYYMMDD.exp]

              	 
	 	
                b. CC = Contractor code

              	 
	 	
                c. YY = Year

              	 
	 	
                d. MM = Month

              	 
	 	
                e. DD = Day

              	 
	 	
                f. .exp = Indicates that it is a file containing all the eligibility and enrollment transactions processed during the daily run.

                See File Layout Attachment – Carrier Eligibility File Layout (.exp)

              	 


        

        

        	 	
                REJECTED ENROLLMENTS FILE [*.rjc]

              	 
	 	
                a. CC= Contractor Code

              	 
	 	
                b. YY = Year

              	 
	 	
                c. MM = Month

              	 
	 	
                d. DD = Day

              	 
	 	
                e. .rjc= Indicates that it is a file containing the records of the beneficiaries who have been rejected.

              	 
	 	
                Notes: ASES will continue to run
                    a separate edition and update cycle for each region. Enrollments are filtered through various editing and verification programs and identified as valid or rejected. This process produces a file (.rjc) that contains all the records that
                    are rejected.

                See File Layout Attachment – Rejected Enrollment (.rjc)

                Note the (.rjc) and (.sus) share the same layout structure.

              	 


        

        

        
          32

          
            


        

        Although geographic regions are no longer applicable, geographic
              regions will still be used for the nomenclature of the files that are sent to the Contractors and the internal processes of ASES.

        

        

        C.  GHP Enrollment

        

        

        In order for an enrollment record to be accepted during the editing and validation processes, it is important to take into account
            the following considerations regarding concepts related to the enrollment processes:

        

        

        
          
            
              1.  Effective Date of Enrollment

            

          

        

        

        

        a.  The Contractor Effective Date

        

        

        Please consult Section IV of this Manual and Section 5.2.2 of the Contract for a discussion of Effective Dates of Enrollment.

        

        

        b.  The PCP1, PCP2 and PMG Effective Dates

        

        

        In cases of new Enrollees, the PCP1, PCP2 and PMG Effective Dates will match the Eligibility Effective Date. If a change for any
            of the PCPs or the PMG is performed through the Contractor, the Contractor will follow the specifications described under Section 5.4 of the contract where the management of those changes is defined.

        

        

        The initial assignment of a PCP2 will only be effectuated through the Contractor and it will be responsible of indicating the PCP2
            Effective Date in the enrollment record. It is under consideration if during Contractor changes, an attempt to conserve the PCP2 will be made.

        

        

        c.  Plan Version/Coverage Code Effective Date

        

        

        The coverage code only will change during the recertification process performed by Medicaid. When a recertification is performed,
            the Effective Date of Eligibility changes to that of the next period, hence the Plan Version Effective Date will match the Eligibility Effective Date.

        

        

        
          
            
              2.  Changes in
                  Coverage Codes and Enrollment

            

          

        

        

        

        The coverage code can only change at the recertification process or when the
            Enrollee requests a redetermination because the medical indigence level has changed. If at the recertification process, the coverage code of a GHP enrollee changes as described in Figure 5 below, the Contractor must send an enrollment record
            with the new plan version (that   matches   the   coverage   code)   with   the  effective   date  of   eligibility   indicated by Medicaid (eligibility effective date) and send a new healthcare insurance identification card to the
          enrollee.

        

        
        
          33

          
            


        

        Figure 5 Enrollee Recertification & Enrollment Maintenance

        

        

        
          

          

        

        

        

        
          
            
              3.   Process Date

            

          

        

        

        

        
        
          Regarding the daily run files (.exp) the process date is the date in which the
              daily run was   executed.    The   process   date   in   the   Contractor   enrollment   records    (.sus) corresponds to the date in which the Contractor issued the enrollee’s healthcare insurance identification card.

        

         

          

        
          34

          
            


        

        D.  Late Enrollment Due to Delayed Eligibility

        

        

        The late enrollment processes involve the processing of an enrollment in the ASES databases for retroactive eligibility periods, or
            for delays in the receipt of eligibility periods (for example, because of a resolution of an appeal of eligibility in favor of an enrollee). Cases in which the eligibility record arrives late from Medicaid (for example, because of a possible
            internal Medicaid appeal process), have to be identified with the letter ‘E’ in the special_enroll field.

        

        

        The letters “E” or “C” in the Tran_ID field will be included for delayed eligibility period enrollments, just like in SYSPREM cases
            (See Section VI).

        

        

        The periods identified as delayed eligibility periods do not have a deadline for payment purposes.

        

        

        E.  Retroactive Eligibility Period Enrollment

        

        

        Refer above to Section 3.E.2. In the same enrollment file, no more than one (1) enrollee may be included for the same member unless
            it is a subscription for a current eligibility period and one (1) to three (3) subscriptions for retroactive eligibility periods.

        

        

        Each enrollment with retroactive eligibility period will be validated against the member’s eligibility history. Therefore, the
            Contractor’s effective date for each enrollment must correspond to the date of each retroactive period in ASES’s member’s eligibility history. Retroactive period enrollments will be labeled with the letter “T” in the Special_enroll field.

         

        

        The letter “E” in the Tran_ID field will be included for retroactive eligibility period enrollments.

        

        

        The periods identified as retroactive (1, 2, 3) eligibility periods do not have a deadline for payment purposes.

        

        

        F.  Enrollment Record

        

        

        The enrollment record that is used by Contractors to notify ASES of the enrollment of an enrollee contains a series of data that are
            used for the purpose of informing the details of the enrollment made and to verify their accuracy and certainty. The enrollment transaction is the Contractor’s confirmation and guarantee that the enrollee has been successfully enrolled in the Contractor databases and that a GHP Welcome Package or membership card has been sent to the enrollee.
           

        

         

          

        
          35

          
            


        

         The Plan Type code for the GHP is “01”. At the moment in which the enrollment record is generated the Plan Version is the same as
            the Coverage Code for the GHP Plans. Currently, ASES contracts falls under the managed care category in which it is required that each member has a designated PCP.

        

        

        G. Enrollment Record Fields

        

        

        The record of each enrollee’s enrollment contains the following information that must be provided by the Contractor:

        

        

        
          
            	

                  	1.	
                    RECORD_TYPE–In every case, and regardless of the transaction in question, this
                        field requires the insertion of code “E” that identifies the entry as an enrollment record for both new enrollments of beneficiaries and changes on records of beneficiaries previously enrolled.

                  


          

        

        

        

        
          
            	

                  	2.	
                    TRAN_ID - This field allows the ASES systems to identify the action to take on
                        the record submitted. It can contain one of the values listed below:

                  


          

        

        

        

        
          
            	

                  	a.	
                    E = New Enrollment. This value identifies that the record is a new enrollment
                        for an enrollee who has not been previously enrolled. It could also imply that this is a retroactive enrollment record for transactions not previously enrolled. For transactions previously enrolled, either by the same or one that is
                        different from the previous enrollment, a “C” would be inserted.

                  


          

        

        

        

        
          
            	

                  	b.	
                    C = Contractor Change. Used when the enrollee has selected a different
                        Contractor than the one in which he/she is presently enrolled. It could also identify a retroactive enrollment record in cases that are carried out by a Contractor different than that arising from the ASES database or by the same
                        Contractor if it has to make a change on a previous enrollment.

                  


          

        

        

        

        
          
            	 	c.	
                    V = Plan Version Change. For MCOs, this transaction code is used when a GHP
                        enrollee’s coverage code changes. In these cases, the Contractor must reissue a health plan ID card displaying the new benefits and submit a version change enrollment record to ASES where the Version number should be equal to the
                        new coverage code. This transaction confirms that the new insurance card was sent to the enrollee. Failure to submit said information to ASES, will trigger an automatic disenrollment of the enrollee at the end of the month, from the
                        Contractor that omits the timely submission. While in these circumstances the enrollee continues being eligible to receive the medical services, the
                        Contractor will remain unable to claim a premium payment for said enrollee until a submission of the required information is performed.

                  


             

            

          

        

        
          36

          
            


        

        
          
            	

                  	d.	
                    I = PMG (Primary Medical Group) Change. It is used to register, in ASES, a
                        change in the beneficiaries’ requested PMG under the same Contractor, Plan Type and Plan Version.

                  


          

        

        

        

        Initially the PCP/PMG will be assigned to the enrollee by the Medicaid office, ASES or the Contractor according to the enrollee’s
            zip code (physical address) and the enrollment capacity of the PCP/PMG. If the daily files (.exp) arrived to the Contractor without a PCP/PMG assigned the Contractor must perform the auto-assignment of PCP/PMG, send the insurance card to the
            enrollee and send the enrollment record to ASES containing the auto-assigned information. Then the enrollee may proceed to make changes and select a different PCP/PMG.

        

        

        
          
            	

                  	e.	
                    1 = PCP1 change. It is used to register, in ASES, a change in the
                        beneficiaries’ requested PCP1 under the same Contractor, Plan Type, Plan Version and PMG. For changes regarding the PCP1 the enrollment capacity of the PCP will be
                          taken into consideration. The enrollee may make changes afterwards. The PCP1 Effective Date is required.

                  


          

        

        

        

        
          
            	

                  	f.	
                    2 = PCP2 change. It is used to register, in ASES, a change in the beneficiaries’ requested PCP2 under the same Contractor, Plan Type, Plan Version, PMG and PCP1. For changes regarding the PCP2 the enrollment capacity of the PCP will be taken into consideration. The enrollee may make changes afterwards. The PCP2 Effective Date is required.

                  


          

        

        

        

        
          
            	

                  	g.	
                    3 = PCP1 and PCP2 change. It is used to register, in ASES, a change in the beneficiaries’ requested PCP1 and PCP2 under the same Contractor, Plan Type, Plan Version and PMG. For changes regarding the PCP1 y PCP2 the enrollment capacity of the PCP will be taken into consideration. The enrollee may make changes afterwards. The PCP1 and Effective Dates are required.

                  


          

        

        

        

        
          
            	

                  	h.	
                    D = Disenrollment (used for Platino carriers) When the beneficiary loose the
                        medicare benefits or if the enrollment is wrong, the Platino carrier may can made a disenrollment.

                  


          

        

        

        

        As we have seen, the content of the Tran_id field determines what
              type of transaction is going to be executed through the enrollment record sent to ASES. Some of the authorized transactions are broken down below. Table 3 below identifies the information that each change will require and states the
            fields that will be impacted by each one.

         

          

        
          37

          
            


        

        Table 3: Hierarchy Table

        

        

        	
                TRAN_ID

              	
                CONTRACTOR

              	
                Plan Version

              	
                Primary

                Center

              	
                PCP1

              	
                PCP2

              
	
                E -New

                Enrollment

              	
                Must be the same as in ASES DB

              	
                Y

              	
                Y

              	
                Y

              	
                O

              
	
                C -Change

                Contractor

              	
                Must be different from ASES DB

              	
                Y

              	
                Y

              	
                Y

              	
                O

              
	
                V -Version

                Change

              	
                Must be the same as in ASES DB

              	
                Must be different from ASES DB

              	
                Y

              	
                Y

              	
                O

              
	
                I -Change

                Primary Medical

                Group

              	
                Must be the same as in ASES DB

              	
                Must be the same as in ASES DB

              	
                Must be different from ASES DB

              	
                Y

              	
                O

              
	
                1 -Change

                PCP1

              	
                Must be the same as in ASES DB

              	
                Must be the same as in ASES DB

              	
                Must be the same as in ASES DB

              	
                Must be different from ASES DB

              	
                N

              
	
                2 -Change

                PCP2

              	
                Must be the same as in ASES DB

              	
                Must be the same as in ASES DB

              	
                Must be the same as in ASES DB

              	
                Must be the same as in ASES DB

              	
                Must be different from ASES DB

              
	
                3 -Change

                PCP1 & PCP2

              	
                Must be the same as in ASES DB

              	
                Must be the same as in ASES DB

              	
                Must be the same as in ASES DB

              	
                Must be different from ASES DB

              	
                Must be different from ASES DB

              


        

        

        Legend:

        

        

        Y = Information required for the transaction type specified.

        O = Optional information.

        N = Information that should not be sent for the transaction type specified.

         

          

        
          38

          
            


        

        (A) New enrollment (“E”):  The system
            will require all fields related to the information about the Contractor, Plan Type, Plan Version, Primary Medical Group and PCP1 to be completed. The PCP2 information will remain as optional information for some cases. The Contractor will be
            assigned by the Medicaid office. The PCP/PMG will be assigned by Medicaid, ASES or the Contractor. If the PCP/PMG were assigned by the Medicaid office or ASES, the Contractor will return the enrollment record with the card issue date as the
            process date of the enrollment after sending the GHP Welcome Package to the Enrollee.

        

        

        (B) Change of Contractor (“C”): The
            system will require registering the name of the new Contractor and inserting information regarding the Plan Type, Plan Version, Primary Medical Group, PCP1, PCP2 (optional) and card issue date as the process date of the enrollment after sending
            the GHP Welcome Package to the Enrollee.

        

        

        (C) Plan Version Change (“V”): The
            Contractor code and Plan Type information provided must match the information in the ASES databases. Only information regarding the new assigned Plan Version will be provided. Information should also be provided in relation to the Primary
            Medical Group and PCP1 Center.

        

        

        (D) Primary Medical Group Change (“I”): Information





            regarding the Contractor, Plan Type and Plan Version must match the information contained in the ASES databases. Only new information will be sent to ASES regarding the new Primary Medical Group (PMG) that corresponds to the enrollee.

        

        

        (E) Change of PCP1 (“1”): It will be
            necessary that the information of Contractor, Plan Type, Plan Version and Primary Medical Group provided coincide with the information contained in the ASES databases. It will be necessary to submit the new information regarding the change in
            PCP1 and it will not be necessary to provide information on the PCP2.

        

        

        (F) Change of PCP2 (“2”): It will not be
            necessary to provide information about the PCP1. The only information allowed to differ with the one contained in the ASES records will be the one related to the PCP2.

        

        

        (G) Change of PCP1 and PCP2 (“3”): It
            will be necessary to submit new information regarding the assigned PCP1 and PCP2. The information provided regarding the other fields should remain unchanged.

        

        

        
          
            	

                  	3.	
                    PROCESS_DATE–Process Date. Refers to the date on which the enrollee contracted
                        the coverage services with the corresponding Contractor. It also refers to the date on which the Contractor processed a change in PMG, Plan Version, Plan Type or PCP.

                  


          

        

        

        

        
          
            	

                  	4.	
                    REGION–Contains
                          the region code assigned by ASES. This code must correspond to the region assigned to the enrollee in the ASES database considering the physical address. The region code is used only to facilitate the daily run processes,
                        premium payments and for reporting purposes. The data will still be divided by region for the daily run files, end of month and premium payment. See Table 4 below for more information about the Region Codes.

                  


             

            

          

        

        
          39

          
            


        

        Table 4: Region Codes

        

        

        	 	
                Region Name

              	 	
                Region Codes

                Used in the

                Data

              
	 	
                North

              	 	
                A

              
	 	
                Metro-North

              	 	
                B

              
	 	
                East

              	 	
                E

              
	 	
                Northeast

              	 	
                F

              
	 	
                San Juan

              	 	
                J

              
	 	
                Southeast

              	 	
                G

              
	 	
                Southwest

              	 	
                S

              
	 	
                Special

              	 	
                P

              
	 	
                West

              	 	
                Z

              


        

        

        
          
            	

                  	5.	
                    CONTRACTOR (carrier) –Two digit Contractor code assigned by ASES to each of
                        the Contractors with the purpose of identification.

                  


          

        

        

        

        
          
            	

                  	6.	
                    MEMBER_PRIMARY_CENTER – PMG code.

                  


          

        

        

        

        
          
            	

                  	7.	
                    FAMILY_ID – Eleven last digits of MPI number assigned by the Medicaid Office.
                        This is the first part of the identifier for the beneficiaries in the ASES database.

                  


          

        

        

        

        
          
            	

                  	8.	
                    MEMBER_SSN - Social Security number of the member. It is required that this
                        number matches with the one for the member in the ASES database.

                  


          

        

        

        

        
          
            	

                  	9.	
                    MEMBER_SUFFIX–Two digit number which identifies a member within a family. This
                        is the second part of the identifier for the beneficiaries in the ASES database.

                  


          

        

        

        

        
          
            	

                  	10.	
                    EFFECTIVE_DATE–Date in which the Contractors start providing coverage for the
                        enrollee under the enrolled Plan or the change for which the enrollment record was submitted becomes effective. This date also refers to the date in which the PMG, PCP or Plan Version change becomes effective.

                  


          

        

        

        

        
          
            	

                  	11.	
                    PLAN_TYPE – Plan Type code that identifies the one under which the member is
                        enrolled.

                  


          

        

        
          

          

        

        
          40

          
            


        

        
          	

                	12.	
                  PLAN_VERSION – Plan version code that identifies the coverage under which the
                      member is enrolled.

                


           

        

        
          
            	

                  	13.	
                    MPI- Master Patient Index. It is a unique number that identifies a member in
                        the ASES and Medicaid Office’s databases.

                  


          

        

        

        

        
          
            	

                  	14.	
                    PCP1–NPI Number. It is used to identify the PCP1 assign or selected by the
                        beneficiaries.

                  


          

        

        

        

        
          
            	

                  	15.	
                    PCP1_EFFECTIVE_DATE–Date in which the PCP1 assignment became effective. If
                        there is a change of PCP1, the initial PCP1 Effective Date will be kept until the Effective Date of the PCP1 Change has been reached.

                  


          

        

        

        

        
          
            	

                  	16.	
                    PCP2– NPI number. It is used to identify the PCP2 selected by the
                        beneficiaries.

                  


          

        

        

        

        
          
            	

                  	17.	
                    PCP2_EFFECTIVE_DATE–Date in which the PCP2 assignment was effective. If there
                        is a change of PCP2, the initial PCP2 Effective Date will be kept until the Effective Date of the PCP2 Change has been reached.

                  


          

        

        

        

        
          
            	

                  	18.	
                    FAMILY PRIMARY CENTER – Not in use.

                  


          

        

        

        

        
          
            	

                  	19.	
                    PMG_eff_date (previous FAMILY_PRIMARY_CENTER_EFF_DATE field) –Date in which
                        the assignment of the enrollee’s PMG became effective. This field is not currently in use.

                  


          

        

        

        

        
          
            	

                  	20.	
                    IPA_PCP_CHANGE_REASON – This field is not currently in use.

                  


          

        

        

        

        
          
            	

                  	21.	
                    MEDICARE INDICATOR – Not in use

                  


          

        

        

        

        
          
            	

                  	22.	
                    HIC NUMBER–MBI number only for dual eligible members.

                  


          

        

        

        

        
          
            	

                  	23.	
                    IPA_ESPECIAL–A code “1” indicates that the member is assigned to a special IPA
                        which is not the family IPA. Used for GHP enrollment.

                  


          

        

        

        

        
          
            	

                  	24.	
                    CONTRACT NUMBER–Contract number assigned by the Contractor. It should be the
                        number by which the member is identified in the Contractors’ ID card and internally in their database.

                  


          

        

        

        

        
          
            	

                  	25.	
                    SPECIAL ENROLL–It is used to identify:

                  


          

        

        
          
             

            

            	

                  	(1)	
                    the enrollment for deemed newborns that are beneficiaries of the Federal
                        Programs by including a letter “N” in the field;

                  


             

            

          

        

        
          41

          
            


        

        
          
            	

                  	(2)	
                    the enrollment for the case when the Medicaid Office sends an eligibility record that is retroactive more than three (3) months from the date in which the record is
                        sent to ASES and therefore to the Contractor by including a letter “E” in the field; and

                  


          

        

        

        

        
          
            	

                  	(3)	
                    the enrollment for a retroactive eligibility period by including a letter “T” in the field.

                  


          

        

         

        

        
          
            	

                  	26.	
                    Other data elements complimented by ASES – When an enrollee’s record is
                        validated, the ASES system enters the following data in the enrollment record:

                  


          

        

        

        

        
          
            	

                  	a.	
                    Reject Identifier - As a result of the validations, the record could be
                        accepted or rejected. This field contains the codes that specify the result of said validation.

                  


          

        

        

        

        “A” = Accepted;

        “M” = Accepted Retroactively;

        “T” = Retroactive Eligibility Period Enrollment

        “R” = Rejected: Will be present only in the .rjc file.

        

        

        Identifier = “A”

        Identifies an accepted enrollment that will be applied on a current or future effective date. In this case, the update process moves
            the enrollment fields of the Contractor, Plan Type, Plan Version, PMG and PCP to the fields intended for new enrollments in the enrollee record. Until such time as the new Effective Date is reached, the enrollee will remain under the current
            enrollment condition (same Contractor, Plan, Version, PMG and PCP). During the end-of-month cycle, the new fields are moved to the current fields and the enrollment becomes effective.

        

        

        Identifier = “M”

        Indicates a retroactive enrollment. In these cases, Enrollment data (Contractor, Plan Type, Plan Version, PMG and PCP) are updated
            directly in the enrollee’s historical record.

        

        

        Identifier = “T”

        It identifies a successfully processed retroactive enrollment.

        

        

        Identifier “R”

        In cases when an enrollment record is not successfully processed because an error has been identified, it indicates a record
            returned for correction.

         

        

        
          
            	

                  	b.	
                    Record Key – Internal number assigned by the ASES system.

                  


          

        

        

        

        
          
            	

                  	c.	
                    Error Codes one (1) to ten (10) – It is possible to record up to ten error
                        codes.

                  


             

            

          

        

        
          42

          
            


        

        
          
            	

                  	27.	
                    Update Date – Date for which the validation is run. Corresponds to the date of
                        the daily cycle the validation run was a part of.

                  


          

        

        

        

        
          
            	

                  	28.	
                    Update User – ASES internal user code.

                  


          

        

        

        

        
          
            	

                  	29.	
                    PMG Tax ID – Include PMG Tax ID

                  


          

        

        

        

        
          
            	

                  	30.	
                    Data Source – Will always contain “MO” to denote the enrollment comes from a
                        Contractor.

                  


          

        

        

        

        Note:

        It is up to the Contractors to process the enrollment records corresponding to the months prior to November 1, 2018 under the region
            model. This includes the retroactive eligibility periods (1,2,3 and late eligibility periods).

        

        

        H.  Rejection of an Enrollment Record

        

        

        An enrollment record related to any type of enrollment, modification
              or update transaction could be rejected if it does not pass the validation tests at the ASES systems. As mentioned above, rejected enrollments are sent daily to
              Contractors in a file (.rjc) that includes error codes for records that have not successfully passed the validation process. Contractors must correct identified errors and resubmit the corrected records to ASES with the next file submission,
              meaning the next business day. For the adequate correction of these errors please refer to the Error Codes Table provided in Section VII.

        

        

        I.   Rejected Enrollment Management

        

        

        The daily process of Contractors in relation to rejected enrollments should include:

        

        

        
          
            	

                  	(1)	
                    Receipt of rejected enrollment records;

                  


          

        

        
          
            	

                  	(2)	
                    Evaluation of rejection codes received;

                  


          

        

        
          
            	

                  	(3)	
                    Identification of situations in which rejection is not clear for consultation
                        with ASES;

                  


          

        

        
          
            	

                  	(4)	
                    Timely correction of identified errors;

                  


          

        

        
          
            	

                  	(5)	
                    Transfer of the corrected records to ASES in a 24 hour period.

                  


             

            

          

        

        
          43

          
            


        

        
          VII. ERROR CODES TABLE
            


        

        

        

        The following table contains the error codes produced by the validation program. Additional descriptions and possible corrective actions have been
            included to assist in the correction process. See Attachment 9 Error Codes Table.

        

        

        
          VIII. GHP DISENROLLMENT (CANCELLATION/TERMINATION OF ELIGIBILITY)
            


           

            

        

        A.  Disenrollment from the GHP

        

        

        The process of a disenrollment from the GHP occurs when the Medicaid Office determines that an enrollee is no longer eligible for
            GHP.

         

        

        A GHP disenrollment occurs when the Medicaid Office determines that (1) an enrollee has lost eligibility to receive medical services
            coverage under the GHP; (2) the eligibility period granted by the Medicaid Office has expired and other reasons specified in Table 5 below:

        

        

        Table 5: Cancellations Code & Cases
                Description

        

        

        	
                Cancellation Code

              	
                Cancellation Description

              
	
                ‘ ‘

              	
                Not Cancelled

              
	
                06

              	
                Change in Family Composition

              
	
                07

              	
                Income Changes

              
	
                08

              	
                Death of the enrollee

              
	
                09

              	
                Moving Out of State

              
	
                10

              	
                Incarceration of the enrollee

              
	
                13

              	
                Enrollee Found Not Eligible

              
	
                30

              	
                Other Reasons

              
	
                31

              	
                Voluntary Closing

              


        

        

        Medicaid will notify the eligibility cancellation to ASES, and ASES will notify the Contractor of the cancellation. Such
            notification shall be effectuated by means of a daily transfer of the daily process Export (.exp) files to the Contractor together with records containing information on new beneficiaries to be enrolled. A letter “I” in the Tran_Id field
            identifies the cancellation records in the daily process Export (.exp) files. This will be done within five (5) calendar days after a final determination on the eligibility cancellation.

        

        

        
          44

          
            


        

        B.  GHP Disenrollment Effective Date

        

        

        The Medicaid Office is the only institution authorized to
            perform the disenrollment of the eligibility of an enrollee. This date is indicated by Medicaid in the Medicaid Cancellation Date field.

         

        

        Cancellations may be received any day of the month. Hence, these cancellations should have a value in the field
            Medicaid_Cancellation_Date.

        

        

        the The effective date of such cancellations
            will be determined by the Medicaid Office and expressed in the Medicaid Cancellation Date field. For said reason cancellations received any day of the month should have a value in the field Medicaid_Cancellation_Date.

        

        

        
          IX. CONTRACTOR DISENROLLMENT
            


        

        

        

        A.  Disenrollment from the Contractor

        

        

        The process of a disenrollment from a Contractor occurs when a disenrollment from the plan is requested by the Contractor or the Enrollee and has been approved by ASES.

        

        

        A Contractor disenrollment occurs when a request for re-enrollment has been received from an Enrollee or a Contractor as set forth
            in Sections 5.3.4 of Contract.

        

        

        B.  Disenrollment Initiated by the Enrollee

        

        

        All Enrollees must be notified at least annually of their disenrollment rights as set forth in Section 5.3 of the Contract and 42
            CFR 438.56. Such notification must clearly explain the process for exercising this disenrollment right, as well as the coverage alternatives available to the Enrollee based on their specific circumstance.

        

        

        An Enrollee wishing to request Disenrollment must submit an oral or written request to ASES or to the Contractor. If the request is
            made to the Contractor, the Contractor shall forward the request to ASES, within five (5) Business Days of receipt of the request, with a recommendation of the action to be taken.

        

        

        An Enrollee may request Disenrollment from the Contractor’s Plan without cause once during the applicable Open Enrollment Period in
            accordance with Section 5.2.5.

        

        

        An Enrollee may request Disenrollment from the Contractor’s Plan for cause at any time, pursuant to Section 5.3.5.4 of the Contract.

         

          

        
          45

          
            


        

        In these cases in which the Enrollee changes contractors, the Contractor that loses the Enrollee will be required to complete the
            transfer of said Enrollee by completing the information asked for in Attachment 9 Member History Move Input File Layout and Attachment 9 MCO Change Transfer Member Information File Layout within the applicable timeframes. For the moment, the
            layouts should be submitted before the date in which the Enrollment Date becomes Effective.

         

          

        
          46

          
            


        

        C.  Effective Date of Temporary Payment Suspension

        

        

        For programmatic purposes of the ASES Information Systems Office, this Effective Date of Temporary Payment Suspension refers to the
            day on which premium payments are suspended for an Enrollee. This temporary suspension takes place in those cases in which the Medicaid Office has sent a change of coverage code for an Enrollee and the Contractor has not submitted an enrollment
            with the new plan version related to the change of coverage. This occurs during the end of month processes. During this process the Card Issue Date field is left blank but the enrollee keeps being eligible and enrolled with the Contractor.

        

        

        Although in cases of Temporary Payment Suspension the eligibility period will continue for the beneficiaries on behalf of whom the
            Medicaid Office has sent a change of coverage code for an enrollee and the Contractor has not submitted an enrollment with the new plan version related to the change of coverage, the premium payment cannot be processed until a new enrollee
            enrollment is sent by the Contractor with the information of the new plan version related to the change of coverage. Once the new plan version is received, premium payments will resume, subject to section 5.3.10 of the Contract.

        

        

        
          X. CONTRACTORS RESPONSIBILITIES IN THE ENROLLMENT PROCESS

        

        
          
 

         

          

        In summary, as part of the enrollment process, it will be the responsibility of the Contractors to ensure compliance with the duties described in Table
            6 below.

         

        

        Table 6: Enrollment Transaction Contractors
                Responsibilities

        

        

        	 	
                Change or Modification

              	 	 	
                Action Required

              	 
	 	
                1. Transfer of Daily Eligibility Files.

              	 	 	
                Daily Update of Eligibility Files in the Contractor’s databases.

              	 
	 	
                2. New Enrollments.

              	 	 	
                GHP Contractors should start the enrollment process with the enrollee and verify each of the enrollments made including the enrollment of
                    newborns (N) and late eligibility cases. They must also enroll beneficiaries who have an Effective Date prior to a cancellation period.

              	 
	 	
                3. Contractor Change.

              	 	 	
                When an enrollee requests a Contractor change through Medicaid, ASES or the Counselor, the ASES system will produce update record containing
                    the new Contractor and that record will be sent to both the new and the previous Contractor.

                 

                  

                The previous Contractor should disaffiliate the member in its databases, and the new Contractor should perform the PMG/PCP Auto Assignment and
                    the enrollment process with ASES.

              	 


        

        

        
          47

          
            


        

        	 	
                4. Changes to the enrollment data. (Change of Plan Version, PMG and/or PCP).

              	 	 	
                Identify beneficiaries who have changed Plan Version, PMG and/or PCP (1 or 2) and notify these changes. The Contractor’s system must be updated
                    in accordance with these modifications as failure to do so may lead to the rejection of the enrollment record in future transactions or to the Disenrollment of the enrollee from the Contractor during the end of month processes.

              	 
	 	
                5. Change in the demographic data of a enrollee. This information is received from the Medicaid Office but does not cause a change in the
                    enrollment.

              	 	 	
                The Contractor must update the enrollee’s record with the new data in its database. If the enrollee informs the Contractor of an address and/or
                    phone change, a recommendation should be made to the enrollee to notify of the change to the Medicaid Office in order to keep the data up to date.

              	 
	 	
                6. Rejected Records

              	 	 	
                Correct the rejected records and resend them to ASES.

              	 
	 	
                7. Cancellation of Enrollee:

                Only the Medicaid Office may cancel the eligibility of an enrollee, having the effect that until such notice of Medicaid is received the
                    enrollee will remain active in the databases of both ASES and the Contractors even when the period of eligibility granted has expired.

              	 	 	
                Identify the cases of beneficiaries with canceled or denied coverage and take action about these, as they are the only beneficiaries to whom
                    services may be denied.

              	 
	 	
                8. Temporary Suspension

              	 	 	
                Contractors should identify when a record received has a different coverage code than is recorded in their databases. In these cases,
                    Contractors must assess whether the new coverage code requires the enrollee to be enrolled in a different “Plan Version”. If so, they must re-enroll these beneficiaries under the new “Plan Version” to correspond with the new coverage
                    code. Subsequently, a change of “Plan Version” must be sent to ASES before the end of the current month.

                Beneficiaries who are not registered with a “Plan Version” that corresponds with the coverage code will be temporarily suspended from premium
                    payments (blanks will be included in the Card Issue Date field) until corrected, subject to Section 5.3.10.

              	 


        

        

        
          XI. PREMIUM PAYMENTS
            


        

        

        

        The premium payment system operates under the concept that premiums are calculated and paid only in relation to beneficiaries who are already enrolled
            before the first day of the month to which the payment corresponds. Beneficiaries enrolled after that date will be considered for the next payment of the corresponding premium.

        

        

        On a monthly basis, the system performs an automatic execution of payment in which the payment that corresponds to each one of the Contractors is
            calculated using the Member Assigned Rate Cell ID as described in Table 7 below according to the beneficiaries that are enrolled in the ASES databases.

         

          

        
          48

          
            


        

        Table 7: Rate Cells

        

        

        	
                RateCellsId

              	 	 	
                RateCellsDec

              	 	
                PC_pop

              	 	
                HCHN_Flag

              
	
                01

              	 	 	
                Under 1

              	 	
                CHIP

              	 	
                N

              
	
                02

              	 	 	
                Age 1-6

              	 	
                CHIP

              	 	
                N

              
	
                03

              	 	 	
                Age 7-13

              	 	
                CHIP

              	 	
                N

              
	
                04

              	 	 	
                Age 14+

              	 	
                CHIP

              	 	
                N

              
	
                05

              	 	 	
                Diabetes

              	 	
                CHIP

              	 	
                Y

              
	
                06

              	 	 	
                Pulmonary

              	 	
                CHIP

              	 	
                Y

              
	
                07

              	 	 	
                Under 1

              	 	
                Commonwealth

              	 	
                N

              
	
                08

              	 	 	
                Age 1-6

              	 	
                Commonwealth

              	 	
                N

              
	
                09

              	 	 	
                Age 7-13

              	 	
                Commonwealth

              	 	
                N

              
	
                10

              	 	 	
                Cancer

              	 	
                Commonwealth

              	 	
                Y

              
	
                11

              	 	 	
                Diabetes/Low Cardio

              	 	
                Commonwealth

              	 	
                Y

              
	
                12

              	 	 	
                Female 14-18

              	 	
                Commonwealth

              	 	
                N

              
	
                13

              	 	 	
                Female 19-44

              	 	
                Commonwealth

              	 	
                N

              
	
                14

              	 	 	
                Female 45+

              	 	
                Commonwealth

              	 	
                N

              
	
                15

              	 	 	
                High Cardio

              	 	
                Commonwealth

              	 	
                Y

              
	
                16

              	 	 	
                Male 14-18

              	 	
                Commonwealth

              	 	
                N

              
	
                17

              	 	 	
                Male 19-44

              	 	
                Commonwealth

              	 	
                N

              
	
                18

              	 	 	
                Male 45+

              	 	
                Commonwealth

              	 	
                N

              
	
                19

              	 	 	
                Pulmonary

              	 	
                Commonwealth

              	 	
                Y

              
	
                20

              	 	 	
                Renal

              	 	
                Commonwealth

              	 	
                Y

              
	
                21

              	 	 	
                Part A Only

              	 	
                Dual Eligible

              	 	
                N

              
	
                22

              	 	 	
                Part A and B

              	 	
                Dual Eligible

              	 	
                N

              
	
                23

              	 	 	
                All

              	 	
                Foster Child/Domestic Abuse

              	 	
                N

              
	
                24

              	 	 	
                Under 1

              	 	
                Medicaid

              	 	
                N

              
	
                25

              	 	 	
                Age 1-6

              	 	
                Medicaid

              	 	
                N

              
	
                26

              	 	 	
                Age 7-13

              	 	
                Medicaid

              	 	
                N

              
	
                27

              	 	 	
                Cancer

              	 	
                Medicaid

              	 	
                Y

              
	
                28

              	 	 	
                Diabetes/Low Cardio

              	 	
                Medicaid

              	 	
                Y

              
	
                29

              	 	 	
                Female 14-18

              	 	
                Medicaid

              	 	
                N

              
	
                30

              	 	 	
                Female 19-44

              	 	
                Medicaid

              	 	
                N

              
	
                31

              	 	 	
                Female 45+

              	 	
                Medicaid

              	 	
                N

              
	
                32

              	 	 	
                High Cardio

              	 	
                Medicaid

              	 	
                Y

              
	
                33

              	 	 	
                Male 14-18

              	 	
                Medicaid

              	 	
                N

              
	
                34

              	 	 	
                Male 19-44

              	 	
                Medicaid

              	 	
                N

              
	
                35

              	 	 	
                Male 45+

              	 	
                Medicaid

              	 	
                N

              
	
                36

              	 	 	
                Pulmonary

              	 	
                Medicaid

              	 	
                Y

              
	
                37

              	 	 	
                Renal

              	 	
                Medicaid

              	 	
                Y

              
	
                38

              	 	 	
                EAP

              	 	
                Medicaid/Commonwealth

              	 	
                N

              
	
                39

              	 	 	
                Maternity Delivery Kick Payment

              	 	
                Medicaid/Commonwealth/CHIP

              	 	
                N

              


        

        

        
          49

          
            


        

        The premium paid for each enrollee will depend on his or her rate cell classification. ASES actuaries are responsible for providing the definition and the methodology for the application of the rate cells. Among the rate cells, they also differentiate twelve (12) of them
              which identify beneficiaries who are patients with complex and costly care needs suffering from chronic diseases or special limitations. These beneficiaries constitute a population known as the High Cost High Need (HCHN) population. In Table
              7, the HCHN rate cells are the ones with a RateCellID that forms part of the following list: 05, 06, 10, 11, 15, 19, 20, 27, 28, 32, 36, 37.

         

        

        Rate Cells updates will be performed on a monthly basis during the End of Month processes and will be notified through the .cncl files. These updates
            will be effective as of the first day of the following month and will be used for the payments corresponding to that month onwards.

        

        

        Premium payments will be made on the first day of the month following the acceptance of the enrollment record by ASES. ASES is not obligated to pay
            premiums for beneficiaries who are not duly enrolled according to ASES’s databases nor for beneficiaries whose records contain transactions that have been rejected in the ASES databases and have not been corrected within the periods established
            by contract.

        

        

        The payment system calculates several payment categories as listed below:

        

        

        A. Types of Payments

        

        

        
          
            
              
                	 	
                        1.

                      	
                        Monthly Payments

                      


              

            

          

        

        

        

        In this case the system produces a payment for those beneficiaries whose enrollment has already taken effect before the first day
            of the month for which the payment transaction is executed. The execution of premium payment is run on the first day of the month.

        

        

        
          
            	

                  	2.	
                    Prorated Payments

                  


          

        

        

        

        Prorated payments are usually calculated for beneficiaries of the GHP funded solely through state funds (State) who have been
            enrolled at some point in a month prior to the month in which the premium payments are to be made. The payment in these cases will satisfy a portion of the month and not a month in its entirety. Under the state-funded GHP a daily prorated
            premium is calculated for the first premium payment from the certification date of the enrollment that falls on that previous month. In contrast, with the federal population the first premium payment is effectuated for the entire month in which
            the enrollee is eligible.

         

          

        
          50

          
            


        

        However, prorated payments are generated for all of the
            beneficiaries that Medicaid cancels during the month for different reasons. In these cases, as the payment would have been done already in advance, an adjustment would be done according to the cancellation date provided by Medicaid. Also,
            newborns that are not classified as deemed newborns and that are evaluated as any other federal member will have prorated payments for the first month from the date of birth.

        

        

        Other reason for prorate payment are the special adjustment for deceased, cancelation during the month. (e.g. PARIS file members
            matched, volunteers, etc.)

        

        

        
          
            	

                  	3.	
                    Retroactive Payments

                  


          

        

        

        

        These payments are calculated when the Effective Date of the Enrollment falls on a period prior to the month for which the premium
            payment process is being executed. In other words, this type of payment is executed when payments are identified corresponding to months prior to the month in which a premium payment is made. The retroactive payments will be computed based on
            the Enrollment Effective Date. The system will process the premiums for enrolled beneficiaries with an Effective Date prior to the payment date in the case of monthly premiums or prorated premiums that have not been previously paid within the
            time limits for retroactive payments. Retroactive payments may result in an adjusted payment if they are the result of a Contractor’s cancellation of a previous enrollment or Contractor change.

        

        

        Premiums are paid retroactively when a Contractor has submitted a late enrollment. Late enrollments could be produced for any of
            the following reasons: (1) the enrollee has been identified as a deemed newborn (in the second letter of the group code =’N); (2) Medicaid has provided a late eligibility record (3) processing of the records rejected by the ASES System for any
            of the reasons described in the Table of Errors. Refer to Attachment 9 Enrollment Error Codes.

        

        

        Deemed Newborns born to a Medicaid-eligible mother shall be provided coverage from the date of birth. The Medicaid identification
            number of the mother serves as the child’s identification number, and all claims for covered services provided to the child may be submitted and paid under such number, unless and until the child is certified eligible by the Medicaid Office.
            Babies identified as deemed newborns must be identified with the letter ‘N’ in the special enroll field provided in the enrollment record.

        

        

        The Medicaid Late Eligibility Cases are the cases that the Medicaid office sent late (with more than three (3) months from the
            date of the certification) for a variety of reasons. These cases must be identified by the Contractor in the enrollment record with the letter ‘E’ in the special_enroll field.

         

          

        
          51

          
            


        

        Correction of Enrollment Errors: these are the cases in which the Contractors have to correct, repeatedly, the enrollment records
            that have been rejected by the ASES system. These records must be corrected in a maximum period of 2 business days.

        

        

        
          
            	

                  	4.	
                    Prorated Retroactive Payments

                  


          

        

        

        

        The prorated retroactive payments are calculated taking into consideration the cases in which the Enrollment Effective Date falls
            on the first month considered for a retroactive payment. These are partial payments of the first month of the eligibility period of beneficiaries. These type of payments are used for GHP State funded State beneficiaries, deemed newborns and
            newborns.

        

        

        
          
            	

                  	5.	
                    Adjustments

                  


          

        

        

        

        A payment adjustment is calculated when there is a need to reverse a payment that was awarded to a Contractor during a previous
            premium payment process. It occurs when, as a result of a retroactive payment calculation, a payment made in relation to the same enrollee is identified within the same period that has been effected under a Contractor change or Plan Version
            change. The adjustments are calculated for those cases where an enrollee changes Contractor and the Contractor executed a late enrollment after ASES had disbursed payment to the first Contractor in a previous payment transaction. In these cases
            an adjustment of premium paid to the first Contractor is made.

        

        

        
          
            	

                  	6.	
                    Special Adjustments

                  


          

        

        

        

        Generally, the special adjustments are carried out as a result of internal audit processes that reveal that a wrongly adjudicated
            payment (like for example, deceased beneficiaries, duplicate payments, PARIS eligibility match, etc.) must be reverted or that, on the contrary, an omitted payment must be adjudicated. For this type of adjustment, the Contractor will receive a list of transactions in which they can identify the type of adjustment (for example: a deceased), the adjusted months and the amount adjusted. The description of this list is found in Attachment 9, Special Adjustment File Layout.

        

        

        
          	
                  Special audit adjustment file [prempay_adj_CC_all_MMDDYYYY.txt]

                
	
                  a. prempay_adj = Premium Payment special adjustment

                
	
                  c. CC = Contractor code

                
	
                  d. all = all regions

                
	
                  d. MM = Month

                
	
                  e. DD = Day (always 01)

                
	
                  f. YY = Year

                
	
                  g. .txt = text file created monthly base like premium payment process

                
	
                  Note: Attachment 9, Special Adjustment File
                        Layout

                


        

         

        

        
          52

          
            


        

        B.  ASES Reasons for not Executing a Premium Payment

        

        

        A premium payment will not be executed in favor of a Contractor in the following circumstances:

        

        

        
          
            	

                  	(1)	
                    If the enrollee is not enrolled in the ASES databases before the first day of the month for which the payment transaction is being executed;

                  


          

        

        
          
            	

                  	(2)	
                    If the enrollment had been rejected by ASES and a new enrollment was not submitted by the Contractor with the relevant corrections

                  


          

        

        
          
            	

                  	(3)	
                    If ASES eligibility data demonstrates that the enrollee had a disenrollment (blank Card Issue Date), eligibility cancellation or changed the Contractor.

                  


          

        

        
          
            	

                  	(4)	
                    If for late enrollment.

                  


          

        

        

        

        C.  EDI 820 Payment File

        

        

        The reconciliation process carried out between ASES and the Contractors in relation to the payment of premiums must take into
            account the content of the EDI 820 files. This file is produced monthly by region, Contractor and Plan Type. It includes details of the types of payment that correspond to each of the beneficiaries assigned to the Contractors contracted for the
            month in question. Refer to Attachment 9, Special Adjustment File Layout.

        

        

        In this file, a distinction is not made about if the payment corresponds to an adjustment from a regular premium payment process or
            a special adjustment. Thus, in cases when special adjustments proceed, ASES will provide a separated file for the special adjustments to the Contractor. The file name is described below.

         

          

        
          	
                  Premium Payment Transactions [PCC0YYMM0000.820]

                
	
                  a. P = Identify Premium Payment

                
	
                  c. CC = Contractor code

                
	
                  d. 9 = Frequency

                
	
                  e. YY = Year

                
	
                  f. MM = Month

                
	
                  g. 0000 = IPA Direct Contract

                
	
                  h. .820 = Indicates that it is a file containing all premium payment transactions processed monthly
                      run.

                
	
                  Note: Attachment 9, Premium Payment Detail 820 File Layout

                


        

        

           

          

           

          

        

        

           

          

           

          

        

        

          

          

          

          

          

        

        
          53

          
            


        

        
          XII. SYSPREM: ENROLLMENT IN HISTORICAL DATA
            


        

        

        

        Generally, enrollments are applied to the current eligibility data contained in the ASES databases. The eligibility period starts from the first
            notification of eligibility in ASES, as the first record received about an enrollee or after a cancellation period in cases of beneficiaries who have been canceled and then re-certified, and extends until a cancellation related to said
            eligibility is received from Medicaid.

        

        

        At any time the status of the Enrollee may change. If the Enrollee’s status changes before a Contractor send an enrollment on time or a record is not
            corrected in a timely manner, the Enrollee’s enrollment data will remain unregistered in the ASES databases, which will prevent the processing of the corresponding premium payment. This is due to the fact that the payment system does not make
            premium payments for beneficiaries who are not enrolled at the moment in which it corresponds to process the premium payment. As an example, in these cases, if an Enrollee is canceled or is enrolled by a second Contractor, the first Contractor
            will be prevented, during the validation phase of the system, from enrolling the enrollee in a period previous to the cancellation or the enrollment from the second Contractor. The main function of SYSPREM will be to allow the registration of
            the Enrollee’s enrollment in historical data in those cases that cannot be processed as current enrollments.

        

        

        A.  SYSPREM Functionality

        

        

        Among the main functions of this system is the identification of enrollment records that are candidates for processing in historical
            data because they are enrollments that do not correspond to a current period of eligibility or current status.

        

        

        B.  Contractors Eligibility File

        

        

        The Contractor’s daily eligibility file will include enrollee information updated in historical data by the SYSPREM subsystem. In
            these transactions, the Tran_id field will contain an “H” to identify the historical data. Contractors must identify this type of transaction without affecting the current data when processing the eligibility file. Once a transaction is
            received, which must be processed through SYSPREM, a process of verification and validation of the information that is contained in the record is carried out. Once the validation tests have been passed, the record, in the database, containing
            the information corresponding to historical transactions is updated. Those records that do not successfully complete the verification processes will be sent in a file of rejected enrollments to the corresponding Contractor for correction.

         

          

        
          54

          
            


        

        The Figure 2 below shows the validation process performed for the purpose of processing a candidate record for SYSPREM.

        

        

        Figure 5: Validation Process under SYSPREM

        

        

        

        

        

        C. Premium Payments for SYSPREM

        

        

        The run for the monthly premium payment will include all SYSPREM records that have been processed during the previous month. The
            payment for these transactions is calculated based on monthly periods from the Enrollment Effective Date of the SYSPREM to:

        

        

        
          
            	

                  	(1)	
                    The month in which the enrollee was enrolled with a different Contractor,

                  


          

        

        
          
            	

                  	(2)	
                    The month in which the enrollee is cancelled or

                  


          

        

        
          
            	

                  	(3)	
                    Until the date of current billing.

                  


             

            

          

        

        
          55

          
            


        

        D. SYSPREM Error Codes

        

        

        The following is a breakdown of the Error Codes that will trigger an evaluation under SYSPREM:

        

        

        Table 8: Primary Error Codes for SYSPREM

        

        

        	 	
                Code

              	 	
                Primary Error Description

              
	 	
                107

              	 	
                Effective Date prior to the current family eligibility period.

              
	 	
                108

              	 	
                Effective date prior to the current enrollee eligibility period.

              
	 	
                280

              	 	
                The family must be eligible in the current eligibility data.

              
	 	
                281

              	 	
                The enrollee must be eligible in the current eligibility data.

              
	 	
                177

              	 	
                Enrolled with another Contractor on or after the effective date.

              


        

        

        Table 9: Secondary Error Codes for SYSPREM

        

        

        	 	
                Code

              	 	
                Secondary Error Description

              
	 	
                083

              	 	
                Social Security Number Not Found.

              
	 	
                093

              	 	
                Suffix not found.

              
	 	
                132

              	 	
                MPI Not Found.

              
	 	
                222

              	 	
                Currently enrolled with the same Contractor

              
	 	
                223

              	 	
                Currently enrolled with another Contractor

              
	 	
                225

              	 	
                Incorrect Social Security Number

              
	 	
                226

              	 	
                Incorrect MPI Number

              
	 	
                22F

              	 	
                Error found in other beneficiaries of the family (GHP).

              


        

        

        The following is a breakdown of the Error Codes that could appear during an evaluation under SYSPREM:

        

        

        Table 10: SYSPREM Error Codes

        

        

        	 	
                Code

              	 	
                New Error Codes Description

              
	 	
                996

              	 	
                Sysprem record successfully inserted in history.

              
	 	
                980

              	 	
                The Process Date of the enrollment record must be greater than the Process Date of the previous enrollment record for the enrollee who appears
                    previously enrolled for the month corresponding to the Effective Date of the enrollment.

              
	 	
                981

              	 	
                The enrollee must not have beneficiaries of his family with errors not acceptable by SYSPREM in the same enrollment file.

              
	 	
                982

              	 	
                The enrollment record must not have an Effective Date prior to 01/01/2006.

              
	 	
                983

              	 	
                Enrolled in history for the Effective Date of the enrollment record.

              
	 	
                984

              	 	
                It is a New Enrollment, the Effective Date is not first of the month and the enrollee is already subscribed in another Contractor at the Effective
                    Date specified.

              
	 	
                985

              	 	
                It is a New Enrollment and the Effective Date should be at least as recent as the enrollee’s Certification Date at the specified Effective Date.

              
	 	
                986

              	 	
                For SYSPREM processing, the Enrollment Effective Date should be before the Effective Date of the current enrolled record at the ASES databases.

              


        

        

        
          56

          
            


        

        In summary, SYSPREM will process and/or enroll transactions in history in those cases in which the enrollment cannot be applied to
            current data or to current periods of eligibility. Some beneficiaries will not appear as enrolled in history because they are not eligible for the Effective Date or because they are enrolled with a different Contractor. Contractors need to
            evaluate the cases rejected by SYSPREM in order to identify errors in the assigned Effective Date and the correctness of the beneficiaries’ data included in the enrollment record.

        

        

        
          XIII. REFERENCES
            


        

        

        

        See Attachment 09

        

        

        
          XIV. APPROVALS
            


        

        

        

        Revision Sheet

        

        

        	
                Project Sponsor:

              	 	 
	

              	 	
                Date

              
	
                Project Manager:

              	 	 
	
                

                

              	 	
                Date

              
	 	 	 
	
                Steering Committee:

              	 	 
	

              	 	
                Date

              
	
                Steering Committee:

              	 	 
	
                

                

              	 	
                Date

              
	
                Steering Committee:

              	 	 
	

              	 	
                Date

              
	
                Steering Committee:

              	 	 
	

              	 	
                Date

              


        

        

        

        

        57

         

      

    

  








  
  
    Attachment 10

    

  

   

    ASES GUIDELINES FOR CO-LOCATION OF BEHAVIORAL HEALTH PROVIDER

    IN PMG SETTINGS

     

      

    Attachment 10

     

      

    VERSION 10.1.18

     

      

    
      1

      
        


    

    

     

        

    ASES GUIDELINES FOR CO-LOCATION OF BEHAVIORAL HEALTH PROVIDER IN PMG SETTINGS

    

    

    In accordance with the provisions of the Puerto Rico Mental Health Code, Law No. 408 of October 2, 2000, as amended, and the Puerto Rico Patient’s Bill of
        Rights and Responsibilities, the Government Health Plan (GHP) is committed to promoting mental and physical health integration, in order to improve program effectiveness and quality of life for enrollees.

    

    

    In developing the full integration of physical and behavioral health, ASES requires placement of a psychologist or other type of Behavioral Health Provider
        in each PMG setting. The Behavioral Health Provider shall be present and available to provide assessment, screening, consultation, and Behavioral Health Services to Enrollees. (Article 8.2.1). Through this model, physicians, behavioral health
        providers and other members of the health team, collaborate in the provision of an integrated care plan to patients. In this context, the communication between physicians and the behavioral health providers is one of the most important step to
        collaboration and integration.

    

    

    Situations that may be address by the behavioral health person, in collaboration with the medical staff, may include, but are not limited to:

    

    

    
      
        	

              	1.	
                Patients with signs of depression or anxiety

              


      

    

    
      
        	

              	2.	
                Patients in the high cost/high needs program

              


      

    

    
      
        	

              	3.	
                Patients with chronic conditions

              


      

    

    
      
        	

              	4.	
                Patients who present problems with adherence to medical treatment

              


      

    

    
      
        	

              	5.	
                Patients with developmental, behavioral, or psychiatric conditions

              


      

    

    
      
        	

              	6.	
                Patients who confront stressful events such as losing a significant other, divorce, caregiving, or others

              


      

    

    
      
        	

              	7.	
                Patients with family, school or work related situational stressors

              


      

    

    
      
        	

              	8.	
                Identification and referral of patients with drugs, alcohol or smoking addictions.

              


      

    

    
      
        	

              	9.	
                Patients referred as high Emergency Room utilizers associated to behavioral health issues.

              


      

    

    
      
        	

              	10.	
                Patients seeking behavioral services at their own initiative

              


      

    

    
      
        	

              	11.	
                Education to patients, community or staff

              


      

    

    

    

    The goal is to achieve better access to care and cost containment, while considering people’s health as a whole. The GHP health care collaborative and
        integrated strategy for physical and behavioral services provides a mean to open communication channels to achieve better access and more focused and cost effective services.

    

    

    The following guidelines are intended to clarify and adequately monitor compliance with the Co-Location requirements. These guidelines seek to ensure
        access to services and adequate communication between professionals.

    

    

    Required Co-Location of Staff per PMG Setting: In view of the different kinds of PMG Settings and particularly, the different number of beneficiaries served, ASES has design the following table detailing the
        minimum required weekly hours of mental health professional availability according to the number of beneficiaries served by the PMG. Total Behavioral Health Provider hours will be determine by the number of PSG beneficiaries attached to the PMG
        regardless of the MCO selected by the beneficiary.

     

        

    
      2

      
        


    

    	 	
            Covered Beneficiaries per PMG

            Setting

          	 	
            Minimum

            Behavioral Health

            Colocation weekly

            Hours Required

          
	 	
            1,000 or less

          	 	
            4 hours

          
	 	
            1,001 – 2,000

          	 	
            8 hrs.

          
	 	
            2,001 – 3,000

          	 	
            12 hrs.

          
	 	
            3,001 – 4,000

          	 	
            16 hrs.

          
	 	
            4,001- 5,000

          	 	
            20 hrs.

          
	 	
            5,001 – 6,000

          	 	
            24 hrs.

          
	 	
            6,001 – 7,000

          	 	
            28 hrs.

          
	 	
            7,001 – 8,000

          	 	
            32 hrs.

          
	 	
            8,001 – 9,000

          	 	
            36 hrs.

          
	 	
            9,001 – 10,000

          	 	
            40 hrs.

          


    

    

    A corrective action plan (“CAP”) will be required of every PMG Setting that does not comply with the required co-location level. The PMG must present the
        CAP to the corresponding Entity within seven (7) calendar days from the receipt of the notice of the need for corrective action. The Entity will evaluate and approve or deny the CAP within seven (7) calendar days from the day such CAP is received.
        All PMGs with an approved CAP must comply with the terms of the CAP and achieve the required co-location within the timeframes established in the CAP.

    

    

    Sanction Matrix. In the event that a PMG does not comply with the required
        co-location levels in any of its PMG settings, the PMG may be subject to penalties according to the following matrix:

    

    

    	 	
            Sanction

            Level

          	 	
            Sanction Type

          	 	
            Timeframe

            to cure

          	 	
            Comments

             

          
	 	
            0

          	 	
            Notice of Non Compliance

            with Colocation Level

          	 	
            30 days

            Day 1-30

          	 	
            A Corrective Action Plan is

            required

          
	 	
            1

          	 	
            New members subscription

            Hold

          	 	
            30 days

            Day 31-60

          	 	 
	 	
            2

          	 	
            PM/PM payment withhold

            and new member

            subscription

          	 	
            30 days

            Day 61-90

             

          	 	
            A Standard $1.50 PM/PM payment

            withhold

          
	 	
            3

          	 	
            Fine

          	 	
            15 days

            Day 91-105

          	 	
            Fines to be defined in accordance

            to contract

          
	 	
            4

          	 	
            PMG Contract Cancelation

          	 	
            Day 106

          	 	 


    

    

    

    

     

    3

  








  
    Attachment 11

    

  

   

  

  
    	
            Administracion de Seguros de Salud

             

              

            November 1, 2018 to September 30, 2019

             

              

            PSG (MI Salud) PMPM Premium Rates

          


  

  
    	
            Rate Cell

          	 	
            PMPM Premium Rate

          	 
	
            Medicaid Pulmonary

          	 	
            $

          	
            208.27

          	 
	
            Medicaid Diabetes or Low Cardio

          	 	
            $

          	
            322.97

          	 
	
            Medicaid High Cardio

          	 	
            $

          	
            704.54

          	 
	
            Medicaid Renal

          	 	
            $

          	
            1,471.71

          	 
	
            Medicaid Cancer

          	 	
            $

          	
            1,688.77

          	 
	
            Medicaid Male 45+

          	 	
            $

          	
            120.77

          	 
	
            Medicaid Male 19-44

          	 	
            $

          	
            87.44

          	 
	
            Medicaid Male 14-18

          	 	
            $

          	
            72.98

          	 
	
            Medicaid Female 45+

          	 	
            $

          	
            157.42

          	 
	
            Medicaid Female 19-44

          	 	
            $

          	
            108.21

          	 
	
            Medicaid Female 14-18

          	 	
            $

          	
            83.30

          	 
	
            Medicaid Age 7-13

          	 	
            $

          	
            75.25

          	 
	
            Medicaid Age 1-6

          	 	
            $

          	
            87.48

          	 
	
            Medicaid Under 1

          	 	
            $

          	
            249.25

          	 
	
            Commonwealth Pulmonary

          	 	
            $

          	
            137.49

          	 
	
            Commonwealth Diabetes or Low Cardio

          	 	
            $

          	
            173.79

          	 
	
            Commonwealth High Cardio

          	 	
            $

          	
            375.75

          	 
	
            Commonwealth Renal

          	 	
            $

          	
            607.43

          	 
	
            Commonwealth Cancer

          	 	
            $

          	
            1,250.44

          	 
	
            Commonwealth Male 45+

          	 	
            $

          	
            66.88

          	 
	
            Commonwealth Male 19-44

          	 	
            $

          	
            47.59

          	 
	
            Commonwealth Male 14-18

          	 	
            $

          	
            45.49

          	 
	
            Commonwealth Female 45+

          	 	
            $

          	
            94.63

          	 
	
            Commonwealth Female 19-44

          	 	
            $

          	
            76.24

          	 
	
            Commonwealth Female 14-18

          	 	
            $

          	
            56.54

          	 
	
            Commonwealth Age 7-13

          	 	
            $

          	
            61.58

          	 
	
            Commonwealth Age 1-6

          	 	
            $

          	
            69.21

          	 
	
            Commonwealth Under 1

          	 	
            $

          	
            260.25

          	 
	
            CHIP Pulmonary

          	 	
            $

          	
            191.68

          	 
	
            CHIP Diabetes

          	 	
            $

          	
            503.89

          	 
	
            CHIP Age 7-13

          	 	
            $

          	
            68.46

          	 
	
            CHIP Age 14+

          	 	
            $

          	
            63.08

          	 
	
            CHIP Age 1-6

          	 	
            $

          	
            91.16

          	 
	
            CHIP Under 1

          	 	
            $

          	
            256.09

          	 
	
            Dual Eligible Part A and B

          	 	
            $

          	
            740.27

          	 
	
            Dual Eligible Part A Only

          	 	
            $

          	
            299.62

          	 
	
            Maternity Delivery Kick Payment

          	 	
            $

          	
            4,641.59

          	 


     

    

     

    

     

  








  
    Attachment 12

    

  

   

  

  
    Attachment 12 - Deliverables

    

    

    
      
        	

              	·	
                All deliverables and documents submitted in accordance with Attachment 12 must be submitted in English.

              


      

    

    
      
        	

              	·	
                Deliverables included in this list as well as other documents are subject to ASES review in accordance with this Contract, will be due to ASES in accordance with the
                    deadlines established in the request for information and readiness schedule established by ASES.

              


      

    

    

    

    	 	 	
            Deliverable Name

          	 	
            Contract

            Citation(s)

          	 	
            Initial Due

            Date

          	 	
            Submission

            Frequency

          
	
            1

          	 	
            Notice of Enrollment

          	 	
            5.2.5.3, 6.2.4.3

          	 	
            8/13/2018

          	 	
            Once

          
	
            2

          	 	
            Newborn Enrollment packet

          	 	
            5.2.6.2

          	 	
            8/20/2018

          	 	
            Once

          
	
            3

          	 	
            Newborn notification form

          	 	
            5.2.6.5

          	 	
            8/13/2018

          	 	
            Once

          
	
            4

          	 	
            Website Screen Access

          	 	
            6.10.5

          	 	
            8/20/2018

          	 	
            Once

          
	
            5

          	 	
            Cultural Competency plan

          	 	
            6.11.2

          	 	
            8/20/2018

          	 	
            Annually

          
	
            6

          	 	
            Marketing plan

          	 	
            6.15.6

          	 	
            8/13/2018

          	 	
            Annually

          
	
            7

          	 	
            Marketing Materials

          	 	
            6.15.6

          	 	
            8/13/2018

          	 	
            Quarterly

          
	
            8

          	 	
            Provider Marketing Materials

          	 	
            6.15.7

          	 	
            8/13/2018

          	 	
            Quarterly

          
	
            9

          	 	
            Enrollee Handbook

          	 	
            6.2.1, 6.4

          	 	
            8/20/2018

          	 	
            Once

          
	
            10

          	 	
            Provider Directory

          	 	
            6.2.1, 6.6

          	 	
            8/13/2018

          	 	
            Quarterly

          
	
            11

          	 	
            Enrollee ID Card

          	 	
            6.2.1, 6.8.1

          	 	
            8/13/2018

          	 	
            Once

          
	
            12

          	 	
            Redetermination Notices

          	 	
            6.2.4.3

          	 	
            8/20/2018

          	 	
            Once

          
	
            13

          	 	
            Disenrollment Notices

          	 	
            6.2.4.3

          	 	
            8/20/2018

          	 	
            Once

          
	
            14

          	 	
            Intentionally Left Blank

          	 	 	 	 	 	 
	
            15

          	 	
            Enrollee Handbook Policy, limited to HCHN

          	 	
            6.3.1

          	 	
            8/20/2018

          	 	
            Once

          
	
            16

          	 	
            Member Notices Policy

          	 	
            6.3.1

          	 	
            8/20/2018

          	 	
            Once

          
	
            17

          	 	
            GHP Call Center Policy and Procedures

          	 	
            6.9.10

          	 	
            8/20/2018

          	 	
            Once

          
	
            18

          	 	
            GHP Call Center Quality Standards

          	 	
            6.9.11

          	 	
            8/20/2018

          	 	
            Annually

          
	
            19

          	 	
            GHP Service Line Outreach Program

          	 	
            6.9.13, 6.9.14

          	 	
            8/13/2018

          	 	
            Annually

          
	
            20

          	 	
            GHP Service Line Scripts

          	 	
            6.9.15

          	 	
            8/13/2018

          	 	
            Quarterly

          
	
            21

          	 	
            Pharmacy UM Protocols

          	 	
            7.5.12.16.2

          	 	
            8/13/2018

          	 	
            Once

          
	
            22

          	 	
            Pre-natal and Maternal Program maternal wellness plan

          	 	
            7.5.8.3.2

          	 	
            8/20/2018

          	 	
            Annually

          
	
            23

          	 	
            Special Coverage Identification & Registration Strategy

          	 	
            7.7.6.1

          	 	
            8/13/2018

          	 	
            Once

          
	
            24

          	 	
            Special Coverage Registration Form

          	 	
            7.7.6.2

          	 	
            8/13/2018

          	 	
            Once

          
	
            25

          	 	
            Special Coverage Notification Form (Enrollee & Provider)

          	 	
            7.7.6.3

          	 	
            8/13/2018

          	 	
            Once

          
	
            26

          	 	
            Protocols for the development of a treatment plan

          	 	
            7.7.6.4

          	 	
            8/13/2018

          	 	
            Once

          
	
            27

          	 	
            Provisions for ensuring that Enrollees with Special Coverage have Immediate Access to specialists

          	 	
            7.7.6.5

          	 	
            8/13/2018

          	 	
            Once

          
	
            28

          	 	
            Strategy for identification of individuals with Special Health Care Needs

          	 	
            7.7.6.6

          	 	
            8/13/2018

          	 	
            Annually

          
	
            29

          	 	
            Policies and procedures for Care Management

          	 	
            7.8.2.4

          	 	
            8/13/2018

          	 	
            Once

          
	
            30

          	 	
            EPSDT Plan

          	 	
            7.9.1.2, 7.9.1.4

          	 	
            8/13/2018

          	 	
            Annually

          
	
            31

          	 	
            EPSDT Outreach and education process

          	 	
            7.9.2.1

          	 	
            8/13/2018

          	 	
            Annually

          
	
            32

          	 	
            High-Utilizers Program

          	 	
            7.14

          	 	
            8/20/2018

          	 	
            Annually

          
	
            33

          	 	
            Communication Forms

          	 	
            8.5.2

          	 	
            8/13/2018

          	 	
            Once

          


    

    

    
      
        


    

    
       

      

      	 	 	
              Deliverable Name

            	 	
              Contract

              Citation(s)

            	 	
              Initial Due

              Date

            	 	
              Submission

              Frequency

            


    

    	
            34

          	 	
            Integration Plan

          	 	
            8.8

          	 	
            8/13/2018

          	 	
            Annually

          
	
            35

          	 	
            Provider Network

          	 	
            9.1.1, 9.1.5

          	 	
            8/20/2018

          	 	
            Once

          
	
            36

          	 	
            Credentialing/Re-credentialing

          	 	
            9.2.3.7.1

          	 	
            8/20/2018

          	 	
            Once

          
	
            37

          	 	
            Provider Selection

          	 	
            9.3.1.5.2

          	 	
            8/13/2018

          	 	
            Once

          
	
            38

          	 	
            Screening for Special Health Care Needs

          	 	
            9.5.2.2

          	 	
            8/13/2018

          	 	
            Once

          
	
            39

          	 	
            Provider Hours

          	 	
            9.5.5.4

          	 	
            8/20/2018

          	 	
            Once

          
	
            40

          	 	
            Provider Contracts

          	 	
            10.1.6.1

          	 	
            8/13/2018

          	 	
            Once

          
	
            41

          	 	
            Provider Guidelines

          	 	
            10.2.1.3

          	 	
            8/20/2018

          	 	
            Annually

          
	
            42

          	 	
            Provider Communications Strategy

          	 	
            10.2.1.6

          	 	
            8/20/2018

          	 	
            Once

          
	
            43

          	 	
            Provider Education

          	 	
            10.2.2

          	 	
            8/20/2018

          	 	
            Annually

          
	
            44

          	 	
            Physician Incentives

          	 	
            10.7.1

          	 	
            8/20/2018

          	 	
            Annually

          
	
            45

          	 	
            UM Policies and Procedures

          	 	
            11.2.2

          	 	
            8/20/2018

          	 	
            Once

          
	
            46

          	 	
            Utilization Management clinical criteria to be used for services requiring Prior Authorization

          	 	
            11.4.3

          	 	
            8/20/2018

          	 	
            Annually

          
	
            47

          	 	
            Referral Process

          	 	
            11.5.2

          	 	
            8/20/2018

          	 	
            Once

          
	
            48

          	 	
            QAPI program

          	 	
            12.2.4

          	 	
            8/20/2018

          	 	
            Annually

          
	
            49

          	 	
            Wellness Plan

          	 	
            12.5.5.4

          	 	
            8/20/2018

          	 	
            Annually

          
	
            50

          	 	
            Fraud, Waste, and Abuse policies and procedures

          	 	
            13.1.6

          	 	
            8/20/2018

          	 	
            Once

          
	
            51

          	 	
            Compliance plan

          	 	
            13.1.6, 13.2.1

          	 	
            8/20/2018

          	 	
            Annually

          
	
            52

          	 	
            Program Integrity Plan

          	 	
            13.1.6, 13.3

          	 	
            8/20/2018

          	 	
            Annually

          
	
            53

          	 	
            Service Verification Sampling Methodology

          	 	
            13.6.2

          	 	
            8/20/2018

          	 	
            Annually

          
	
            54

          	 	
            Grievance and Appeal System forms

          	 	
            14.1.12

          	 	
            8/20/2018

          	 	
            Once

          
	
            55

          	 	
            Grievance and Appeals Policies

          	 	
            14.1.4

          	 	
            8/20/2018

          	 	
            Once

          
	
            56

          	 	
            Notice of the disposition of the Grievance

          	 	
            14.3.8

          	 	
            8/20/2018

          	 	
            Once

          
	
            57

          	 	
            Notice of Adverse Benefit Determination

          	 	
            14.4.6

          	 	
            8/20/2018

          	 	
            Once

          
	
            58

          	 	
            Notice of Disposition of an Appeal

          	 	
            14.5.18

          	 	
            8/20/2018

          	 	
            Once

          
	
            59

          	 	
            Staff training plan and a current organizational chart

          	 	
            15.3.2

          	 	
            8/20/2018

          	 	
            Annually

          
	
            60

          	 	
            Implementation plan

          	 	
            15.5.1

          	 	
            8/13/2018

          	 	
            Once

          
	
            61

          	 	
            Payment schedule

          	 	
            16.2.1

          	 	
            8/13/2018

          	 	
            Once

          
	
            62

          	 	
            Business Continuity & Disaster Recovery Test Report

          	 	
            18.2.8.2

          	 	
            8/20/2018

          	 	
            Annually

          
	
            63

          	 	
            Certified Public Accountant Solvency Info

          	 	
            23.2.3

          	 	
            8/13/2018

          	 	
            Annually

          
	
            64

          	 	
            Plan for Routine Audits

          	 	
            23.4.1.9

          	 	
            8/20/2018

          	 	
            Once

          
	
            65

          	 	
            Copy of its insurance license

          	 	
            31.1

          	 	
            8/13/2018

          	 	
            Once

          
	
            66

          	 	
            Record Retention

          	 	
            34.1.6

          	 	
            8/20/2018

          	 	
            Once

          


    

    

    

    

     

  








  
    
      
        
          
            Attachment 13

             

            

          

          
            [CERTIFIED TRANSLATION]

            ATTACHMENT 13

          

          
            
               

              

            

          

        

        
          This Attachment contains Normative Letters referenced throughout the Contract. It is not an exhaustive list of all ASES Normative Letters. Contractor
              must abide by all ASES Normative Letters, regardless of whether they are included in this Attachment.

           

            

          
            
              


          

        

        
          [CERTIFIED TRANSLATION]

           

          

        

        	
                
                  

                

              	 	
                
                  GOVERNMENT OF PUERTO RICO

                  Health Insurance Administration

                

              	
                
                  Hon. Ricardo A. Rosselló Neváres

                  Governor

                   

                  Ms. Angela M. Avila Marrero

                  Executive Director

                

              


        
          

          

          October 20, 2017

        

        
          

          

          TO ALL UNIONS AND LABOR ORGANIZATIONS THAT PROVIDE HEALTH INSURANCE BENEFITS TO THEIR MEMBERS PURSUANT TO PUBLIC LAW NO. 158-2006

          

          

          Greetings. The Health Insurance Administration (ASES, Spanish acronym) is the agency authorized pursuant to Public Law No. 95-1963, as amended, to
              regulate, oversee, negotiate, and contract with the health insurance plans that are selected by public employees through their employer contribution, as per the provisions of the referenced Public Law No. 95. Public Law No. 158-2006 is an
              amendment to Public Law 95 that allows unions that are duly established in accordance with Public Law No. 45 to negotiate and contract health insurance benefits for their members. Public Law No. 158 does not, however, establish its own work
              calendar, and is thus subject to the calendar established by ASES for the processes of Public Law No. 95.

          

          

          In contract year 2018, the ASES was in the Request for Proposals (RFP) process whereby the insurance entities that would offer the benefit of health
              insurance to this population starting on January 1, 2018 would be chosen. However, in light of the catastrophe created by hurricanes Irma and María in Puerto Rico, it was impossible to comply with the work calendar established for this
              purpose.

          

          

          For this reason, and in order for the population covered by Public Law No. 95 to have continuity of services under the best possible conditions, the
              ASES has communicated to the insurance entities that are currently offering the referenced benefit that the provisions of Clause 51 of the contract currently in force and effect between the parties are being activated. This clause allows the
              ASES to extend the contracts that are currently in effect for a period of up to 90 days under the same conditions. In other words, with the same benefit and premiums that were negotiated until December 31, 2017.

          

          

        

        	 	
                

              
	 
	
                
                  PO Box 195661, San Juan, PR 00919-5661  Tel: 787.474.3300  Fax: 787.474.3348  www.ases.pr.gov

                

              


        
          

          

        

        
          
            


        

        
          [CERTIFIED TRANSLATION]
            
               

              

            

          

          In light of these circumstances, and for the reasons stated in the first paragraph of this letter, we have advised unions to work with their
              insurance brokers or designated persons to make the corresponding arrangements with the insurance entities that provide their health insurance plans so that they will make the corresponding adjustment extending coverage until March 31, 2018.
              We will be sending out a new communication with the calendar showing the dates of the administrative processes.

          

          

          If you have any questions regarding this matter, please contact Mr. Carlos Guzmán,
                Public Law No. 95 project manager, at telephone number 787-474-3300 ext. 2344 or by email at cguzman@asespr.org.

          

          

          Cordially,

          [signed]

          Angela Avila Marrero

          Executive Director

           

            

          
            
              


          

          

        
          
            [CERTIFIED TRANSLATION]

             

            

          

        

        	
                
                  

                

              	 	
                
                  GOVERNMENT OF PUERTO RICO

                  Health Insurance Administration

                

              	
                
                  Hon. Ricardo A. Rosselló Neváres

                  Governor

                   

                  Ms. Angela M. Avila Marrero

                  Executive Director

                

              


        
          

          

          July 20, 2018

          

          

          CIRCULAR LETTER 18-07-20

          

          

          Secretaries, Directors, Heads of Agencies, Departments, Offices, Commissions, Administrations, Organisms, Entities, Public
              Corporations, Municipalities, Insurance Entities Contracted by the ASES to offer services to public employees pursuant to Public Law No. 95 of June 29, 1963, and Insurance Entities offering health insurance benefits to the unionized employees
              of the Government of Puerto Rico pursuant to Public Law No. 158-2006.

          

          

          OATRH 2018-001 MEMORANDUM PROTOCOL

          

          

          The purpose of issuing this Circular Letter is to establish protocols in keeping with the Special Joint Memorandum No. 2018-01 and 2018-02 of the
              Human Resources Management and Transformation Office of the Government of Puerto Rico (OATRH, Spanish acronym).  Said informative memoranda sent to all of the agencies, instrumentalities, and public corporations of the Government of Puerto
              Rico announce the opinion of the U.S. Supreme Court in the case of Janus v. American Federation of State, County, and Municipal Employees, Council 31,
              No. 16-1466, 585 U.S.     (2018), (“Janus v. AFSCME”) and how it will be
              applicable in the Government of Puerto Rico.

          

          

          In accordance with Memorandum 2018-01 and 2018-02 of the OATRH, starting on July 16, 2018, the public employees of the Government of Puerto Rico, its instrumentalities, and public corporations will have the right to authorize and de-authorize the collection of service charges if they are
              not affiliated with an exclusive representative. Additionally, public employees who do not wish to join a union will have the right to freely and voluntarily submit a request for opting out at any time. After submitting said request, the
              agencies, public corporations, and/or instrumentalities of the Government of Puerto Rico will be required to make the necessary arrangements to stop the withholding of dues and/or other related charges from said employee’s wages, unless the
              public employee submits written authorization for same. No public employee may be incentivized or pressured to exercise his or her right to join or to opt out of a labor union.

          

          

          The ruling of the U.S. Supreme Court in Janus v. AFSCME is
              also applicable to the bona fide organizations established pursuant to the Public Servant Association Fees Act, Public Law No. 134 of July 19, 1960, as
              amended. The referenced law establishes that the contributions of public employees who belong to same “...may be revoked one year after their effective date” (Article 2.—[Public servant association dues, withholdings) (3 L.P.R.A. sec. 702
              Section (b)]). This provision is no longer applicable and thus revocations of withholding authorizations will also be accepted for bona fide organizations at any time, without having to wait one year.

           

            

        

        	 	
                

              
	 	 
	
                
                  PO Box 195661, San Juan, PR 00919-5661  Tel: 787.474.3300  Fax: 787.474.3348  www.ases.pr.gov

                

              


        
          

          

        

        
          2

          
            


        

        
          
            
              [CERTIFIED TRANSLATION]

               

              

            

          

        

        
          In order to adjust the procedures of the ASES in keeping with the ruling of the U.S. Supreme Court in Janus v. AFSCME and Memoranda 2018-01 and 2018-02 of the OATRH, the provisions regarding the employer contributions of those employees who exercise their right to opt out of their union and who
              wish to receive healthcare coverage through Public Law No. 95 of June 29, 1963 (“Public Law No. 95-1963”) administered by the ASES are hereby modified.

          

          

          Specifically, Circular Letter 2017-11-06, in its Section entitled “PUBLIC LAW NO. 158 OF AUGUST 2006”, Art. 7, section (d), currently provides that:

          

          

        

        
          “d. The employee does not wish to be covered by the selected insurance entity. In this case, the employee will
              not be able to use his or her employer contribution to obtain coverage from any of the entities contracted by the ASES nor for direct-pay coverage payment”.

          

          

        

        
          In accordance with the instructions of Memoranda 2018-01 and 2018-02 of the OATRH, after the issuance of this Circular Letter, the public employees
              who freely and voluntarily exercise their right to opt out of their unions will be treated under the same conditions that are expressed in the referenced Circular Letter in the section entitled “PUBLIC LAW 158 OF AUGUST 2006”, Art. 9, which
              establishes the following:

          

          

        

        
          “9. If during the effective period of the contract, the insured is reclassified and becomes a managerial
              employee, he or she will cease to be eligible for the health insurance plan negotiated pursuant to Public Law No. 158. In these cases, the employee will have the following thirty (30) calendar days after the date on which he or she learns
              about the change to seek coverage from any of the insurance entities contracted by the ASES pursuant to Public Law No. 95. The employee must submit to the insurer the certification from the agency showing that he or she is no longer unionized
              and evidence of the cancellation of his or her healthcare coverage under Public Law No. 158...”

          

          

        

        
          Although the change from unionized to managerial is not configured, the opting out of a public employee from his or her union is an even that
              prevents the employee from continuing to receive the health insurance plan benefit as negotiated by his or her representative pursuant to Public Law No. 158-2006. Thus, the same procedure established in the referenced Article 9 will be used
              for these cases. In other words, any employee who decides to opt out of his or her union will have the following thirty (30) days after the date on which his or her opting out is notified to seek coverage under any of the insurance entities
              contracted by the ASES pursuant to Public Law No. 95-1963. The employee must submit to the insurer the certification from the agency showing that he or she is no longer a unionized employee and evidence of the cancellation of the healthcare
              coverage acquired under Public Law No. 158-2006.

          

          

          We request strict compliance with the provisions of this Circular Letter. If you have
                any questions, please contact Mr. Carlos E. Guzmán Otero, Public Law No. 95 project manager, by email at cguzman@asespr.org or by telephone at (787) 474-3300 ext. 2344.

          

          

          Cordially,

          [signed]

          Yolanda García Lugo, MS, MBA

          Deputy Executive Director

           

            

          
            
              


          

          
            
              [CERTIFIED TRANSLATION]

            

          

          

          

        

        	
                
                  

                

              	
                
                  COMMONWEALTH OF

                  PUERTO RICO

                  Puerto Rico Health Insurance

                  Administration (ASES, Spanish acronym)

                

              


        
           

          

          NORMATIVE LETTER 15-1012 Amended

          (To amend Normative Letter 15-03-25-A and Normative Letter 15-03-25-B)

          

          

          October 13, 2015

        

        	
                To:

              	
                Healthcare Entities

              
	 	
                Pharmacy Benefit Manager

              
	 	
                Primary Medical Groups, including Obstetricians/Gynecologists Participating in the

              
	 	
                Health Insurance Plan of the Government of Puerto Rico (PSG, Spanish acronym)

              
	
                Subjects:

              	
                Model for the Provision of Contraceptive Services for the entire population of reproductive age of the PSG

              


        
          

          

          
            
In
              keeping with the changes in legislation established in the “Patient Protection and Affordable Care Act”, the Government Healthcare Plan expands access
              to methods of contraception for its entire population of reproductive age, free of charge. The new guidelines for access to these methods are detailed below. These guidelines took effect on April 1, 2015 under the model of contracting with
              insurers for the different healthcare regions established by the ASES.

          

          

          The services for accessing and dispatching contraceptives will be provided by the family planning clinics contracted for these purposes and
              established in the different municipalities of the regions of the Government Healthcare Plan.

          

          

          The following methods of contraception will be provided according
                to the different covered categories:

           

              

        

        	
                
                  Category

                

              	
                
                  Brand Name

                

              	
                
                  Dispatch

                

              	
                
                  Limitations

                

              
	
                
                   

                   

                   

                  Birth control 

                  pills

                

              	
                
                   

                   

                  Lutera,

                  Ortho Micronor,

                  Cyclen, Tri-cyclen/ Tri-

                  Sprintec,

                  Ortho-Tri Cyclen Low

                

              	
                
                   

                  Three packets for

                  ninety days with three

                  refills, one year

                  covered without need for medical evaluation or new prescription.

                

              	
                
                  Active smoker for over 35 years

                  Diabetes for over 20 years

                  Symptomatic gallbladder disease

                  Liver disease

                  Stroke

                  History of thrombophlebitis

                  Irregular blood pressure

                  Myocardial infarction

                  History of breast cancer

                

              
	
                
                   

                   

                   

                  Hormonal 

                  Injection

                

              	
                
                   

                   

                   

                  Depo-Provera

                

              	
                
                   

                  Three packets for ninety days with three refills, one year covered without need for medical evaluation or new prescription.

                

              	
                
                  No more than two (2) consecutive years

                  Active smoker for over 35 years

                  Diabetes for over 20 years

                  Symptomatic gallbladder disease

                  Liver disease

                  Stroke

                  History of thrombophlebitis

                

              


        
          

          

        

        	 	
                

              


        
           

            

          #1571 Alda Street Urb. Caribe San Juan Puerto Rico 00926-2706

          PO Bo 195661 San Juan, PR 00919-5661

          Tel: 787-474-3300 Fax: 787-474-3345

           

            

          
            
              


          

          
            
              
                [CERTIFIED TRANSLATION]

                 

                

              

            

          

          Normative Letter 15-1012 Amended

          (To amend Normative Letter 15-03-25-A and Normative Letter 15-03-25-B)

          -2-

          

          

        

        	 	 	 	
                
                  Irregular blood pressure

                  Myocardial Infarction

                  History of breast cancer

                

              
	
                
                  Intrauterine

                  Device

                  (Copper T)

                

              	
                
                   

                  DIU-Paragard

                

              	
                
                   

                  One every 10 years

                

              	
                
                  Abnormal Pap

                  Positive for venereal diseases

                  Wilson’s Disease

                

              


        
          

          

          The following methods of contraception are available through the contracted planning clinics, however, they are not covered by the Government Healthcare Plan.

          

          

        

        	
                
                  Category

                

              	
                
                  Brand Name

                

              	
                
                  Dispatch

                

              	
                
                  Limitations

                

              
	
                
                  Barrier 

                  Method

                

              	
                
                  Latex condom, with 

                  spermicide

                

              	
                
                  Must be paid for by the 

                  insured.

                

              	
                
                  Latex or spermicide allergy

                

              
	
                
                   

                   

                   

                   

                  Emergency

                  Methods

                

              	
                
                   

                   

                   

                   

                  Plan B

                

              	
                
                   

                   

                   

                   

                  Must be paid for by the insured.

                

              	
                
                  Body weight greater than 164 lbs

                  Active smoker for over 35 years

                  Diabetes for over 20 years

                  Symptomatic gallbladder disease

                  Liver disease

                  Stroke

                  History of thrombophlebitis

                  Irregular blood pressure

                  Myocardial infarction

                  History of breast cancer

                

              


        
          

          

          *The ASES will periodically evaluate the cost-effectiveness of the available methods in order to maintain the viable options for
              the populations served. Any change in product will be notified to the participating providers in a normative letter.

          

          

          Attachment 1 details the protocol for referrals to family
              planning clinics, including the referral form required to refer the insured who qualify and wish to access the methods of contraception.

          

          

          We request the cooperation of all providers in order to comply with the normative [letter].

          

          

          Cordially,

          [signed]

          Sandra V. Peña Pérez, PT, MHSA

          Deputy Executive Director

          

          

        

        
          
            
              	c	
                      Atty. Maria del Carmen Rosario

                    


            

          

          Director Office of Legal Affairs / Compliance and Clinical Affairs Office

           

            

        

        
          
            


        

        
          
            [CERTIFIED TRANSLATION]

             

            

          

        

      

       
        

        

        
          
            


        

      

      
        [CERTIFIED TRANSLATION]

         

        

         
          

          

          
            
              


          

        

      

      
        [CERTIFIED TRANSLATION]

         

        

        
          	
                  
                    

                  

                	
                  
                    COMMONWEALTH OF

                    PUERTO RICO

                    Puerto Rico Health Insurance

                    Administration (ASES, Spanish acronym)

                  

                


          
            

            

            NORMATIVE LETTER 15-1112

            November 12, 2015

            

            

          

          
            TO THE CONTRACTED HEALTHCARE ENTITIES, PRIMARY MEDICAL GROUPS, AND PROVIDERS OF THE HEALTHCARE PLAN OF THE GOVERNMENT OF PUERTO
                RICO (PSG)

            

            

            REVIEW OF ICD10 COVERAGE AND DIAGNOSIS

             

              

            
              
          

            

          

          
            The Compliance and Clinical Affairs Office attached to the Health Insurance Administration (ASES, Spanish acronym) has validated the coding of the
                Special Coverage from ICD-9 to ICD-10 for Attachment 7, Attachment 13, Normative Letter 15-0617 (Diagnostic Codes for Special Needs Children), and the codes in the ASES Quality Handbook.

            

            

            It is important to clarify that use of the new ICD10 CM diagnostic codes does not increase the number of diseases, but rather the specificity and
                description of the disease itself. The validation was performed for the general codes of the families that group diagnoses.

            

            

            The attachment that is included with this Normative Letter includes the diagnostic codes in ICD10 CM revised and approved by ASES with the
                collaboration of the Department of Health to be applied to the above-mentioned documents. A file will be sent to you electronically with the lists that are included as attachments. We have named them: Special Need Childrens [sic], Special Coverage Adults, HIV ICD10 and Quality Program Incentive in the file that is sent out so that you may identify them.

            

            

            It is important for the contracted entities to validate the configuration of all of their systems and of the operational areas that process
                diagnostic codes in accordance with the revision by ASES. The use of the general family code can be applied as long as the specificity rule established in the regulation by CMS is not omitted.

            

            

            Cordially,

            [signed]

            Sandra V. Pena, MHSA, PT

            Deputy Executive Director

            

            

          

          
            
              
                	c	
                        Maria del C. Rosario, Director

                      


              

            

            Office of Legal Affairs / Compliance and Clinical Affairs Office

          

          
            

            

          

          	 	
                  

                


          
            

            

            #1571 Alda Street Urb. Caribe San Juan Puerto Rico 00926-2706

            PO Bo 195661 San Juan, PR 00919-5661

            Tel: 787-474-3300 Fax: 787-474-3345

            

            

            
              
                


            

            
              
                [CERTIFIED TRANSLATION]

                

                

              

              
                

                

              

              

              
                
                  


              

            

            
              
                [CERTIFIED TRANSLATION]

                 

                

              

              
              

              

              
                
                  


              

            

            
              
                [CERTIFIED TRANSLATION]

                 

                

              

              
              

              

              
                
                  


              

            

            
              
                [CERTIFIED TRANSLATION]

                 

                

              

              

              

              

              

              
                
                  


              

            

            
              
                [CERTIFIED TRANSLATION]

                 

                

              

              

              

              
                
                  


              

            

            
              [CERTIFIED TRANSLATION]

               

              

            

            

            

              
                
                  


              

            

            
               [CERTIFIED TRANSLATION]

               

              

              
                

              

              

              
                
                  


              

            

            [CERTIFIED TRANSLATION]
               

              

            

            

            

            
              
                


            

            
              [CERTIFIED TRANSLATION]

            

            

            
              
                
                  


              

            

            
              [CERTIFIED TRANSLATION]

               

              

            

            
              

            

            

              
                
                  


              

              
                [CERTIFIED TRANSLATION]

              

              

              
                

                

                
                  
                    


                

                
                  [CERTIFIED TRANSLATION]

                   

                  

                

                
                  

                  

                  
                    
                      


                  

                

                
                  
                    [CERTIFIED TRANSLATION]

                  

                  

                  

                  

                  

                  

                  

                  
                    
                      


                  

                

                
                  [CERTIFIED TRANSLATION]

                   

                  

                

                
                  

                  

                  
                    
                      


                  

                  
                    [CERTIFIED TRANSLATION]

                     

                    

                  

                  
                    

                    

                    
                      
                        


                    

                  

                  
                    [CERTIFIED TRANSLATION]

                     

                    

                  

                  
                    

                    

                    
                      
                        


                    

                    
                      [CERTIFIED TRANSLATION]

                       

                      

                    

                    
                      

                      

                      
                        
                          


                      

                      
                        [CERTIFIED TRANSLATION]

                         

                        

                      

                      
                        

                        

                        
                          
                            


                        

                      

                    

                  

                

                
                  [CERTIFIED TRANSLATION]

                   

                  

                

                

                  

                  

                  
                    
                      


                  

                  
                    [CERTIFIED TRANSLATION]

                     

                    

                  

                  
                    

                    

                    
                      
                        


                    

                  

                  [CERTIFIED TRANSLATION]

                   

                  

                  
                  

                  

                  
                    
                      


                  

                  
                    [CERTIFIED TRANSLATION]

                      

                    

                  

                  
                    

                    

                    
                      
                        


                    

                    
                      [CERTIFIED TRANSLATION]

                       

                      

                      
                      

                      

                      
                        
                          


                      

                      
                        [CERTIFIED TRANSLATION]

                         

                        

                      

                      
                        

                      

                    

                    

                    

                  

                

              

              
                
                  


              

              
                
                  [CERTIFIED TRANSLATION]

                   

                  

                

                	
                        
                          

                        

                      	
                        
                          COMMONWEALTH OF

                          PUERTO RICO

                          Puerto Rico Health Insurance

                          Administration (ASES, Spanish acronym)

                        

                      


                
                  

                  

                  NORMATIVE LETTER 15-0612

                  (Amending #09-0505A)

                  

                  

                  June 12, 2015

                  

                  

                

                
                  TO THE CONTRACTED HEALTHCARE ENTITIES, PRIMARY MEDICAL GROUPS, AND PROVIDERS OF THE HEALTHCARE PLAN OF THE GOVERNMENT OF PUERTO RICO (PSG)

                  PROCEDURE FOR MANAGING PATIENTS

                  WITH POSITIVE HIV/AIDS DIAGNOSIS

                     

                    

                    The Compliance and Clinical Affairs Office attached to the Health Insurance Administration (ASES, Spanish acronym) has decided to
                        update the clinical protocol that is used to request the special coverage and standardize the service to be provided to all beneficiaries diagnosed with HIV/AIDS.

                  

                

                
                  

                  

                  The procedures established herein will take effect on the date of issuance of this normative letter and are detailed below:

                  

                  

                

                
                  
                    
                      	

                            	A.	
                              Procedure for individuals who are not PSG beneficiaries and who are diagnosed for the first time with HIV/AIDS:

                            


                    

                  

                

                
                  
                    
                      	

                            	a.	
                              The skilled employees who work at the CPTETS Centers of the Department of Health, the Clinical Centers specializing in the management of HIV/AIDS
                                  patients, or any community organization, whether public or private, that receive Ryan White Parts A, B/ADAP, C, and D funds, hereinafter referred to as clinics or centers specializing in HIV/AIDS, will be responsible for
                                  providing access to any person who is interested in being tested for the HIV virus.

                            


                    

                  

                  
                    
                      	

                            	b.	
                              If there is an HIV diagnosis, the case manager or the designated skilled employee will be in charge of giving the person an orientation about the
                                  services provided by any of the clinics or centers specializing in HIV/AIDS.

                            


                    

                  

                  
                    
                      	

                            	c.	
                              The case manager or designated skilled employee will advise the individual about the services provided by the PSG for his or her health condition.
                                  Additionally, the case manager or skilled employee will schedule the person’s appointment with the Medicaid Office for the corresponding evaluation of eligibility for the PSG and will inform him or her about the documents
                                  that he or she must submit the day of the appointment and that are required for the process, in addition to scheduling a follow-up appointment at the clinic or center specializing in HIV/AIDS chosen by the individual to
                                  treat his or her condition.

                            


                    

                  

                

                
                  
                    
                      	

                            	B.	
                              Procedure for individuals diagnosed for the first time with HIV/AIDS and who are eligible for the PSG for the first time:

                            


                    

                  

                

                
                  
                    
                      	

                            	a.	
                              the Medicaid program, after evaluating the person and determining that he or she is eligible to receive healthcare services through the PSG, will
                                  issue a document known as MA-10 and the beneficiary will be advised to visit the regional office of the healthcare entity corresponding to his or her geographical area to complete the eligibility process for the PSG.

                            


                    

                  

                  

                  

                

                	 	
                        

                      
	 
	
                        
                          #1571 Alda Street Urb. Caribe San Juan Puerto Rico 00926-2706

                        

                        
                          PO Bo 195661 San Juan, PR 00919-5661

                        

                        Tel: 787-474-3300 Fax: 787-474-3345

                      


                
                  

                  

                

                
                  
                    


                

                
                  [CERTIFIED TRANSLATION]

                

                 

                

                	
                        
                          

                        

                      	
                        
                          COMMONWEALTH OF

                          PUERTO RICO

                          Puerto Rico Health Insurance

                          Administration (ASES, Spanish acronym)

                        

                      


                
                  

                  

                

                
                  Once the insured completes the eligibility process with the healthcare entity in his or her region, he or she will
                      be able to begin to receive services. The effective date of the person’s eligibility must coincide with the date given by the Medicaid program.

                  
                    
                      	

                            	b.	
                              The case manager, primary care physician (PCP), or HIV doctor will proceed to process the beneficiary’s special coverage by sending to the
                                  corresponding healthcare entity the form approved by the ASES for said purpose, signed by the physician (PCP) or any HIV doctor, the evidence showing that the person is eligible for the PSG according to the revised
                                  clinical protocol for registering special conditions, see (table 1), as well as a copy of the MA-10 or a copy of the health insurance card, if available, and a copy of the beneficiary’s picture ID.

                            


                    

                  

                  
                    
                      	

                            	c.	
                              Once the healthcare entity receives the documents requesting the special coverage for the beneficiary, the special coverage letter must be issued
                                  within a period of no more than 72 work hours, as established in the contract, and in accordance with the instructions given by the ASES, which establish that said coverage shall not have an expiration date. The special
                                  coverage letter will be sent by regular mail to the beneficiary and to the case manager at the clinic or center specializing in HIV/AIDS that made the request. Likewise, the healthcare entity will be responsible of
                                  ensuring that the special coverage has been registered in its system in order to guarantee that all of the healthcare services will be provided to the beneficiary.

                            


                    

                  

                  
                    
                      	

                            	d.	
                              The healthcare entity will be responsible for activating the pharmacy coverage so that the beneficiary may access his or her medications as soon as
                                  they are prescribed in keeping with the coverage of the PSG. In cases in which the PSG beneficiary has private health insurance, he or she must obtain a letter or certification from said private health insurance plan
                                  stating whether it includes pharmacy coverage or not. If the private health insurance plan does provide pharmacy coverage, the letter must provide coverage details, including whether it covers HIV/AIDS treatment drugs. It
                                  will be the responsibility of the beneficiary to provide said letter to the case manager at the clinic or center specializing in HIV/AIDS where he or she will receive services, who will in turn send the letter to the
                                  Pharmacy Department of the healthcare entity, or the beneficiary may visit the regional office of the healthcare entity and deliver the letter there. In this way, it is guaranteed that the beneficiary will have access to
                                  the medications needed to treat his or her HIV/AIDS condition, in turn allowing for the coordination of services. The ASES reserves the right to audit the healthcare entity in order to ensure that the pharmacy coverages of
                                  the beneficiaries are active and that coordination of benefits is taking place when applicable.

                            


                    

                  

                  
                    
                      	

                            	e.	
                              It is understood that the primary medical group (PMG) does not have exclusivity and has had a limited intervention in the process of requesting the
                                  special coverage for any beneficiary diagnosed with HIV/AIDS. However, it is recognized that the PCP provides orientation in order to guarantee access to the service at any of the clinics or centers specializing in
                                  HIV/AIDS because the risk of the special coverage lies with the entity.

                            


                    

                  

                  

                  

                

                	 	
                        

                      
	 
	
                        
                          #1571 Alda Street Urb. Caribe San Juan Puerto Rico 00926-2706

                          PO Bo 195661 San Juan, PR 00919-5661

                        

                        Tel: 787-474-3300 Fax: 787-474-3345

                      


                
                  

                  

                

                
                  
                    


                

                
                  
                    [CERTIFIED TRANSLATION]

                  

                  

                  

                

                	
                        
                          

                        

                      	
                        
                          COMMONWEALTH OF

                          PUERTO RICO

                          Puerto Rico Health Insurance

                          Administration (ASES, Spanish acronym)

                        

                      


                
                  

                  

                

                
                  
                    
                      	

                            	C.	
                              Procedure for beneficiaries who have lost their eligibility:

                            


                    

                  

                

                
                  The special coverage will remain in effect for as long as the beneficiary is eligible for the PSG. If the
                      beneficiary loses his or her eligibility and is re-certified as eligible within a period of no more than six (6) months, then the special coverage will be reactivated without the need for new diagnostic tests, evaluations, and without
                      having to submit any documents as established in the clinical protocol approved by the ASES. When the period without eligibility exceeds six (6) months, the case manager, PCP, or HIV doctor who provides the services to the beneficiary
                      will be bound to submit a certification of current treatment to the insurer.

                

                
                  
                    
                      	

                            	D.	
                              Access to service and prescription management:

                            


                    

                  

                

                
                  
                    
                      	

                            	a.	
                              It is not a requirement that the prescriptions issued to these patients be given by an infectious diseases specialist. They may be issued by an HIV
                                  doctor or any other doctor who offers services at any of the clinics or centers specializing in HIV/AIDS, as long as said doctor has been duly accredited by the healthcare entity to provide services for the PSG.

                            


                    

                  

                  
                    
                      	

                            	b.	
                              It will be the responsibility of each healthcare entity to notify the PMB of every doctor who is retained and is authorized to treat beneficiaries
                                  with HIV/AIDS so that said doctors are recognized by the system, in order to guarantee access to the medications prescribed by them.

                            


                    

                  

                  
                    
                      	

                            	c.	
                              The clinics or centers specializing in HIV/AIDS will be responsible for maintaining the providers who provide their services credentialed with the
                                  healthcare entities in accordance with the contractual provisions established by both parties.

                            


                    

                  

                  
                    
                      	

                            	d.	
                              The healthcare entities will be responsible for entering into their systems every patient who is diagnosed for the first time with HIV/AIDS, as well
                                  as every existing patient who has already been registered, thus guaranteeing their access to the medical services that they need to treat their condition without requiring a referral and to the medications included in the
                                  pharmacy coverage of the PSG.

                            


                    

                  

                  
                    
                      	

                            	e.	
                              All of the healthcare entities contracted to offer services under the PSG are bound to contract with all of the clinics or centers specializing in
                                  HIV/AIDS, whether public or private, and even if they are not located in the geographical area to which they provide services.

                            


                    

                  

                  

                  

                

                
                  
                    
                      	

                            	E.	
                              Exceptions:

                            


                    

                  

                

                
                  
                    
                      	

                            	a.	
                              When the beneficiary is in critical health due to his or her HIV/AIDS condition or if he or she has lost his or her eligibility and must be
                                  medicated immediately according to clinical judgment, the ADAP Program or any of the clinics or centers specializing in HIV/AIDS that receive Ryan White A, B/ADAP, C, or D funds shall provide the medications to the
                                  beneficiary if he or she meets the eligibility criteria established by said law, prior to submitting to the Medicaid eligibility process and depending on the availability of funds.

                            


                    

                  

                  

                  

                

                	 	
                        

                      


                
                  

                  

                

                
                  #1571 Alda Street Urb. Caribe San Juan Puerto Rico 00926-2706

                  PO Bo 195661 San Juan, PR 00919-5661

                  Tel: 787-474-3300 Fax: 787-474-3345

                   

                    

                

                
                  
                    


                

                
                  
                    [CERTIFIED TRANSLATION]

                     

                    

                  

                

                	
                        
                          

                        

                      	
                        
                          COMMONWEALTH OF

                          PUERTO RICO

                          Puerto Rico Health Insurance

                          Administration (ASES, Spanish acronym)

                        

                      


                
                  

                  

                

                
                  
                    
                      	

                            	b.	
                              The cost of the medications that are dispatched to any patient on a date prior to being certified in the special coverage of the Healthcare Plan of
                                  the Government of Puerto Rico could be the responsibility of ADAP or of any of the clinical centers and public/private community organizations that are recipients (grantees) or sub-recipients (sub-grantees) of funds under
                                  Parts A, B, C, and D of the Ryan White Act, as amended, as long as the patient has been found to be eligible under the Ryan White Act. However, the cost will fall on the ASES from the date on which the eligibility was
                                  granted under the special coverage of the Puerto Rico Government Healthcare Plan. This exception is established so that the grantees and sub-grantees of funds under the Ryan White Act comply with the legal precept known as
                                  the payer or last resort  established in said law.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	c.	
                              The dispatching of protease inhibitors to the eligible population of the PSG, and the cost of same, will be the responsibility of the Department of
                                  Health (ADAP) as per the Puerto Rico Medicaid State Plan.

                            


                    

                  

                  
                    
                      	

                            	d.	
                              In accordance with article VI-Secondary Payor
                                  of the contract executed between the ASES and the healthcare entities, in the event that the beneficiary were to have another health insurance plan and were to be eligible for the PSG, the special coverage will be
                                  activated when the beneficiary’s coverage (pharmacy, laboratories, among others) under any other primary plan offering the same services included in this coverage has been exhausted.

                            


                    

                  

                  

                  

                

                
                  If you have any questions regarding this normative letter, please contact Ms. Milagros Soto Mejía at the ASES Compliance and Clinical
                      Affairs Office at msoto@asespr.org. The revised protocol approved for the management of HIV/AIDS patients
                      under special coverage is attached.

                  

                  

                  Cordially;

                  [signed]

                  William Ruiz Alejandro

                  Director

                  Compliance and Clinical Affairs Office

                  

                  

                

                
                  
                    
                      	C:	
                              Dr. Ana Ríus Armendáriz, Secretary of the Puerto Rico Department of Health

                            


                    

                  

                  Eng. Ricardo Rivera Cardona-ASES Executive Director

                  Atty. Sandra V. Peña Pérez-ASES Deputy Executive Director

                

                
                  

                  

                  Attachments:

                  Table 1: Protocol for the management of HIV/AIDS patients

                  

                  

                

                	 	
                        

                      


                
                  

                  

                  #1571 Alda Street Urb. Caribe San Juan Puerto Rico 00926-2706

                  PO Bo 195661 San Juan, PR 00919-5661

                  Tel: 787-474-3300 Fax: 787-474-3345

                   

                    

                  
                    
                      


                  

                  [CERTIFIED TRANSLATION]
                     

                    

                  

                  Table I

                  NORMATIVE LETTER 15-0612

                  (Amending #09-0505A)

                  

                  

                

                	
                        Special

                        Condition

                      	
                        Definitive Diagnostic Criteria for

                        Inclusion in Coverage

                      	 	
                        Effectiveness and

                        Duration of Special

                        Coverage

                      	 	
                        Services included

                        in the Special

                        Coverage

                      	 	
                        Assignment of Risk

                      
	
                         

                        HIV/AIDS

                      	
                         

                        A-  Evidence of the result of any of the following lab tests:

                        1-    Western Blot
                            positive

                        2-    HIV viral load

                        3-    Positive 4th
                            generation with validation of antibody sub-types or antigens for acute infection

                        The record may be requested by one of the following providers:

                         

                        * Primary care physician

                        * HIV/AIDS clinic physician

                        * Case manager at HIV/AIDS clinic

                      	 	
                         

                        Effectiveness: coverage will begin on the date on which
                            the definitive diagnosis is established.

                         

                        Duration: the special coverage for every patient with
                            HIV/AIDS will be in effect while the patient remains eligible in the PSG.

                      	 	
                         

                        Every type of service while active in the registry.

                      	 	
                         

                        Insurer: services included for the condition in the
                            special coverage or any other service contemplated under special coverage, regardless of this diagnostic category.

                         

                        GMP/PCP: receives monthly capitation corresponding to
                            the insured, as established in the contracting model of the MCO.

                      


                
                  

                  

                

                
                  
                    


                

                
                  [CERTIFIED TRANSLATION]

                  

                  

                

                	
                        
                          

                        

                      	 	
                        
                          GOVERNMENT OF PUERTO RICO

                          Health Insurance Administration

                        

                      	
                        
                          Hon. Ricardo A. Rosselló Neváres

                          Governor

                           

                          Ms. Angela M. Avila Marrero

                          Executive Director

                        

                      


                
                  

                  

                  Normative Letter 17-0619

                  

                  

                  June 19, 2017

                  

                  

                

                	
                        To:

                      	
                        Healthcare Entities contracted under Mi
                              Salud

                      
	 	 
	
                        Subject:

                      	
                        New instructions for J-Codes deposit

                      


                
                  

                  

                  The entities contracted under Mi Salud
                      are currently required to submit the data related to the medications with J Codes, as established in Normative Letter 16-1129. Starting this quarter (Q4), all of the entities must deposit the J-Codes in the ASES FTP , and also in the FTP of the Abarca company. In order to facilitate and standardize the process, a file was created in the Share File (FTP)
                      in Abarca for each entity to deposit its reports in compliance with the following instructions:

                  

                  

                

                
                  
                    
                      	

                            	*	
                              Send to Abarca and to ASES the quarterly use by the medical part of brand-name products (J Codes) stipulated in the normative letter using the file layout included in attachment 1.

                            


                    

                  

                  

                  

                  
                    
                      	

                            	*	
                              Deposit the files no later than 15 days after the closing of
                                  the quarter.

                            


                    

                  

                  
                    	 	
                            *

                          	
                            Due Date:

                          


                  

                

                
                  
                    	 	
                            *

                          	
                            Q1: April 15

                          


                  

                  
                    	 	
                            *

                          	
                            Q2:  July 15

                          


                  

                  
                    	 	
                            *

                          	
                            Q3: October 15

                          


                  

                  
                    	 	
                            *

                          	
                            Q4: January 15

                          


                  

                

                
                  

                  

                  
                    
                      	

                            	*	
                              Identify the reports to be deposited with the following nomenclature: JCODES, year, month, and version number.

                            


                    

                  

                  *  JCODESYYMMV#

                  

                  

                  Example: JCODES1701V1

                  

                  

                  
                    
                      	

                            	*	
                              The Abarca FTP address is: ftp.abarcahealth.com.
                                  In the Abarca FTP you will find a file with the name J-Code & Rebates in which to make the deposit.

                            


                    

                  

                  

                  

                

                	 	
                        

                      
	 	 
	
                        PO Box 195661, San Juan, PR 00919-5661  Tel: 787.474.3300  Fax: 787.474.3348  www.ases.pr.gov

                      


                
                  

                  

                

                
                  
                    


                

                
                  
                    [CERTIFIED TRANSLATION]

                  

                  

                  

                

                
                  Page 2

                  New J-Code Deposit Instructions

                  

                  

                

                
                  
                    
                      	

                            	*	
                              Each entity will receive its username and password information separately. Likewise, each entity will be sent the document Installation Instructions FileZilla Open Source Software which contains the instructions for the configuration of the FTP in order to connect to
                                  the Abarca server.

                            


                    

                  

                  

                  

                

                
                  Failure to deposit this report by the entities contracted under the Government Healthcare Plan may entail fines and
                      sanctions by the ASES.

                  

                  

                  If you have any questions about the J-Codes



                      report, please contact Atty. Nayda Rivera, from Abarca, at 787-523-1225, or by email at nayda.Rivera@AbarcaHealth.com. We appreciate the
                      support of all the entities contracted by Mi Salud in the implementation of these instructions and in immediately sending the J Codes
                      data that may be pending.

                  

                  

                  Cordially,

                  [signed]

                  Milagros Soto Mejía, MHSA, MMHC

                  Acting Director

                  Planning, Quality, and Clinical Affairs Office

                  

                  

                  attachments (2)

                  

                  

                

                
                  
                    
                      	c	
                              Nayda Rivera, Abarca Health

                            


                    

                  

                  Nélida Luna, MC-21

                  Jesús Hernández, Compliance Director, ASES

                   

                    

                

                
                  
                    


                

                
                  
                    
                      [CERTIFIED TRANSLATION]

                    

                  

                  

                  

                

                	
                        
                          

                        

                      	 	
                        
                          GOVERNMENT OF PUERTO RICO

                          Health Insurance Administration

                        

                      	
                        
                          Hon. Ricardo A. Rosselló Neváres

                          Governor

                           

                          Ms. Angela M. Avila Marrero

                          Executive Director

                        

                      


                
                   

                    

                  Normative Letter 18-0813

                  

                  

                

                
                  
                    
                      	Date:	
                              August 13, 2018

                            


                    

                  

                  

                  

                  
                    
                      	To:	
                              All Contracted Entities,

                            


                    

                  

                  Pharmacy Benefit Managers (PBM),

                  Pharmacy Plan Administrators (PPA),

                  Primary Medical Groups,

                  Providers Participating in the Government Healthcare Plan (PSG)-Mi Salud

                

                
                  

                  

                

                	
                        Subject: New Instruction for Deposit of J-Codes

                      


                
                  

                  

                

                
                  This new normative letter cancels and replaces Normative Letters 16-1129 and 17-0619. Effective immediately, all contracted insurers
                      of the PSG-Mi Salud are required to:

                  

                  

                

                
                  
                    
                      	

                            	1.	
                              Deposit all of the data for J-Code drugs administered to the
                                  beneficiaries of the PSG.

                            


                    

                  

                  
                    
                      	

                            	2.	
                              Deposit the data in the ASES Share File (FTP) and also in the FTP of the
                                      Abarca Health company. The address of the Abarca Health FTP is: ftp.abarcahealth.com. In the FTP of said company you
                                  will find a file with the name: J-Code & Rebates in which you will make the deposit. The file will be prepared using
                                  the format that is included as an attachment to this normative letter. Each entity will receive its username and password information separately from Abarca Health. The instructions for configuring access to the Abarca
                                  Health FTP will be emailed to the insurers.

                            


                    

                  

                  
                    
                      	

                            	3.	
                              Deposit the files no more than 15 days after the closing of the quarter. The due dates are the following:

                            


                    

                  

                

                	 	
                        Q1

                      	
                        (January to March)

                      	
                        -April 15

                      
	 	
                        Q2

                      	
                        (April to June)

                      	
                        -July 15

                      
	 	
                        Q3

                      	
                        (July to September)

                      	
                        -October 15

                      
	 	
                        Q4

                      	
                        (October to December)    

                          

                      	-January 15


                
                  
                    
                      	

                            	4.	
                              Identify the reports to be deposited with the following names: JCODES, year, month, and version number.

                            


                    

                  

                  
                    
                      	

                            	1.	
                              JCODESYYMMV#; Example: JCODES1701V1

                            


                    

                  

                  
                    
                      	

                            	5.	
                              Going forward, every J-Codes claim that is reported to ASES must include the NDC of the product and the amount of units dispensed of that NDC as administered, so [insurers] are required to review this instructions with the service providers and make sure that the
                                  format of their respective billing program includes this information.

                            


                    

                  

                  

                  

                

                	 	
                        

                      
	 	 
	
                        PO Box 195661, San Juan, PR 00919-5661  Tel: 787.474.3300  Fax: 787.474.3348  www.ases.pr.gov

                      


                
                  

                  

                  
                    
                      


                  

                  
                    
                      
                        [CERTIFIED TRANSLATION]

                      

                    

                  

                  

                  

                

                
                  Page 2

                  Normative Letter 18-0813

                

                
                  

                  

                

                
                  Failure by the contracted entities to comply with depositing the required FTPs on time with the correct and
                      complete data may entail fines and sanctions by the PRIHA.

                  

                  

                  The following drugs will continue to be managed through medical prescription and only under the pharmacy benefit of the beneficiaries
                      of the PSG-Mi Salud de Puerto Rico:

                  

                  

                  
                    

                    

                  

                  Likewise, please remember that only hematologists-oncologists
                      may bill the following products both under pharmacy and under the medical part. Other providers must give the patient a prescription in order for
                      the medication to be dispensed by their preferred pharmacy.

                  

                  

                  
                  

                  

                  If you have any questions regarding the J-Code report, please contact me or Atty. Nayda Rivera, from Abarca, at 787 523-1225, or by
                      email at nayda.Rivera@abarcahealth.com.

                  

                  

                  We appreciate the support of all of the entities contracted by Mi Salud in the implementation of these instructions and in sending the
                      J-Code data on time.

                  

                  

                  Cordially,

                  [signed]

                  Milagros Soto Mejía, MHSA, MMHC

                  Acting Director

                  Planning, Quality, and Clinical Affairs Office

                  

                  

                

                
                  
                    
                      	c	
                              Nayda Rivera - Abarca Health

                            


                    

                  

                

                
                  Atty. Carolina Guzmán - Director, ASES Compliance Office

                   

                    

                  
                    
                      


                  

                

                
                  
                    
                      
                        [CERTIFIED TRANSLATION]

                      

                    

                  

                

                 

                

                	
                        
                          

                        

                      	 	
                        
                          GOVERNMENT OF PUERTO RICO

                          Health Insurance Administration

                        

                      	
                        
                          Hon. Ricardo A. Rosselló Neváres

                          Governor

                           

                          Ms. Angela M. Avila Marrero

                          Executive Director

                        

                      


                
                  

                  

                  October 17, 2017

                  

                  

                

                
                  TO ALL AGENCIES, MUNICIPALITIES, AND INSTRUMENTALITIES OF THE GOVERNMENT OF PUERTO RICO WHOSE EMPLOYEES HAVE THE
                      BENEFIT OF HEALTH INSURANCE PURSUANT TO PUBLIC LAW NO. 95-1963 AS AMENDED

                  

                  

                  
                    	
                            RE:

                          	
                            EXTENSION OF HEALTH INSURANCE COVERAGES

                          


                  

                  

                  

                  The Health Insurance Administration (ASES, Spanish acronym) is the agency authorized pursuant to Public Law No. 95-1963, as amended,
                      to regulate, oversee, negotiate, and contract with the health insurance plans that are selected by public employees through their employer contribution as per the provisions of the referenced Public Law No. 95.

                  

                  

                  In contract year 2018, the ASES was in the Request for Proposals (RFP) process whereby the insurance entities that would offer the
                      benefit of health insurance to this population starting on January 1, 2018 would be chosen. However, in light of the catastrophe created by hurricanes Irma and María in Puerto Rico, it was impossible to comply with the work calendar
                      established for this purpose.

                  

                  

                  For this reason, and in order for the population covered by Public Law No. 95 to have continuity of services under the best possible
                      conditions, the ASES has communicated to the insurance entities that are currently offering the referenced benefit to activate the provisions of Clause 51 of the contract currently in force and effect between the parties. This clause
                      allows the ASES to extend the contracts that are currently in effect for a period of up to 90 days under the same conditions. In other words, with the same benefit and premiums that were negotiated until December 31, 2017. The
                      enrollment campaign will be carried out from mid December 2017 to the end of the month of February 2018; and the effective date will be April 1, 2018. A new communication will be issued with the specific details of the campaign, as
                      well as a general invitation to the health insurance coordinators of the agencies, municipalities, and instrumentalities of the Government of Puerto Rico.

                  

                  

                  If you have any questions regarding this matter, please contact Mr. Carlos Guzmán, Public Law 95 project manager, at 787-474-3300 ext.
                      2344 or by email at: cguzman@asespr.org.

                  

                  

                  Cordially,

                  [signed]

                  Ángela M. Ávila Marrero

                  Executive Director

                  

                  

                

                	 	
                        

                      
	 	 
	
                        PO Box 195661, San Juan, PR 00919-5661  Tel: 787.474.3300  Fax: 787.474.3348  www.ases.pr.gov

                      


                
                  

                  

                

                
                  
                    


                

                
                  
                    
                      
                        
                          [CERTIFIED TRANSLATION]

                        

                      

                    

                  

                  

                  

                

                	
                        
                          

                        

                      	
                        
                          COMMONWEALTH OF

                          PUERTO RICO

                          Puerto Rico Health Insurance

                          Administration (ASES, Spanish acronym)

                        

                      


                
                  

                  

                

                
                  October 21, 2015

                   

                    

                

                
                  CORRECTIONS

                  TO NORMATIVE LETTER 15-1012 AMENDED

                  

                  

                

                
                  
                    
                      	To:	
                              Healthcare Entities,

                            


                    

                  

                  Pharmacy Benefit Manager,

                  Primary Medical Groups,

                  and Participating Providers of the Government Healthcare Plan (PSG)

                

                
                  

                  

                  We officially make the following correction to Normative Letter 15-1012 amended, issued on Tuesday, October 13, 2015, regarding the
                      Model for the Provision of Contraceptive Services for the entire population of reproductive age of the Healthcare Plan of the Government of Puerto Rico.

                  

                  

                  THE CATEGORY OF HORMONAL INJECTION STATES:

                  

                  

                

                	
                        
                          Category

                        

                      	
                        
                          Brand Name

                        

                      	 	
                        
                          Dispatch

                        

                      	 	
                        
                          Limitations

                        

                      
	
                        
                           

                           

                           

                           

                          Hormonal Injection

                        

                      	
                        
                           

                           

                           

                           

                          Depo-Provera

                        

                      	 	
                        
                           

                           

                          Three packets for ninety days with three refills, one year covered without need for medical evaluation or new prescription.

                        

                      	 	
                        
                          No more than two (2) consecutive years

                          Active smoker for over 35 years

                          Diabetes for over 20 years

                          Symptomatic gallbladder disease

                          Liver disease

                          Stroke

                          History of thrombophlebitis

                          Irregular blood pressure

                          Myocardial Infarction

                          History of breast cancer

                        

                      


                
                  

                  

                

                	 	
                        

                      


                
                   

                    

                  #1571 Alda Street Urb. Caribe San Juan Puerto Rico 00926-2706

                  PO Bo 195661 San Juan, PR 00919-5661

                  Tel: 787-474-3300 Fax: 787-474-3345

                   

                    

                  
                    
                      


                  

                  
                    
                      
                        
                          
                            [CERTIFIED TRANSLATION]

                          

                        

                      

                    

                  

                  CORRECTIONS Normative Letter 15-1012 amended

                  Page -2-

                  

                  

                  IT SHOULD READ AS FOLLOWS:

                  

                  

                

                	
                        
                          Category

                        

                      	
                        
                          Brand Name

                        

                      	
                        
                          Dispatch

                        

                      	
                        
                          Limitations

                        

                      
	
                        
                           

                           

                           

                           

                          Hormonal 

                          Injection

                        

                      	
                        
                           

                           

                           

                           

                          Depo-Provera

                        

                      	
                        
                           

                           

                           

                           

                          One every three months

                        

                      	
                        
                          No more than two (2) consecutive years

                          Active smoker for over 35 years

                          Diabetes for over 20 years

                          Symptomatic gallbladder disease

                          Liver disease

                          Stroke

                          History of thrombophlebitis

                          Irregular blood pressure

                          Myocardial Infarction

                          History of breast cancer

                        

                      


                
                  

                  

                  Cordially,

                  [signed]

                  Sandra V. Peña Pérez, PT, MHSA

                  Deputy Executive Director

                  

                  

                

                
                  
                    
                      	c	
                              María del Carmen Rosario, Esq.

                            


                    

                  

                  Director, Office of Legal Affairs / Compliance and Clinical Affairs Office

                   

                    

                

                
                  
                    


                

                
                  
                    
                      
                        
                          
                            
                              [CERTIFIED TRANSLATION]

                            

                          

                        

                      

                    

                  

                  

                  

                

                	
                        
                          

                        

                      	
                        
                          COMMONWEALTH OF

                          PUERTO RICO

                          Puerto Rico Health Insurance

                          Administration (ASES, Spanish acronym)

                        

                      


                
                   

                    

                  NORMATIVE LETTER 15-1012 Amended

                  (To amend Normative Letter 15-03-25-A and Normative Letter 15-03-25-B)

                  

                  

                  October 13, 2015

                

                
                  
                    
                      	To:	
                              Healthcare Entities,

                            


                    

                  

                  Pharmacy Benefit Manager,

                  Primary Medical Groups, including Obstetricians/Gynecologists Participating in the

                  Health Insurance Plan of the Government of Puerto Rico (PSG, Spanish acronym)

                  

                  

                  
                    
                      	
                              Subjects:

                            	
                              Model for the Provision of Contraceptive Services for the entire population of reproductive age of the PSG

                            


                    

                  

                

                
                  

                  

                  
                    


                  In keeping with the changes in legislation established in the “Patient Protection and Affordable Care Act”, the Government Healthcare Plan expands access to methods of contraception for its entire population of reproductive age, free of charge. The new guidelines
                      for access to these methods are detailed below. These guidelines took effect on April 1, 2015 under the model of contracting with insurers for the different healthcare regions established by the ASES.

                  

                  

                  The services for accessing and dispatching contraceptives will be provided by the family planning clinics contracted for these
                      purposes and established in the different municipalities of the regions of the Government Healthcare Plan.

                  

                  

                  The following methods of contraception will



                        be provided according to the different covered categories:

                   

                      

                

                	
                        
                          Category

                        

                      	
                        
                          Brand Name

                        

                      	 	
                        
                          Dispatch

                        

                      	 	
                        
                          Limitations

                        

                      
	
                        
                           

                           

                           

                          Birth control pills

                        

                      	
                        
                           

                           

                          Lutera,

                          Ortho Micronor,

                          Cyclen, Tri-cyclen/ Tri-

                          Sprintec,

                          Ortho-Tri Cyclen Low

                        

                      	 	
                        
                           

                          Three packets for

                          ninety days with three

                          refills, one year

                          covered without need for medical evaluation or new prescription.

                        

                      	 	
                        
                          Active smoker for over 35 years

                          Diabetes for over 20 years

                          Symptomatic gallbladder disease

                          Liver disease

                          Stroke

                          History of thrombophlebitis

                          Irregular blood pressure

                          Myocardial infarction

                          History of breast cancer

                        

                      
	
                        
                           

                           

                           

                          Hormonal Injection

                        

                      	
                        
                           

                           

                           

                          Depo-Provera

                        

                      	 	
                        
                           

                          Three packets for ninety days with three refills, one year covered without need for medical evaluation or new prescription.

                        

                      	 	
                        
                          No more than two (2) consecutive years

                          Active smoker for over 35 years

                          Diabetes for over 20 years

                          Symptomatic gallbladder disease

                          Liver disease

                          Stroke

                          History of thrombophlebitis

                        

                      


                
                  

                  

                

                	 	
                        

                      


                
                   

                    

                  #1571 Alda Street Urb. Caribe San Juan Puerto Rico 00926-2706

                  PO Bo 195661 San Juan, PR 00919-5661

                  Tel: 787-474-3300 Fax: 787-474-3345

                   

                    

                  
                    
                      


                  

                  
                    
                      
                        
                          
                            
                              
                                [CERTIFIED TRANSLATION]

                              

                            

                          

                        

                      

                    

                  

                  

                  

                  Normative Letter 15-1012 Amended

                  (To amend Normative Letter 15-03-25-A and Normative Letter 15-03-25-B)

                  -2-

                  

                  

                

                	 	 	 	
                        
                          Irregular blood pressure

                          Myocardial Infarction

                          History of breast cancer

                        

                      
	
                        
                          Intrauterine

                          Device

                          (Copper T)

                        

                      	
                        
                           

                          DIU-Paragard

                        

                      	
                        
                           

                          One every 10 years

                        

                      	
                        
                          Abnormal Pap

                          Positive for venereal diseases

                          Wilson’s Disease

                        

                      


                
                  

                  

                  The following methods of contraception are available through the contracted planning clinics, however, they are not covered by the Government Healthcare Plan.

                  

                  

                

                	
                        
                          Category

                        

                      	
                        
                          Brand Name

                        

                      	
                        
                          Dispatch

                        

                      	
                        
                          Limitations

                        

                      
	
                        
                          Barrier Method

                        

                      	
                        
                          Latex condom, with spermicide

                        

                      	
                        
                          Must be paid for by the insured.

                        

                      	
                        
                          Latex or spermicide allergy

                        

                      
	
                        
                           

                           

                           

                           

                          Emergency

                          Methods

                        

                      	
                        
                           

                           

                           

                           

                          Plan B

                        

                      	
                        
                           

                           

                           

                           

                          Must be paid for by the insured.

                        

                      	
                        
                          Body weight greater than 164 lbs

                          Active smoker for over 35 years

                          Diabetes for over 20 years

                          Symptomatic gallbladder disease

                          Liver disease

                          Stroke

                          History of thrombophlebitis

                          Irregular blood pressure

                          Myocardial infarction

                          History of breast cancer

                        

                      


                
                  

                  

                  *The ASES will periodically evaluate the cost-effectiveness of the available methods in order to maintain the
                      viable options for the populations served. Any change in product will be notified to the participating providers in a normative letter.

                  

                  

                  Attachment 1 details the protocol
                      for referrals to family planning clinics, including the referral form required to refer the insured who qualify and wish to access the methods of contraception.

                  

                  

                  We request the cooperation of all providers in order to comply with the normative [letter].

                  

                  

                  Cordially,

                  [signed]

                  Sandra V. Peña Pérez, PT, MHSA

                  Deputy Executive Director

                  

                  

                

                
                  
                    
                      	c	
                              Atty. María del Carmen Rosario

                            


                    

                  

                  Director Office of Legal Affairs / Compliance and Clinical Affairs Office

                

                
                  

                  

                

              

              

              

               

            

          

        

      

    

  








  
    
       Attachment 14

       

      

      Puerto Rico Government

      Puerto Rico Health Insurance Administration

      

      

      Guidelines for the Development of Program

      Integrity Plan

      

      

      2018 – 2021

      

      

      (This document is to be used by all Contractors participating in the Government Health Plan (GHP) of Puerto Rico. The purpose of this document is to
          assist Contractors as they formulate their own GHP Program Integrity Plans.)

       

      

      
        
          


      

      
      TABLE OF CONTENTS

      

      

      	
              Topic

            	
              Page

            
	
              Medicaid Program Integrity Requirements

            	
              4-5

            
	
              Introduction, Program Integrity Basis and Scope, Regulation Citations & Overall
                  Requirements

            	
              6-7

            
	
              Definitions

            	
              7-10

            
	
              Program Integrity Plan

            	
              11

            
	
              Guidelines for Sub-Parts A, B & E

            	 
	
              Sub-Part A: Fraud Detection and Investigation Program

            	
              12-29

            
	 	
              PI A001: State plan requirement. 42 CFR 455.12

              PI A002: Methods for identification, investigation, and referral. 42 CFR 455.13, 42 CFR

              438.608(a)(1)(vii), 42 CFR 438.608(a)(7)

              PI A003: Preliminary investigation. 42 CFR 455.14, 42 CFR 438.608(a)(1)(vii)

              PI A004: Full investigation. 42 CFR 455.15, 42 CFR 438.608(a)(1)(vii)

              PI A005: Resolution of full investigation. 42 CFR 455.16, 42 CFR 438.608(a)(1)(vii)

              PI A006: Reporting requirements. 42 CFR 455.17

              PI A007: Provider's statements on claims forms. 42 CFR 455.18

              PI A008: Provider's statement on check. 42 CFR 455.19

              PI A009: Enrollee verification procedure. 42 CFR 455.20, 42 CFR 438.608(a)(5)

              PI A010: Cooperation with State Medicaid Fraud Control Units. 42 CFR 455.21, 42 CFR 438.608(a)(7)

              PI A011: Suspension of payments in cases of fraud. 42 CFR 455.23, 42 CFR 438.608(a)

            	 
	 	 	 
	
              Sub-Part B: Disclosure of Information by Providers

            	
              30-36

            
	 	
              PI B001: Purpose. 42 CFR 455.100

              PI B002; Definitions. 42 CFR 455.101

              PI B003: Determination of ownership or control percentages. 42 CFR 455.102, 42 CFR 438.608(b)

              PI B004: State Plan requirements. 42 CFR 455.103

              PI B005: Disclosure of Information by Providers and Fiscal Agents. 42 CFR 455.104, 42 CFR 438.608(b)

              PI B006: Disclosure by providers: Information related to business transactions. 42 CFR 455.105, 42 CFR
                  438.608(b)

              PI B007: Disclosure by providers: Information on persons convicted of crimes. 42 CFR 455.106, 42 CFR
                  438.608(b)

            	 
	 	 	 
	
              Sub-Part E: Provider Screening and Enrollment

            	
              37-40

            


      

      

      
        2

        
          


      

      	 	
              PI E001: Termination or denial of enrollment. 42 CFR 455.416

              PI E002: Reactivation of provider enrollment. 42 CFR 455.420

              PI E003: Appeals rights. 42 CFR 455.422

              PI E004: Criminal background checks. 42 CFR 455.434

              PI E005: Federal database checks. 42 CFR§ 455.436, 42 CFR 438.608(b)

            	 
	
              Other

            	 
	
              State Medicaid Directors Letter (SMDL) #09-001

            	
              40

            


      

      

      
        3

        
          


      

      The Contractor shall comply with the following Medicaid Program
            Integrity requirements:

      

      

      
        
          	

                	A.	
                  Sixty (60) Calendar Days after the date of execution of the GHP Contract, the Contractor must submit to the ASES Compliance Office a copy of the policies and procedures
                      for (i) identifying and tracking potential provider fraud cases, (ii) conducting preliminary and full investigation, and (3) referring cases of suspected fraud to an appropriate law enforcement agency. This Compliance Plan shall be
                      developed in accordance with 42 CFR 438.608 and Section 13.2 of the Contract.

                


        

      

      

      

      
        
          	

                	B.	
                  On a quarterly basis, each Contractor must submit to the ASES Compliance Office a report with the following information for the most recent quarter: (i) a list of
                      preliminary and full investigations conducted and the results of such investigations, (ii) a list of all audits performed and any audit findings, (iii) a list of any administrative actions issued against Contractor, Subcontractors or
                      Providers, (iv) a list of any overpayments and provider referrals referred to the Department of Justice or Medicaid Fraud Control Unit. If there are no such items to report, submit a certification signed by the Compliance Director and
                      the Authorized Certifier attesting to that fact.

                


        

      

      

      

      
        
          	

                	C.	
                  On a quarterly basis, each Contractor must submit to the ASES Compliance Office a report with the following information: (i) a list of fraud investigations pending but
                      not yet initiated, (ii) a list of fraud investigations currently in progress, and (iii) a list of completed fraud investigations. If there are no such items to report, submit a certification signed by the Compliance Director and the
                      Authorized Certifier attesting to that fact.

                


        

      

      

      

      
        
          	

                	D.	
                  Each Contractor shall Immediately notify ASES of any suspected or confirmed instances of provider fraud, waste or abuse or enrollee abuse or neglect so that such cases
                      can be referred to the appropriate federal or state agency, including but limited to the U.S. Department of Justice, the Office of Inspector General of the U.S. Department of Health and Human Services, or the Medicaid Fraud Control
                      Unit.

                


        

      

      

      

      
        
          	

                	E.	
                  Each Contractor must submit to the ASES Compliance Office a certification signed by the Compliance Director and the Authorized Certifier indicating that any full
                      investigations were conducted in accordance with 42 CFR 455.15.

                


        

      

      

      

      
        
          	

                	F.	
                  Each Contractor must notify ASES within two (2) Business Days to notify ASES of any adverse or negative action that the Contractor has taken with regard to a network
                      provider application (upon initial application or application renewal), or any other action that limits the ability of providers to participate in the network or program, as set forth in Section 13.5.11 of the GHP Contract.

                


        

      

      

      

      
        
          	

                	G.	
                  Each Contractor must ensure prompt terminations of inactive Providers due to inactivity in the past 12 months.

                


        

      

      

      

      
        
          	

                	H.	
                  Each Contractor must assist in the Medicaid Provider Enrollment process as necessary to validate information submitted by providers. This assistance may include, but is
                      not limited to, the following actions as required of all Contractors:

                


           

          

        

      

      
        4

        
          


      

      
        
          	

                	1.	
                  Each Contractor must review the credentialing forms of all providers and any subcontractors performing services under the GHP Contract to ensure that any disclosures
                      required by 42 CFR 455.104 are included.

                


        

      

      

      

      
        
          	

                	2.	
                  Each Contractor must ensure all Provider Contracts incorporate appropriate language with regard to the ownership of, and any significant business transactions with,
                      subcontractors to ensure that the disclosures required by 42 CFR 455.105 will be made. Each Contractor must also request that providers complete a business transactions form and verify compliance with this regulation.

                


        

      

      

      

      
        
          	

                	3.	
                  Each Contractor must establish a method to capture criminal convictions and other adverse actions for any individuals or entities with ownership and control interests in
                      the provider, as well as for any managing employees of the provider, to ensure that the disclosures required by federal regulation 42 CFR 455.106 have been made.

                


        

      

      

      

      
        
          	

                	4.	
                  The Contractor must develop and implement procedures to ensure that such convictions and other actions identified during the Contractor’s credentialing and contracting
                      process are reported Immediately to ASES in accordance with GHP contract requirements. Copies of such procedures shall be submitted to the ASES Compliance Office.

                


        

      

      

      

      
        
          	

                	5.	
                  Each Contractor must submit to the ASES Compliance Office a certification signed by the Compliance Director and the Authorized Certifier certifying all of the above.

                


        

      

      

      

      
        
          	

                	I.	
                  Each Contractor must comply requirements set forth in 42 CFR 455.20 and 42 CFR 438.608(a)(5) to ensure that services represented to have been delivered by network
                      providers were in fact received by enrollees. The Contractor shall document in a quarterly report compliance with these regulations.

                


        

      

      

      

      
        
          	

                	J.	
                  Each Contractor shall conduct a risk assessment of the Contractor’s various Fraud, Waste, and Abuse processes. The risk assessment shall include a listing of the
                      Contractor’s top three (3) vulnerable areas and outline action plans to mitigate risks.

                


           

          

        

      

      
        5

        
          


      

      Introduction

      

      

      Under the authority of Sections 1902(a)(4), 1903(i)(2), and 1909 of the Social Security Act the Medicaid Program must have a program to detect and
          investigate fraud, waste and abuse. Medicaid Managed Care Organizations (hereinafter “Contractors”) have similar responsibilities as set forth in 42 CFR 438.608.

      

      

      The Puerto Rico Government, the Department of Health, and the Medicaid Office, acting as the single state agency, are responsible for the management of
          the Medicaid and SCHIP grant funds. These funds are transferred to the Puerto Rico Health Insurance Administration (ASES), and are combined with state funds to provide health benefits coverage to the medically indigent population through
          contracts with health plans. Acting as a sub-grantee to the Puerto Rico Medicaid Program, ASES establishes contracts with Contractors and other organizations to facilitate enrollee access to covered services through provider networks.

      

      

      Program Integrity Program Basis and Scope

      

      

      This document sets forth guidelines with minimum criteria for the compliance with Program Integrity Policies and Procedures that each Contractor must
          have for the administration of the Government Health Plan as set forth in Article 13 of the Contract. This document includes guidelines for the elaboration of the three (3) main sections in the Contractors’ Program Integrity Plan (PIP):

      

      

      1.  Fraud Detection and Investigation

      2.  Providers and Fiscal Agents Disclosure of Information on Ownership and Control

      3.  Program Integrity Program

      

      

      Regulation Citation

      

      

      Sections 1902(a)(4) [42 USC 1396(a)(4)1, (61)2, (64)3]; 1903(i)(2) [42 USC 1396(b)(i)(2)]4 1936[42 USC 1396u-6]5) and regulations at
          42 CFR Parts 438, 455, 1001 and 1002.

      

      

      Overall Requirement

      

      

      In accordance with ASES’s obligations under 42 CFR 455.436 and the CMS State Medicaid Director Letter #09-001, all Contractors and Providers are required
          to regularly perform the federal database searches set forth at 42 CFR 455.436 upon enrollment and re-enrollment as well as on a monthly basis thereafter.

      

      

      Contractors are also required to notify ASES, which shall in turn notify the Department of Health and Human Services-Office of Inspector General
          (HHS-OIG), of any action taken to limit the ability of an individual or entity to participate in its program, as stated in 42 CFR 1002.3.

      

      

      Each Contractor must consult ASES prior to taking any proposed actions on a Provider Contract based on program integrity concerns. Contractors shall
          report each provider whom it proposes to disenroll, suspend, terminate or otherwise restrict from participation in its provider network based on program integrity concerns.
          Contractors are required to report such affected providers directly to ASES for potential referral to HHS-OIG and the Medicaid Fraud Control Unit.

      
        6

        
          


      

       Definitions

      

      

      Abuse means provider practices that are inconsistent with
          sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.
          It also includes recipient practices that result in unnecessary cost to the Medicaid program.

      

      

      Agent means any person who has been delegated the authority to
          obligate or act on behalf of a provider.

      

      

      Contract means The written agreement between ASES and the
          Contractor for the GHP; comprised of the Contract, any addenda, appendices, attachments, or amendments thereto.

      

      

      Contractor means the Managed Care Organization that is a Party
          of this Contract, licensed as an insurer by the Puerto Rico Commissioner of Insurance (“PRICO”), which contracts hereunder with ASES under the GHP program for the provision of Covered Services and Benefits to Enrollees on the basis of PMPM
          Payments.

      

      

      Conviction or Convicted means that a judgment of conviction has been entered by a Federal, State, or local court, regardless of whether an appeal from that judgment is pending.

      

      

      Disclosing Entity means a Medicaid provider (other than an
          individual practitioner or group of practitioners) or a fiscal agent.

      

      

      Exclusion means that items or services furnished by a specific
          provider who has defrauded or abused the Medicaid program will not be reimbursed under Medicaid.

      Fraud means an intentional deception or misrepresentation made
          by a person with the knowledge that the deception could result in some unauthorized benefit for him/her or some other person. It includes any act that constitutes fraud under applicable Federal or Puerto Rico law.

      

      

      Furnished refers to items and services provided directly by,
          or under the direct supervision of, or ordered by, a practitioner or other individual (either as an employee or in his or her own capacity), a provider, or other supplier of services. (For purposes of denial of reimbursement within this part, it
          does not refer to services ordered by one party but billed for and provided by or under the supervision of another.)

      

      

      Group of practitioners means two or more health care
          practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).

      

      

      Immediately means within twenty-four (24) hours.

       

        

      
        7

        
          


      

      Indirect ownership interest means an ownership interest in an
          entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity.

      

      

      Managing employee means a general manager, business manager,
          administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

      

      

      Other disclosing entity means any other Medicaid disclosing
          entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or XX of the Act. This includes:

      

      

      
        
          	

                	(a)	
                  Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance
                      organization that participates in Medicare (title XVIII);

                


        

      

      

      

      
        
          	

                	(b)	
                  Any Medicare intermediary or carrier; and

                


        

      

      

      

      
        	 	
                (c)

              	
                Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related
                    services for which it claims payment under any plan or program established under title V or title XX of the Act.

              


      

      

      

      Person with an ownership or control interest means a person or
          corporation that—

      

      

      
        
          	

                	(a)	
                  Has an ownership interest totaling 5 percent or more in a disclosing entity;

                


        

      

      

      

      
        
          	

                	(b)	
                  Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;

                


        

      

      

      

      
        	 	
                (c)

              	
                Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;

              


      

      

      

      
        	 	
                (d)

              	
                Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that
                    interest equals at least 5 percent of the value of the property or assets of the disclosing entity;

              


      

      

      

      
        	 	
                (e)

              	
                Is an officer or director of a disclosing entity that is organized as a corporation; or

              


      

      

      

      
        	 	
                (f)

              	
                Is a partner in a disclosing entity that is organized as a partnership.

              


      

      

      

      Provider or Practitioner means a physician or other individual
          licensed under Puerto Rico law to practice his or her profession.

      

      

      Program Integrity Plan (PIP) means the program, processes and
          policies that each Contactor has implemented to comply with integrity requirements. The PIP shall be developed in accordance with federal regulations and these guidelines.

       

        

      
        8

        
          


      

      Provider Contract means any written contract between the
          Contractor and a Provider that requires the Provider to order, refer, provide or render Covered Services under this Contract. The execution of a Provider Contract makes the Provider a Network Provider.

      

      

      Significant business transaction means any business
          transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider's total operating expenses.

      

      

      Subcontractor means—

      

      

      (a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities
          of providing medical care to its patients; or

      

      

      (b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real
          property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.

      

      

      Supplier means an individual, agency, or organization from
          which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).

      

      

      Stakeholder means the single state agency, the sub-grantee and
          all organizations contracted to provide health care management and services to Medicaid beneficiaries.

      

      

      Suspension means that items or services furnished by a
          specified provider who has been convicted of a program-related offense in a Federal, State, or local court will not be reimbursed under Medicaid.

      

      

      Termination means—

      

      

      (1) For a—

      

      

      (i)  Medicaid or CHIP provider, a State Medicaid program or CHIP has taken an action to revoke the provider's billing privileges, and the provider has
          exhausted all applicable appeal rights or the timeline for appeal has expired; and

      

      

      (ii) Medicare provider, supplier or eligible professional, the Medicare program has revoked the provider or supplier's billing privileges, and the
          provider has exhausted all applicable appeal rights or the timeline for appeal has expired.

      

      

      (2)(i) In all three programs, there is no expectation on the part of the provider or supplier or the State or Medicare program that the revocation is
          temporary.

      

      

      (ii) The provider, supplier, or eligible professional will be required to reenroll with the applicable program if they wish billing privileges to be
          reinstated.

      

      

      (3) The requirement for termination applies in cases where providers, suppliers, or eligible professionals were terminated or had their billing
          privileges revoked for cause which may include, but is not limited to—

       

        

      
        9

        
          


      

      (i)  Fraud;

      (ii) Integrity; or

      (iii) Quality.

      

      

      Wholly owned supplier means a supplier whose total ownership
          interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider 11

       

          

      
        10

        
          


      

      
        Program Integrity Plan
          


      

      

      

      Fraud Detection and Investigation (Sub Part A) represents the first element that must be included as part of program integrity activities. The
          Contractors must also comply with required elements for disclosure of information by providers and Subcontractors (Sub Part B) as well as provider screening and enrollment (Sub Part E).

      

      

      All Contractors, and any Subcontractors delegated responsibility for the coverage of services and payment of claims under the GHP Contract must have
          dedicated staff, resources, and policies and procedures to detect and prevent Fraud, waste, and Abuse in accordance with Federal and Puerto Rico regulations. Contractors shall have written policies setting forth (i) methods for the
          identification, investigation and referral of suspected cases; (ii) procedures to perform preliminary investigations and full investigations; (iii) procedures to address the resolution of full investigations; (iv) procedures to comply with
          reporting requirements; and (v) policies for assessing provider’s statements and attestations, such as those included in any reports, claims or other submissions. These policies and practices must also address cooperation with the Puerto Rico
          Government and the Medicaid Fraud Control Unit as well as procedures to withhold payments in cases of credible allegations of Fraud. Contractors are required to submit to the ASES Compliance Office a copy of their PIPs for evaluation by August
          12, 2018 and annually thereafter. The PIP shall be developed in accordance with 42 CFR 438.608 and the guidelines provided herein.

      

      

      Each guideline includes the name or title of the guideline, scope, purpose, process and general information. This document shall be incorporated as
          Attachment 14 to the GHP Contract each Contractor holds with ASES.

      

      

      The Program Integrity Plan (PIP) of each Contractor shall be monitored by ASES on a periodic basis. ASES shall reserve the right to request changes to
          the Contractor’s PIP as necessary to address any actual or potential non-compliance or program integrity issues.

       

        

      
        11

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SA1

            	 	
              State Plan Requirements

            	 
	 	
              Scope

            	 	
              Applies to Single State Agency (Medicaid Office) and Sub-Grantee (ASES)

            	 
	 	
              Purpose

            	 	
              This guideline describes the commitment of the single state agency and the sub-grantee in adhering to the statute rules and regulations and the
                  implementation of a Program Integrity Plan for the Medicaid Program.

            	 
	 	
              General

            	 	
              The grantee and the sub-grantee will abide by the following guidelines on how to manage the integrity program activities in the whole service
                  delivery system.

            	 
	 	
              Guidelines

            	 	
              1.   The single
                  state agency and sub-grantee acknowledge the need to adhere to a Medicaid Integrity Program as defined in the state plan.

              2.   The
                  grantee and sub-grantee agree to establish a structure to manage Program Integrity Plan (PIP) activities.

              3.   The
                  organization structure to perform above mentioned activities is furnished with a Program Integrity Plan (PIP) of members representing the single state agency, the sub-grantee and each contracted organization.

              4.   The PIP
                  leads the efforts toward achieving compliance with state plan requirements regulation by establishing the minimum criteria of required PI program policies and procedures.

              5.    PIP
                  monitors Contractor’s PIP compliance on regular basis.

              6.   The PIP
                  chairman develops the meeting calendar each year, develops the committee agenda, and keeps minutes of all meetings and call for meetings.

              7.   Sub-grantee




                  facilitates the development and update of the Program Integrity Plan guidelines, reports and notification to guarantees its distribution and final acceptance among contracted companies and regulatory agencies.

              8.   Sub-grantee

                  review performance of each organization, level of adherence to policies and recommend corrective action plan development for areas that must be improved.

              9.   Sub-grantee




                  develops an annual report that is to be submitted to the Medicaid Integrity Group and to the CMS Region 2. The report will include the areas and companies reviewed during the period and the findings of each company, if any.

              10. The PIP
                  provides guidance and guarantees that each contracted companies develop and implement policies and procedures in their organizations.

              11. The PIP
                  guidelines are integrated into each Contractor’s Program Integrity Plan Policies and Procedures; and are assumed as a standard operating procedure to prevent fraud, waste and abuse in the management of Medicaid funds and health plan
                  benefit coverage for the indigent population.

            	 


      

      

      
        12

        
          


      

      Government of Puerto Rico

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SA02

            	 	
              Methods for identification, investigation and referral

            	 
	 	
              Scope

            	 	
              Grantee, Sub-grantee and Contractors

            	 
	 	
              Purpose

            	 	
              This guide describes what the Contractor must include in their PIP to guarantee the use of methods for the identification, investigation, and
                  referral of suspected fraud and abuse cases.

            	 
	 	
              General

            	 	
              The Contractor must establish methods for the identification, investigation and referral of suspected cases, that guarantees the use of a
                  consistent and objective approach that does not infringe on the rights of the persons involved to address fraud, waste and abuse when performing PIP activities.

            	 
	 	
              Guidelines

            	 	
              The PIP must include an explicit definition of methods to perform identification of cases suspected of fraud, waste and abuse

              a.    what is fraud, waste and abuse

              b.    how is detected fraud, waste
                  and abuse

              c.    who performs the
                  identification

              d.    when preliminary, full
                  investigation and resolutions are done

               

              The PIP must have a detailed process to perform investigations on each suspected case guaranteeing objective methods to identify potential cases
                  and perform investigations

              a.    open and documents the case

              b.    initiate data gathering
                  process

              c.    follow a protocol to verify
                  information

              d.    issue a report of findings

              e.    refer case to next level

              f.     close the case

               

              The PIP must include a variety of methods for the identification, investigation and referral of suspected cases, accepted in the industry and
                  without infringing provider or beneficiary rights. Methods might include

              a.    electronic data exchanges

              b.    data mining

              c.    claims registries /
                  reconciliation

              d.    targeted procedures

              e.    profiling

               

              The PIP must include a systematic approach of data analysis by:

              a.    flagging the case

              b.    identifying cause for flagging (i.e. over-under payment)

              c.    establishing actions and sanctions

               

                

              The PIP must have procedures in place for referring suspect fraud cases to ASES including at a minimum:

            	 


       

      

      
        13

        
          


      

      	 	
              Guidelines

            	 	
              a.   an
                  organizational structure to address the reports.

              b.   a due
                  process that includes but is not limited to: case identification, complete record with supporting materials, notification letter to suspect, notification letter to single state agency, documentation of entrance and exit interviews, and if
                  necessary copy of referral letters and case resolution letter to and from legal authorities.

              c.   a
                  flowchart to work in cooperation with the grantee and sub-grantee as well as with the state legal authorities such as: Contractor’s Legal Affairs Department, ASES, Single State Agency – Department of Health Legal Department, State
                  Department of Justice, and the Office of Inspector General.

              d.   a follow
                  up process to work with legal authorities each case of fraud, waste and abuse suspicion until final disposition and notification to the single state agency.

               

            	 


      

      

      
        14

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SA03

            	 	
              Preliminary Investigations

            	 
	 	
              Scope

            	 	
              Grantee, Sub-grantee and Contractors

            	 
	 	
              Purpose

            	 	
              To provide guidance on how to perform a preliminary investigation when the agency or Contractor receives a complaint of fraud or abuse from any
                  source or identifies any questionable practices.

            	 
	 	
              General

            	 	
              The Contractor must conduct a preliminary investigation to determine whether there is sufficient basis to warrant a full investigation.

            	 
	 	
              Guidelines

            	 	
              The PIP defines a standard operating procedure to complete a preliminary investigation of all suspect cases of fraud, waste and abuse.

               

              The PIP identifies the requirements to complete the preliminary investigation when evaluating providers and beneficiaries. It should include at
                  least:

              a.    Source of information

              b.    Identification method (how the
                  case is detected)

              c.    Cause for investigation

              d.    Case documentation

              e.    Analysis of Data and documents

              f.     Report of Findings

              g.    Action Taken (Recommended
                  Action)

               

              The PIP includes a mechanism to keep tracking and documentation of all preliminary investigations and results.

               

              The PIP establishes a mechanism to report preliminary investigations activity to the sub-grantee (ASES) which will be in charge of reporting
                  activity to the single state agency (Medicaid Office) or other applicable federal and state agencies.

            	 


      

      

      
        15

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

      

      

      	 	
              Title SA04

            	 	
              Full Investigations

            	 
	 	
              Scope

            	 	
              Grantee, Sub-grantee and Contractors

            	 
	 	
              Purpose

            	 	
              To provide guidance and minimum set of elements in the PIP to perform full investigations on incidents of fraud and abuse.

            	 
	 	
              General

            	 	
              If the findings of a preliminary investigation give the agency reason to believe that an incident of fraud or abuse has occur in the Medicaid
                  program, the organization must take the appropriate actions.

            	 
	 	
              Guidelines

            	 	
              The PIP must define the process to conduct a full investigation and specify when a case requires the full investigation. Full investigations must
                  be done in accordance with federal regulation and based in the company written policy. The company must submit copy of the written policies to ASES for review and approval.

               

              The PIP must define the process to refer the cases to the Contractor’s fraud liaison (i.e. Contractor’s compliance office), to the single state
                  agency (Medicaid Office), and to ASES which will be in charge of referring the case to the appropriate law enforcement agency when there is a reason:

              a.    to suspect a provider has
                  engaged in fraud or abuse of the program.

              b.    to suspect a recipient is
                  defrauding the program.

              c.    to suspect a recipient has
                  abused the Medicaid program.

               

              The PIP must have a mechanism to keep tracking and documentation of all full investigations performed in progress and closed.

               

              The PIP must have a mechanism to report to the sub-grantee (ASES) investigations in progress, conducted and results.

            	 


      

      

      
        16

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

      

      

      	 	
              Title SA05

            	 	
              Resolution of full investigation

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contractors

            	 
	 	
              Purpose

            	 	
              To provide guidance on minimum actions that must be taken in order to complete the process of a full investigation.

            	 
	 	
              General

            	 	
              The full investigations must continue until the cases are referred, solved or closed.

            	 
	 	
              Guidelines

            	 	
              The PIP must include the process to guarantee that a full investigation must continue until:

              a.    appropriate legal action is
                  initiated.

              b.    the case is closed or dropped
                  because of insufficient evidence to support the allegations of fraud or abuse.

              c.    the matter is resolved between
                  the organization and the provider or recipient

              ✓ the resolution may include but is not limited to:

              1)   Sending a
                  warning letter to the Provider or recipient, giving notice that continuation of the activity in question will result in further action;

              2)  Suspending
                  or terminating the Provider from network participation (if not suspended or terminated from participation in the Medicaid program as determined by ASES);

              3)    Seeking
                  recovery of payments made to the Provider; or

              4)    Imposing
                  other sanctions provided under the Contractor’s PIP plan.

               

                

              The PIP must guarantee that there is a mechanism to keep tracking and documentation of all full investigations until resolution.

            	 


      

      

      
        17

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SA06

            	 	
              Reporting Requirements

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contracted Organizations

            	 
	 	
              Purpose

            	 	
              To provide guidance on how to adhere to a minimum set of elements that must be included in the process to report fraud and abuse information to
                  the appropriate organizations officials.

            	 
	 	
              General

            	 	
              The Contractor must submit a progress report the fraud and abuse information and statistics to ASES on quarterly basis.

            	 
	 	
              Guidelines

            	 	
              The PIP must describe the mechanism to report fraud and abuse data to the appropriate fraud liaison, sub-grantee (ASES) and grantee (Office for
                  the Medically Indigent).

               

              The PIP progress report must include at least the following information:

              a.    # of
                  complaints on fraud and abuse received.

              b.    # of
                  complaints that warrant preliminary investigation.

              c.    Detailed
                  information for each case of suspected provider fraud and abuse that warrants a full investigation:

              ✓       Provider’s




                  name and id number

              ✓       Source
                  of the complaint

              ✓       Type of
                  the provider

              ✓       Nature
                  of the complaint

              ✓       Estimate




                  amount of money involved

              ✓       Legal and
                  administrative disposition of the case and actions taken by the law enforcement officials to whom the case has been referred.

               

              Suspected fraud cases must be report immediately in a written format to ASES Compliance Office or Office of Program Integrity.

               

              The PIP reports must be submitted in electronic format to facilitate its inclusion in the Puerto Rico Government Medicaid Program PI Annual
                  Report.

            	 


      

      

      
        18

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

      

      

      	 	
              Title SA07

            	 	
              Provider’s statements on claims forms

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contractors

            	 
	 	
              Purpose

            	 	
              To provide guidance on how to comply with regulation on Provider’s statements on claims forms.

            	 
	 	
              General

            	 	
              The Contractor must provide that all provider claims forms be imprinted in boldface type with the following statement, or with alternate wording
                  that is approved by the CMS Regional Office.

            	 
	 	
              Guidelines

            	 	
              The PIP must include that providers are required to attest in the claim forms that they agree with the following statement:

              

              

              ü “This is to certify that the
                  foregoing information is true accurate and complete”.

              ü “I understand that payment of
                  this claim will be from federal and state funds and that any falsification or concealment of a material fact maybe prosecutes under federal and state laws”.

              

              

              For electronic claims, providers must attest that they agree with the following statements:

              

              

              ü “This is to certify the
                  truthfulness of the foregoing information and certify that is true, accurate, complete and that the service was provided”.

              

              

              The statements may be printed above the claimant’s signature or, if they are printed on the reverse of the form, a reference to the statements
                  must appear immediately preceding the claimant’s signature. 

                

            	 


      

      

      
        19

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

      

      

      	 	
              Title SA08

            	 	
              Provider’s statements on check

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contracted Organizations

            	 
	 	
              Purpose

            	 	
              To provide guidance on how to comply with regulation on provider’s statements on check.

            	 
	 	
              General

            	 	
              The Contractor may print the following wording above the claimant’s endorsement on the reverse of checks or warrants payable to each provider.

            	 
	 	
              Guidelines

            	 	
              The PIP must include that Providers are required to attest (in addition to the statements required in Providers claims form) that they agree with
                  the following statement either by having it written on checks or temporarily in a legal document as an affidavit:

               

              ü “I understand in endorsing or
                  depositing this check that payment will be from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws”.

               

              The above attestation must be included in all electronic and checks payment.

               

              The PIP must indicate frequency and responsible for conducting spot checks to guarantee the Contractor complies with the Provider’s statements
                  and / or the Provider signature appears on a legal document attesting compliance.

            	 


      

      

      
        20

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SA09

            	 	
              Enrollee verification procedure

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contracted Organizations

            	 
	 	
              Purpose

            	 	
              To verify that the services listed on claims forms have been rendered.

            	 
	 	
              General

            	 	
              The organization must have a method for verifying with Enrollees whether services billed by providers were received.

            	 
	 	
              Guidelines

            	 	
              The PIP must include a description of how the Contractor performs claims matches with medical records to guarantee adequacy of billing.

               

              The PIP must define the mechanism to monitor frequency of encounters and services rendered to Enrollees billed by providers.

               

              The PIP will provide periodic updates on reconciliation findings report to the sub-grantee and grantee.

               

              ASES will select a sample to perform independent reviews to verify that Enrollee’s services billed by providers (as well as encounters under
                  capitated environment) were indeed rendered. This review will be performed through confirmations with Enrollees.

            	 


      

      

      Note: All Contractors are required to comply with Law 114 which requires that the beneficiaries must receive an Evidence of Medical Benefits with a
          detailed of the services and expenses incurred during a quarter. ASES Compliance Office will review each Contractor’s compliance with Law 114.

       

        

      
        21

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018- 2021

      

      

      	 	
              Title SA10

            	 	
              Cooperation with Medicaid Fraud Control Units and/or law enforcement agencies

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contractors Organizations

            	 
	 	
              Purpose

            	 	
              To provide guidance on how to communicate findings and to cooperate with any Puerto Rico or federal law enforcement agency. To request that all
                  contracted companies must communicate preliminary findings to ASES.

            	 
	 	
              General

            	 	
              The Contractor must have a mechanism to provide information to the regulatory and legal authorities on cases, investigations, schemes and any
                  other activity where intention to commit fraud, abuse and waste of services occur.

            	 
	 	
              Guidelines

            	 	
              The PIP must demonstrate it has an effective mechanism to cooperate with the Medicaid Office, ASES, the Medicaid Fraud Control Unit as
                  well as with other program divisions in charge of preventing and prosecuting cases related to fraud, waste and abuse of services under the Medicaid program. To this end, ASES has established the Medicaid Integrity Group (MIG) with the
                  participation of the OIG and the Medicaid office.

               

              The PIP must establish a process to guarantee the organization complies with the following:

               

              ✓ All cases of suspected provider fraud are referred to the antifraud / integrity organization’s unit.

              ✓    If the
                  antifraud / integrity unit determines that it may be useful in carrying out the unit’s responsibilities, promptly comply with a request from the unit for –

               

              i.     Access
                  to, and free copies of, any records or information kept by the organization or its contractors;

              ii.   Computerized



                  data stored by the organization or its contractors. These data must be supplied without charge and in the form requested by the unit;

              iii.  Access to
                  any information kept by providers to which the organization is authorized access. In using this information, the unit must protect the privacy rights of recipients;

              ✓ Communicate to ASES (and other appropriate Federal and State agencies, as required) preliminary findings within 2 business days of completing the investigation; and

              ✓   On referral
                  from the unit, coordinate with ASES and the appropriate law enforcement agency before initiating any available administrative or judicial action to recover improper payments to a provider.

               

            	 


      

      

      
        22

        
          


      

      	 	 	 	
              The PIP must recommend the Contractor to have in the Provider’s Contract a disclaimer that as a contracted provider any data related to services
                  or payments provided must be available for review of the integrity staff.

               

                

            	 


       

      

      
        23

        
          


      

      Puerto Rico Government

      Program Integrity Plan –2018-2021

       

        

      	 	
              Title SA11

            	 	
              Suspension of payments in cases of potential fraud

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contracted Organizations

            	 
	 	
              Purpose

            	 	
              To provide guidance on elements to be considered when suspending payments to providers who committed fraud.

            	 
	 	
              General

            	 	
              The organization must suspend payments to providers as a mechanism to prevent wrong disbursement of payments when there is a credible allegation
                  of fraud for which an investigation is pending unless the agency has a good cause to not suspend payments or to suspend payment only in part.

            	 
	 	
              Guidelines

            	 	
              The PIP will establish a mechanism and adhere to the following elements concerning suspension of payments:

               

              (a)    Basis for suspension.

              ·     The State Medicaid
                  Agency (ASES) must suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending under the Medicaid program against an individual or entity unless the
                  agency has good cause to not suspend payments or to suspend payment only in part.

              ·    The State Medicaid Agency
                  (ASES) may suspend payments without first notifying the provider of its intention to suspend such payments.

              ·      A provider may request,
                  and must be granted, administrative review where State law so requires.

               

              Therefore, the Contractor must refer to ASES all suspected cases of fraud as indicated in item (d) below, in order for ASES
                  to make a determination related to the suspension of payment after the proper evaluation and in consultation with the applicable law enforcement agency, such as the Medicaid Fraud Control Unit. In addition, the Contractor must suspend
                  payments at the direction of ASES if ASES finds that a credible allegation of fraud exists for which an investigation is pending under the Medicaid program.

               

              (b)   Notice of suspension. If directed by ASES, the Contractor must send notice of its suspension of program payments within:

              ·     Five (5) days of taking
                  such action unless requested in writing by a law enforcement agency to temporarily withhold such notice.

              ·    Thirty (30) days if requested by law enforcement in writing to delay sending such notice, which request for delay may be renew in writing up to twice and in no event may exceed
                  ninety (90) days.

               

                

            	 


      

      

      
        24

        
          


      

      	 	

            	 	
              ·      The notice must include or
                  address all of the following:

              ü State that payments are being suspended in accordance with 42 CFR 455.23;

              ü Set forth the general
                  allegations as to the nature of the suspension action, but need not disclose any specific information concerning an ongoing investigation

              ü State that the suspension is
                  for a temporary period, as stated on 42 CFR 455.23(c) and cite the circumstances under which suspension will be terminated;

              ü Specify, when applicable, to
                  which type or types of Medicaid claims (capitation or claims) or business units of a provider suspension is effective.

              ü Inform the provider of the
                  right to submit written evidence for consideration by the agency.

              ü Set forth the applicable
                  administrative appeals process and corresponding citations to State law.

               

              (c)    Duration of suspension

              1)    All
                  suspension of payment actions under this section will be temporary and will not continue after either of the following:

              ü The agency or the prosecuting
                  authorities determine that there is insufficient evidence of fraud by the provider.

              ü Legal proceedings related to
                  the provider’s alleged fraud are completed.

              2)   It must be
                  documented in writing the termination of a suspension including, where applicable and appropriate, any appeal rights available to a provider.

               

              (d)   Referrals to the ASES, Medicaid, Medicaid Fraud Control Unit and OIG.

              (1) Whenever the Contractor investigation may lead to the initiation of a payment suspension in whole or part, the
                  Contractor must make a fraud referral to ASES who will notify the OIG and the Medicaid Fraud Control Unit and any other appropriate law enforcement agency as required by 42 CFR 455.23(d)

              (2) The fraud referral must meet all of the following requirements:

              ·         Be made in writing
                  and provided to ASES not later than the next two (2) Business Days after the Contractor determines that there is a potential fraud.

              ·          Conform to fraud
                  referral performance standards issued by the Secretary.

              ·         A recommendation
                  of the Contractor related to good cause not to suspend payments or to suspend payment only in part after evaluating the elements included in items (e) and (f) below.

            	 


      

      

      
        25

        
          


      

      	 	 	 	
              (3)(i) If the Medicaid Fraud Control Unit or other law enforcement agency accepts the fraud referral for
                  investigation, a payment suspension may be approved until such time as the investigation and any associated enforcement proceedings are completed.

              (ii) On a quarterly basis, the Contractor must request a certification from the Medicaid Fraud Control Unit or other law
                  enforcement agency that any matter accepted on the basis of a referral continues to be under investigation thus warranting continuation of the suspension.

              (4) If the Medicaid Fraud Control Unit or other law enforcement agency declines to accept the fraud referral for
                  investigation, an approved payment suspension may be discontinued by ASES unless ASES has alternative Federal or State authority by which it may impose a suspension or makes a fraud referral to another law enforcement agency. In that
                  situation, the provisions of paragraph (d)(3) of this section apply equally to that referral as well.

              (5) A decision to exercise the good cause exceptions in paragraphs (e) or (f) of this section not to suspend
                  payments or to suspend payments only in part does not relieve the Contractor of the obligation to refer any suspected case of fraud as provided in paragraph (d)(1) of this section.

              (e)   Good cause not to suspend payments. ASES may find that good cause exists not to suspend payments, or not to continue a payment suspension
                  previously imposed, to an individual or entity against which there is an investigation of a credible allegation of fraud if any of the following are applicable:

              (1) Law enforcement officials have specifically requested that a payment suspension not be imposed because such a
                  payment suspension may compromise or jeopardize an investigation.

              (2) Other available remedies can be implemented by Contractor more effectively or quickly protect Medicaid funds.

              (3) ASES determines, based upon the submission of written evidence by the individual or entity that is the subject
                  of the payment suspension, that the suspension should be removed.

              (4) Beneficiary access to items or services would be jeopardized by a payment suspension because of either of the
                  following:

              (i) An individual or entity is the sole community physician or the sole source of essential specialized services in
                  a community.

              (ii) The individual or entity serves a large number of recipients within a HRSA-designated medically underserved
                  area.

            	 


      

      

      
        26

        
          


      

      	 	 	 	
              (5) Law enforcement declines to certify that a matter continues to be under investigation per the requirements of
                  paragraph (d)(3) of this section.

              (6) ASES determines that payment suspension is not in the best interests of the Medicaid program.

              (f)   Good cause to suspend payment only in part. ASES may find that good cause exists to suspend payments in part, or to convert a payment
                  suspension previously imposed in whole to one only in part, to an individual or entity against which there is an investigation of suspected fraud if any of the following are applicable:

              (1) Recipient access to items or services would be jeopardized by a payment suspension in whole or part because of
                  either of the following:

              (i) An individual or entity is the sole community physician or the sole source of essential specialized services in
                  a community. (ii) The individual or entity serves a large number of recipients within a HRSA-designated medically underserved area.

              (2) ASES determines, based upon the submission of written evidence by the individual or entity that is the subject
                  of a whole payment suspension to the Contractor, that such suspension should be imposed only in part.

              (3)(i) The allegation of fraud focuses solely and definitively on only a specific type of claim or arises from only
                  a specific business unit of a provider; and

              (ii) Contractor documents in writing to ASES that a payment suspension in part would effectively ensure that
                  potentially fraudulent claims were not continuing to be paid.

              (4) Law enforcement, Medicaid Fraud Control Unit or OIG declines to certify that a matter continues to be under
                  investigation per the requirements of paragraph (d)(3) of this section.

              (5) ASES determines that payment suspension only in part is in the best interests of the Medicaid program.

              (g)    Termination


                  of Payment Suspension:

              1. Reasons for termination of payment suspension:

              a.   determination by the
                  Medicaid Fraud Control Unit that there is insufficient evidence of fraud by the provider

              i. law enforcement declination to investigate a fraud referral

              ii. discontinuance of a pending investigation

              b.   legal proceedings related
                  to the provider's alleged fraud are completed

              i. settlement

              ii. judgment

              iii. dismissal

            	 


      

      

      
        27

        
          


      

      	 	 	 	
              2. The following steps will be taken when the Payment Suspension process is to be discontinued:

              a.   ASES will notify the
                  entity in writing with effective date to end payment suspension

              b.   The entity must notify the
                  provider in writing of effective date to end payment suspension and will provide blind copies to previously identified parties.

              c.    The entity must take the
                  necessary action to remove the payment suspension.

              3. After payment suspension has ended, Contractor is responsible for monitoring claims to ascertain whether or not any
                  inappropriate payments are made or to identify aberrant billing patterns, in which case appropriate action will be initiated.

              4. Contractor must submit to ASES on a quarterly basis a report summarizing information on the following:

              a.    With regard to
                  recommended payment suspensions:

              1. The nature of the suspected fraud;

              2. The basis for the proposed suspension; and

              3. The outcome of implemented suspensions.

              b.     With regard to
                  situations in which Contractor recommends that good cause exists to not suspend payments, to suspend payments only in part, or to discontinue a payment suspension:

              1. The nature of the suspected fraud; and

              2. The nature of the good cause.

              (h)    Documentation and record retention. Contractor must meet the following requirements:

              (1) Maintain for a minimum of ten (10) years from the date of issuance all materials documenting the life cycle of a
                  payment suspension that was imposed in whole or part, including the following:

              (i) All notices of suspension of payment in whole or part.

              (ii) All fraud referrals to the Medicaid Fraud Control Unit or other law enforcement agency.

              (iii) All quarterly certifications of continuing investigation status by law enforcement.

              (iv) All notices documenting the termination of a suspension.

              (2)(i) Maintain for a minimum of ten (10) years from the date of issuance all materials documenting each instance where a
                  payment suspension was not imposed, imposed only in part, or discontinued for good cause.

              (ii) This type of documentation must include, at a minimum, detailed information on the basis for the existence of the good
                  cause not to suspend payments, to suspend payments only in part, or to discontinue a payment suspension and, where applicable, must specify how long the Contractor anticipates such good cause will exist.

            	 


      

      

      
        28

        
          


      

      	 	 	 	
              (3) Annually report to ASES summary information on each of following:

              (i) Suspensions of payment, including the nature of the suspected fraud, the basis for suspension, and the outcome of the
                  suspension.

              (ii) Situations in which the good cause existed to not suspend payments, to suspend payments only in part, or to discontinue
                  a payment suspension as described in this section, including describing the nature of the suspected fraud and the nature of the good cause.

            	 


      

      

      
        29

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SB12

            	 	
              Disclosure of Information by Providers and Fiscal Agents

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contracted Organizations

            	 
	 	
              Purpose

            	 	
              To provide definition of concepts in order to fully adhere to the regulation on providers control and ownership of facilities and on disclosure
                  of information on a provider's owners and other persons convicted of criminal offenses against Medicare, Medicaid, or the title XX services program.

            	 
	 	
              General

            	 	
              The Contractor must adhere to standard definitions when dealing with disclosure of information by providers and Subcontractors when establishing
                  mechanism to regulate providers’ control and ownership of facilities

            	 
	 	
              Guidelines

            	 	
              The PIP will adhere to the following definitions of concepts to keep consistency with federal regulation and application of law:

               

              Agent means any person who has been delegated the
                  authority to obligate or act on behalf of a Provider.

               

              Disclosing entity means a Medicaid Provider (other
                  than an individual practitioner or group of practitioners), or a fiscal agent.

               

              Other disclosing entity means any other Medicaid
                  disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the federal programs (Medicaid, CHIP, FQHCs). This includes:

               

              (a)       Any



                  hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII);

              (b)        Any



                  Medicare intermediary or carrier; and

              (c)        Any



                  entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under title V or title
                  XX of the Act.

               

              Fiscal agent means a contractor that processes or pays
                  vendor claims on behalf of the Medicaid agency.

               

              Group of practitioners means two or more health care
                  practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment).

               

              Indirect ownership interest means an ownership
                  interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity. The amount of indirect ownership
                  interest is determined by multiplying

               

              the percentages of ownership in each entity. For example, if A own 10 percent of the stock in a corporation which owns 80 percent of the stock of
                  the disclosing entity, A’s interest equates to an 8 percent indirect ownership interest in the disclosing entity and must be reported.  Conversely, if B owns 80 percent of the stock of a corporation which own 5 percent of the stock of the
                  disclosing entity, B’s interest equates to a 4 percent indirect ownership interest in the disclosing entity and need not be reported.

            	 


      

      

      
        30

        
          


      

      	 	
              Guideline

               

            	 	
              Managing employee means a general manager, business
                  manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of an institution, organization, or agency.

               

              Ownership interest means the possession of equity in
                  the capital, the stock, or the profits of the disclosing entity.

               

              Person with an ownership or control interest means a
                  person or corporation that –

              (a)          Has an ownership
                  interest totaling 5 percent or more in a disclosing entity;

              (b)          Has an indirect
                  ownership interest equal to 5 percent or more in a disclosing entity;

              (c)          Has a combination
                  of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;

              (d)          Owns



                  an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity;

              (e)          Is an officer or
                  director of a disclosing entity that is organized as a corporation; or

              (f)          Is a partner in a
                  disclosing entity that is organized as a partnership.

              In order to determine percentage of ownership, mortgage, deed of trust, note, or other obligation, the percentage of interest owned in the
                  obligation is multiplied by the percentage of the disclosing entity's assets used to secure the obligation. For example, if A owns 10 percent of a note secured by 60 percent of the provider's assets, A's interest in the provider's assets
                  equates to 6 percent and must be reported. Conversely, if B owns 40 percent of a note secured by 10 percent of the provider's assets, B's interest in the provider's assets equates to 4 percent and need not be reported.

            	 


      

      

      
        31

        
          


      

      	 	 	 	
              Significant business transaction means any business
                  transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider’s total operating expenses.

               

              Subcontractor means –

               

              (a)  An
                  individual, agency or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or

              (b)  An
                  individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid
                  agreement.

               

              Supplier means an individual, agency or organization
                  from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).

               

              Wholly owned supplier means a supplier whose total
                  ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider.

            	 


      

      

      
        32

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SB13

            	 	
              Disclosure by disclosing entities: Information on ownership and control.

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contractors

            	 
	 	
              Purpose

            	 	
              To provide guidelines on what information must be disclosed by entities that have ownership and control over facilities.

            	 
	 	
              General

            	 	
              The Contractor must have a mechanism to monitor on a timely manner the providers and fiscal agents that own or control facilities where Medicaid
                  beneficiaries receive services.

            	 
	 	
              Guidelines

            	 	
              The Contractor must require each disclosing entity to disclose the following information in a timely manner:

              (a)  Type of Information that must be disclosed.

              (1)   (i) The
                  name and address of any person (individual or corporation) with an ownership or control interest in the disclosing entity, fiscal agent, or the entity contracted by ASES. The address for corporate entities must include as applicable
                  primary business address, every business location, and P.O. Box address.

              (ii)  Date of birth and Social
                  Security Number (in the case of an individual).

              (iii) Other tax identification
                  number (in the case of a corporation) with an ownership or control interest in the disclosing entity (or fiscal agent or the entity contracted by ASES) or in any subcontractor in which the disclosing entity (or fiscal agent or the entity
                  contracted by ASES) has a 5 percent or more interest.

              (2) Whether the person (individual or corporation) with an ownership or control interest in the disclosing entity
                  (or fiscal agent or the entity contracted by ASES) is related to another person with ownership or control interest in the disclosing entity as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an
                  ownership or control interest in any subcontractor in which the disclosing entity (or fiscal agent or the entity contracted by ASES) has a 5 percent or more interest is related to another person with ownership or control interest in the
                  disclosing entity as a spouse, parent, child, or sibling.

              (3) The name of any other disclosing entity (or fiscal agent or the entity contracted by ASES) in which an owner of
                  the disclosing entity (or fiscal agent or the entity contracted by ASES) has an ownership or control interest.

              (4) The name, address, date of birth, and Social Security Number of any managing employee of the disclosing entity
                  (or fiscal agent or the entity contracted by ASES).

               

              (b) When the disclosures must be provided.

              (1) Disclosures from providers or disclosing entities. Disclosure from any Provider or disclosing entity is due at
                  any of the following times:

              (i)     Upon the provider or disclosing entity submitting the provider application.

            	 


      

      

      
        33

        
          


      

      	 	 	 	
              (ii)     Upon the provider or
                  disclosing entity executing the provider agreement.

              (iii)    Upon request of ASES
                  during the re-validation of enrollment process under § 455.414.

              (iv)    Within 35 days after any
                  change in ownership of the disclosing entity.

              (2) Disclosures from Contractors or other state-contracted entities - Disclosures are due at any of the following
                  times:

              (i)  Upon submitting the proposal
                  in accordance with the State's procurement process.

              (ii) Upon executing the contract with the State.

              (iii) Upon renewal or extension of the contract.

              (iv) Within thirty five (35) days after any change in ownership of the fiscal agent, manage care organizations or
                  contracted entity.

               

              Updated information must be furnished to ASES or the Contractor, as applicable, at intervals between recertification or contract renewals, within
                  thirty five (35) days of a written request.

               

              (c) Consequences for failure to provide required disclosures.

              ü  Federal financial participation
                  (FFP) is not available in payments made to a disclosing entity that fails to disclose ownership or control information as required by this section.

              ü The Contractor shall not approve
                  a Provider Contract, and must terminate an existing agreement or contract, if the Provider or fiscal agent fails to disclose ownership or control information as required by this section.

               

              The PIP will include the process to provide an annual report to ASES on above information and data.

            	 


      

      

      
        34

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SB14

            	 	
              Disclosure by providers: Information related to business transactions.

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contractors

            	 
	 	
              Purpose

            	 	
              The Contractor must establish a mechanism to facilitate the Providers disclose information related to their business transactions when own or
                  control facilities where Medicaid beneficiaries received services.

            	 
	 	
              Guidelines

            	 	
              The PIP must describe the mechanism to allow providers owning or controlling facilities disclose information related to business transactions.

               

              The PIP must attest the organization abide by the following regulation:

               

              (a)      Provider Contracts. The Contractor must enter into an agreement with each Provider or Provider group under which the Provider agrees to furnish to it or to the grantee /
                  sub-grantee on request, information related to business transactions.

              (b)     Information
                    that must be submitted. A Provider must submit, within 35 days of the date on a request by the organization full and complete information about –

              ü The ownership of any
                  Subcontractor with whom the Provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and

              ü Any significant business
                  transactions between the Provider and any wholly owned Supplier, or between the Provider and any Subcontractor, during the 5-year period ending on the date of the request.

               

              The PIP must include withholding of payment processes and procedures to enforce above guideline.

            	 


      

      

      
        35

        
          


      

      Puerto Rico Government

      Program Integrity Plan –2018-2021

          

        

      	 	
              Title SB15

            	 	
              Disclosure by Providers: Information on persons convicted of crimes

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contractors

            	 
	 	
              Purpose

            	 	
              To provide guidance on type of information providers must report in compliance with integrity program.

            	 
	 	
              General

            	 	
              The Contractor is obliged to request providers to report any conviction of crimes or any other in the program integrity regulation.

            	 
	 	
              Guidelines

            	 	
              The PIP must include a mechanism to confirm that information included below is considered as part of the integrity activities.

               

              (a)  Information that must be disclosed. Before the Contractor enters into or renews a Provider Contract, or at any time upon written request by
                  the Contractor, the Provider must disclose to the Contractor the identity of any person who:

              (1)      Has
                  ownership or control interest in the Provider, or is an agent or managing employee of the provider; and

              (2)      Has
                  been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, or the Title XXI services program since the inception of those programs.

               

              (b) Notification



                    to Inspector General.

              (1)    The
                  Contractor must notify ASES of any disclosures made under paragraph (a) of this section within 20 Business Days from the date it receives the information, as set forth in Section 29.4 of the GHP Contract.

              (c) ASES will notify the HHS Inspector General and the Medicaid Fraud Control Unit of any
                  disclosures related to criminal convictions within twenty (20) Business Days from the date that ASES receives the information (Section 29.6) Denial or termination of provider participation.

              (1)     The
                  Contractor may refuse to enter into or renew an agreement with a provider if any person who has an ownership or control interest in the Provider, or who is an agent or managing employee of the Provider, has been convicted of a criminal
                  offense related to that person’s involvement in any program established under Medicare, Medicaid or the title XX Services Program.

              (2)     The
                  Contractor may refuse to enter into or may terminate a provider agreement if it determines that the provider did not fully and accurately make any disclosure required under paragraph (a) of this section.

            	 


       

      

      
        36

        
          


      

      Puerto Rico Government

      Program Integrity Plan –2018-2021

       

        

      	 	
              Title SE16

            	 	
              Provider Screening and Enrollment

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contractors

            	 
	 	
              Purpose

            	 	
              To provide guidance on termination or denial of network participation and criminal background checks.

            	 
	 	
              General

            	 	
              The Contractor is obligated to establish procedures for termination of Provider Contracts and to obtain Provider consent to criminal background
                  checks.

            	 
	 	
              Guidelines

            	 	
              The PIP must include a process to confirm that the requirements included below are considered as part of the integrity activities.

               

              1. Terminations or denials -:

               

              (a) Contractor shall terminate the Provider Contract of any provider where any person with a 5 percent or greater direct or
                  indirect ownership interest in the provider did not submit timely and accurate information and cooperate with any required screening methods in 42 CFR part 455.

               

              (b) Contractor shall not offer a Provider Contract to any provider where any person with a 5 percent or greater direct or
                  indirect ownership interest in the provider has been convicted of a criminal offense related to that person's involvement with the Medicare, Medicaid, or title XXI program in the last 10 years, unless ASES determines that denial or
                  termination of enrollment is not in the best interests of the Medicaid program and that determination is documented in writing.

               

              (c) ASES must deny enrollment or terminate the enrollment of any provider that is terminated on or after January 1, 2011,
                  under Medicare and Medicaid, or CHIP in any other State.

               

              (d) ASES must terminate a provider's enrollment or deny enrollment of the provider if the provider or a person with an
                  ownership or control interest or who is an agent or managing employee of the provider fails to submit timely or accurate information, unless ASES determines that termination or denial of enrollment is not in the best interests of the
                  Medicaid program and the State Medicaid agency documents that determination in writing.

               

              (e) ASES must terminate or deny enrollment if the provider, or any person with a 5 percent or greater direct or indirect
                  ownership interest in the provider, fails to submit sets of fingerprints in a form and manner to be determined by the ASES within 30 days of a CMS or a ASES request, unless ASES determines that termination or denial of enrollment is not
                  in the best interests of the Medicaid program and ASES documents that determination in writing.

            	 


      

      

      
        37

        
          


      

      	 	 	 	
              (f)  ASES must terminate or deny enrollment if the provider fails to permit access to provider locations for any site visits
                  under § 455.432, unless ASES determines that termination or denial of enrollment is not in the best interests of the Medicaid program and that determination is documented in writing.

               

              (g)  ASES may terminate or deny the provider's enrollment if:

               

              (1) it is determined that the provider has falsified any information provided on the application; or

               

              (2) the identity of any provider applicant cannot be verified.

               

              2. Reactivation of Provider Contract

               

              After terminating a Provider Contract for any reason, before the provider is offered a new Provider Contract, the Contractor must re-screen the
                  provider.

               

              3. Criminal background checks

               

              As a condition of executing a Provider Contract, the Contractor must require providers to consent to criminal background checks including
                  fingerprinting when required by ASES, law enforcement agencies or Puerto Rico law.

               

              4. Verification of Provider License

               

              As a condition of executing a Provider Contract, the Contractor must confirm that the provider purporting to be licensed in accordance with the
                  laws of Puerto Rico is so licensed and that the provider’s license has not expired or is currently subject to any limitations.

            	 


      

      

      
        38

        
          


      

      Puerto Rico Government

      Program Integrity Plan 2018 – 2021

       

        

      	 	
              Title SE17

            	 	
              Screen to Confirm the Identity and Exclusions Status

            	 
	 	
              Scope

            	 	
              Grantee, Sub-Grantee and Contractors

            	 
	 	
              Purpose

            	 	
              To provide guidance on the process to confirm the identity and determine exclusion status

            	 
	 	
              General

            	 	
              The Contractor is obligated to confirm the identity and determine the exclusion status of Providers and any person with an ownership or control
                  interest or who is an agent or managing employee of the Provider through routine checks of Federal databases.

            	 
	 	
              Guidelines

            	 	
              The PIP must ensure Provider compliance with screening employees for identity and exclusions. To further protect against payments for items and
                  services furnished or ordered by excluded parties, all current Providers and providers applying to contract with the Contractor must take the following steps to confirm identities and to determine whether their employees and contractors
                  are excluded individuals or entities:

              ü Providers have the obligation to screen
                  all employees and subcontractors to confirm the identity and determine the exclusion status through routine checks of Federal databases. The Contractor should communicate this obligation to providers.

              ü Providers should explicitly be required
                  to agree to comply with this obligation as a condition of contracting.

              ü Providers should be informed that they
                  must search the Social Security Administration's Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the Excluded Parties List System (EPLS), and any such other
                  databases as the Secretary may prescribe.

              ü Contractors and Providers should search
                  the LEIE and EPLS no less frequently than monthly to capture exclusions and reinstatements that have occurred since the last search.

              ü Providers should be required to
                  immediately report to the Contractor any exclusion information discovered. Contractors are required to immediately report to ASES any exclusion information discovered.

               

              This line of defense in combating fraud and abuse must be conducted accurately, thoroughly, and routinely. The Contractor must notify ASES
                  promptly of any administrative action recommended against a provider for failure to comply with these screening and reporting obligations. See 42
                  CFR section 1002.4(b)(3). The Contractor can satisfy this obligation by communicating the relevant information to ASES, whom shall notify the and the appropriate Regional Office of the OIG Office of Investigations and the Medicaid Fraud
                  Control Unit.

               

              The Contractors also should inform Providers that civil monetary penalties may be imposed by ASES against Medicaid providers and entities
                  contracted by ASES who employ or enter into contracts with excluded individuals or entities to provide items or services to Medicaid recipients. (Section 1128A(a)(6) of
                  the Act; and 42 CFR section 1003.200(a)(3)).

            	 


      

      

      
        39

        
          


      

      State Medicaid Directors Letter (SMDL) #09-001

      

      SMD #09-001.pdf

       

        

      
        40

        
          


      

      
        	
                
                  DEPARTMENT OF HEALTH & HUMAN SERVICES

                  Centers for Medicare & Medicaid Services

                  7500 Security Boulevard, Mail Stop S2-26-12

                  Baltimore, Maryland 21244-1850

                  

                  

                  
                     

                      

                     

                  

                

              	
                
                  

                

              
	
                Center for Medicaid and State Operations 

                

              	
                

                

              
	 	
                SMDL #09-001

              


        

      

      January 16, 2009

      

      

      Dear State Medicaid Director:

      

      

      The Center for Medicaid and State Operations (CMSO) is issuing this State Medicaid Director Letter to strengthen the integrity of the Medicaid program and
          help States reduce improper payments to providers. This letter advises States of their obligation to direct providers to screen their own employees and contractors for excluded persons, This letter specifically:

      

      

      
        
          	(1)	
                  Clarifies Federal statutory and regulatory prohibitions regarding Medicaid payments for any items or services furnished or ordered by individuals or entities that have
                      been excluded from participation in Federal health care programs;

                


        

      

      

      

      
        
          	(2)	
                  Reminds States of the consequences for failure to prevent payments for items or services furnished or ordered by excluded individuals and entities;

                


        

      

      

      

      
        
          	(3)	
                  Sets forth the Centers for Medicare & Medicaid Services' (CMS) policy with respect to States'
                      responsibility to communicate to providers their obligation to screen employees and contractors for excluded individuals and entities both prior to hiring or contracting and on a periodic basis, and the manner in which overpayment
                      calculations should be made; and

                


        

      

      

      

      
        
          	(4)	
                  Identifies the List of Excluded Individuals/Entities (LEIE) as a resource providers may utilize to determine whether any of their employees and contractors has been
                      excluded.

                


        

      

      

      

      Background

      

      

      The HHS Office of Inspector General (HHS-OIG) excludes individuals and entities from participation in Medicare, Medicaid, the State Children's Health
          Insurance Program (SCHIP), and all Federal health care programs (as defined in section 1128B(f) of the Social Security Act (the Act)) based on the authority contained in various sections of the Act, including sections 1128, 1128A, and 1156.

      

      

      When the HHS-OIG has excluded a provider, Federal health care programs (including Medicaid and SCHIP programs) are generally prohibited from paying for any
          items or services furnished, ordered, or prescribed by excluded individuals or entities, (Section 1903(i)(2) of the Act; and 42 CFR section 1001.1901(b)) This payment ban applies to any items or services reimbursable under a Medicaid program that
          are furnished by an excluded individual or entity, and extends to:

       

        

      
        41

        
          


      

      Page 2 - State Medicaid Director

      

      

      
        
          	

                	•	
                  all methods of reimbursement, whether payment results from itemized claims, cost reports, fee schedules, or a prospective payment system;

                


        

      

      
        
          	

                	•	
                  payment for administrative and management services not directly related to patient care, but that are a necessary component of providing items and services to Medicaid
                      recipients, when those payments are reported on a cost report or are otherwise payable by the Medicaid program; and

                


        

      

      
        
          	

                	•	
                  payment to cover an excluded individual's salary, expenses or fringe benefits, regardless of whether they provide direct patient care, when those payments are reported on
                      a cost report or are otherwise payable by the Medicaid program.

                


        

      

      

      

      In addition, no Medicaid payments can be made for any items or services directed or prescribed by an excluded physician or other authorized person when the
          individual or entity furnishing the services either knew or should have known of the exclusion. This prohibition applies even when the Medicaid payment itself is made to another provider, practitioner or supplier that is not excluded. (42 CFR
          section 1001.l901(b))

      

      

      The listing below sets forth some examples of types of items or services that are reimbursed by Medicaid which, when provided by excluded parties, are not
          reimbursable1:

      

      

      
        
          	

                	•	
                  Services performed by excluded nurses, technicians, or other excluded individuals who work for a hospital, nursing home, home health agency or physician practice, where
                      such services are related to administrative duties, preparation of surgical trays or review of treatment plans if such services are reimbursed directly or indirectly (such as through a pay per service or a bundled payment) by a
                      Medicaid program, even if the individuals do not furnish direct care to Medicaid recipients;

                


        

      

      
        
          	

                	•	
                  Services performed by excluded pharmacists or other excluded individuals who input prescription information for pharmacy billing or who are involved in any way in filling
                      prescriptions for drugs reimbursed, directly or indirectly, by a Medicaid program;

                


        

      

      
        
          	

                	•	
                  Services performed by excluded ambulance drivers, dispatchers and other employees involved in providing transportation reimbursed by a Medicaid program, to hospital
                      patients or nursing home residents;

                


        

      

      
        
          	

                	•	
                  Services performed for program recipients by excluded individuals who sell, deliver or refill orders for medical devices or equipment being reimbursed by a Medicaid
                      program;

                


        

      

      
        
          	

                	•	
                  Services performed by excluded social workers who are employed by health care entities to provide services to Medicaid recipients, and whose services are reimbursed,
                      directly or indirectly, by a Medicaid program;

                


        

      

      
        
          	

                	•	
                  Services performed by an excluded administrator, billing agent, accountant, claims processor or utilization reviewer that are related to and reimbursed, directly or
                      indirectly by a Medicaid program;

                


        

      

      

      

      

      

       

      1 This list is drawn from the 1999 HHS-OIG Special Advisory Bulletin: The Effect of Exclusion From Participation in Federal Health Care Programs.

       

        

      
        42

        
          


      

      Page 3 - State Medicaid Director

      

      

      
        
          	

                	•	
                  Items or services provided to a Medicaid recipient by an excluded individual who works for an entity that has a contractual agreement with, and is paid by, a Medicaid
                      program; and

                


        

      

      
        
          	

                	•	
                  Items or equipment sold by an excluded manufacturer or supplier, used in the care or treatment of recipients and reimbursed, directly or indirectly, by a Medicaid
                      program.

                


        

      

      

      

      Consequences to States of Paying Excluded Providers

      

      

      Because it is prohibited by Federal law from doing so, CMS shall make no payments to States for any amount expended for items or services (other than an
          emergency item or service not provided in a hospital emergency room) furnished under the plan by an individual or entity while being excluded from participation (unless the claim for payment meets an exception listed in 42 CFR section
          1001.l901(c)). Any such payments actually claimed for Federal financial participation constitute an overpayment under sections 1903(d)(2)(A) and 1903(i)(2) of the Act, and are therefore subject to recoupment. It is thus incumbent on States to
          take all reasonable steps to prevent making payments that must ultimately be refunded to CMS.

      

      

      Previous Guidance Regarding Preventing Payments For Goods and Services Furnished by Excluded Individuals and Entities

      

      

      In a State Medicaid Director Letter issued on June 12, 2008, CMS notified States of their own obligation to attempt to determine whether an excluded
          individual has an ownership or control interest in an entity that is a Medicaid provider, and of States' obligation to report information regarding such excluded individuals to the HHS-OIG. In a State Medicaid Director Letter issued on March 17,
          1999, and in a follow-up State Medicaid Director Letter issued on May 16, 2000 ("Medicare/Medicaid Sanction Reinstatement Report"), CMS described the HHS-OIG's authority to exclude persons based on actions taken by State Medicaid Agencies.

      

      

      In the State Medicaid Director Letter dated May 16, 2000, CMS reminded States that the Medicare/Medicaid Sanction-Reinstatement Report, formerly known as
          HCFA Publication 69 and now replaced by the Medicare Exclusion Database (the MED) is a vital resource available to States for ascertaining and verifying whether an individual or entity is excluded and should not be receiving payments. The
          guidance also stated that the payment prohibition applies to any managed care organization contracting with an excluded party.

      

      

      In a second State Medicaid Director Letter dated May 16, 2000 (“State’s Obligation to notify the Department of Health and Human Services Office of Inspector
          General”), CMS reminded States of their responsibility to promptly notify the HHS-OIG of any action taken by a State to limit the ability of an individual or entity to participate in its program. See 42 CFR section 1002.3(b)(3).

       

        

      
        43

        
          


      

      Page 4 - State Medicaid Director

      

      

      Policy Clarification: States Should Advise Medicaid Providers to Screen for Exclusions

      

      

      To further protect against payments for items and services furnished or ordered by excluded parties, States should advise all current providers and
          providers applying to participate in the Medicaid program to take the following steps to determine whether their employees and contractors are excluded individuals or entities:

      

      

      
        
          	

                	•	
                  States should advise providers of their obligation to screen all employees and contractors to determine whether any of them have been excluded. States should communicate
                      this obligation to providers upon enrollment and reenrollment.

                


        

      

      
        
          	

                	•	
                  States should explicitly require providers to agree to comply with this obligation as a condition of enrollment.

                


        

      

      
        
          	

                	•	
                  States should inform providers that they can search the HHS-OIG website by the names of any individual or entity.

                


        

      

      
        
          	

                	•	
                  States should require providers to search the HHS-OIG website monthly to capture exclusions and reinstatements that have occurred since the last search.

                


        

      

      
        
          	

                	•	
                  States should require that providers immediately report to them any exclusion information discovered.

                


        

      

      

      

      This line of defense in combating fraud and abuse must be conducted accurately, thoroughly, and routinely. States must notify the HHS-OIG promptly of any
          administrative action the State takes against a provider for failure to comply with these screening and reporting obligations. See 42 CFR section 1
          002.3(b)(3). States can satisfy this obligation by communicating the relevant information to the appropriate Regional Office of the OIG Office of Investigations.

      

      

      States also should inform providers that civil monetary penalties may be imposed against Medicaid providers and managed care entities (MCEs)2 who employ or enter into contracts with excluded individuals or entities to provide items or
          services to Medicaid recipients. (Section 1128A(a)(6) of the Act; and 42 CFR section 1003.102(a)(2))

      

      

      Policy Clarification: Calculation of Overpayments to Excluded Individuals or Entities

      

      

      As stated above, Federal health care programs, including Medicaid, are generally prohibited from paying for any items or services furnished, ordered, or
          prescribed by excluded individuals or entities. The amount of the Medicaid overpayment for such items or services is the actual amount of Medicaid dollars that were expended for those items or services. When Medicaid funds have been expended to
          pay an excluded individual's salary, expenses, or fringe benefits, the amount of the overpayment is the amount of those expended Medicaid funds. We recognize that there may be instances when the connection between expended Medicaid funds and the

      

      

      

      

      

      2 This State Medicaid Director Letter uses the term “managed care entity” to refer briefly to managed care
            organizations (MCOs), prepaid inpatient health plans, prepaid ambulatory health plans, and primary care case management (PCCM). States should not confuse this abbreviation with the statutory definition of managed care entity which only refers
            to MCOs and PCCMs. See section 1932(a)(1)(B) of the Act.

       

          

      
        44

        
          


      

      Page 5 - State Medicaid Director

      

      

      items or services furnished by the excluded individual or entity are too attenuated to trace. When such circumstances arise, the overpayment is no more than
          the amount which the State is certain was paid with Medicaid dollars.

      

      

      Where Providers Can Look for Excluded Parties

      

      

      While the MED is not readily available to providers, the HHS-OIG maintains the LEIE, a database accessible to the general public that provides information
          about parties excluded from participation in Medicare, Medicaid, and all other Federal health care programs. The LEIE website is located at http://www.oig.hhs.gov/fraud/exclusions.asp
          and is available in two formats. The on-line search engine identifies currently excluded individuals or entities. When a match is identified, it is possible for the searcher to verify the accuracy of the match using a Social Security Number (SSN)
          or Employer Identification Number (EIN). The downloadable version of the database may be compared against an existing database maintained by a provider. However, unlike the on-line format, the downloadable database does not contain SSNs or EINs.

      

      

      Additionally, some States maintain their own exclusion lists, pursuant to 42 CFR section 1002.210 or State authority, which include individuals and entities
          whom the State has barred from participating in State government programs. States with such lists should remind providers that they are obligated to search their State list routinely whenever they search the LEIE.

      

      

      Conclusion

      

      

      We know you share our commitment to combating fraud and abuse. We all understand that provider enrollment is the first line of defense in this endeavor. If
          we strengthen our efforts to identify excluded parties, the integrity and quality of the Medicaid program will be improved, benefiting Medicaid recipients and taxpayers across the country.

      

      

      If you have any questions or would like any additional information on this guidance, please direct your inquiries to Ms. Claudia Simonson, Centers for
          Medicare & Medicaid Services, Center for Medicaid and State Operations, Medicaid Integrity Group, 233 North Michigan Avenue, Suite 600, Chicago, Illinois 60601 or c1audia.simonson@cms.hhs.gov.
          Thank you for your assistance in this important endeavor.

      

      

      	 	
              Sincerely,

            
	 	 
	 	
              /s/

            
	 	
              Herb B. Kuhn

            
	 	
              Deputy Administrator

            
	 	
              Acting Director, Center for Medicaid and State Operations

            


       

      

      
        45

        
          


      

      Page 6 - State Medicaid Director

      

      

      cc:

      

      

      CMS Regional Administrators

      

      

      CMS Associate Regional Administrators

      Division of Medicaid and Children's Health

      

      

      Ann C. Kohler

      NASMD Executive Director

      American Public Human Services Association

      

      

      Joy Wilson

      Director, Health Committee

      National Conference of State Legislatures

      

      

      Matt Salo

      Director of Health Legislation

      National Governors Association

      

      

      Debra Miller

      Director for Health Policy

      Council of State Governments

      

      

      Christie Raniszewski Herrera

      Director, Health and Human Services Task Force

      American Legislative Exchange Council

      

      

      Barbara W. Levine

      Chief, Government Relations and Legal Affairs

      Association of State and Territorial Health Officials

      

      

      

      

      46

    

  








  
    Attachment 15

    

  

   

  

  
    Attachment 15: Form A-102 - Evidence of Lack of Providers and Providers Refusal to

    Contract

    

    

    Pursuant to section 9.1.10 of the Contract, the Contractor must use this Form to evidence the lack of providers in its Network or refusal to contract as
        part of the General Network or the PPN. The Contractor must carry out all efforts to contract with those providers including specialists ensuring network adequacy requirements are met. The Contractor must validate and submit all supporting
        documents evidencing the lack of Providers or refusal to contract required in this Form.

    

    

    
      	
              Provider Name 

            	
               

            	
               

            
	
               

            	
               

            	
               

            
	
              NPI 

                

            	
               

            	
               

            
	
               

            	
               

            	
               

            
	
              Specialty

            	
               

            	
               

            
	
               

            	
               

            	
               

            
	
              Municipality

            	
               

            	
               

            


    

    

    

    
      	
              List of MCO’s Recruitment Activities and dates of such activities:

            
	

            
	

            
	

            
	
               

            
	

            
	

            	 


    

    

    

    
      	
              Provide the Dates and Outcomes of Meetings with provider:

            
	
               

            
	
               

            
	
               

            
	
               

            
	
               

            
	
               

            	 


    

    

    

    
      	
              
                Explain the issues causing concerns or barriers to Contracting:

              

            
	
               

            
	
               

            
	
               

            
	
               

            	 


    

    

    

    
      
        


    

    
      	
              
                Provide description of contract offers to the provider including fees and any other incentives:

              

            
	
               

            
	
               

            
	
               

            
	
               

            
	
               

            
	
               

            	 


    

    

    

    
      	
              
                Provide reasons why the provider refused the contract:

              

            
	
               

            
	
               

            
	
               

            
	
               

            
	
               

            
	
               

            	 


    

    

    

    
      
        	
                
                  
                    Describe provider counter offers:

                  

                

              
	
                 

              
	
                 

              
	
                 

              
	
                 

              
	
                 

              
	
                 

              	 


      

    

    

    

    
      
        
          	
                  
                    
                      
                        Describe remedies offered by MCO to address provider’s concerns in order to come to terms with the contract

                      

                    

                  

                
	
                   

                
	
                   

                
	
                   

                
	
                   

                
	
                   

                
	
                   

                	 


        

      

    

    

    

    Please attach to this form any relevant document in support of your responses.

     

    

     

    

     

  








  
    
      Attachment 16

      

    

    

    

    
      ATTACHMENT 16 – LIST OF REPORTS

      

      

      	 	
              REPORT NUMBER

            	 	
              REPORT TITLE

            	 	
              PROGRAM AREA

            	 	
              ASES REVIEW DEPT.

            	 	
              CONTRACT SECTION

            	 	
              FREQUENCY

            
	 	
              1

            	 	
              Call Center Report

            	 	
              Administrative

            	 	
              Customer Service

            	 	
              18.2.2.1

            	 	
              Monthly

            
	 	
              2

            	 	
              Enrollee Enrollment Materials Report

            	 	
              Administrative

            	 	
              Customer Service

            	 	
              18.2.2.2

            	 	
              Quarterly

            
	 	
              3

            	 	
              Fraud Waste Abuse Report

            	 	
              Administrative

            	 	
              Compliance

            	 	
              3 18.2.2.3

            	 	
              Quarterly

            
	 	
              4

            	 	
              Privacy and Confidentiality Report

            	 	
              Administrative

            	 	
              Compliance

            	 	
              18.2.2.4

            	 	
              Monthly

            
	 	
              5

            	 	
              Systems Incident Report

            	 	
              Administrative

            	 	
              Information Systems

            	 	
              18.2.2.5

            	 	
              Annually or 10 Business Days following incident

            
	 	
              6

            	 	
              Federal Qualified Health Center (FQHC) Report

            	 	
              Administrative

            	 	
              Compliance

            	 	
              18.2.2.6

            	 	
              Quarterly

            
	 	
              7

            	 	
              Special Coverage Registry Report

            	 	
              Administrative

            	 	
              Clinical Affairs

            	 	
              18.2.2.7

            	 	
              Monthly

            
	 	
              8

            	 	
              High Cost High Needs Registry Report

            	 	
              Administrative

            	 	
              Planning & Quality

            	 	
              18.2.2.8

            	 	
              Monthly

            
	 	
              9

            	 	
              Disclosure of Information on Annual Business Transactions

            	 	
              Administrative

            	 	
              Compliance

            	 	
              18.2.2.9

            	 	
              Annually

            
	 	
              10

            	 	
              Statistical Reports

            	 	
              Administrative

            	 	
              Planning

            	 	
              18.2.2.10

            	 	
              45 days of end of year

            
	 	
              11

            	 	
              Claims Activity Report

            	 	
              Claims

            	 	
              Clinical Affairs

            	 	
              18.2.3.1

            	 	
              Monthly

            
	 	
              12

            	 	
              Encounter Data

            	 	
              Claims

            	 	
              Information Systems

            	 	
              18.2.3.2

            	 	
              Monthly

            
	 	
              13

            	 	
              CMS 416 Report

            	 	
              Covered Services

            	 	
              Planning & Quality

            	 	
              18.2.4.1

            	 	
              Annually

            
	 	
              14

            	 	
              Executive Director and Utilization Data Report

            	 	
              Covered Services

            	 	
              Planning & Quality

            	 	
              18.2.4.2

            	 	
              Quarterly

            


      

      

      
        
          


      

      
        List of Required Reports

      

      

      

      	 	
              REPORT NUMBER

            	 	
              REPORT TITLE

            	 	
              PROGRAM AREA

            	 	
              ASES REVIEW DEPT.

            	 	
              CONTRACT SECTION

            	 	
              FREQUENCY

            
	 	
              15

            	 	
              Network Provider List

            	 	
              Provider Reports

            	 	
              Planning & Quality

            	 	
              18.2.5.1

            	 	
              Monthly

            
	 	
              16

            	 	
              Geographic Access Report

            	 	
              Provider Reports

            	 	
              Planning & Quality

            	 	
              18.2.5.2

            	 	
              Quarterly

            
	 	
              17

            	 	
              Appointment Availability Report

            	 	
              Provider Reports

            	 	
              Planning & Quality

            	 	
              18.2.5.3

            	 	
              Quarterly

            
	 	
              18

            	 	
              Provider Satisfaction Survey Report

            	 	
              Provider Reports

            	 	
              Planning & Quality

            	 	
              18.2.5.4

            	 	
              Annually

            
	 	
              19

            	 	
              Provider Training and Outreach Evaluation Report

            	 	
              Provider Reports

            	 	
              Planning & Quality

            	 	
              18.2.5.5

            	 	
              Quarterly

            
	 	
              20

            	 	
              Physician Incentive Program Report

            	 	
              Provider Reports

            	 	
              Planning & Quality

            	 	
              18.2.5.6

            	 	
              Annually

            
	 	
              21

            	 	
              Grievances and Appeals Report

            	 	
              Quality

            	 	
              Customer Service

            	 	
              18.2.6.1

            	 	
              Quarterly

            
	 	
              22

            	 	
              Health Care Improvement Program Plan (HCIPP) Report

            	 	
              Quality

            	 	
              Planning & Quality

            	 	
              18.2.6.2

            	 	
              Quarterly

            
	 	
              23

            	 	
              Enrollee Satisfaction Survey Report

            	 	
              Quality

            	 	
              Planning & Quality

            	 	
              18.2.6.3

            	 	
              Annually

            
	 	
              24

            	 	
              Audited HEDIS Results Report

            	 	
              Quality

            	 	
              Planning & Quality

            	 	
              18.2.6.4

            	 	
              Annually

            
	 	
              25

            	 	
              Integration Model Report

            	 	
              Utilization Management

            	 	
              Clinical Affairs

            	 	
              18.2.7.1

            	 	
              Quarterly

            
	 	
              26

            	 	
              Systems Availability and Performance Report

            	 	
              Systems

            	 	
              Information Systems

            	 	
              18.2.8.1

            	 	
              Monthly

            
	 	
              27

            	 	
              Business Continuity and Disaster Recovery (BC-DR) Test Report

            	 	
              Systems

            	 	
              Information Systems

            	 	
              18.2.8.2

            	 	
              Annually

            
	 	
              28

            	 	
              Unaudited Financial Statement

            	 	
              Financial Management

            	 	
              Finance

            	 	
              18.2.9.1

            	 	
              Quarterly

            
	 	
              29

            	 	
              Report on Controls Placed in Operation and Tests of Operating Effectiveness

            	 	
              Financial Management

            	 	
              Finance

            	 	
              18.2.9.2

            	 	
              Annually

            
	 	
              30

            	 	
              Audited Financial Statements

            	 	
              Financial Management

            	 	
              Finance

            	 	
              18.2.9.3

            	 	
              Annually

            
	 	
              31

            	 	
              Cost Avoidance Report

            	 	
              Financial Management

            	 	
              Finance

            	 	
              18.2.9.4

            	 	
              Quarterly

            
	 	
              32

            	 	
              Report to Puerto Rico Insurance Commissioner's Office

            	 	
              Financial Management

            	 	
              Compliance

            	 	
              18.2.9.5

            	 	
              Annually

            
	 	
              33

            	 	
              Annual Corporate Report

            	 	
              Financial Management

            	 	
              Compliance

            	 	
              18.2.9.6

            	 	
              Annually

            
	 	
              34

            	 	
              Pharmacy Certification

            	 	
              Financial Management

            	 	
              Finance

            	 	
              18.2.9.7

            	 	
              Every two weeks

            
	 	
              35

            	 	
              Incurred But Not Paid (IBNR) Report

            	 	
              Financial Management

            	 	
              Financial Management

            	 	
              18.2.9.8

            	 	
              Quarterly

            
	 	
              36

            	 	
              Medical Loss Ratio Report

            	 	
              Financial Management

            	 	
              Finance

            	 	
              18.2.9.9

            	 	
              Annually

            


      

      

      

        page 2 of 2

      

       

    

  








  
    
      Attachment 17

      

    

    

    

    
      HIE Plan

      Attachment 17

      Version 10.1.18

       

        

      
        
          


      

      

       

        

      STRATEGIC PLAN FOR THE ADOPTION OF HEALTH INFORMATION EXCHANGE

      (HIE) BY THE GOVERNMENT HEALTH PLAN (GHP) PROVIDER NETWORK

      

      

      The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009,
          established a set of national initiatives to promote the adoption and meaningful use of health information technology (commonly referred to as HIT), including the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. Since the
          inception of the Puerto Rico Medicaid EHR Incentive Program in 2012, the Puerto Rico Health Insurance Administration (ASES by its Spanish acronym) has been the state-level entity chartered with the administration of the program and leading the
          implementation of the State Medicaid Health Information Technology Plan (SMHP). The Puerto Rico Medicaid EHR Incentive Program, also known as the HIT Provider Incentive Program (HITPIP) has issued over $170M in payments to Puerto Rico providers
          to over 3,900 providers as of March 31, 2018..

      

      

      On April 24, 2018 CMS issued a Proposed Rule (CMS-1694-P) that establishes new requirements or revises existing requirements for eligible professionals
          (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs) participating in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (now referred to as the Promoting Interoperability Programs). In addition, the
          Proposed Rule includes changes to the requirements that apply to States operating Medicaid Promoting Interoperability Programs, including Puerto Rico. The Proposed Rule is part of a series of recent CMS initiatives, such as MyHealthEData, to
          ensure the healthcare system puts patients first. One of the key elements in the Proposed Rule is that providers must use the 2015 Edition of Certified Electronic Health Record Technology (CEHRT)1 beginning in 2019 to drive interoperability using Application Programming Interfaces (APIs).

      

      

      Since the inception of the EHR Incentive Programs, ASES has recognized that providers are the gateway to an organized and integrated healthcare delivery
          systems. The implementation of this Strategic Plan will further the integration of all the health care provider networks as an organized health care system, allowing ASES to plan for, provide/purchase, and coordinate all core services along the
          continuum of health care services for the population served by the GHP. The adoption and meaningful use (MU) of EHRs and the secure and effective exchange of the patient health information constitute the backbone of an organized integrated health
          system with the necessary elements for interoperability.

      

      

      

      1 Certified


            EHR Technology refers to commercial products that have been certified by designated third parties to meet the requirements established by the Office of the National Coordinator for Health Information Technology (ONC) to ensure that Electronic
            Health Record (EHR) technologies meet the adopted standards and certification criteria to help providers and hospitals achieve Meaningful Use (MU) objectives and measures established by the Centers for Medicare and Medicaid Services (CMS).

       

          

      
        
          


      

      ASES has been implementing a strategic plan focused on adoption and meaningful use of CEHRT by the GHP provider network since 2014. One of the key
          elements of the strategic plan was seeking support from MCOs contracted for the GHP to promote adoption and meaningful use of CEHRT by their health care provider network as well as active participation in the Puerto Rico Health Information
          Network (PRHIN), Puerto Rico’s state-level Health Information Exchange (HIE), to enable health information exchange among health care providers.

      

      

      As a means of aligning State-level HIT initiatives with CMS policy in the Proposed Rule (CMS-1694-P) and capitalizing on the new GHP contracting cycle,
          ASES is creating a strategic plan that focuses on health information exchange and interoperability. The strategic plan is intended to promote health information exchange among GHP providers through interoperable CEHRT and implementing enabling
          HIT/HIE infrastructure. The goals of the ASES HIE Strategic Plan are as follows:

      

      

      
        
          	

                	·	
                  Increase the size, scope, and services of public HIT/HIE
                        infrastructure - The HIT/HIE infrastructure in Puerto Rico is comprised of a number of initiatives that have grown organically, primarily to support provider demonstration of meaningful use (MU). In order for HIE to become a
                      more significant activity in Puerto Rico, it is important to establish connectivity to broader State and Federal HIT/HIE infrastructure. In addition, the development of a State-level provider directory will facilitate more efficient
                      electronic exchange among GHP contractors;

                


        

      

      

      

      
        
          	

                	·	
                  Support statewide HIE adoption and use – HIE activity in
                      Puerto Rico has mostly revolved around meaningful use (MU) and has been driven by hospitals given their role in the health system. For HIE to deliver on its promise in Puerto Rico’s health system, HIE must become a principal activity
                      in clinical settings. Therefore, the strategic plan strives to promote sustainable HIE models, identifying use cases that will generate a critical mass of HIE activity, and supporting providers in HIE onboarding activities.

                


        

      

      

      

      
        
          	

                	·	
                  Empower patients through HIE – HIE is a key underpinning
                      element to new payment models and patient care. Therefore, the public health system must actively promote HIE and educate health care providers, patients, and others about HIE and its benefits. Puerto Rico needs to take initial steps
                      towards putting patients at the center of the GHP by promoting consumer-mediated HIE using CHERT capabilities.

                


        

      

      

      

      
        
          	

                	·	
                  Support state-wide contingency planning- Unfavorable events
                      occur within all complex systems. The Puerto Rico health care sector and its HIE infrastructure are no exception. HIE could potentially be part of the response to unfavorable events in Puerto Rico, such as natural disasters or
                      significant failure of key infrastructure. Likewise, negative events could potentially befall the Puerto Rico HIT/HIE infrastructure, requiring contingency plans to deal with unfavorable events and their consequences.

                


           

          

        

      

      
        
          


      

      Initiatives to Achieve ASES HIE Strategic Plan Goals

      

      

      The achievement of ASES’s goals for its HIE Strategic Plan depend on effective collaboration with GHP contractors to ensure that all health care provider
          networks move forward in a concerted and consistent manner in support and compliance with this Plan. The following initiatives are critical to achieving ASES’ goals:

      

      

      
        
          	

                	I.	
                  Periodically assess GHP contactor readiness and maturity to support HIE

                


        

      

      

      

      ASES will seek to get detailed information from GHP contractors on the level to which their current IT infrastructure and HIT services
          comply with ONC Certification Criteria and the GHP contractor’s plans (including timelines) for their IT infrastructure and HIT services to meet ONC Certification Criteria.

      

      

      
        
          	

                	II.	
                  Promote and require GHP health care provider networks to adopt CEHRT

                


        

      

      

      

      The Medicaid EHR Incentive program is intended to stimulate health care service provider adoption of CEHRT through financial
          incentives. As interoperability becomes a more important factor in meeting the goals for the public health system both at the State and Federal levels, GHP health care service providers/ organizations will be required to adopt CEHRT to continue
          contributing to the overall goals and objectives of the Medicaid program.

      

      

      ASES will request that the MCOs perform a series of periodic surveys within their GHP health care provider networks to gather data
          related to the following:

      

      

      
        	 	
                -

              	
                Number of health care providers/organizations using CEHRT;

              


      

      

      

      
        
          	

                	-	
                  Number of health care providers using DIRECT Secure Messaging to receive/send clinical data (directed health information exchange), how frequently it is used in clinical
                      settings, and the use cases supported by DIRECT Secure Messaging;

                


        

      

      

      

      
        
          	

                	-	
                  Number of health care service providers/ organizations that are active participants of a Health Information Exchange, how frequently it is used in clinical settings, the
                      use cases supported through the Health Information Exchange, and which of those are most often used by service providers/ organizations; and

                


        

      

      

      

      
        
          	

                	-	
                  Benefits that health care service providers/ organizations have been able to reap from health information exchange activities and issues they have faced in participating
                      in HIE.

                


        

      

      

      

      ASES will utilize the results of the surveys conducted by the MCOs to measure and monitor the number of providers who have not adopted
          CEHRT, identify the types of health care providers/ organizations who have not adopted CEHRT, and their barriers to CEHRT adoption.

       

        

      
        
          


      

      
        
          	

                	III.	
                  Promote health information exchange through CEHRT by GHP health care provider networks

                


        

      

      

      

      The results of the GHP health care provider network surveys will also be used to identify gaps in HIE infrastructure adoption and the
          obstacles health care service providers/ organizations face in using HIE in clinical settings. The information gleaned from the surveys will support continuous reviews of the feasibility and potential effectiveness of ASES HIT/HIE infrastructure
          initiatives.

      

      

      In addition, the survey results will be used to develop a roadmap to stimulate HIE activity by GHP health care provider networks. The
          roadmap will focus on identifying and stimulating HIE activity that adds value to health care service providers/ organizations in clinical settings, especially those capable of being facilitated through CEHRT, in order to drive critical mass of
          HIE activity that can enhance the network effect. The impact of the HIE roadmap’s activities will be measured through the periodic MCO surveys. As part of the HIE roadmap implementation effort, ASES will identify key stakeholders that can support
          GHP health care service providers/organizations HIE adoption and maturity efforts such as:

      

      

      
        
          	

                	-	
                  Educational awareness programs related to HIE, including its benefits, how to engage in HIE activity, and the privacy and security concerns associated with HIE;

                


        

      

      

      

      
        
          	

                	-	
                  Performing provider HIE readiness assessments and support health care service provider/ organization capability development; and

                


        

      

      

      

      
        
          	

                	-	
                  Support provider onboarding to HIEs and other HIT infrastructure.

                


        

      

      

      

      A significant component of the HIE roadmap will be to design and deliver awareness and educational programs that stimulate CEHRT and
          HIE adoption.

      

      

      
        
          	

                	IV.	
                  Require GHP contractor support for ASES initiatives to implement HIT/HIE infrastructure

                


        

      

      

      

      ASES has recently undertaken a group of related HIT/HIE initiatives, including development and implementation of a State-level
          provider directory to facilitate health information exchange among GHP contractors and health care service providers/ organizations. ASES initially plans to use the health care provider network information submitted periodically by MCOs (Network
          Provider Lists or NPLs) to stand up an initial version of the provider directory. In subsequent versions, ASES plans to implement a federated model in which MCO and health care provider/organization EHR systems are leveraged to create a dynamic
          provider directory. Therefore, effective collaboration between ASES and GHP contractors will be instrumental in a successful implementation of the provider directory.

      

      

      The MCO survey results will be leveraged to glean the feasibility of the provider directory’s overall approach. In addition, ASES
          expects support from MCOs with the following activities:

      

      

      
        
          	

                	-	
                  Reviewing and implementing NPL data exchange formats;

                


           

          

        

      

      
        
          


      

      
        
          	

                	-	
                  Validating health care provider/ organization demographic, contact, and practice information submitted to ASES in the NPLs;

                


        

      

      

      

      
        
          	

                	-	
                  Obtaining health care provider/ organization DIRECT Secure Messaging electronic service information (ESI); and

                


        

      

      

      

      
        
          	

                	-	
                  Testing and validating Fast Health Interoperability Resources (FHIR) APIs to implement a federated provider directory model.

                


        

      

      

      

      ASES expects full cooperation from GHP contractors at it continues to develop public HIT/HIE infrastructure initiatives that will
          benefit the health care sector in Puerto Rico.

      

      

      HIE STRATEGIC PLAN DEVELOPMENT EXPECTED TIMELINE

      

      

      

       

        

      
        
          


      

      HIE STRATEGIC PLAN SUPPORTING INITIATIVE IMPLEMENTATION PLANNING

      

      

      	 	
              GOAL I.

              Periodically assess GHP contactor readiness and maturity to support HIE

            
	 	
              OBJECTIVES

            	 	
              ACTIVITIES

            	 	
              DATES

            
	 	
              I.A Evaluate GHP contractor IT infrastructure and HIT
                  services to determine their alignment with ONC Certification criteria

            	 	
              I.A.1 Coordinate and execute interviews, meetings, and
                  workshops with GHP contractors to gather data related to their IT infrastructure and HIT services.

               

              I.A.2 Assess the extent to which GHP contractor IT
                  infrastructure and HIT services comply with ONC Certification criteria.

               

              I.A.3 Discuss potential opportunities for GHP contractors
                  to incorporate ONC Certification criteria into their IT infrastructure and HIT services development roadmaps.

            	 	
              December 3-28, 2018

               

               

              January 3, 2019 –February 1, 2019

               

              February 4 – March 1, 2019

            


      

      

      	 	
              GOAL II.

              Promote and require GHP health care provider networks to adopt CEHRT

            
	 	
              OBJECTIVES

            	 	
              ACTIVITIES

            	 	
              DATES

            
	 	
              II.A. Obtain reliable current data regarding the GHP health
                  care provider networks’ adoption and implementation of CEHRT, Meaningful Use demonstration, and their active participation in HIE.

            	 	
              II.A.1 Initial engagement with GHP contractors to present
                  the ASES HIE Strategic Plan, identify contacts, and review expected roles and responsibilities.

               

              II.A.2 Submit the HIT/HIE Implementation Survey to GHP
                  contractors for discussion and definition of data gathering processes, methods, and techniques.

               

              II.A.3 Release the HIT/HIE Implementation Survey to GHP
                  health care provider networks.

               

              II.A.4 Collect HIT/HIE Implementation Survey responses
                  from GHP health care provider networks.

               

              GHP contractors will gather data for their health care provider networks and report survey results to ASES.

            	 	
              November 1 – 16 2018

               

               

              November 26 -30 2018

               

               

              December 3 -7, 2018

               

              December 10 –January 18, 2019

            
	 	
              II.B Identify gaps in HIE

              adoption and obstacles

              GHP health care

              provider networks face

              in demonstrating MU

              and using HIE in clinical settings

            	 	
              II.B.1 Analyze survey results and identify CEHRT MU and

              HIE adoption gaps.

              II.B.2 Share analysis findings with GHP contractors and
                  stakeholders through a formal report. The report will define strategies and propose implementation plans to facilitate MU demonstration by GHP health care provider networks and participation in HIE as part of their clinical processes.

            	 	
              January 21, 2019

              – February 28, 2019

              February 29 –

              March 29, 2019

               

            


      

      

      
        
          


      

      	 	
              GOAL III.

              Promote health information exchange through CEHRT by GHP health care provider networks

            
	 	
              OBJECTIVES

            	 	
              ACTIVITIES

            	 	
              DATES

            
	 	
              III.A Identify gaps in HIE adoption and obstacles GHP
                  health care provider networks face in demonstrating MU and using HIE in clinical settings

            	 	
              III.A.1 Analyze survey results and identification of CEHRT
                  MU and HIE adoption gaps.

               

               

              III.A.2 Share analysis findings with GHP contractors and
                  stakeholders through a formal report. The report will define strategies and propose implementation plans to facilitate MU demonstration by GHP health care provider networks and participation in HIE as part of their clinical processes.

            	 	
              January 21, 2019 – February 28, 2019

               

              February 29 –

              March 29, 2019

            
	 	
              III.B Define and establish roadmap to stimulate HIE
                  activity in GHP health care provider networks

            	 	
              III.B.1 Define preliminary HIE adoption roadmap based on
                  HIE adoption gaps identified through the analysis of survey results.

               

              III.B.2 Discuss preliminary HIE adoption roadmap with GHP
                  contractors to refine goals, objectives, and implementation approaches.

               

              III.B.3 Finalize HIE adoption roadmap and communicate plan
                  to GHP contractors.

            	 	
              April 1 – April 26, 2019

               

               

              April 29 –May 10, 2019

               

               

              May 13 – June 10, 2019

            
	 	
              III.C Deliver HIE adoption roadmap activities and
                  periodically report results

            	 	
              III.C.1 Perform roadmap activities such as GHP health care
                  provider network readiness assessments and support provider onboarding to HIEs and other infrastructure as established in the HIE adoption roadmap.

               

              III.C.2 Report activities and results periodically to ASES
                  to evaluate the overall progress of the HIE adoption roadmap.

            	 	
              June 11, 2019 – March 27, 2020

               

               

               

              June 11, 2019 – March 27, 2020

            
	 	
              III.D Develop and schedule educational initiatives and
                  programs to be offered to GHP health care provider networks

            	 	
              III.D.1 Identify preliminary awareness and educational
                  programs based on survey results, focusing on the identified gaps in CEHRT adoption, MU demonstration, and use of HIE in clinical settings.

               

              III.D.2 Communicate initial plan to GHP contractors.

               

              III.D.3 Discuss preliminary awareness and education
                  programs with GHP contractors to optimize program design and leverage their existing programs, infrastructure, and delivery methods.

               

              III.D.4 Finalize awareness and educational program design,
                  including target audience, program contents, delivery methods, and effectiveness metrics.

               

              III.D.5 Communicate final plan to GHP contractors.

            	 	
              June 11 – July 19, 2019

               

               

               

              July 22 - 26, 2019

               

              July 29 – August 30, 2019

               

               

               

              September 2 - 20, 2019

               

               

              September 23 - 27, 2019

            
	 	
              III.E Deliver educational initiatives and programs for GHP
                  health care provider networks.

            	 	
              III.E.1 Schedule and deliver the awareness and educational
                  programs for the GHP health care provider networks.

               

              III.E.2 Conduct follow up efforts to determine the
                  awareness and educational programs’ effectiveness based on defined metrics.

            	 	
              September 30, 2019 – January 31, 2020

               

              February 3 –

              March 27, 2020

            


      

      

      
        
          


      

      	 	
              GOAL IV.

              Require GHP contractor support for ASES initiatives to implement HIT/HIE infrastructure

            
	 	
              OBJECTIVES

            	 	
              ACTIVITIES

            	 	
              DATES

            
	 	
              IV.A Share ASES HIT/HIE initiative planning with GHP
                  contractors and establish workgroups

            	 	
              IV.A.1 Initial engagement with GHP contractors to present
                  ASES HIT/HIE initiatives in support of the HIE Strategic Plan, identify contacts, and review expected GHP contractor roles and responsibilities.

               

              IV.A.2 Assign tasks and establish program management

              processes.

            	 	
              November 1 – 16 2018

               

               

               

                

              November 1 – December 3, 2018

            
	 	
              IV.B Implementation of ASES HIT/HIE initiatives

            	 	
              IV.B.1 ASES will execute its HIT/HIE initiatives with
                  support from GHP contractors as previously established.

               

              IV.B.2 GHP contractors will report to ASES regarding any
                  plans, internal initiatives, or findings from its activities in support ASES’s HIE Strategic Plan that may impact or imply risks to the planning associated with ASES’s HIT/HIE initiatives.

            	 	
              December 4, 2018 – September 27, 2019

               

              December 4, 2018 – September 27,

              2019

            
	 	
              IV.C Monitor results and adjust ASES HIT/HIE initiative
                  planning based on the overall HIE Strategic Plan

            	 	
              IV.C.1 ASES will monitor results of the implementation of
                  its HIT/HIE initiatives. Based on results obtained in terms of GHP health care provider network adoption of CEHRT and HIT/HIE, ASES will make necessary adjustments to its strategy and implementation plans.

               

              IV.C.1 ASES will communicate progress and any changes in
                  the planning of its HIT/HIE initiatives to GHP contractors, as per program management processes.

            	 	
              December 4, 2018 –September 27,

              2019

               

              December 4, 2018 – September 27, 2019

            


      

      

      

      

       

    

  








  
    
      Attachment 18

      

    

    

    

    
      2019-000052

      Business Associate Agreement

      

      

      THIS BUSINESS ASSOCIATE AGREEMENT (“Agreement”)







          is made by, and between Triple-S Salud, Inc., represented herein by the undersigned authorized individual, having its principal offices located at San Juan (“Business Associate”) and The Puerto Rico Health Insurance Administration (“PRHIA”), represented herein by the individual signing below, who is
          authorized to act for and on behalf of PRHIA and with its principal offices at San Juan, Puerto Rico. PRHIA and Business Associate, collectively, may hereinafter be referred to as the “Parties.”

      

      

      WHEREAS, PRHIA and Business Associate are
          parties to one or more agreements and/or may in the future become parties to additional agreements (collectively, the “Underlying Agreements”), pursuant to which Business Associate provides certain services to PRHIA and, in connection with such
          services, creates, receives, uses or discloses for or on behalf of PRHIA certain individually identifiable Protected Health Information relating to patients and/or insured members of health plans with which PRHIA is involved (“PHI”) that is
          subject to protection under the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, as amended by the Health Information Technology for Economic and Clinical Health Act, Title XIII of Division A and Title IV of
          Division B, of the American Recovery and Reinvestment Act of 2009 (“HITECH Act”) and regulations promulgated thereunder, as such law and regulations may be amended from time to time (collectively, “HIPAA”); and

      

      

      WHEREAS, PRHIA and Business Associate wish to
          comply in all respects with the requirements of HIPAA, including requirements applicable to the relationship between a Covered Entity and its Business Associates;

      

      

      THEREFORE, in consideration of the mutual promises contained herein and other good and valuable consideration, the sufficiency of
          which is hereby acknowledged, the Parties agree as follows:

       

        

      
        
          


      

      
        
          	Section 1.	
                  Definitions.

                


        

      

      

      

      
        
          	

                	a.	
                  “Business Associate” shall have the same meaning given to such term as defined in 45 CFR § 160.103 and, for purposes of this Agreement, shall mean the Business Associate
                      indicated above.

                


        

      

      

      

      
        
          	

                	b.	
                  “Covered Entity” shall have the same meaning given to such term as defined in 45 CFR § 160.103.

                


        

      

      

      

      
        
          	

                	c.	
                  “Electronic Protected Health Information“ or “e-PHI” shall have the same meaning given to such term as defined in 45 CFR §160.103 limited to the information created,
                      received, transmitted or maintained by the Business Associate in electronic form format or media.

                


        

      

      

      

      
        
          	

                	d.	
                  “Individual” shall have the same meaning given to such term as defined in 45 CFR § 160.103 and shall include a person who qualifies as a personal representative in
                      accordance with 45 CFR § 164.502(g).

                


        

      

      

      

      
        
          	

                	e.	
                  “Privacy Rule” shall mean the Standards for Privacy of Individually Identifiable Health Information at 45 CFR part 160 and part 164, subparts A and E respectively.

                


        

      

      

      

      
        
          	

                	f.	
                  “Protected Health Information” or “PHI” shall have the same meaning given to such term as defined in 45 CFR §160.103, limited to the information created, transmitted,
                      maintained, or received by Business Associate from or on behalf of PRHIA.

                


        

      

      

      

      
        
          	

                	g.	
                  “Required By Law” shall have the same meaning given to such term as defined in 45 CFR§ 164.103 and The Health Information Technology for Economic and Clinical Health Act
                      (HITECH) Division A: Title XIII, Subtitle D.

                


        

      

      

      

      
        
          	

                	h.	
                  “Security Rule” shall mean the Standards for Security of Electronic Protected Health Information as specified in 45 C.F.R. Part 160 and subparts A and C of Part 164.

                


        

      

      

      

      
        
          	

                	i.	
                  Other definitions: The following terms used in this Agreement shall have the same meaning as those in the Privacy Rule and Security Rule: Breach, Designated Record Set,
                      Disclosure, Notice of Privacy Practices, Secretary, Security Incident, Standard, Subcontractor, Transaction, Unsecured Protected Health Information, and Use. Other terms shall have the definitions set forth in this Agreement.

                


           

          

        

      

      
        
          


      

      
        
          	Section 2.	
                  Obligations and Activities of Business Associate.

                


        

      

      

      

      2.1       Business Associate may not use or disclose Protected
          Health Information other than as permitted or required by this Agreement, the Underlying Agreements or as Required by Law.

      

      

      2.2       Business Associate agrees to use appropriate
          safeguards, including without limitation, administrative, physical and technical safeguards set forth in the Security Rule, to prevent use or Disclosure of the Protected Health Information other than as provided for by this Agreement and to
          reasonably and appropriately employ the same standards as Required by Law to protect the confidentiality, integrity and availability of any Electronic Protected Health Information (e-PHI) that it may receive, maintain or transmit on behalf of the
          PRHIA.

      

      

      2.3       Business Associate agrees to mitigate, to the extent
          practicable, any harmful effect that is known to Business Associate of a use or Disclosure of Protected Health Information by Business Associate in violation of the requirements of this Agreement.

      

      

      2.4       Business Associate agrees to report to PRHIA, in
          writing, within twenty-four (24) hours, any use or disclosure, or suspected use or disclosure, of the Protected Health Information not provided for by this Agreement or any Security Incident resulting in an attempted or successful unauthorized
          access, use, disclosure, modification, or destruction of information or interference with system operations or acquisition of any PHI, including e-PHI, of which it becomes aware. Business Associate shall report the unauthorized use or disclosure
          using the notification process specified in the services agreement executed between Business Associate and PRHIA. All reports shall include the information required by the Privacy Rule and Security Rule, to the extent available.

       

        

      
        
          


      

      Business Associate hereby reports to PRHIA that incidents including, but not limited to, ping sweeps or other common network
          reconnaissance techniques, attempts to log on to a system with an invalid password or username, and denial of service attacks that do not result in a server being taken off line, may occur from time to time.

      

      

      2.5       Business Associate must in accordance with 45 CFR
          164.502(e)(1)(ii) and 164.308(b)(2), if applicable, ensure that any Subcontractors, agents or affiliates of the Business Associate, that create, receive,
          maintain, or transmit PHI on behalf of the Business Associate agree to the same restrictions, conditions, and requirements that apply to the Business Associate with respect to such information. Business Associate must obtain satisfactory
          assurances in the form of a written agreement or memorandum of understanding directly from Subcontractors stipulating that the Subcontractor agrees to comply with the same restrictions and conditions set forth in this Agreement. Business
          Associate must ensure that any agent or Subcontractor to whom the Business Associate provides PHI not export PHI beyond the borders of the Commonwealth of Puerto Rico without express written agreement of the PRHIA.

      

      

      2.6       Business Associate agrees to provide access, at the
          written request of PRHIA, and in the time and manner designated by PRHIA, to Protected Health Information in a Designated Record Set, to PRHIA or an Individual in order to meet the requirements under 45 CFR §164.524.

      

      

      2.7       Business Associate agrees to make any amendment(s) to
          Protected Health Information in a Designated Record Set that the PRHIA directs or agrees to pursuant to 45 CFR §164.526 at the written request of PRHIA or an Individual, and in the time and manner designated by PRHIA.

      

      

      2.8       Business Associate agrees to make available to PRHIA
          internal practices, books, and records relating to the use and Disclosure of PHI, or at the request of the PRHIA, to the Secretary, in a time and manner designated by the PRHIA or the Secretary, for purposes of the Secretary determining
          compliance with the Privacy and Security Rules.

       

        

      
        
          


      

      2.9       Business Associate agrees to document such
          Disclosures of PHI and information related to such Disclosures as would be required for PRHIA to respond to a request by an Individual for an accounting of Disclosures of Protected Health Information in accordance with 45 CFR §164.528.

      

      

      2.10     Business Associate agrees to provide to PRHIA or an
          Individual, in time and manner designated by PRHIA, information collected in accordance with Section 2.9 of this Agreement, to permit PRHIA to respond to a request by an Individual for an accounting of Disclosures of Protected Health Information
          by Business Associate in accordance with 45 CFR §164.528.

      

      

      2.11     Business Associate understands and agrees that it will
          not access or use any Protected Health Information of any Individual except for those Individuals whose PHI has been disclosed to Business Associate, or is created, received, maintained, or transmitted by or to Business Associate on behalf of
          PRHIA, and it will further limit access to that Protected Health Information that is necessary to the activities undertaken by Business Associate on behalf of PRHIA and as otherwise permitted by this Agreement.

      

      

      2.13     Business Associate will, pursuant to the HITECH Act
          and its implementing regulations, comply with the requirements of the Privacy Rule, including those contained in 45 CFR §§ 164.502(e) and 164.504(e)(1)(iii. To the extent Business Associate is to carry out one or more of PRHIA’s obligations under
          Subpart E of 45 C.F.R. Part 164, Business Associate agrees to comply with the requirements of Subpart E that apply to PRHIA in the performance of such obligations. Business Associate will not directly or indirectly receive remuneration in
          exchange for any Protected Health Information, subject to the exceptions contained in the HITECH Act, without a valid authorization from the applicable Individual. Business Associate will not use Protected Health Information to engage in any
          communication which might be deemed to be “Marketing” under the HITECH Act without prior written permission from PRHIA and without Individual authorizations, to the extent required by the HITECH Act and its implementing regulations. In addition,
          Business Associate will, pursuant to the HITECH Act and its implementing regulations, comply with all applicable requirements of the Security Rule.

       

        

      
        
          


      

      2.14     Business Associate agrees to make uses of and
          disclosures and requests for Protected Health Information consistent with HIPAA and any of PRHIA’s Minimum Necessary policies and procedures provided to Business Associate and consistent with PRHIA’s Notice of Privacy Practices. PRHIA asserts
          that its Minimum Necessary policies and procedures are consistent with 45 C.F.R. §164.514(d) and Business Associate agrees to comply with the provisions of that rule.

      

      

      2.15     To the extent Business Associate submits Standard
          Transactions on behalf of PRHIA or assists PRHIA with submission of Standard Transactions, Business Associate shall comply with HIPAA’s Transaction and code set Standards for such Transactions and will provide documentation of such compliance
          upon request of Covered Entity.

      

      

      
        
          	Section 3.	
                  Permitted Uses and Disclosures by Business Associate.

                


        

      

      

      

      3.1       Business Associate may use or disclose Protected
          Health Information, or any information derived from that Protected Health Information, only as explicitly permitted in the Underlying Agreements and this Agreement, and only if such use or Disclosure, respectively, is in compliance with each
          applicable requirement of 45 CFR § 164.504(e) and 164.314(a)(2). This means that:

      

      

      3.1.1         Except as otherwise limited in this Agreement,
          Business Associate may use Protected Health Information for the proper management and administration of the Business Associate or to carry out the legal responsibilities of the Business Associate.

       

        

      
        
          


      

      3.1.2         Except as otherwise limited in this Agreement,
          Business Associate may disclose Protected Health Information for the proper management and administration of the Business Associate or to carry out the legal responsibilities of Business Associate, provided that such disclosures are Required By
          Law, or Business Associate obtains reasonable assurances from the person/organization to whom the information is disclosed that it will remain confidential and used or further disclosed only as Required By Law or for the purpose for which it was
          disclosed to the person/organization, and the person/organization notifies the Business Associate of any instances of which it is aware in which the confidentiality of the information has been Breached.

      

      

      3.1.3          In accordance with 45 CFR 164.502(e)(1)(ii) and
          164.308(b)(2), if applicable, ensure that any Subcontractors that create, receive, maintain, or transmit Protected Health Information on behalf of the Business Associate agree to the same restrictions, conditions, and requirements that apply to
          the Business Associate with respect to such information.

      

      

      3.2       Business Associate understands and agrees that its
          access to Protected Health Information stored in databases and information systems at the PRHIA is subject to review and audit by the PRHIA, the Secretary, or agents of the HHS and OCR at any time, that remote audits of such access may occur at
          any time, that on-site audits of such access will be conducted during regular business hours, and that any review or audit may occur with or without prior notice by PRHIA. The fact that PRHIA reviews or audits, or fails to review or audit, or has
          the right to review and audit, Business Associate’s access does not relieve Business Associate of the responsibility to comply with this Agreement, nor does PRHIA’s (i) failure to detect or (ii) detection, but failure to notify Business Associate
          or to require Business Associate’s remediation of any unsatisfactory practice, constitute acceptance of such practice or waiver of  PRHIA’s enforcement rights under this Agreement.

       

        

      
        
          


      

      
        
          	Section 4.	
                  Application of Security and Privacy Provisions to Business Associate.

                


        

      

      

      

      4.1       Security Measures: The Security Rule, including 45
          CFR §164.308, 164.310, 164.312 and 164.316, dealing with the administrative, physical and technical safeguards as well as policies, procedures and documentation requirements that apply to PRHIA shall in the same manner apply to Business Associate
          as Required By Law. If Business Associate requires access to PRHIA’s electronic patient information systems, electronic health record (EHR) or electronic infrastructure systems (either on site or remote), Business Associate will supply the
          necessary information of employees to uniquely identify such employees as employees with a need to access systems and will supply to PRHIA’s Information Security Officer a valid state or federal issued photo ID in order for such employees to
          receive a unique user name and password to access the system(s).

      

      

      4.2       Application of Civil and Criminal Penalties: If
          Business Associate violates any Security provision as Required By Law specified in Section 4.1 above, sections 1176 and 1177 of the Social Security Act, 42 U.S.C. §1320d-5, 1320d-6, shall apply to Business Associate with respect to such violation
          in the same manner that such sections apply to PRHIA if it violates such Security provision.

      

      

      
        	
                Section 5. 

              	
                Information Breach and Restriction Notification Requirements.

              


      

      

      

      5.1       Business Associate expressly recognizes that PRHIA
          may have certain reporting and Disclosure obligations to the Secretary and the Individual in case of a Security Breach of Unsecured Protected Health Information.

      

      

      5.2       Where Business Associate uses or Discloses Unsecured
          Protected Health Information in a manner not permitted by this Agreement, Business Associate without unreasonable delay and in no case later than the timeframe set forth in Section 2.4 of this Agreement, following the discovery of any
          impermissible use, Disclosure, or Breach of such information, shall notify PRHIA of such Breach, use or Disclosure. Such notice shall include the identification of each Individual whose Unsecured Protected Health Information has been, or is
          reasonably believed by the Business Associate to have been, accessed, acquired or disclosed. Business Associate shall cooperate with PRHIA to assist PRHIA in determining whether an impermissible use or Disclosure is a Breach, and shall provide a
          written risk assessment, in accordance with 45 C.F.R. §164.402, upon request of PRHIA.

       

        

      
        
          


      

      5.3      Business Associate shall be liable for the costs
          associated with any Breach if caused by the Business Associate’s negligent or willful acts or omissions, or the negligent or willful acts or omissions of Business Associate’s agents, officers, employees or Subcontractors. PRHIA, in its sole and
          absolute discretion, may elect to delegate to Business Associate any requirement to notify affected Individuals of a Breach of Unsecured Protected Health Information, if such Breach results from, or is related to, an act or omission of Business
          Associate or the subcontractors, agents, employees or representatives of Business Associate.

      

      

      5.4       PRHIA agrees to notify Business Associate of any
          restrictions on the use or disclosure of Protected Health Information to which PRHIA has agreed that may affect Business Associate’s use or disclosure of Protected Health Information pursuant to this Agreement.

      

      

      
        
          	Section 6.	
                  Insurance and Indemnification

                


        

      

      

      

      6.1      Indemnification. The Business Associate agrees to
          indemnify, defend and hold harmless PRHIA and PRHIA’s employees, affiliates, directors, officers, Subcontractors, agents or other members of its workforce from any costs, damages, expenses, judgments, losses, and attorney’s fees arising from any
          breach of this Agreement by Business Associate, or arising from any negligent or wrongful acts or omissions of Business Associate, including failure to perform its obligations under the Privacy Rule or Security Rule. The Business Associate’s
          indemnification obligation shall survive the expiration or termination of this Agreement for any reason.

      

      

      
        
          	Section 7.	
                  Terms and Termination.

                


        

      

      

      

      7.1       Term. The Term of this Agreement shall commence as of
          the Effective Date (as defined below), and shall terminate on the latest termination date of the Underlying Agreements or on the date PRHIA terminates this agreement for cause as authorized on paragraph (7.2) of this section, whichever is sooner.

       

        

      
        
          


      

      7.2        Termination for Cause. The Parties acknowledge that
          in the event the PRHIA learns of a pattern or activity or practice of the Business Associate that constitutes violation of a material term of this Agreement, then Business Associate promptly shall take reasonable steps to cure the violation. If
          such steps are, in the judgment of the PRHIA, unsuccessful, ineffective or not feasible, then PRHIA may terminate, in its sole discretion, this Agreement and/or any or all of the Underlying Agreements upon written notice to the Business
          Associate, if feasible.

      

      

      7.3       Effect of Termination. Except as provided in the
          following paragraph of this section, upon termination of this Agreement or the Underlying Agreements for any reason, Business Associate shall return or, only with PRHIA’s prior written permission, destroy all Protected Health Information received
          from PRHIA, or created or received by Business Associate on behalf of PRHIA. This provision shall apply to Protected Health Information that is in the possession of Subcontractors or agents of Business Associate. Business Associate shall retain
          no copies of the Protected Health Information except as otherwise permitted by PRHIA.

      

      

      In the event that Business Associate determines that returning or destroying the Protected Health Information is infeasible, Business
          Associate shall provide to PRHIA notification, in writing, of the conditions that make return or destruction infeasible.  Said notification shall include: (i) a statement that the Business Associate has determined that it is not feasible to
          return or destroy the Protected Health Information in its possession, and (ii) the specific reasons for such determination. The PRHIA may disagree with the Business Associate’s determination. Upon mutual agreement of the Parties that return or
          destruction of Protected Health Information is infeasible, Business Associate shall extend the protections of this Agreement to such Protected Health Information and limit further uses and Disclosures of such Protected Health Information to those
          purposes that make the return or destruction infeasible, for as long as Business Associate maintains such Protected Health Information. If it is infeasible for the Business Associates to obtain, from a Subcontractor or agent, any Protected Health
          Information in the possession of the Subcontractor or agent, the Business Associate must provide a written explanation to PRHIA and require the Subcontractors and agents to agree to extend any and all protections, limitations, and restrictions
          contained in this Agreement to the Subcontractors’ and/or agents’ use and/or Disclosure of any Protected Health Information retained after the termination of this Agreement, and to limit any further uses and/or Disclosures to the purposes that
          make the return or destruction of Protected Health Information infeasible.

       

        

      
        
          


      

      7.4        Automatic Termination. This agreement will
          automatically terminate without any further action of the Parties upon the latest termination or expiration of the Underlying Agreements.

      

      

      7.5       Effective Date. The effective date of this Agreement
          (the “Effective Date”) shall be the date of the last signature below.

      

      

      Section 8. Miscellaneous.

      

      

      8.1       Regulatory References. A reference in this Agreement
          to a section in the Privacy and Security Rules means the section as in effect or as amended, and for which compliance is required.

      

      

      8.2      Agreement. The Parties agree to negotiate in good
          faith to take such action as is necessary to amend the Underlying Agreements from time to time as is necessary for PRHIA to comply with the requirements of HIPAA; provided, however, that the Agreement shall be modified only in accordance with
          Section 8.3 of this Agreement.

      

      

      8.3      Amendments; Waiver. This agreement may not be modified, nor shall any provision hereof be waived or amended, except in a
          writing duly signed by authorized representatives of the Parties. A waiver with respect to one event shall not be construed as continuing, or as a bar to a waiver of any right or remedy as to subsequent events. The Parties agree to negotiate in
          good faith to take such action as is necessary to amend this agreement from time to time as is necessary for compliance with the requirements of the HIPAA rules and any other applicable law.

      

      

      
        
          


      

      
        8.4        Survival. Sections 2.3, 2.4,
            2.6, 2.8, 2.10, 3.2, 5.2, 5.3, 6.1 and 7.3, 8.4, 8.5, 8.6, 8.7 and 8.8 shall survive the termination of this Agreement and/or the Underlying Agreements.

      

       

      
      8.5        No Third Party Beneficiaries/Independent
          Contractors. Except as set forth in Section 6.1, nothing express or implied in this Agreement is intended to confer, nor shall anything herein confer, upon any person other than the Parties and the respective successors or assigns of the Parties,
          any rights, remedies, obligations, or liabilities whatsoever.

      

      

      8.6       Interpretation. Any ambiguity in this Agreement shall
          be resolved in favor of a meaning that permits PRHIA and Business Associate to comply with the HIPAA Privacy and Security Rules. In the event of a conflict between this Agreement and any Underlying Agreements, this Agreement shall control.

      

      

      8.7        Notices. Any notice required or permitted by this
          Agreement to be given or delivered shall be delivered in accordance with the notice provisions of the Underlying Agreements. The Parties may change their addresses for purposes of this Agreement by written notice to the other party.

      

      

      8.8       Severability. Whenever possible, each provision of
          this Agreement shall be interpreted so as to be effective and valid under applicable law. If any provision of this Agreement should be prohibited or found invalid under applicable law, such provision shall be ineffective to the extent of such
          prohibition or invalidity without invalidating the other of such provision or the remaining provisions of this Agreement.

      

      

      8.9        Governing Law. To the extent not preempted by
          federal law, the Agreement shall be governed and construed in accordance with the laws governing the Underlying Agreements.

      

      

      8.10     Assignment, Binding Nature, and Benefits. This
          Agreement binds and benefits the Parties, and their respective successors and permitted assigns. Business Associate may not assign or subcontract rights or obligations under this Agreement without the express written consent of PRHIA. PRHIA may
          assign its rights and obligations under this Agreement to any successor or affiliate.

       

        

      
        
          


      

      8.11      Counterparts. This Agreement may be executed in
          multiple counterparts, which shall constitute a single Agreement, and by facsimile or pdf signatures, which shall be treated as originals.

      

      

      IN WITHNESS WHEREOF, the parties have duly executed this Agreement this September 21, 2018.

      

      

      	
              s/Madeline Hernández Urquiza

            	
              s/Angela M. Avila Marrero

            
	
              Madeline Hernández Urquiza

            	
              Angela M. Avila Marrero

            
	
              President

            	
              Executive Director

            
	
              Triple-S Salud, Inc.

            	
              PR Health Insurance Administration

            
	
              EIN: 66-0555677

            	
              EIN: 66-0500678

            
	 	 
	
              Address:

            	
              Address:

            
	
              PO Box 363628

            	
              PO Box 195661

            
	
              San Juan, PR 00919-1580

            	
              San Juan, PR 00919-5661

            


      

      

      

      

       

    

  








  
     Attachment 19

      

     

    

    
      PUERTO RICO HEALTH INSURANCE ADMINISTRATION

      ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO

      

      

      

      

      

      Revised version 8/2/2018

      

      

      
        
          


      

      	 
              TABLE OF CONTENTS

               


      

      

      	
              I.

            	
              INTRODUCTION

            	
              2

            
	 	 	 
	
              II.

            	
              REPORTING TIMEFRAMES

            	
              3

            
	 	 	 
	
              III.

            	
              EVALUATION & POINT DISTRIBUTION

            	
              4

            
	 	 	 
	
              IV.

            	
              RETENTION FUND & COMPLIANCE PERCENTAGE

            	
              8

            
	 	 	 
	
              V.

            	
              DEFINITIONS

            	
              9

            
	 	 	 
	
              VI.

            	
              HIGH COST CONDITIONS INITIATIVE

            	
              11

            
	 	 	 
	
              VII.

            	
              CHRONIC CONDITIONS INITIATIVE

            	
              14

            
	 	 	 
	
              VIII.

            	
              HEALTHY PEOPLE INITIATIVE

            	
              20

            
	 	 	 
	
              IX.

            	
              EMERGENCY ROOM HIGH UTILIZERS INITIATIVE

            	
              22

            


       

      

      
        
          


      

      
      
        
          	I.	
                  INTRODUCTION

                


        

      

      

      

      The Puerto Rico Health Insurance Administration’s (ASES, by its acronym in Spanish) focus is on providing quality services that are patient-centered and
          aimed at increasing the use of screening, prevention and appropriate delivery of care in a timely manner to all Medicaid, Children’s Health Insurance Program
            (CHIP) and Medicare-Medicaid Dual Eligible (Platino) Enrollees in Puerto Rico. The Health Care Improvement Program (HCIP) is one of the tools developed by ASES to reach this goal.

      

      

      This Manual has the sole purpose of providing the necessary guidelines for attaining the required performance indicators for each of the categories
          measured under the HCIP as specified and subject to revision by ASES in this Manual, and incorporated in Section 12.5 of the Government Health Plan (GHP)/MI Salud Model Contract (Contract) executed between the Contractor and ASES. As the HCIP
          guidelines or performance benchmarks are updated, ASES will share these changes with Contractors and update this Manual. ASES shall maintain a Retention Fund created by withhold amounts of the Per Member Per Month (PMPM) Payment each month as
          part of the HCIP described in Section 22.4 of the Contract. A portion of the retained PMPM amount shall be associated with each HCIP initiatives outlined below:

      

      

      
        
          	1.	
                  High Cost Conditions Initiative

                


           

          

        

      

      
        
          	2.	
                  Chronic Conditions Initiative

                


           

          

        

      

      
        
          	3.	
                  Healthy People Initiative

                


           

          

        

      

      
        
          	4.	
                  Emergency Room High Utilizers Initiative

                


        

      

      

      

      ASES will reimburse the Contractor according to compliance with each of the categories of performance indicators for each of the four (4) HCIP
          Initiatives specified in this Manual. The Planning, Quality and Clinical Affairs Office will audit the results of the data in the timeframes stated in Section 22.4.2.2 of the Contract for the performance indicators in the above named initiatives.
          This Manual describes, in detail, the requirements and the specific metrics for each initiative of the HCIP for the Contract period November 1, 2018 through September 30, 2021, with an option to extend to September 30, 2022, at ASES’ discretion.
          In the event ASES exercises the optional extension, an updated HCIP Manual will be provided. The HCIP will start on the implementation date of the Contract and will be updated annually as GHP benchmarks are set and measures or metrics are revised
          or modified accordingly.

       

        

      
        2

        
          


      

      
        
          	II.	
                  REPORTING TIMEFRAMES

                


        

      

      

      

      The Contractor will submit a report for each quality initiative on a quarterly basis as established in the following table. The reporting templates will
          be provided by ASES and the Contractor must submit them through the ASES Sharefile. Information for accessing the ASES Sharefile will be forthcoming.

      

      

      	 	
              QUARTER &

               
              CONTRACT

               
              YEAR

            	 	 
              INCURRED SERVICE TIME PERIOD

               	 	
              PAYMENT AS OF

            	 	
              SUBMISSION DATE

            
	 	
              Contract

              Year (CY)

              2019

            	 	
              *National Benchmark — ASES will establish the Puerto Rico benchmark (GHP national benchmark) for the
                  metrics included in this manual using the period from July 1, 2016 through June 30, 2017.

            
	 	
              Q1

            	 	
              11/01/2018 through 01/31/2019

            	 	
              April 30, 2019

            	 	
              May 31, 2019

            
	 	
              Q2

            	 	
              02/01/2019 through 04/30/2019

            	 	
              July 31, 2019

            	 	
              August 31, 2019

            
	 	
              Q3

            	 	
              05/01/2019 through 07/31/2019

            	 	
              October 31, 2019

            	 	
              November 30, 2019

            
	 	
              Q4

            	 	
              08/01/2019 through 10/31/2019

            	 	
              January 31, 2019

            	 	
              February 28, 2020

            
	 	
              CY 2020

            
	 	
              Q1

            	 	
              11/01/2019 through 01/31/2020

            	 	
              April 30, 2020

            	 	
              May 31, 2020

            
	 	
              Q2

            	 	
              02/01/2020 through 04/30/2020

            	 	
              July 31, 2020

            	 	
              August 31, 2020

            
	 	
              Q3

            	 	
              05/01/2020 through 07/31/2020

            	 	
              October 31, 2020

            	 	
              November 30, 2020

            
	 	
              Q4

            	 	
              08/01/2020 through 10/31/2020

            	 	
              January 31, 2020

            	 	
              February 28, 2021

            
	 	
              CY 2021

            
	 	
              Q1

            	 	
              11/01/2020 through 01/31/2021

            	 	
              April 30, 2021

            	 	
              May 31, 2021

            
	 	
              Q2

            	 	
              02/01/2021 through 04/30/2021

            	 	
              July 31, 2021

            	 	
              August 31, 2021

            
	 	
              Q3

            	 	
              05/01/2021 through 07/31/2021

            	 	
              October 31, 2021

            	 	
              November 30, 2021

            
	 	
              Q4

            	 	
              08/01/2021 through 09/30/2021

            	 	
              December 30, 2021

            	 	
              January 30, 2022

            


      

      

      
        3

        
          


      

      
        
          	III.	
                  EVALUATION & POINT DISTRIBUTION

                


           

          

        

      

      As previously indicated, the HCIP is divided into four categories:

       

        

      
        
          	1.	
                  High Cost Conditions Initiative

                


           

          

        

      

      
        
          	
                  2.

                	
                  Chronic Conditions Initiative

                


           

          

        

      

      
        
          	3.	
                  Healthy People Initiative

                


           

          

        

      

      
        
          	4.	
                  Emergency Room High Utilizers Initiative

                


        

      

       

        

      Under each initiative, there is a list of conditions, indicators and performance measures which the Contractor must report on a quarterly basis. The
          performance indicators for each initiative are outlined in the tables below.

      

      

      Prior to the implementation date of the Contract, ASES will provide the Contractors with a final set of conditions, performance measures, technical
          specifications, and benchmarks that will be used in the first year (CY 2019) for each initiative included under the HCIP. For the first quarter (Q1) of the CY 2019 evaluation, the Contractor will be required to develop and submit a HCIP Plan
          (HCIPP) addressing each initiative and how the Contractor will achieve improvements. The Contractor is required to design its HCIPP based on the national GHP benchmarks of each metric included in this Manual. The HCIPP will be submitted to ASES
          no later than December 31, 2018, and will be reviewed and approved by ASES during the month of January 2019. The Retention Fund reimbursement for Q1 of CY 2019 will be in accordance with the fulfillment of this requirement and the submission of
          the templates with the results. For Q2 and Q3 of CY 2019, the Contractor is required to submit a revised HCIPP with updated metrics results and a report of the activities carried out according to the HCIPP submitted for Q1. ASES will determine
          the impact of these activities based on the updated quarterly results and comparison to the relevant national GHP benchmark for the selected metric. Compliance with the submission of these reports will be the basis for the reimbursement of
          Retention fund withhold for these quarters.

      

      

      For Q4 of CY 2019, ASES will update the GHP benchmarks for the Contractor using the twelve (12) months prior to January 1, 2019 (from January 1, 2018 to
          December 31, 2018). Thereafter, ASES will continue reviewing performance metrics using the results of the previous twelve (12) months, including the current quarter. The Contractor-reported results will be compared to GHP national benchmarks to
          determine compliance.

       

        

      
        4

        
          


      

      For Q4 of CY 2019 and Q1 and Q2 of CY 2020, the Contractor must show any improvement on each metric when compared to the GHP benchmarks. For Q3 and Q4 of
          CY 2020, the Contractor will be required to demonstrate established improvement targets for each metric when compared to the GHP benchmarks.

      

      

      These specific targets for improvement for each metric will be established by ASES based on the analysis of individual metrics and overall results of
          data for calendar year 2019, and will be shared with the Contractor once established. Metric targets will be revised for CY 2021 and CY 2022 based on the analysis of data of calendar year 2020 and 2021 as indicated in the table below. For CY 2021
          and CY 2022, ASES may substitute or adjust selected metrics. Changes to metrics utilized may be adjusted by ASES based on program quality and value based contracting goals. Any changes will be shared with the Contractor, and the HCIP will be
          updated to reflect those changes.

      

      

      For the Emergency Room High Utilizers Initiative, improvement means a decrease the Emergency Room utilization rate when compared to the GHP national
          benchmark (or other benchmark as developed by ASES) and an increase of the primary care physician (PCP) outpatient visits rate for the targeted population (refer to Section IX of this Manual).

      

      

      	 	
              QUARTER &

               
              CONTRACT

               
              YEAR (CY)

            	 	
              INCURRED

               
              SERVICE TIME 

               
              PERIOD

            	 	
              EVALUATION CRITERIA OR EXPECTED GOAL

            
	 	
              CY 2019

            	 	
              *GHP National Benchmark — ASES will establish the Puerto Rico benchmark (GHP.national benchmark) for the
                  metrics included in this manual using the period from.January 1, 2017 through December 31, 2017

            
	 	
              Q1

            	 	
              11/01/2018 through 01/31/2019

            	 	
              Q I Plan & Report submission

            
	 	
              Q2

            	 	
              02/01/2019 through 04/30/2019

            	 	
              Report submission and on Plan implemented activities

            
	 	
              Q3

            	 	
              05/01/2019 through 07/31/2019

            	 	
              Report submission and on Plan implemented activities

            
	 	
              Contractor GHP Benchmark Data Analysis — From January 1, 2018 to December 31, 2018: To be provided by
                  ASES.

            
	 	
              Q4

            	 	
              08/01/2019 through 10/31/2019

            	 	
              Any improvement over GHP benchmark

            


      

      

      
        5

        
          


      

      
        	 	
                QUARTER &

                 
                CONTRACT

                 
                YEAR (CY)

              	 	
                INCURRED

                 
                SERVICE TIME

                 
                 PERIOD

              	 	
                EVALUATION CRITERIA OR EXPECTED GOAL

              


      

      	 	
              CY 2020

            
	 	
              Q1

            	 	
              11/01/2019 through 01/31/2020

            	 	
              Any improvement over GHP benchmark

            
	 	
              Q2

            	 	
              02/01/2020 through 04/30/2020

            	 	
              Any improvement over GHP benchmark

            
	 	
              Contractor GHP Benchmark Data Analysis — From January 1, 2018 to December 31, 2018: To be provided by ASES.

            
	 	
              Q3

            	 	
              05/1/2020 through 07/31/2020

            	 	
              Improvement goal to be established by ASES through analysis of individual metrics and overall results of data for CY 2019; goals will be shared with
                  the Contractor

            
	 	
              Q4

            	 	
              08/01/2020 through 10/31/2020

            	 	
              Improvement goal to be established by ASES through analysis of individual metrics and overall results of data for CY 2019; goals will be shared with
                  the Contractor

            
	 	
              CY 2021

            
	 	
              Q1

               

            	 	
              11/01/2020 through 01/31/2021

               

            	 	
              Improvement goal to be established by ASES through analysis of.individual metrics and over-all results of data; Goals will be shared.with
                  Contractors.

            
	 	
              Q2

               

            	 	
              02/1/2021 through 04/30/2021

            	 	
              Improvement goal to be established by ASES through analysis of.individual metrics and over-all results of data; Goals will be shared.with
                  Contractors.

            
	 	
              Contractor GHP Benchmark Data Analysis — From January 1, 2018 to December 31, 2018: To be providedby ASES.

            
	 	
              Q3

            	 	
              05/1/2021 through 07/31/2021

            	 	
              Improvement goal to be established by ASES through analysis of individual metrics and overall results of data; goals will be shared with the
                  Contractor.

            
	 	
              Q4

            	 	
              08/01/2021 through 09/30/2021

            	 	
              Improvement goal to be established by ASES through analysis of individual metrics and overall results of data; goals will be shared with the
                  Contractor.

            


      

      

      
        6

        
          


      

      The scale of values per indicator, as determined by ASES, is divided into the three levels indicated below. 

       

        

      They will apply when a specific amount of improvement over the GHP benchmark is required per metric:

       

        

      
        
          	•	
                  1 Point = Full compliance with the expected goal; meets or exceeds (90%–100%) the expected goal as defined in the HCIP manual.

                


           

          

        

      

      
        
          	•	
                  0.5 point = Partial compliance; results reported are 70% or over, but less than 90% (70.00%–89.99%) of the established goal.

                


           

          

        

      

      
        
          	•	
                  0 points = Fails; results reported are less than 70% (0%–69.99%) of the established goal.

                


        

      

      

      

      The point distribution by program is as follows, and is based on the scored measures found in the measures tables in Section VI of this Manual.

      

      

      	 	
              PROGRAM

            	
              POINTS

            
	 	
              High Cost Conditions Initiative

            	
              12

            
	 	
              Chronic Conditions Initiative

            	
              16

            
	 	
              Healthy People Initiative

            	
              10

            
	 	
              Emergency Room High Utilizers Initiative

            	
              2

            
	 	
              Total Possible Points

            	
              40

            


      

      

      
        7

        
          


      

      
        
          	IV.	
                  RETENTION FUND & COMPLIANCE PERCENTAGE

                


        

      

       

        

      ASES will withhold a portion of the monthly PMPM Payment otherwise payable to the Contractor in order to validate the Contractor has met the specified
          performance targets under the HCIP. The Retention Fund, comprised of the withheld amounts, will be reimbursed to the Contractor when a determination is made by ASES that the Contractor has complied with the improvement standards and criteria
          established by ASES in accordance with this Manual.

      

      

      On a monthly basis, ASES will withhold a Retention fund equivalent to 2% of the total PMPM Payments. A portion of the retained amount will be associated
          with each of the HCIP initiatives outlined below for each of the specified timeframes, as per Section 22.4 of the Contract.

      

      

      	 	
              TIME PERIOD (INCURRED SERVICE FROM CONTRACT

               
              TERM)

            	 	
              MONTHLY RETENTION FUND

              PERCENTAGE

            
	 	
              Contract Year Quarters Defined in Section II – Reporting Timeframes

            	 	
              2%

            
	 	
              HCIP INITIATIVE

            	 	
              RETENTION FUND BREAKDOWN

            
	 	
              High Cost Conditions Initiative

            	 	
              0.6%

            
	 	
              Chronic Conditions Initiative

            	 	
              0.6%

            
	 	
              Healthy People Initiative

            	 	
              0.6%

            
	 	
              Emergency Room High Utilizers Initiative

            	 	
              0.2%

            


      

      

      No later than thirty (30) calendar days after receipt of the Contractor’s quarterly submission, ASES shall determine if the Contractor has met the
          applicable performance objectives for each initiative metric for that period. The evaluation result and compliance will determine the percent to be disbursed to the Contractor as described in the following table.

      

      

      	 	
              COMPLIANCE PERCENT

            	 	
              DISBURSEMENT PERCENTAGE OF MONTHLY PMPM

            
	 	
              100.0%–90.0% (36.0–40.0 points)

            	 	
              100%

            
	 	
              89.9%–80.0% (32.0–35.5 points)

            	 	
              75%

            
	 	
              79.9%–70.0% (28.0–31.5 points)

            	 	
              50%

            
	 	
              69.9%–50.0% (20.0–27.5 points)

            	 	
              25%

            
	 	
              49.9% and below (19.5 points or less)

            	 	
              0%

            


      

      

      
        8

        
          


      

      
        
          	V.	
                  DEFINITIONS

                


           

          

        

      

      The following definitions apply to measures of the HCIP Manual:

       

        

      
        
          	

                	1.	
                  Incurred date: The date on which the service was provided.

                


           

          

        

      

      
        
          	

                	2.	
                  Intervention: Activities targeted at the achievement of client stability,
                      wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, care coordination, collaboration and service facilitation.

                


           

          

        

      

      
        
          	

                	3.	
                  Performance measures: Periodic measurement of outcomes and results used to assess
                      the effectiveness and efficiency of quality or improvement initiatives on selected indicators.

                


           

          

        

      

      
        
          	

                	4	
                  Per member per month (PMPM) payment: The fixed monthly amount that the
                      Contractor is paid by ASES for each enrollee to ensure that benefits under the Contract are provided. This payment is made regardless of whether the enrollee receives benefits during the period covered by the payment.

                


           

          

        

      

      
        
          	

                	5.	
                  Preventive services: Health care services provided by a physician or other
                      provider within the scope of his or her practice under Puerto Rico law to detect or prevent disease, disability, behavioral health conditions or other health conditions; and to promote physical and behavioral health and efficiency.

                


           

          

        

      

      
        
          	

                	6.	
                  Primary care physician (PCP): A licensed medical doctor (MD) who is a provider
                      and who, within the scope of practice and in accordance with Puerto Rico certification and licensure requirements, is responsible for providing all required primary care to enrollees. The PCP is responsible for determining services
                      required by enrollees, provides continuity of care and provides referrals for enrollees when medically necessary. A PCP may be a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist or
                      pediatrician.

                


           

          

        

      

      
        
          	

                	7.	
                  Retention fund: The amount of withhold by ASES of the monthly PMPM payment
                      otherwise payable to the Contractor in order to incentivize the Contractor to meet performance targets under the HCIP described in this Manual. This amount shall be equal to the percent of that portion of the total PMPM payment that
                      is determined to be attributable to the Contractor’s administration of the HCIP described in this Manual and Sections 12.5 and 22.4 of the Contract. Amounts withheld will be reimbursed to the Contractor in whole or in part (as set
                      forth in this Manual and Sections 12.5 and 22.4 of the Contract) in the event of a determination by ASES that the Contractor has complied with the quality standards and criteria established in this Manual.

                


           

          

        

      

      
        9

        
          


      

      
        
          	

                	8.	
                  Health Care Improvement Program (HCIP): Approach developed to improve the quality
                      of services provided to enrollees. The HCIP consists of four (4) initiatives: High Cost Conditions Initiative, Chronic Condition Initiative, Healthy People Initiative and Emergency Room High Utilizers Initiative.

                


           

          

        

      

      
        
          	

                	9.	
                  Health Care Improvement Program Plan (HCIPP): For the Q1 of CY 2019 evaluation,
                      the Contractor will be required to develop and submit a HCIPP for each initiative outlined in the HCIP Manual.

                


           

          

        

      

      
        
          	

                	10.	
                  Active Enrollee: GHP Enrollee with continuous enrollment during the HCIP measurement quarter.

                


        

      

      

      

      Note:

       

        

      Definition references in this manual are from the Contract and NCQA (National Committee for Quality Assurance)

       

        

      
        10

        
          


      

      
        
          	VI.	
                  HIGH COST CONDITIONS INITIATIVE

                


           

          

        

      

      The High Cost Conditions Initiative focuses on those enrollees with a high cost condition that may be part of the High Cost High Need (HCHN) Program
          specified in Section 7.8.3 of the Contract. The Contractor must develop initiatives to improve the health of the population for each health condition identified through the indicators listed below. The Contractor must be prepared to report
          quarterly on the quality measures listed below for each condition. Prior to the implementation date of the Contract, the ASES Office of Planning, Quality and Clinical Affairs will select the high cost conditions and the respective improvement
          metrics that will be taken into consideration for the quarterly reports on this initiative. The reporting templates for each selected condition will be provided to the Contractor through the ASES ShareFile site. Each reporting template will be in
          Excel format. ASES shall reimburse the Contractor the applicable percentage of the Retention fund in accordance with the Contractor’s performance across the scored measures and the point distribution section of this Manual.

       

        

      

      	
               

            	
              HIGH COST

               

              CONDITIONS

            	
               

            	
              QUALITY MEASURES

            	
               

            	
              SCORED MEASURES

            	
              POINTS

            
	
               

            	
               

            	
              Medicaid/Federal and Commonwealth High Cost Conditions

            	
                

            
	
               

            	
              Cancer

            	
               

            	
              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      Emergency Department (ED) Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	
               

            	
                    Admissions/1000

               

            	
              1

            


      

      

      
        11

        
          


      

      	 	
              HIGH COST

               
              CONDITIONS

            	 	
              QUALITY MEASURES

            	 	
              SCORED MEASURES

            	
              POINTS

            
	 	
              End-Stage Renal Disease (ESRD)

               

            	 	
              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	
              •     Admissions/1000

            	
              1

               

            
	 	
              Multiple Sclerosis

            	 	
              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	
              •     Admissions/1000

              •     Adherence to Formulary Drugs

            	
              1

              1

               

            
	 	
              Rheumatoid

              Arthritis

               

            	 	
              •      Disease-modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

               

            	 	
              •     Disease-modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis

               

              •     Generic Dispensing Rate

            	
              1

               

               

               

              1

               

            
	 	
              CHIP High Cost Conditions

            


      

      

      
        12

        
          


      

      	 	
              HIGH COST

               
               CONDITIONS

            	 	
              QUALITY MEASURES

            	 	
              SCORED MEASURES

            	
              POINTS

            
	 	
              Cancer

            	 	
              •      Generic Dispensing Rate

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	
              •     Admissions/1000

            	
              1

               

            
	 	
              Children and Youth with Special Healthcare Needs (CYSHCN)

            	 	
              •      Well-child visits in first 15 months of life

              •      Well-child visits in the 3rd, 4th, 5th and 6th years of life

              •      Adolescent Well-care visits

              •      Annual Dental Visit

            	

            	
              •     Well-child


                  visits in first 15 months of life

               

              •    Well-child
                  visits in the 3rd, 4th, 5th and 6th years of life

               

              •     Adolescent


                  Well-care visits

            	
              1

               

                

              1

               

              

              1

            
	 	
              Hemophilia

            	 	
              •      Well-child visits in first 15 months of life

              •      Well-child visits in the 3rd, 4th, 5th and 6th years of life

              •      Generic Dispensing Rate

              •      Adherence to Formulary Drugs

              •      BMI Assessment

            	 	
              •     Adherence
                  to Formulary Drugs

            	
              1

               

            
	 	
              Autism

            	 	
              •      Well-child visits in first 15 months of life

              •      Well-child visits in the 3rd, 4th, 5th and 6th years of life

              •      Generic Dispensing Rate

              •      Adherence to Formulary Drugs

              •      Incidence rate

              •      Prevalence rate

               

            	 	
              •    Well-child
                  visits in the 3rd, 4th, 5th and 6th years of life

            	
              1

               

            
	

            	
              Total Points

            	
              12

            


      

      

      
        13

        
          


      

      
        
          	VII.	
                  CHRONIC CONDITIONS INITIATIVE

                


        

      

       

        

      The Chronic Conditions Initiative focuses on those enrollees with a Chronic Condition. The Contractor must develop initiatives to improve the health of
          the population for each health condition identified through the indicators listed below. The Contractor must be prepared to report quarterly on the quality measures listed below for each condition. Prior to the implementation date of the
          Contract, the ASES Office of Planning, Quality and Clinical Affairs will select the chronic conditions and the respective improvement metrics that will be taken into consideration for the quarterly reports on this initiative. The reporting
          templates for each selected condition will be provided to the Contractor through the ASES ShareFile site. Each reporting template will be in Excel format. ASES shall reimburse the Contractor the applicable percentage of the retention fund in
          accordance with the Contractor’s performance across the scored measures and the point distribution section of this Manual.

       

        

      	 	
              CHRONIC

               
              CONDITIONS

            	 	
              QUALITY MESURES

            	 	
              SCORED MEASURES

            	
              POINTS

            
	 	
              Medicaid/Federal and Commonwealth Chronic Conditions

            
	 	
              Diabetes (Including CHIP population)

               

            	 	
              •      Comprehensive Diabetes Care:

              o       HbA1c

              o       o Eye exam

              o       o Nephropathy screen

              •      Generic Dispensing Rate

              •      PHQ-4

              •      Statin Use

              •      Adherence to oral diabetic medications

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	
              •     Comprehensive Diabetes Care:

               

              o       HbA1c

              o       Eye exam

              o       Nephropathy screen

               

              •     Admissions/1000

            	
               

               

               

              1

              1

              1

               

            


      

      

      
        14

        
          


      

      	 	
              CHRONIC

               
              CONDITIONS

            	 	
              QUALITY MESURES

            	 	
              SCORED MEASURES

            	
              POINTS

            
	 	
              Asthma

              (Including CHIP)

            	 	
              •      Medication management for people with Asthma

              •      Asthma medication ratio

              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Ambulatory visits per quarter for population

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	
              •     Admissions/1000

               

              •     ED Use/1000

            	
              1

               

              1

            
	 	
              Severe Heart Failure

               

            	 	
              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	
              •     Admissions/1000

               

              •     Readmission Rate

            	
              1

               

              1

            


      

      

      
        15

        
          


      

      	 	
              CHRONIC

               
              CONDITIONS

            	 	
              QUALITY MESURES

            	 	
              SCORED MEASURES

            	
              POINTS

            
	 	
              Hypertension

            	 	
              •      Controlling High Blood Pressure

              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

              •      Adherence to Formulary Drugs

              •      Adherence to antihypertensive (RAS Agonist) medication

            	 	
              •  Adherence to
                  anti-hypertensive (RAS Agonist) medication

            	
              1

            
	 	
              Chronic Obstructive Pulmonary Disease (COPD)

               

            	 	
              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	
              •     Admissions/1000

            	
              1

            


      

      

      
        16

        
          


      

      	 	
              CHRONIC

               
              CONDITIONS

            	 	
              QUALITY MESURES

            	 	
              SCORED MEASURES

            	
              POINTS

            
	 	
              Chronic

              Depression

               

            	 	
              •      Follow up after Hospitalization for Mental Illness

              •      Follow up after ED visit for Mental Illness

              •      Use of Opioids at High Dosage

              •      Use of Opioids from Multiple Providers

              •      Generic Dispensing Rate

              •      Adherence to Formulary Drugs

              •      Inpatient Admission/1000

              •      Readmission Rate

              •      Antidepressant Medication Management

            	 	
              •     Follow up
                  after Hospitalization for Mental Illness

               

              •     Readmission


                  Rate

               

              •     Antidepressant


                  Medication Management

            	
              1

               

              1

               

              1

            
	 	
              Substance Use Disorders (SUD) (Buprenorphine User)

               

            	 	
              •      Follow up after Emergency Department Visits for Alcohol and Other Drug Abuse or Dependence

              •      Adherence to treatment (12 months)

            	 	
              •     Adherence to treatment (12 months)

            	
              1

            
	 	
              Serious Mental Illness (SMI) Other than Depression

               

            	 	
              •      Follow up after Hospitalization for Mental Illness

              •      Follow up after ED visit for Mental Illness

              •      Use of Opioids at High Dosage

              •      Use of Opioids from Multiple Providers

              •      Generic Dispensing Rate

              •      Adherence to Formulary Drugs

              •      Inpatient Admission

            	 	 	 


      

      

      
        17

        
          


      

      	 	
              CHRONIC

               
              CONDITIONS

            	 	
              QUALITY MESURES

            	 	
              SCORED MEASURES

            	
              POINTS

            
	 	
              Diabetes

            	 	
              •      Comprehensive Diabetes Care:

              o       HbA1c

              o       Eye exam

              o       Nephropathy screen

              •      Generic Dispensing Rate

              •      PHQ-4

              •      Statin Use

              •      Adherence to oral diabetic medications

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	 	 
	 	
              Asthma

            	 	
              •      Medication management for people with Asthma

              •      Asthma medication ratio

              •      Generic Dispensing Rate

              •      PHQ-4

              •      Admissions/1000

              •      ED Use/1000

              •      Readmission Rate

              •      Ambulatory visits per quarter for population

              •      Adherence to Formulary Drugs

              •      Medication Reconciliation Post Discharge

              •      Medication Reconciliation Annual

            	 	 	 


      

      

      
        18

        
          


      

      	 	
              CHRONIC

               
              CONDITIONS

            	 	
              QUALITY MESURES

            	 	
              SCORED MEASURES

            	
              POINTS

            
	  	
              Attention-Deficit/Hyperactivity Disorder (ADHD)

            	 	
              •      Follow up care for children with prescribed ADHD medication

              

              

            	 	
              •    Follow up
                  care for children with prescribed ADHD medication

            	
              1

            
	 	
              •      Adherence to Formulary Drugs

            	 	
              •     Adherence
                  to Formulary Drugs

            	
              1

            
	 	
              Total Points

            	
              16

            


      

      

      
        19

        
          


      

      
        
          	VIII.	
                   HEALTHY PEOPLE INITIATIVE

                


        

      

       

        

      The Healthy People Initiative focuses on preventive screening for enrollees, including populations identified with high cost or chronic conditions. The
          Contractor must be prepared to report quarterly on the quality measures listed below. Prior to the implementation date of the Contract, the ASES Office of Planning, Quality and Clinical Affairs will select the respective improvement metrics that
          will be taken into consideration for the quarterly reports on this initiative. The reporting templates for each selected conditions will be provided to the Contractor through the ASES ShareFile site. Each reporting template will be in Excel
          format. ASES shall reimburse the Contractor the applicable percentage of the Retention fund in accordance with the Contractor’s performance across the scored measures and the point distribution section of this Manual.

       

        

      	 	
              EFFECTIVENESS OF

               
              CARE

            	 	
              QUALITY MEASURE

            	 	
              SCORED MEASURES

            	
              POINTS

            
	

            	
              Healthy People Initiative

            
	 	
              ABA

            	 	
              •      Adult BMI Assessment

            	 	 	 
	 	
              WCC

            	 	
              •      Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

              •      BMI Percentile

              •      Counseling for
                    Nutrition

              •      Counseling
                  for Physical Activity

            	 	 	 
	 	
              CIS

            	 	
              •      Childhood
                  Immunization Status

            	 	 	 
	 	
              BCS

            	 	
              •      Breast Cancer Screening

            	 	
              •     Breast Cancer Screening

            	
              1

            
	 	
              CCS

            	 	
              •      Cervical Cancer Screening

            	 	
              •     Cervical Cancer Screening

            	
              1

            
	 	
              CHL

            	 	
              •      Chlamydia Screening in Women

            	 	 	 
	 	
              COL

            	 	
              •      Colorectal Cancer Screening

            	 	
              •     Colorectal Cancer Screening

            	
              1

            
	 	
              AMM

            	 	
              •      Antidepressant Medication Management

            	 	 	 
	 	
              SSD

            	 	
              •      Diabetes
                  Screening for People with Schizophrenia or Bipolar Disorder who are using

              •    Antipsychotic Medications

            	 	
              •    Diabetes
                  Screening for People with Schizophrenia or Bipolar Disorder who are using Antipsychotic Medications.

            	
              1

            
	 	
              FUH

            	 	
              •     Follow-Up
                  After Hospitalization for Mental Illness

            	 	 	 


      

      

      
        20

        
          


      

      
        	 	
                EFFECTIVENESS OF

                 
                CARE

              	 	
                QUALITY MEASURE

              	 	
                SCORED MEASURES

              	
                POINTS

              


      

      	 	
              URI

            	 	
              •      Appropriate
                  Treatment for Children With Upper Respiratory Infection

               

            	 	
              •   Appropriate
                  Treatment for Children With Upper Respiratory Infection

            	
              1

            
	 	
              Access/Availability of Care

            
	 	
              AAP

            	 	
              •      Adults’
                  Access to Preventive/Ambulatory Health Services

            	 	 	
              1

            
	 	
              CAP

            	 	
              •      Children
                  and Adolescents’ Access to Primary Care Practitioners

            	 	 	 
	 	
              ADV

            	 	
              •      Annual Dental Visit

            	 	
              •     Annual Dental Visit

            	
              1

               

            
	 	
              PPC

            	 	
              •      Prenatal and Postpartum Care

              •      Timeliness of Prenatal Care

              •      Postpartum Care

            	 	
               

               

              •     Timeliness of Prenatal Care

               

              •     Postpartum Care

            	
               

               

              1

               

              1

            
	 	
              Other Utilization

            
	 	
              FPC

            	 	
              •      Frequency of Ongoing Prenatal Care

            	 	 	 
	 	
              W15

            	 	
              •      Well-Child Visits in the First 15 Months of Life

            	 	 	 
	 	
              AWC

            	 	
              •      Adolescent Well-Care Visits

            	 	 	 
	 	
              FSP

            	 	
              •      Frequency of Selected Procedures

            	 	 	 
	 	
              AMB

            	 	
              •      Ambulatory Care

            	 	 	 
	 	
              IAD

            	 	
              •      Identification of Alcohol and Other Drug Services

            	 	 	 
	 	
              MPT

            	 	
              •      Overall Mental Health Utilization readmission Rate

              •      Mental Health Use of Opioids at High Dosage

              •      Mental
                  Health Use of Opioids from Multiple Providers

              •      Overall Mental Health admission per thousand

            	 	 	
              1

            
	 	
              Total Points

            	
              10

            


      

      

      
        21

        
          


      

      
        
          	IX.	
                  EMERGENCY ROOM
                        HIGH UTILIZERS INITIATIVE

                


        

      

       

        

      The Emergency Room High Utilizers Initiative is designed to identify high users of emergency services (including behavioral health) for non-emergency
          situations and to allow for early interventions to ensure appropriate utilization of services and resources. The Contractor will submit to ASES for approval a work plan with detailed activities and interventions aimed at Emergency Room High
          Utilizers. The reporting templates for each metric will be provided to the Contractor through the ASES ShareFile site. Each reporting template will be in Excel format. ASES shall reimburse the Contractor the applicable percentage of the Retention
          fund in accordance with the Contractor’s performance across the scored measures and the point distribution section of this manual.

      

      

      Starting from Q1 of CY 2020, the Contractors will be measured by the decrease of the
            emergency room utilization rate compared to the MIi Salud national benchmark and the increase for the PCP outpatient visits rate.

       

          

      Each metric will have a value of 1 point.

      

      

      For purpose of the HCIP, ASES will consider the UM Metrics described below for compliance and release to the applicable percent of the retention fund for
          this particular program.

      

      

      
        
          	1.	
                  Overall emergency room utilization rate x 1,000 on identified population with 7 or more visits to the emergency room (1 POINT)

                


           

          

        

      

      
        
          	2.	
                  PCP outpatient visits x 1,000 on identified population with seven (7) or more visits to the emergency room
                        (1 POINT)

                


        

      

    

    

    

    

    

    22

     

  








  
    
      Attachment 20

      

    

    

    

    
      ATTACHMENT 20 - NETWORK

      ADEQUACY REQUIREMENTS

      

      

      The following Network Adequacy requirements reflect Article 9 of the GHP MCO Contract. ASES
            developed and revised previous network access and availability standards using a data driven approach, informed by the requirements of the managed care rule and focused on meeting the unique needs of the GHP population in Puerto Rico.

      

      

      ASES updated the Network Adequacy standards from data elements and supporting information noted below were used to inform the development of the standards.

      

      

      
        
          	

                	•	
                  Current and projected Medicaid enrollment, including aggregate demographic information pertaining to race/ethnicity and language.

                


        

      

      
        
          	

                	•	
                  A gap analysis was performed that outlined the current standards against the MMC rules. Information was
                        reviewed and prioritized and a framework for the various provider types and standards was
                      created.

                


        

      

      
        
          	

                	•	
                  Utilization data was analyzed to identify referral patterns for Specialty Care Providers (SCP) service volume allowing identification of Puerto Rico's high volume SCPs; only high volume SCPs were included into the network standard framework.

                


        

      

      

      

      Through an iterative process and intense review of key data element and supporting information, ASES developed the following Network Adequacy standards:

      

      

      Puerto Rico Network Standards

      

      

      1. Definitions:

      Adult: An individual age twenty-one (21) or older unless otherwise specified.

      

      

      Enrollee: A person who is currently enrolled in the Contractor's GHP Plan, as provided in this Contract, and
            who, by virtue of relevant Federal and Puerto Rico laws and regulations, is an Eligible Person listed
            in Section 1.3.1 of this Contract.

      

      General Network: The entire group of Providers with Provider Contracts with the Contractor, including those that are and those that are not members of the Contractor's Preferred Provider Network.

       

          

      
        
          


      

      
      
        Network Adequacy Requirements

         

        

         

      

      
        Network Adequacy Standards: The Provider-to-Enrollee Ratios; Provider Per Municipality requirements; Required Network Provider requirements, and Time and Distance requirements developed in accordance with 42 CFR 438.68, as
          defined by ASES in Section 9.4 to measure the adequacy and appropriateness of the Contractor's provider network to meet the needs of the enrolled population.

      

      

      

      Network Provider: A Medicaid-enrolled Provider that has a Provider Contract with a Contractor under the GHP Program. This term includes Providers in the General Network and Providers in the PPN.

      

      

      Non-Urban Area: For purposes of measuring network adequacy, defined by ASES as municipalities with populations below 49,999 people.

      

      

      Pediatric Enrollee: An Enrollee aged zero (0) through twenty (20) (inclusive) unless otherwise specified.

      

      

      Preferred Provider Network (“PPN”): A group of Network Providers that (i) GHP Enrollees may access without any requirement of a Referral or Prior Authorization; (ii) provides services to GHP Enrollees without
          imposing any Co-Payments on Medicaid or CHIP-Eligible populations; and (iii) meets the Network requirements described in Article 9 of this Contract.

      

      

      Provider Per Municipality Requirements: Required number of specified Providers per municipality that must be included in the Contractor's provider network per Section 9.4.3.3.

      

      

      Primary Care Physician: A licensed medical doctor (MD) who is a Provider and who, within the scope of practice and in accordance with Puerto Rico certification and licensure requirements, is responsible for
          providing all required Primary Care to Enrollees. The PCP is responsible for determining services required by Enrollees, provides continuity of care, and provides Referrals for Enrollees when Medically Necessary.

      

      

      Primary Medical Group (“PMG”): A grouping of associated Primary Care Physicians and other Providers for the delivery of services to GHP Enrollees using a coordinated care model. PMGs may be organized as Provider
          care organizations, or as another group of Providers who have contractually agreed to offer a coordinated care model to GHP Enrollees under the terms of this Contract.

      

      

      Provider-to-Enrollee Ratio: Ratios established in Section 9.4 as part of the Network Adequacy Standards that are applicable to the Contractor's General Network and PPN.

       

        

      
        Page 2 of 7 

        
          


      

      
        Network Adequacy Requirements

      

       

      
      Urban Area: For purposes of measuring network adequacy, defined by ASES as municipalities with populations of at least 50,000 people. (San Juan, Carolina, Trujillo Alto, Caguas, Guaynabo, Bayamón, Toa Alta, Toa Baja, Vega Baja, Rio Grande, Humacao, Arecibo, Ponce, Aguadilla, Mayaguez).
          ASES will notify Contractors if this list of Urban Area changes.

      

      

      2. General Requirements

      

      

      The Contractor must maintain an Island-wide provider network that complies with the Network
            Adequacy Standards specified in Section 9.4. The Contractor must use Geographical-access and thermomapping to demonstrate that the contracted network is distributed across Puerto Rico such that it meets the needs of Enrollees. The Contractor shall provide adequate Access to Enrollees at all times.

      

      

      3. Required Provider Ratios:

      

      

      The Contractor shall comply with the following Provider-to-Enrollee Ratios, Provider Per Municipality requirements, and Required Network Providers standards for the General Network.

      

      

      The following specialties are considered PCPs:

      

      

      
        
          	

                	•	
                  Family Practice

                


        

      

      
        
          	

                	•	
                  Internal Medicine (Adults only)

                


        

      

      
        
          	

                	•	
                  General Medicine

                


        

      

      
        
          	

                	•	
                  Gynecologist (selected as the Enrollee's PCP, if the Enrollee is female
                        and twelve (12) years of age or older)

                


        

      

      
        
          	

                	•	
                  Pediatrics

                


        

      

      

      

      	 	
              Table 1: PCP Provider-to-Enrollee Ratio Requirements

            
	 	
              Provider Type

            	 	
              Provider-to-Enrollee Ratio Requirement

            
	 	
              Primary Care Provider (Adult and Pediatric)

            	 	
              One (1) PCP per one thousand seven hundred (1 ,700) Enrollees (excluding Gynecologists)

            
	 	
              Gynecologist

            	 	
              One (1) Gynecologist (selected as the Enrollee's PCP if Enrollee is 12 or older) per
                    two thousand eight hundred (2,800) Enrollees (1:2,800)

            


      

      

      In the event the Contractor assigns Enrollees to a PCP that exceeds the stated Provider-to-Enrollee Ratio requirement, the Contractor must obtain prior written approval for an exception from ASES to continue to assign Enrollees to the PCP. All approved exceptions must be reported in the

          annual Provider Network and Evaluation plan described in Section 18.3.

       

          

      
        Page 3 of 7 

        
          


      

      
        Network Adequacy Requirements

      

      

      	 	
              Table 2: Hospital Provider-to-Enrollee Ratio Requirement

            
	 	
              Provider Type

            	 	
              Provider-to-Enrollee Ratio Requirement

            
	 	
              Hospital

            	 	
              One (1) Hospital per fifty thousand (50,000)
                    Enrollees (1:50,000).

            


      

      

      4. Provider Access Requirements per Municipality

      

      

      The Contractor must maintain the following access requirements per each Municipality.

      

      

      	 	
              Table 3: Provider Per Municipality Requirements

            
	 	
              Provider Type

            	 	
              Provider Access Requirement per Municipality

            
	 	
              Adult and Pediatric PCPs

            	 	
              Provider network must have two (2) Adult and one (1) Pediatric PCP(s), in each municipality.

            
	 	
              Psychologist

            	 	
              One (1) Psychologist in each municipality.

            


      

      

      5. Required Network Providers

      

      

      The Contractor must maintain the following access requirements in the Contractor's General Network.

      

      

      	 	
              Table 4: Required Network Providers

            
	 	
              Provider Type

            	 	
              Provider Network Requirement

            
	 	
              Certified Buprenorphine
                  Providers

            	 	
              All available providers.

            
	 	
              Emergency stabilization Units

            	 	
              All available providers.

            
	 	
              FQHC

            	 	
              The Contractor's provider network must have one (1) FQHC.

            
	 	
              Government Health Care Facilities

            	 	
              All Government Health Care Facilities identified in Section 9.6.

            
	 	
              Psychiatric Hospitals

            	 	
              All available providers.

            
	 	
              Psychiatric Partial Hospitals

            	 	
              All available providers.

            


      

      

      
        Page 4 of 7 

        
          


      

      
        
          Network Adequacy Requirements

        

      

       

          

      6. Time and Distance and Appointment Availability Standards:

      

      

      The Contractor shall comply with the minimum Time and Distance Standards for the General Network specified in Section 9.4.4. Time and Distance Standards are
          developed for Urban and Non-Urban Areas as defined in Article 2 of this Contract.

      

      

      	 	
              Table 5: Puerto Rico Time and Distance and Appointment Availability Standards

            
	 	
              Provider Type

            	 	
              Time and Distance

            	 	
              Appointment Availability

            
	 	
              Primary Care Provider

              (Adult and Pediatric)

               

            	 	
              Urban and Non-Urban:

              Choice of two (2) providers

              within 15 miles/30 minutes

            	 	
              Routine: within thirty (30)

              Calendar Days of request

               

              Urgent: urgent conditions

              shall be available within

              twenty-four (24) hours

            
	 	
              Obstetrics and Gynecology

              (Adult and Pediatric)

               

              For female Enrollees age twelve (12) and older.

               

            	 	
              Urban and Non-Urban:

              choice of two (2) providers

              within 15 miles/30 minutes.

               

            	 	
              Routine: within thirty (30)

              Calendar Days of request

               

              Urgent: urgent conditions

              shall be available within

              twenty-four (24) hours

            
	 	
              High Volume Specialty Care Providers

              (Adult and Pediatric)

               

              See Table 6 below and

              Contract section

              9.4.4.4.1.1.1 (Adults) and

              9.4.4.4.1.2.1 (Pediatric) for

              list of High Volume

              Providers.

            	 	
              Urban: (1) of each type of

              High Volume Specialty Care

              Provider within 30 miles/60

              minutes

               

              Non-Urban: (1) of each type

              High Volume Specialist

              within 45 miles/90 minutes

            	 	
              Routine: within thirty (30)

              Calendar Days of request

               

              Urgent: urgent conditions

              shall be available within

              twenty-four (24) hours

            
	 	
              Dental Providers

               

              (Adult and Pediatric)

            	 	
              Urban: (1) Dental Provider within 30 miles/60 minutes

               

              Non-urban: (1) Dental

              Provider within 45 miles/90

              minutes

            	 	
              Routine: Within sixty (60)

              Calendar Days following the

              request

               

              Urgent: urgent conditions

              shall be available within

              twenty-four (24) hours

            


      

      

      
        Page 5 of 7 

        
          


      

      
        
          
            Network Adequacy Requirements

          

        

      

      

      	 	
              Mental Health Providers (Adult and Pediatric)

               

              See Table 6 below and

              9.4.4.6.1 of Contract for list of Mental Health Providers.

            	 	
              Urban: (1) Mental Health Provider within 30 miles/60 minutes

               

              Non-urban: (1) Mental Health Provider within 45 miles/90 minutes

            	 	
              Routine: within fourteen

              (14) Calendar Days

              following the request

               

              Urgent: urgent conditions

              shall be available within

              twenty-four (24) hours

               

              Crisis services, face-to-face

              appointments shall be

              available within two (2)

              hours

            
	 	
              Substance Use Disorder (SUD) Providers (Adult and Pediatric)

               

              See Table 6 below and 9.4.4.7.1 of Contract for list of SUD Providers.

            	 	
              Urban: (1) SUD Provider within 30 miles/60 minutes

               

              Non-urban: (1) SUD

              Provider within 45 miles/90 minutes

            	 	
              Routine: within fourteen

              (14) Calendar Days

              following the request

               

              Urgent: urgent conditions

              shall be available within

              twenty-four (24) hours

               

              Detoxification services shall

              be provided immediately

              according to clinical

              necessity

            
	 	
              Hospitals

            	 	
              Urban: (1) Hospital within

              30 miles/60 minutes

               

              Non-urban: (1) Hospital

              within 45 miles/90 minutes

            	 	
              NA

               

            
	 	
              Emergency Room

              (Hospital or freestanding)

               

            	 	
              Urban: (1) Emergency Room within 30 miles/60 minutes

               

              Non-urban: (1) Emergency Room within 45 miles/90 minutes

            	 	
              NA

            


      

      

      
        Page 6 of 7 

        
          


      

      
        
          
            Network Adequacy Requirements

          

        

      

      

          7. Provider Types

      

      

      	 	
              Table 6: Provider Types

            
	 	
              Provider Type

            	 	
              Adult (ages 19 and over)

              providers

            	 	
              Pediatric (ages 0-18)

              providers

            
	 	
              Primary Care Provider

               

            	 	
              Internists,

              Family Practice,

              General Practice

            	 	
              Family Practice,

              General Practice,

              Pediatricians

            
	 	
              High Volume Specialty Care Providers

              (Adult and Pediatric)

               

            	 	
              Cardiology,

              Dermatology,

              Endocrinology,

              Gastroenterology,

              Hematology,

              Oncology,

              Nephrology,

              Neurology,

              Orthopedic Surgery,

              Otolaryngology,

              Podiatry,

              Psychiatry,

              Pulmonology,

              Rheumatology,

              Surgery,

              Urology

            	 	
              Allergy & Immunology,

              Cardiology,

              Dermatology,

              Endocrinology,

              Gastroenterology,

              Orthopedic Surgery,

              Otolaryngology,

              Pulmonology,

              Speech, Language and

              Hearing,

              Surgery

            
	 	
              Mental Health
                  (Adult and

              Pediatric)

            	 	
              Emergency or Stabilization

              Units,

              Psychiatrists,

              Psychologists,

              Licensed Clinical Social

              Worker, Licensed


                  Marriage

              Counselor

            	 	
              Emergency or Stabilization

              Units,

              Psychiatrists,

              Psychologists,

              Licensed Clinical Social

              Worker, Licensed Marriage

              Counselor

            
	 	
              SUD

              (Adult and Pediatric)

               

            	 	
              Addiction Medicine,

              Inpatient Facility,

              SUD Treatment
                    Programs

              (including intensive

              outpatient, inpatient,

              partial hospitalization,

              residential,

              withdrawal management

            	 	
              Addiction Medicine,

              Inpatient Facility,

              SUD Treatment Programs

              (including intensive

              outpatient, inpatient,

              partial hospitalization,

              residential,

              withdrawal management

            


      

      

      7. Stakeholder Engagement

      

      

      In compliance with the
            CMS federal regulation, ASES will be soliciting public and provider feedback on the Network adequacy standards.

      

      

      

      

      
        Pa ge 7 of 7 

      

       

    

  








  
  
    
      Attachment 21

      

    

    

    

    
      ATTACHMENT 21

      GUIDELINES FOR REVERSE COLLOCATION OF THE PRIMARY CARE PHYSICIANS IN MENTAL HEALTH FACILITIES

      

      

      In accordance with the provisions of the Puerto Rico Mental Health Code, Law No. 408 of October 2, 2000, as amended, and the Puerto Rico Patient’s Bill
          of Rights and Responsibilities, the Government Health Plan (GHP) is committed to promoting mental and physical health integration, in order to improve program effectiveness and quality of life for enrollees.

      

      

      Reverse collocation is an integrated care model in which medical services are available to members being treated in behavioral health settings. It has
          been known that patients with comorbid conditions that include chronic or acute medical conditions and behavioral health diagnoses are at higher risk for increased utilization and costs in health care. Persons with serious mental illness have
          high levels of medical co-morbidity compared to the general population, as well as increased risk for diabetes, obesity, and high cholesterol due to the use of some second-generation antipsychotic medications (Milbank Memorial Fund, 2010)

      

      

      In the reverse collocation model, a primary care physician is located part or full time in a behavioral health facility to monitor the physical health of
          patients. They use the Behavioral Health Facilities (BHF) records, and coordinate follow up with the member’s PMG as necessary.

      

      

      Enrollees with Serious Mental Illness (SMI) shall benefit from this integration by having their physical and behavioral needs assisted at the same point
          of service. Those patients with a diagnosis of a SMI who are registered as such, shall receive all primary care medical services by the BHF. The reverse collocated primary care physician has access to the complete pharmacy formulary to assist all
          medical needs of SMI patients including referrals to laboratories and to specialists.

      

      

      Patients in the behavioral health facility (not SMI) may receive primary medical consultations from the collocated physician. In this case, the physician
          can only prescribe from the emergency pharmacy formulary and refer patients to their PMG for follow- up.

      

      

      Behavioral Health Facilities (BHF)

      

      

      The following BHF will be considered for purposes of the Reverse Collocation requirements.

      

      

      1. Psychiatric Hospitals (or a unit within a general hospital)

      2. Emergency or Stabilization Units

      3. Partial Hospitalization Units

      4. Intensive Ambulatory Services Units

      5. Ambulatory Services Units

      6. Addiction Services Unit (detoxification, ambulatory, impatient)

      

      

      
        1

        
          


      

      Required Reverse Collocation Staff per BHF

      

      

      
        
          	

                	1.	
                  Ambulatory Services Units must have at least one collocated PCP 5 days per week for 4 hours.

                


        

      

      

      

      
        
          	

                	2.	
                  Addiction Services Units must have at least one collocated PCP 3 days per week for 4 hours

                


        

      

      

      

      
        
          	

                	3.	
                  Psychiatric Hospitals are required to have at least a PCP on call on a daily basis.

                


        

      

      

      

      
        
          	

                	4.	
                  Partial Hospitalization Units must have at least one collocated PCP 2 days per week for 4 hours.

                


        

      

      

      

      
        
          	

                	5.	
                  Stabilization units must have one PCP for consultation (on call) on a daily basis

                


        

      

      

      

      In the event that a BHF does not comply with the required collocation level, may be subject to sanctions according to the following matrix:

      

      

      	 	
              Sanction Level

            	 	
              Sanction Type

            	 	
              Timeframe to cure

            	 	
              Comments

            
	 	
              0

            	 	
              Notice of Non Compliance with Reverse Colocation Level and CAP

            	 	
              60 days

              (Day 1-60)

            	 	
              A corrective action plan (“CAP”) will be required of every BHF Setting that does not comply with the required Reverse Collocation level. All BHF
                  with an approved CAP must comply with the terms of the CAP and achieve the required collocation within the timeframes established in the CAP.

            
	 	
              1

            	 	
              Fine

            	 	
              30 days (Day 61-90)

            	 	
              Fines to be defined in accordance to the contract

            
	 	
              2

            	 	
              Contract Cancelation

            	 	
              Day 91

            	 	 


      

      

      

      

      
        2

      

       

    

  








  
    Attachment 22

      
    

    
    
    
      
      
        
          

        

        
           CONSENT FOR STERILIZATIONNOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE
              WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS.  Form Approved: OMB No. 0937-0166 Expiration date: 12/31/2018  CONSENT TO STERILIZATIONI have asked for and received information about
              sterilization from. When I first askedDoctor or Clinic  for the information, I was told that the decision to be sterilized is com- pletely up to me. I was told that I could decide not to be sterilized. If I de- cide not to be sterilized, my
              decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as Temporary Assistance for Needy Families (TANF) or Medicaid that I am now getting or for which I
              may become eligible.I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN.I was told about those temporary methods of birth
              control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized.I understand that I will be sterilized by an operation known as
              a . The discomforts, risksSpecify Type of Operationand benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction.I understand that the operation will not be done until at least 30
              days after I sign this form. I understand that I can change my mind at any timeand that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federallyfunded programs.I
              am at least 21 years of age and was born on: DateI, , hereby consent of my ownfree will to be sterilized by Doctor or Clinic  by a method called . My  Specify Type of Operation  consent expires 180 days from the date of my signature below.I
              also consent to the release of this form and other medical records about the operation to:Representatives of the Department of Health and Human Services,or Employees of programs or projects funded by the Department but only for determining if
              Federal laws were observed.I have received a copy of this form.  Signature Date  You are requested to supply the following information, but it is not re- quired: (Ethnicity and Race Designation) (please check)  Ethnicity:Hispanic or Latino
              Not Hispanic or Latino  Race (mark one or more):American Indian or Alaska Native AsianBlack or African AmericanNative Hawaiian or Other Pacific Islander White  INTERPRETER'S STATEMENTIf an interpreter is provided to assist the individual to
              be sterilized:I have translated the information and advice presented orally to the in- dividual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in  language and explained its contents to
              him/her. To the best of my knowledge and belief he/she understood this explanation.  Date  STATEMENT OF PERSON OBTAINING CONSENTBefore signed theName of Individualconsent form, I explained to him/her the nature of sterilization operation ,
              the fact that it isSpecify Type of Operationintended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it.I counseled the individual to be sterilized that alternative methods of birth control are
              available which are temporary. I explained that steriliza- tion is different because it is permanent. I informed the individual to besterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health
              services or any benefits provided byFederal funds.To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and
              appears to understand the nature and consequences of the procedure.  Signature of Person Obtaining Consent  Date  Facility  AddressPHYSICIAN'S STATEMENTShortly before I performed a sterilization operation uponon  Name of Individual Date of
              SterilizationI explained to him/her the nature of the sterilization operation, the fact that it is  Specify Type of Operationintended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it.I
              counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that steriliza- tion is different because it is permanent.I informed the individual to be sterilized that
              his/her consent can be withdrawn at any time and that he/she will not lose any health servicesor benefits provided by Federal funds.To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears
              mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure.(Instructions for use of alternative final paragraph: Use the first paragraph below except
              in the case of premature delivery or emergencyabdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used.
              Cross out the para- graph which is not used.)At least 30 days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed.This sterilization was performed less than 30 days but
              more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested):Premature deliveryIndividual's expected date of delivery:
              Emergency abdominal surgery (describe circumstances):  Physician's Signature  Date    Interpreter's SignatureHHS-687 (10/12) 

        

      

       

      
        
          


      

      
        
          

        

        
           PAPERWORK REDUCTION ACT STATEMENTA Federal agency may not conduct or sponsor, and a person is not
              required to respond to, a collection of information unless it displays the currently valid OMB control number. Public reporting burden for this collection of information will vary; however, we estimate an average of one hour per response,
              including for reviewing instructions, gathering and maintaining the necessary data, and disclosing the information. Send any comment regarding the burden estimate or any other aspect of this collection of information to the OS Reports
              Clearance Officer, ASBTF/Budget Room 503 HHH Building, 200 Independence Avenue, SW., Washington, DC 20201.Respondents should be informed that the collection of information requested on this form is authorized by 42 CFR part 50, subpart B,
              relating to the sterilization of persons in federally assisted public health programs. The purpose of requesting this information is to ensure that individuals requesting sterilization receive information regarding the risks, benefits and
              consequences, and to assure the voluntary and informed consent of all persons undergoing sterilization procedures in federally assisted public health programs. Although not required, respondents are requested to supply information on their
              race and ethnicity. Failure to provide the other information requested on this consent form, and to sign this consent form, may result in an inability to receive sterilization procedures funded through federally assisted public health
              programs.All information as to personal facts and circumstances obtained through this form will be held confidential, and not disclosed without the individual’s consent, pursuant to any applicable confidentiality regulations. [43 FR 52165,
              Nov. 8, 1978, as amended at 58 FR 33343, June 17, 1993; 68 FR 12308, Mar. 14, 2003]  HHS-687 (10/12) 

        

      

       

       

      

       

      








  
    Attachment 23

    

    

    

    
      PUERTO RICO HEALTH INSURANCE ADMINISTRATION

      

      

      POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF

      MEDICAID OVERPAYMENTS TO PROVIDERS

      

      

      	
              A.

            	
              OBJECTIVES (42 CFR 433.300)

            


      

      

      To establish the policies and procedures of the Puerto Rico Health Insurance Administration (ASES for its anachronism in Spanish) to recoup overpayments
          made to its providers in accordance with 42 CFR 433, Subpart F-Refunding of Federal Share of Medicaid Overpayments to Providers and to implement:

      

      

      
        
          	

                	1)	
                  Section 1903(d)(2)(A) of the Social Security Act (the "Act"), which directs that quarterly Federal payments to the States under title XIX (Medicaid) of the Act are to be
                      reduced or increased to make adjustment for prior overpayments or underpayments that the Secretary determines have been made.

                


        

      

      

      

      
        
          	

                	2)	
                  Section 1903(d)(2) (C) and (D) of the Act, which provides that a State has 1-year from discovery of an overpayment for Medicaid services to recover or attempt to recover
                      the overpayment from the provider before adjustment in the Federal Medicaid payment to the State is made; and that adjustment will be made at the end of the 1-year period, whether or not recovery is made, unless the State is unable to
                      recover from a provider because the overpayment is a debt that has been discharged in bankruptcy or is otherwise uncollectable.

                


        

      

      

      

      
        
          	

                	3)	
                  Section 1903(d)(3) of the Act, which provides that the Secretary will consider the pro rata Federal share of the net amount recovered by a State during any quarter to be
                      an overpayment.

                


        

      

      

      

      	
              B.

            	
              DEFINITIONS (42 CFR 433.304)

            


      

      

      
        
          	

                	1)	
                  Abuse (in accordance with 42 CFR 455.2) - provider practices that are
                      inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally
                      recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program.

                


        

      

      

      

      
        
          	

                	2)	
                  Discovery (or discovered) - identification by any ASES, the Federal Government,
                      or the provider of an overpayment, and the communication of that overpayment finding or the initiation of a formal recoupment action without notice as described in 42 CFR 433.316.

                


        

      

      

      

      
        
          	

                	3)	
                  Fraud (in accordance with 42 CFR 455.2) - an intentional deception or
                      misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

                


        

      

      

      

      
        
          	

                	4)	
                  Overpayment - the amount paid by a Medicaid agency to a provider which is in
                      excess of the amount that is allowable for services furnished under section 1902 of the Act and which is required to be refunded under section 1903 of the Act.

                


        

      

      

      

      
        
          


      

      PUERTO RICO HEALTH INSURANCE ADMINISTRATION

      

      

      POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF

      MEDICAID OVERPAYMENTS TO PROVIDERS

      

      

      
        
          	

                	5)	
                  Provider (in accordance with 42 CFR 400.203) - any individual or entity
                      furnishing Medicaid services under a provider agreement with the Medicaid agency.

                


        

      

      

      

      
        
          	

                	6)	
                  Recoupment - any formal action by ASES to initiate recovery of an overpayment
                      without advance official notice by reducing future payments to a provider.

                


        

      

      

      

      
        
          	

                	7)	
                  Third party (in accordance with 42 CFR 433.136) - an individual, entity, or
                      program that is or may be liable to pay for all or part of the expenditures for medical assistance furnished under a State plan.

                


        

      

      

      

      	
              C.

            	
              APPLICABILITY (42CFR 433.310)

            


      

      

      The provisions of these policies and procedures apply to:

      

      

      
        
          	

                	1)	
                  Overpayments made to providers that are discovered by ASES;

                


        

      

      

      

      
        
          	

                	2)	
                  Overpayments made to providers that are initially discovered by the provider and made known to ASES; and

                


        

      

      

      

      
        
          	

                	3)	
                  Overpayments that are discovered through Federal reviews.

                


        

      

      

      

      	
              D.

            	
              BASIC REQUIREMENTS FOR REFUNDS (42 CFK 433.312)

            


      

      

      
        
          	

                	1)	
                  ASES has 1-year from the date of discovery of an overpayment to a provider to recover or seek to recover the overpayment before the Federal share must be refunded to CMS.

                


        

      

      

      

      
        
          	

                	2)	
                  ASES must refund the Federal share of overpayments at the end of 1-year period following discovery, whether or not ASES has recovered the overpayment from the provider.
                      Notwithstanding, ASES is not required to refund the Federal share of an overpayment made to a provider when ASES is unable to recover the overpayment amount because the provider has been determined bankrupt or out of business in
                      accordance with 42 CFR 433.318.

                


        

      

      

      

      
        
          	

                	3)	
                  The date upon which an overpayment occurs is the date upon which ASES, using its normal method of reimbursement for a particular class of provider (e.g., check, interfund
                      transfer), makes the payment involving unallowable costs to a provider.

                


        

      

      

      

      	
              E.

            	
              WHEN DISCOVERY OF OVERP AYMENT OCCURS AND ITS SIGNIFICANCE. (42 CFR 433.316)

            


      

      

      
        
          	

                	1)	
                  The date on which an overpayment is discovered is the beginning date of the 1-year period allowed for a State to recover or seek to recover an overpayment before a refund
                      of the Federal share of an overpayment must be made to CMS.

                


        

      

      

      

      
        
          


      

      PUERTO RICO HEALTH INSURANCE ADMINISTRATION

      

      

      POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF

      MEDICAID OVERPAYMENTS TO PROVIDERS

      

      

      
        
          	

                	2)	
                  Unless ASES chooses to initiate a formal recoupment action against a provider without first giving written notification of its intent, ASES must notify the provider in
                      writing of any overpayment it discovers in accordance with ASES' policies and procedures and must take reasonable actions to attempt to recover the overpayment in accordance with State law and procedures.

                


        

      

      

      

      
        
          	

                	3)	
                  An overpayment resulting from a situation other than fraud is discovered on the earliest of:

                


        

      

      

      

      
        
          	

                	a)	
                  The date on which ASES first notifies a provider in writing of an overpayment and specifies a dollar amount that is subject to recovery;

                


        

      

      

      

      
        
          	

                	b)	
                  The date on which a provider initially acknowledges a specific overpaid amount in writing to ASES; or

                


        

      

      

      

      
        
          	

                	c)	
                  The date on which ASES initiates a formal action to recoup a specific overpaid amount from a provider without having first notified the provider in writing.

                


        

      

      

      

      
        
          	

                	4)	
                  Overpayments resulting from fraud. An overpayment resulting from fraud is discovered on the date of the final written notice (as defined in 42 CFR 433.304) of the
                      overpayment determination that ASES sends to the provider.

                


        

      

      

      

      
        
          	

                	5)	
                  If a Federal review at any time indicates that ASES has failed to identify an overpayment or that ASES has identified an overpayment but has failed to either send written
                      notice of the overpayment to the provider that specified a dollar amount subject to recovery or initiate a formal recoupment from the provider without having first notified the provider in writing, CMS will consider the overpayment as
                      discovered on the date that the Federal official first notifies ASES in writing of the overpayment and specifies a dollar amount subject to recovery.

                


        

      

      

      

      
        
          	

                	6)	
                  Any adjustment in the amount of an overpayment during the 1-year period following discovery (made in accordance with the approved State plan, Federal law and regulations
                      governing Medicaid, and the appeals resolution process specified in ASES' administrative policies and procedures) has the following effect on the 1-year recovery period:

                


        

      

      

      

      
        
          	

                	a)	
                  A downward adjustment in the amount of an overpayment subject to recovery that occurs after discovery does not change the original 1-year recovery period for the
                      outstanding balance.

                


        

      

      

      

      
        
          	

                	b)	
                  An upward adjustment in the amount of an overpayment subject to recovery that occurs during the 1-year period following discovery does not change the 1-year recovery
                      period for the original overpayment amount. A new 1-year period begins for the incremental amount only, beginning with the date of ASES' written notification to the provider regarding the upward adjustment.

                


        

      

      

      

      
        
          


      

      PUERTO RICO HEALTH INSURANCE ADMINISTRATION

      

      

      POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF

      MEDICAID OVERPAYMENTS TO PROVIDERS

      

      

      
        
          	

                	7)	
                  A partial collection of an overpayment amount by ASES from a provider during the 1-year period following discovery does not change the 1-year recovery period for the
                      original overpayment amount due to CMS.

                


        

      

      

      

      
        
          	

                	8)	
                  Any appeal rights extended to a provider do not extend the date of discovery.

                


        

      

      

      

      	
              F.

            	
              OVERPAYMENTS INVOLVING PROVIDERS WHO ARE BANKRUPTCY OR OUT OF BUSINESS (42 CFR 433.318)

            


      

      

      
        
          	

                	1)	
                  ASES is not required to refund the Federal share of an overpayment made to a provider as required by 42 CFR 433.312(a) to the extent that ASES is unable to recover the
                      overpayment because the provider has been determined bankrupt or out of business in accordance with the provisions of this section. ASES must notify the provider that an overpayment exists in any case involving a bankrupt or
                      out-of-business provider and, if the debt has not been determined uncollectable, take reasonable actions to recover the overpayment during the 1-year recovery period in accordance with policies prescribed by applicable State law and
                      administrative procedures.

                


        

      

      

      

      
        
          	

                	2)	
                  Overpayments are considered debts that ASES is unable to recover within the 1-year period following discovery if the following criteria are met:

                


        

      

      

      

      
        
          	

                	a)	
                  The provider has filed for bankruptcy, as specified in paragraph (c) of this section; or

                


        

      

      

      

      
        
          	

                	b)	
                  The provider has gone out of business and the State is unable to locate the provider and its assets, as specified in paragraph (4) of this section.

                


        

      

      

      

      
        
          	

                	3)	
                  ASES is not required to refund to CMS the Federal share of an overpayment at the end of the 1-year period following discovery, if:

                


        

      

      

      

      
        
          	

                	a)	
                  The provider has filed for bankruptcy in Federal court at the time of discovery of the overpayment or the provider files a bankruptcy petition in Federal court before the
                      end of the 1-year period following discovery; and

                


        

      

      

      

      
        
          	

                	b)	
                  ASES is on record with the court as a creditor of the petitioner in the amount of the Medicaid overpayment.

                


        

      

      

      

      
        
          	

                	4)	
                  ASES is not required to refund to CMS the Federal share of an overpayment at the end of the 1-year period following discovery if the provider is out of business on the
                      date of discovery of the overpayment or if the provider goes out of business before the end of the 1-year period following discovery. A provider is considered to be out of business on the effective date of a determination to that
                      effect under State law. ASES must:

                


        

      

      

      

      
        
          


      

      PUERTO RICO HEALTH INSURANCE ADMINISTRATION

      

      

      POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF

      MEDICAID OVERPAYMENTS TO PROVIDERS

      

      

      
        
          	

                	a)	
                  Document its efforts to locate the party and its assets. These efforts must be consistent with applicable State policies and procedures; and

                


        

      

      

      

      
        
          	

                	b)	
                  Make available an affidavit or certification from the appropriate State legal authority establishing that the provider is out of business and that the overpayment cannot
                      be collected under State law and procedures and citing the effective date of that determination under State law.

                


        

      

      

      

      A provider is not out of business when ownership is transferred within the State unless State law and procedures deem a provider that
          has transferred ownership to be out of business and preclude collection of the overpayment from the provider.

      

      

      
        
          	

                	5)	
                  If the 1-year recovery period has expired before an overpayment is found to be uncollectable under the provisions of this section, if ASES recovers an overpayment amount
                      under a court-approved discharge of bankruptcy, or if a bankruptcy petition is denied, ASES must refund the Federal share of the overpayment in accordance with the procedures specified in 42 CFR 433.320.

                


        

      

      

      

      	
              G.

            	
              PROCEDURES FOR REFUNDS TO CMS (42 CFR 433.320)

            


      

      

      
        
          	

                	1)	
                  In accordance with section 1903(d) of the Social Security Act, ASES shall reduce its claims of reimbursement to the extent of any overpayment in the expense reports
                      submitted to CMS, and on the corresponding quarter with respect to the adjustment.

                


        

      

      

      

      
        
          	

                	2)	
                  ASES must refund the Federal share of overpayments that are subject to recovery to CMS through credit on the Quarterly Statement of Expenditures (Form CMS-64).
                      Accordingly, the Federal share of overpayments subject to recovery must be credited on the Form CMS- 64 report submitted for the quarter in which the 1-year period following discovery, established in accordance with 42 CFR 433.316,
                      ends.

                


        

      

      

      

      
        
          	

                	3)	
                  A credit on the Form CMS-64 must be made whether or not the overpayment has been recovered by ASES from the provider.

                


        

      

      

      

      
        
          	

                	4)	
                  Effect of reporting collections and submitting reduced expenditure claims. (1) The State is not required to refund the Federal share of an overpayment at the end of the 1-year period if the State has already
                      reported a collection or submitted an expenditure claim reduced by a discrete amount to recover the overpayment prior to the end of the 1-year period following discovery.

                


        

      

      

      

      
        
          	

                	5)	
                  If ASES does not refund the Federal share of such overpayment, the State will be liable for interest on the amount equal to the Federal share of the non-recovered,
                      non-refunded overpayment amount. Interest during this period will be at the current Value of Funds Rate (CYFR), and will accrue beginning on the day after the end of the 1-year period following discovery until the last day of the
                      quarter for which the State submits a CMS-64 report refunding the Federal share of overpayment.

                


        

      

      

      

      
        
          


      

      PUERTO RICO HEALTH INSURANCE ADMINISTRATION

      

      

      POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF

      MEDICAID OVERPAYMENTS TO PROVIDERS

      

      

      
        
          	

                	6)	
                  ASES is not required to report on the Form CMS-64 any collections made on overpayment amounts for which the Federal share has been refunded previously. Furthermore, if
                      ASES has refunded the Federal share of an overpayment and subsequently makes recovery by reducing future provider payments by a discrete amount, ASES need not reflect that reduction in its claim for Federal financial participation.

                


        

      

      

      

      
        
          	

                	7)	
                  If the amount of an overpayment is adjusted downward after the agency has credited CMS with the Federal share, ASES may reclaim the amount of the downward adjustment on
                      the Form CMS-64. Under this provision:

                


        

      

      

      

      
        
          	

                	a)	
                  Downward adjustment to an overpayment amount previously credited to CMS is allowed only if it is properly based on the approved State plan, Federal law and regulations
                      governing Medicaid, and the appeals resolution processes specified in ASES' administrative policies and procedures.

                


        

      

      

      

      
        
          	

                	b)	
                  The 2-year filing limit for retroactive claims for Medicaid expenditures does not apply. A downward adjustment is not considered a retroactive claim but rather a
                      reclaiming of costs previously claimed.

                


        

      

      

      

      
        
          	

                	8)	
                  If an overpayment has not been determined uncollectable in accordance with the requirements of 42 CFR 433.318 at the end of the 1-year period following discovery of the
                      overpayment, ASES must refund the Federal share of the overpayment to CMS in accordance with the procedures specified above.

                


        

      

      

      

      
        
          	

                	9)	
                  If ASES recovers any portion of an overpayment under a court-approved discharge of bankruptcy, ASES must refund to CMS the Federal share of the overpayment amount
                      collected on the next quarterly expenditure report that is due to CMS for the period that includes the date on which the collection occurs.

                


        

      

      

      

      
        
          	

                	10)	
                  If a provider's petition for bankruptcy is denied in Federal court, ASES must credit CMS with the Federal share of the overpayment on the later of:

                


        

      

      

      

      
        
          	

                	a)	
                  The Form CMS-64 submission due to CMS immediately following the date of the decision of the court; or

                


        

      

      

      

      
        
          	

                	b)	
                  The Form CMS-64 submission for the quarter m which the 1-year period following discovery of the overpayment ends.

                


        

      

      

      

      
        
          	

                	11)	
                  If a provider is determined bankrupt or out of business under this section after the 1-year period following discovery of the overpayment ends and ASES has not been able
                      to make complete recovery, ASES may reclaim the amount of the Federal share of any unrecovered overpayment amount previously refunded to CMS. CMS allows the reclaim of a refund if ASES submits to CMS documentation that it has made
                      reasonable effort to obtain recovery. If ASES reclaims a refund of the Federal share of an overpayment:

                


        

      

      

      

      
        
          


      

      PUERTO RICO HEALTH INSURANCE ADMINISTRATION

      

      

      POLICIES AND PROCEDURES FOR REFUNDING OF FEDERAL SHARE OF

      MEDICAID OVERPAYMENTS TO PROVIDERS

      

      

      
        
          	

                	b)	
                  In bankruptcy cases, ASES must submit to CMS a statement of its efforts to recover the overpayment durng the period before the petition for bankruptcy was filed; and

                


        

      

      

      

      
        
          	

                	c)	
                  In out-of-business cases, ASES must submit to CMS a statement of its efforts to locate the provider and its assets and to recover the overpayment during any period before
                      the provider is found to be out of business in accordance with 42 CFR 433.318.

                


        

      

      

      

      
        
          	

                	12)	
                  ASES must report the following information to support each Quarterly Statement of Expenditures Form CMS-64:

                


        

      

      

      

      
        
          	

                	a)	
                  Amounts of overpayments not collected during the quarter but refunded because of the expiration of the 1-year period following discovery;

                


        

      

      

      

      
        
          	

                	b)	
                  Upward and downward adjustments to amounts credited in previous quarters;

                


        

      

      

      

      
        
          	

                	c)	
                  Amounts of overpayments collected under court-approved discharges of bankruptcy;

                


        

      

      

      

      
        
          	

                	d)	
                  Amounts of previously reported overpayments to providers certified as bankrupt or out of business during the quarter; and

                


        

      

      

      

      
        
          	

                	e)	
                  Amounts of overpayments previously credited and reclaimed by ASES.

                


        

      

      

      

      	
              H.

            	
              MAINTENANCE OF RECORDS (42 CFR433.322)

            


      

      

      ASES must maintain a separate record of all overpayment activities for each provider in a manner that satisfies the retention and access requirements of
          45 CFR 92.42.

      

      

      

      

       

    

  








   

  
    Attachment 24

    

  

  

  

  
    	
            

          	
            ELIGIBLE PROFESSIONALS PATIENT VOLUME CERTIFICATION

            BY INSURANCE CARRIERS

            ELECTRONIC HEALTH RECORD (EHR) INCENTIVE PROGRAM

          
	
            The Eligible Professionals Certification is required for incentive payment eligibility verification and will be used only for the Puerto Rico Medicaid
                Health Information Technology Provider Incentive Program (HITPIP).

          
	
            The primary objective of the Patient Volume Certification is to assure that Electronic Health Records (EHR) Incentives are released according to
                Centers for Medicare and Medicaid Services (CMS) guidelines and regulations as per 42 CFR 495. Puerto Rico Health Insurance Administration (PRHIA) is monitoring and providing guidance for Professionals to comply with the eligibility
                requirements.

          
	
            Section 1. To be completed by ASES.

          
	
            Individual Professional Contact Information

          
	
            First Name

          	
            M.I.

          	
            Last Name

          	
            Sufix

          	
            Physician Type

             

          
	 	 	 	 	 	 
	
            Taxonomy

          	
            TIN (Tax Identification Number)

          	
            NPI (National Provider Identifier)

          	
            Professional License

            Number

          
	 	 	 	 
	
            Address 1

          	
            Address 2

          
	 	 
	 	 
	
            City

          	
            State

          	
            Zip Code

          	
            E-Mail

          	
            Phone Number

          
	 	 	 	 	 
	
            Section 2. To be completed by ASES

          
	
            INSTRUCTIONS

          
	
            Confirm the type of attestation with a check mark (√): □Group





                □Individual. If the provider pertain to a Group but will attest as individual please make the check mark on the individual box and also provide the
                name of the Group or Groups where he/she bring services. If the provider is attesting under a Group please make the check mark on the Group and provide the information of the Group under he/she is attesting.

          
	
            Name and NPI of the Group under the EP is attesting with:

          	
            Encounters were performed only at FQHCs (330 Centers)

          
	 	
            ☐ Yes

          	
            ☐ No

          
	
            Names and NPIs of other Group(s) where the provider also bring services:

          


    

    

    
      
        


    

    	
            Section 3. To be completed by the Carrier.

          
	
            INSTRUCTIONS

            (A roster must be included with this certification if the provider attest under a Group)

          
	
            Please submit encounters data for a period of any 90 continuous days in the calendar year preceding the incentive payment year or in the preceding
                twelve months of the attestation date. The Medicaid patient volume calculation as established by CMS is as follows:

            (i)          All Medicaid patient
                encounters in any representative, continuous 90-day period in the calendar year preceding the Eligible Professional payment year, or in the 12 months before the Eligible Professional’s attestation date; by

            (ii)         The total patient
                encounters in the same 90-day period.

            Only MI Salud Medicaid encounters (State and Federal) should be included in the numerator. Categories 230 (CHIP) only can be considered eligible when encounters are performed at FQHCs (330 Center). Encounters at FQHCs should be identified in the aging with the POS 50. Please identify the Platino
                  encounters with the patient contract number and a “P”.

          
	
            CARRIER PATIENT VOLUME CERTIFICATION

          
	
            Carrier

          	
            90 days

            Encounters

            Period

            (Start Date - End

            Date)

          	
            Total Encounters

            Including MI

            Salud Buy-In, any

            other Buy-In and

            Private Sector

            Clients

            (Denominator)

          	
            All MI Salud

            Medicaid

            Encounters (State

            and Federal

            Codes 100, 110,

            300, 310, 320,

            330)

            (Numerator)

          	
            Medicare Platino

            Encounters (State

            and Federal

            Codes 100, 110,

            300, 310, 320,

            330)

            (Numerator)

          	
            FQHCs Needy

            Individuals

            Encounters

            with

            Codes 100, 110,

            230, 300, 310,

            320, 330

            (Numerator)

          
	 	 	 	 	 	 
	
            AGING REPORT FOR A 12 MONTH PERIOD INCLUDING THE 90 DAY PERIOD OF THE ATTESTATION

          
	
            PAYER

          	
            PATIENT ID

          	
            EVALUATION

            AND

            MANAGEMENT

            CODE

          	
            DATE OF

            SERVICE

          	
            PLACE OF SERVICE

          	
            RENDERING

            PHYSICIAN NPI

          
	
            By signing this form, I certify that the information related to the "Patient Encounters" provided is correct and valid. By this means, we commit to
                send all the supporting "Patient Encounters" information to ASES. All information must be submitted using the established format and according to the contract with ASES no later than 7 business days from the date of encounter’s request. All
                encounters should be included regardless of whether they were paid or not.

          
	
            Name

          	
            Position

          	
            Signature

          	
            Date

          
	 	 	 	 
	
            After completing the Certification, please send it to ASES at the following electronic address:

            Hitpip_helpdesk@asespr.org and also to the provider who requested it in order to complete the attestation process by the provider. In case you have any questions please contact ASES at 787-474-3300.

          
	
            Section 4. For ASES/HITPIP use only:

          
	
            Professional data submitted at SLR:

          	
            Date of submission at SLR:

          
	
            Reporting 90 days Period

          	
            Medicaid Encounters

          	
            Medicare Platino Encounters

          	
            FQHCs Federal Needy Individuals Encounters

          	
            Not Hospital Base Percentage

          	
            Patient Volume Percentage Verified by ASES

          
	 	 	 	 	 	 
	
            Process by:

          	
            Date:

          


    

    

    

    

     

  








  
  
    
      Attachment 25

      

    

    

    

    
      ATTACHMENT 25

      

      

      HIGH-UTILIZERS PROGRAM (HUP)

      

      

      The High Utilizers Program (HUP) shall be designed by the Contractor to target Enrollees with complex physical, behavioral and social needs, including
          catastrophic or high-risk conditions, with a history of frequent encounters with health care providers, where care could be provided in a less costly or more appropriate setting.

      

      

      The Contractor’s program shall ensure Enrollees’ maximum wellness and autonomy while leveraging a variety of practices such as; coordinated care,
          preventive care, education, patient tracking, discharge monitoring, data mining, and medication reconciliation which ultimately drive utilization to appropriate settings of care.

      

      

      The program overtime should demonstrate quantifiable successful reductions in unnecessary utilization, increased utilization in appropriate settings of
          care, and reductions in overall program costs.

      

      

      Contractors are required to implement best practices to address high-utilizers of services that are more appropriately delivered in less costly settings,
          for example strategies to decrease nonemergent use of the emergency room, referrals for and reductions of drug-seeking behaviors with providers. The Contractor shall develop and implement a HUP strategy and submit it to ASES for approval.

      

      

      The HUP must include the following components:

      

      

      
        	
                1.

              	
                The methodology and criteria to identify the high-utilizer population.

              


      

      
        
          	2.	
                  A description of integrated initiatives, combining physical and behavioral health with social needs.

                


        

      

      
        
          	3.	
                  Create partnerships at state, regional, and local levels to leverage resources across governmental agencies such as the Department of Health, the Department of Family and
                      Social Services, Housing, Transportation among others, extending to the private sector and non-profit organizations.

                


        

      

      
        
          	4.	
                  Develop meaningful data practices and mining tools on the high-utilizer population that can drive interventions and measure their success.

                


        

      

      
        
          	5.	
                  Provide quarterly utilization and quality reports including changes and improvements on utilization trends for the identified Enrollees as well as modifications to the
                      strategy in response to the results.

                


        

      

      

      

      The Contractor’s HUP strategy must describe in detail criteria, protocols and processes to be perform to comply with the following steps and requirement:

       

        

      Version 1 – August 2018

      
        1

        
          


      

      
        
          	1.	
                  Case Identification- based on statistical data analysis, each Contractor shall
                      develop methods and criteria for the identification of high utilizers for both physical and behavioral health by Enrollee and by Providers as well as the approach to deal with identified cases and trends including, but not limited to:

                


        

      

      

      

      
        
          	

                	a)	
                  Enrollees who have accessed the emergency room seven (7) or more times within twelve (12) months.

                


        

      

      
        
          	

                	b)	
                  Specific conditions and measures to be addressed and justification for the selected conditions.

                


        

      

      
        
          	

                	c)	
                  Top 5% enrollees by facility (physical and behavioral) utilization and cost incurred.

                


        

      

      
        
          	

                	d)	
                  Top 5% of enrollees with highest number of readmissions to an inpatient setting (physical and behavioral) within 30 calendar days of discharge

                


        

      

      
        
          	

                	e)	
                  Facilities and PCPs by readmission rate, with enrollees identified as high utilizers of the emergency department.

                


        

      

      
        
          	

                	f)	
                  Pharmacy focused initiatives such as polypharmacy and opioid overutilization.

                


        

      

      

      

      
        
          	2.	
                  Prioritization and focus- The strategy shall specify how the Contractor will
                      determine the scope, focus and prioritization process of the HUP.

                


        

      

      

      

      
        
          	3.	
                  High-Utilizers Management- Described the specific process and administrative structure for the HUP. It shall cover at minimum:

                


        

      

      

      

      
        
          
            	

                  	a)	
                    Administrative Structure- Description of administrative structure, available
                        resources and the process to select and assigned cases and the hierarchy process when a member is identified into multiple programs, to avoid duplication, such as HCHN, Special Coverage and or High Utilizers. Include the composition
                        of the multidisciplinary team to address the different kinds of needs: social, behavioral, transportation, etc.

                  


          

        

        
          
            	

                  	b)	
                    Health Risk Assessment (HRA) - Within sixty (60) Calendar Days after the
                        Contractor’s selection as a candidate for the HUP, all Enrollees in the HUP shall be administered an HRA to further evaluate their healthcare needs. This assessment is in addition to the standard HRA process identified in Section
                        7.1.5 which occurs at the point of enrollment. The Contractor shall submit the HRA form to ASES for approval.

                  


          

        

        
          
            	

                  	c)	
                    Care Plan and Baseline Measures- Development of a Care Plan within forty-five
                        (45) Calendar Days of the HRA. The Contractor shall establish baseline measures for each Enrollee, such as BMI, Blood Pressure, Hemoglobin A1c, and other clinical measures depending on the enrollee’s diagnosis and needs. The
                        baselines measures shall be monitored on a continuous basis, in order to track quality improvement and the effectiveness of the personalized Care Plan.

                  


          

        

      

      
        

           

          
            Version 1 – August 2018

          

        

      

      
        2

        
          


      

      
        
          	

                	d)	
                  Medical Oversight and Interdisciplinary Coordination- Description of
                      communication and coordination within the Contractor, and the Contractor, the PCP and other care partners in the community. How the Contractor’s Care Managers will have oversight of each case, will communicate, coordinate, and educate
                      the providers involved in the care of the member, including PCPs. The Strategy shall describe how the multidisciplinary team approach will be reached including how social workers, psychologists, outreach personnel, nutritionists, and
                      nurses, together with physicians, will work to remove social and behavioral barriers to care by coordinating with available government services and community interventions.

                


        

      

      
        
          	

                	e)	
                  Enrollee Education- the Contractor shall educate enrollees participating in the HUP, as well as their Primary Care Medical Group and PCPs, to ensure ongoing enrollee education and the appropriate access
                      point of services. The Contractor shall continue monitoring enrollees that were identified as HUP to ensure that their conditions remain under control.

                


        

      

      
        
          	

                	f)	
                  Coordination of Services/Transitions of Care- For participating enrollees admitted into hospitals, the Contractor shall provide direct support with Provider appointment assistance and visits to
                      each Enrollee. The Care Managers will follow the discharge plan to ensure the enrollee will have the necessary medications and equipment at discharge to reduce the possibility of re-admission.

                


        

      

      
        
          	

                	g)	
                  Provider Financial Incentives- If the Contractor has any Provider Financial
                      Incentive program(s) in place or planned as part of its High Utilizers Strategy, include a full description of each incentive program.

                


        

      

      

      

      
        
          	4.	
                  Reporting Requirements: The Contractor shall provide a quarterly report to ASES
                      on each condition/category being addressed. The results shall be monitor at individual and cumulative levels for all Enrollees in the HUP as well as those exiting the program. The Contractor must keep a baseline record for each
                      Enrollee by condition/category that shall include, as available, the past twelve (12) months historical data of patients identified in the HUP. The Contractor shall keep track of patients to be able to submit the quarterly and
                      cumulative reports. Comparisons must be established and tracked between the quarterly, cumulative, and baseline data. The categories include, but are not limited to, the following:

                


        

      

      

      

      
        
          	

                	a)	
                  Utilization Management Measurements:

                


        

      

      

      

      
        
          	

                	i.	
                  Total Cost – Total cost in aggregate and total cost per Enrollee for the period. This cost includes all components: physical and behavioral health services provided, as
                      well as prescription drugs.

                


        

      

      

      

      
        
          	

                	ii.	
                  Hospitalizations – Total number of hospitalizations, average length of stay (ALOS), total cost of hospitalizations, hospitalizations and cost per Enrollee for the period,
                      an top reasons/conditions for hospitalizations at individual and aggregate levels.

                


           

          

          
            Version 1 – August 2018

          

        

      

      
        3

        
          


      

      
        
          	

                	iii.	
                  Emergency Department (ED) Visits – Total number of visits to ED, total cost of ED visits, and visits and ED cost per member for the period, in addition to the top
                      reasons/conditions for ED visits at individual and aggregate levels.

                


        

      

      

      

      
        
          	

                	iv.	
                  Pharmacy Utilization – Total number of prescriptions, cost of prescriptions, and number and cost of prescriptions per Enrollee for the period, in addition to the top
                      conditions treated at the individual and aggregate level.

                


        

      

      

      

      
        
          	

                	b)	
                  Quality Measurements- The frequency of the quality measurements will be
                      determined by the Contractor’s care management team(s), in cooperation with ASES, the Care Management Team on a case by case basis,

                


        

      

      

      

      
        
          	

                	i.	
                  All Enrollees:

                


        

      

      

      

      
        
          	

                	·	
                  Quality of Life indicators (similar to SF-36)

                


        

      

      

      

      
        
          	

                	·	
                  Follow-Up after hospitalization

                


        

      

      

      

      
        
          	

                	·	
                  Medication reconciliation

                


        

      

      

      

      
        
          	

                	·	
                  Depression screening (PHQ9)

                


        

      

      

      

      
        
          	

                	ii.	
                  Enrollees with Specific Conditions (Such as Diabetes, CHF, Hypertension, Asthma, etc.)

                


        

      

      

      

      
        
          	

                	·	
                  Quality of Life indicators (similar to SF-36)

                


        

      

      

      

      
        
          	

                	·	
                  Follow-Up after hospitalization

                


        

      

      

      

      
        
          	

                	·	
                  Medication reconciliation

                


        

      

      

      

      
        
          	

                	·	
                  Depression screening (PHQ9)

                


        

      

      

      

      
        
          	

                	·	
                  Use the baseline measures for the specific conditions as define in 3c above. You may use the quality
                        indicators included for the HCIP for those conditions that coincide in both Programs.

                


        

      

    

    

    

    

    

    
      Version 1 – August 2018

    

    
      4

    

     

    

  








  
    
      Attachment 26

    

    

    

    
      Encounter Data Requirements

      Attachment 26

      Version 10.1.18

       

        

      
        
          


      

    

    

    
      

      

      

      General Encounter Data Standards

      

      

      
        
          	

                	·	
                  The CONTRACTOR’s claims management system shall contain the following capabilities for the purpose of encounter data submissions:

                


        

      

      

      

      
        
          	

                	·	
                  Collection and maintenance of sufficient enrollee encounter data to identify the provider who delivers any item(s) or service(s) to enrollees.

                


        

      

      

      

      
        
          	

                	·	
                  Submission of enrollee encounter data to ASES at a frequency and level of detail to be specified by CMS and ASES, based on program administration, oversight, and program
                      integrity needs.

                


        

      

      

      

      
        
          	

                	·	
                  Submission of all enrollee encounter data that ASES is required to report to CMS.

                


        

      

      

      

      
        
          	

                	·	
                  Specifications for submitting encounter data to ASES in standardized Accredited Standards Committee (ASC) X12N 837 and National Council for Prescription Drug Programs
                      (NCPDP) formats, and the ASC X12N 835 format as appropriate.

                


        

      

      

      

      
        
          	

                	·	
                  Adherence to HIPAA Standards

                


        

      

      

      

      Quality of Submission

      

      

      The Contractor shall submit encounter data that meets established ASES data quality standards. These standards are designed to ensure receipt of complete
          and accurate data for program administration and will be closely monitored and strictly enforced. ASES will revise and amend these standards as necessary to ensure continuous quality improvement. The Contractor shall make changes or corrections
          to any systems, processes or data transmission formats as needed to comply with ASES data quality standards as originally defined or subsequently amended. The Contractor shall comply with industry-accepted clean claim standards for all encounter
          data, including submission of complete and accurate data for all fields required on standard billing forms or electronic claim formats to support proper adjudication of a claim. In the event that the Contractor denies provider claims for
          reimbursement due to lack of sufficient or accurate data required for proper adjudication, the Contractor shall submit all available claim data to ASES without alteration or omission. Where the Contractor has entered into capitated reimbursement
          arrangements with providers, the Contractor shall require submission of all utilization or encounter data to the same standards of completeness and accuracy; the Contractor shall require this submission from providers as a condition of the
          capitation payment and shall make every effort to enforce this contract provision to ensure timely receipt of complete and accurate data. The Contractor shall be required to submit all data relevant to the adjudication and payment of claims in
          sufficient detail, as defined by ASES, in order to support comprehensive financial reporting and utilization analysis. The Contractor shall submit encounter data according to standards and formats as defined by ASES, complying with standard code
          sets and maintaining integrity with all reference data sources including provider and member data. All encounter data submissions will be subjected to systematic data quality edits and audits on submission to verify not only the data content but
          also the accuracy of claims processing. Any batch submission which contains fatal errors that prevent processing or that does not satisfy defined threshold error rates will be rejected and returned to the Contractor for immediate correction.
          Re-submittals of rejected files, or notification of when the file will be resubmitted shall be completed within one (1) business day.

       

        

      
        
          


      

      
        
          

          

        

      

      ASES will reject an entire file or an individual encounter failing certain edits, as deemed appropriate and necessary by ASES to ensure accurate processing
          or encounter data quality, and will return these transactions to the Contractor for research and resolution. ASES will require expeditious action on the part of the Contractor to resolve errors or problems associated with said claims or the
          adjudication thereof, including any necessary changes or corrections to any systems, processes or data transmission formats.

      

      

      Provision of Encounter Data

      

      

      Any encounter data from a subcontractor shall be included in the file from the Contractor. The Contractor shall not submit separate encounter files from
          subcontractors.

      

      

      The files shall contain settled claims and claim adjustments, including but not limited to adjustments necessitated by payment errors, processed during that
          payment cycle, as well as encounters processed during that payment cycle from providers with whom the Contractor has a capitation arrangement.

      

      

      The level of detail associated with encounters from providers with whom the Contractor has a capitation arrangement shall be equivalent to the level of
          detail associated with encounters for which the Contractor received and settled a fee-for-service claim.

      

      

      The Contractor shall adhere to federal and/or ASES payment rules in the definition and treatment of certain data elements, e.g., units of service that are
          standard fields in the encounter data submissions and will be treated similarly by ASES across all MCOs.

      

      

      The Contractor shall institute processes to insure the validity and completeness of the data it submits to ASES.  At its discretion, ASES will conduct
          general data validity and completeness audits using industry-accepted statistical sampling methods. Data elements that will be audited include but are not limited to: member ID, date of service, provider ID (including NPI number and Medicaid I.D.
          Number), category and sub category (if applicable) of service, diagnosis codes, procedure codes and modifiers, revenue codes, adherence to hard benefit limits, date of claim processing, and date of claim payment. Control totals shall also be
          reviewed and verified.

      

      

      The Contractor shall be able to receive, maintain and utilize data extracts from ASES and its contractors, e.g., pharmacy data from ASES or its PBM.

       

        

       

        

       

    

  








  
    
      Attachment 27

      

    

    

    

    
      

      

      

      Puerto Rico Health Insurance Administration

      Policy for Medication Exception Requests

      

      

      
        
          	

                	I.	
                  PURPOSE:

                


        

      

      

      

      To define the Puerto Rico Health Insurance Administration (ASES, for its acronym in Spanish) policy and procedures to manage exception requests from
          prescribers under MI Salud, also known as the Government Health Insurance Plan, for medications that: (i) are not in the Formulary of Medications Covered (FMC, for its acronym in Spanish); or (ii) are covered with utilization management edits
          under the FMC such as step therapy, quantity or dose limits or prior authorization requirements and prescribers wish to bypass such restrictions.

      

      

      
        
          	

                	II.	
                  POLICY:

                


        

      

      

      

      The Managed Care Organizations (MCOs) will maintain a standardized procedure for making timely and appropriate Exception Request decisions in accordance
          with ASES requirements and in compliance with 42 C.F.R. § 438.210(d)(3) to avoid delays that may jeopardize the enrollee’s life, health, or ability to regain maximum function.

      

      

      An exception request may be used for (i) Non-FMC drugs, or (ii) medications covered with utilization management edits under the FMC (such as step therapy,
          quantity or dose limits, or prior authorization requirements), when the prescriber wishes to bypass such restrictions. In those cases, the MCO must suggest that the prescriber first consider using drugs listed on the List of Medications by
          Exception (LME). If the prescriber demonstrates that none of the alternatives in the LME are clinically viable for the patient, then the MCO can consider approving coverage for drugs outside of the LME.

      

      

      An Exception Request may also be used to bypass certain utilization management restrictions applicable to drugs that are listed on the FMC or LME, such as a
          step therapy requirement, quantity or dose limit, or prior authorization requirement.

      

      

      
        
          	

                	III.	
                  SCOPE:

                


        

      

      

      

      
        This policy applies to ASES’ contracted pharmacy benefit management (PBM) organization, MCOs and their MI Salud providers including, but not limited to,
            physicians, hospitals, behavioral facilities, ambulatory facilities, and pharmacies prescribing and/or dispensing outpatient drugs.

      

      

      

      

      

      

      •PO


            Box 195661, San Juan, PR 00919-5661 •Tel : 787.474.3300 •Fax: 787.474.3348 •www.ases.pr .gov

       

      

      
        
          


      

      
      
        
          	

                	IV.	
                  DEFINITIONS:

                


        

      

      

      

      	 	
              TERM

            	 	
              DEFINITION

            
	 	
              Formulary of Medications Covered Dugs (FMC, for its acronym in Spanish)

            	 	
              FMC means “Formulario de Medicamentos en Cubierta” in Spanish. The FMC is the list of preferred and non-preferred medications covered by MI Salud,
                  though ASES may assign different levels of cost-sharing within the FMC.

               

            
	 	
              List of Medications by Exception (LME)

            	 	
              List of medications that are not included in the FMC, but that have been evaluated and approved by ASES’ Pharmacy and Therapeutics (P&T)
                  Committee to be covered only through an exception process if certain clinical criteria are met. Covered outpatient drugs that are not included on the LME may still be covered under an Exception Request, unless statutorily excluded.

               

            
	 	
              Exception Request

            	 	
              A request to obtain coverage by exception of a drug that is not included in MI Salud’s FMC, or to bypass utilization management restrictions that
                  apply to drugs listed on the FMC. Exception Requests may be evaluated based on the MCO’s own clinical criteria or through the standards set forth under this policy.

               

            
	 	
              Medical Necessity

            	 	
              As defined by Section 7.2 of the Contract with MCOs

              7.2.1 Based on generally accepted medical practices specific to the medical or behavioral health condition of the enrollee at the time of treatment,
                  Medically Necessary Services are those that relate to (i) the prevention, diagnosis, and treatment of health impairments; (ii) the ability to achieve age-appropriate growth and development; or (iii) the ability to attain, maintain, or
                  regain functional capacity. The scope of Medically Necessary Services must not be any more restrictive than that of Puerto Rico's Medicaid program.

              Additionally, Medically Necessary services must be:

               

              7.2.1.1 Appropriate and consistent with the diagnosis of the treating provider and the omission of which could adversely affect
                  the eligible enrollee's medical condition;

              7.2.1.2 Compatible with the standards of acceptable medical practice in the community;

              7.2.1.3 Provided in a safe, appropriate, and cost-effective setting given the nature of the diagnosis and the severity of the
                  symptoms;

              7.2.1.4 Not provided solely for the convenience of the enrollee or the convenience of the provider or hospital; and

              7.2.1.5 Not primarily custodial care (for example, foster care).

              7.2.2 In order for a service to be Medically Necessary, there must be no other effective and more conservative or substantially less costly
                  treatment, service, or setting available.

            


      

      

      
        2

        
          


      

      
        
          	

                	V.	
                  BACKGROUND:

                


        

      

      

      

      ASES’ contract with the MCOs stipulates that certain medications, not otherwise covered under MI Salud, might be covered through an exception process by
          which the patient’s health care provider must substantiate the clinical need for such exception.

      

      

      Preferred and non-preferred medications covered by MI Salud are included in the FMC, though different levels of cost-sharing may apply. In addition, MI
          Salud has developed, through its Pharmacy & Therapeutics (P&T) Committee, a List of Medications by Exception (LME) that may be covered under special circumstances. The medications in the LME will be subject to the MCO’s evaluation upon
          the participating physician’s request for exception, on a case-by-case basis, to determine if it complies with the protocol established by ASES for said medication. If it is not in compliance, the medication will be denied; and if it complies, it
          will be approved.

      

      

      Medications not included in the FMC will be not be paid for by MI Salud unless
          an Exception Request is granted. If an Exception Request is submitted, drugs listed on the LME will be preferred over non-FMC drugs or LME covered outpatient drugs. An Exception Request may also be used to bypass certain utilization management
          restrictions applicable to drugs that are listed on the FMC, such as a step therapy requirement, quantity or dose limit, or prior authorization requirement. A patient may appeal a decision to deny an Exception Request.

      

      

      Certain drugs are considered excluded from coverage and will not be paid for by MI Salud even if an Exception Request is submitted. For example, under
          Section 1927(d)(2) of the Social Security Act, MI Salud will not cover drugs used to promote fertility, drugs used for cosmetic purposes or hair growth, drugs used for the symptomatic relief of cough and colds, most prescription vitamins and
          mineral products, non-prescription drugs or over-the counter-medication unless specifically included in MI Salud coverage, and drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be
          purchased exclusively from the manufacturer or its designee. Drugs that are not prescribed for a medically accepted indication are also excluded and will not be covered. These drugs are considered “statutorily excluded.” Also excluded are drugs
          prescribed for the purpose of treating a condition not covered under MI Salud. In addition, the Puerto Rico Medicaid State Plan excludes certain drugs such as those to treat hepatitis C from coverage, as these drug therapies are covered under
          other non-Medicaid government health programs.

      

      

      
        
          	

                	VI.	
                  PROCESSING OF REQUESTS FOR EXCEPTION:

                


        

      

      

      

      If a medication not included on the FMC, but included on the LME, is submitted to the Pharmacy Benefit Manager (PBM) for adjudication, the pharmacy will
          receive the following message at the point of sale: LME Drug: Exception request required. Validate other alternatives in FMC before proceeding. If a medication not included on the LME is submitted to the PBM for adjudication, the pharmacy will receive the following message at the point of sale: Non- FMC/LME Drug. Exception request required. Validate other alternatives in FMC/LME before proceeding.

       

        

      
        3

        
          


      

      To request an exception, the prescribing physician must complete a request using the standardized Medication Request Form or, if necessary, an equivalent
          form and submit it to the MCO along with the necessary medical documentation (described in Section D.1.b below) showing compliance with ASES protocol for said medication. If the request or additional documentation or evidence (described in
          Section D.1.b below) is included with the prescription, the pharmacy will send the case to the MCO to process the request for exception.

      

      

      
        
          	A.	
                  Receipt of Exception Requests

                


        

      

      

      

      
        
          	

                	1.	
                  Exception Requests will only be accepted in writing from the patient’s health care provider and shall be received in the MCO’s Pharmacy Clinical Unit via regular mail,
                      e-mail, or fax.

                


        

      

      
        
          	

                	i.	
                  Regular mail requests will be stamped with the date and time it is received by the MCO and will serve as the starting time for evaluation period. For email or fax
                      requests, the receipt date and time will be used.

                


        

      

      

      

      
        
          	

                	2.	
                  Exception Requests shall include the following standard information: the prescription, a supporting statement setting forth the clinical justification and medical
                      necessity for the prescribed medication that meets all the requirements described in Section D.1.b below, and expected duration of treatment, as required by the protocol for the medication.

                


        

      

      

      

      
        
          	

                	3.	
                  Incomplete requests that do not include all of the information listed in Section A.2 above will be returned by the MCO or pharmacy receiving the request to the
                      prescribing physician or health care provider by fax or e-mail, for completion as soon as practicable, and within 24 hours. The processing time starts when the information required in Section A.2 above is received.

                


        

      

      

      

      
        
          	B.	
                  Timeframes

                


        

      

      

      

      
        
          	

                	1.	
                  The outcome of the MCO’s determination to approve or deny the Exception Request shall be communicated in accordance with Section E below to the enrollee, pharmacy and
                      prescribing physician within 24 hours after the request is received and the MCO receives the standard information necessary in Section A.2 above to make a
                      determination.

                


        

      

      

      

      
        
          	

                	2.	
                  In an emergency situation, the MCO must authorize at least a 72-hour supply of the requested drug as long as the drug is not statutorily excluded. An emergency situation
                      means that a lack of access to the requested drug may seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Terms that may indicate that a request should be treated as an emergency situation include, but are not limited to, “rush,” “stat,” “immediately,” “patient’s life is in danger,” “urgent,” or “expedite.” However, MCOs
                      must evaluate the request to determine based on the information presented whether the patient is in an emergency situation.

                


           

          

        

      

      
        4

        
          


      

      Such evaluations must be conducted using appropriate clinical judgment, and shall not be used to deny a 72-hour emergency supply of the
          requested drug if an emergency situation does in fact exist. If a requested drug cannot be dispensed in a quantity, dose or form limited to a 72-hour emergency supply, e.g. injection vials or drugs infused by a pump or other device, the emergency
          dispense must be authorized in the minimum necessary form or increment that exceeds the 72-hour supply.

      

      

      
        
          	

                	3.	
                  If additional time is needed to process a request, the MCO shall determine whether to grant the extension as soon as practicable, and within 24 hours. ASES’s
                      authorization to grant an extension is delegated to the MCOs, as long as the MCOs comply with the intent and purpose set forth in ASES Contract Section 7.5.12.4.2.2. governing Prior Authorization, and as also applied to Exception
                      Requests.

                


        

      

      

      

      “ASES may, in its discretion, grant an extension of the time allowed for Prior Authorization decisions where:

      i. The Enrollee, or the Provider, requests the extension; or

      ii. The MCO justifies to ASES a need for the extension in order to collect additional information, such that the extension is in the
          Enrollee’s best interest.”

      

      

      The maximum time allowed when granting an exception must be no more than 72 hours. However, the MCO must still authorize the required
          72-hour supply of the requested drug in an emergency situation as set forth in Section B.2 above, even if an extension is granted.

      

      

      
        
          	C.	
                  Additional Information

                


        

      

      

      

      
        
          	

                	1.	
                  If a request is received, but additional information is needed to complete the evaluation, the request will be placed in a status of Need More Information (NMI) in the
                      PAHub. Required information will be requested through fax, email or by contacting the prescribing physician, notifying the prescriber that the MCO will allow 72 hours for its submission. While in NMI status, the 24-hour timeframe
                      specified in Section B.1 above will be paused and continued once the additional information necessary to complete the evaluation is received.

                


        

      

      

      

      
        
          	

                	a.	
                  Examples of appropriate additional information requests include, but are not limited to:

                


        

      

      
        
          	

                	1)	
                  Diagnosis

                


        

      

      
        
          	

                	2)	
                  Relevant patient medical history or data

                


        

      

      
        
          	

                	3)	
                  Documentation of prior use of other alternative therapies (including the specific therapies, times used, and clinical results)

                


        

      

      
        
          	

                	4)	
                  Medical justification for the requested drug such as: alternative drugs on the FMC which are contraindicated, patient has experienced or would experience an adverse
                      reaction to FMC drugs, evidence of therapeutic failure after available alternatives on FMC were attempted, drug is not covered in the FMC for a particular diagnosis

                


           

          

        

      

      
        5

        
          


      

      
        
          	

                	5)	
                  Laboratory results, if requested on protocol

                


        

      

      

      

      
        
          	

                	2.	
                  If the additional information needed to complete the evaluation is not submitted to the MCO within 72 hours after the request for additional information is sent, the
                      request will be considered inactive unless the MCO, prior to the expiration of the seventy two (72) hours, confirms that the available information is sufficient for a determination. If considered inactive for lack of requested
                      information, a notification letter will be sent to the pharmacy and the prescribing physician.

                


        

      

      

      

      
        
          	D.	
                  Evaluation and Determination

                


        

      

      

      

      
        
          	

                	1.	
                  The MCO shall first verify that:

                


        

      

      

      

      
        	 	
                a.

              	
                The request is for a drug:

              


      

      
        
          	

                	i.	
                  That is included on the FMC with certain clinical or other utilization management restrictions that the prescriber seeks to bypass through an exception, not included in
                      the FMC but it is included LME, or is not included on the LME but is a covered prescription drug that is not statutorily excluded, and

                


        

      

      
        
          	

                	ii.	
                  That has been prescribed for a medically accepted indication as defined by Section 1927(k)(6) of the Social Security Act, meaning that the use of the drug is approved by
                      the FDA or is supported by one or more citations included or approved for inclusion in the American Hospital Formulary Service Drug Information, the United States Pharmacopeia – Drug Information (or its successor publications), or the
                      DRUGDEX Information System, and

                


        

      

      
        
          	

                	iii.	
                  That complies with the clinical criteria and protocols established by ASES for drugs included in the LME, or is consistent with general medically accepted guidelines for
                      non-LME drugs or where the Exception Request seeks to bypass applicable clinical criteria and protocols.

                


        

      

      

      

      
        
          	

                	b.	
                  The prescribing physician must provide a written and signed supporting statement setting forth the clinical reason or reasons that the requested prescription drug is
                      medically necessary to treat the patient’s disease or medical condition. His or her supporting statement must indicate that the requested prescription drug is medically necessary because:

                


        

      

      If the physician is requesting an LME alternative:

      
        
          	

                	i.	
                  All FMC alternatives for the requested drugs are contraindicated with drugs that the patient is already taking. The MCO must request that the patient’s medical records
                      show such contraindication, or that the prescribing physician provide scientific literature showing the strong possibility of serious adverse health effects as a result of taking the FMC alternatives; or

                


           

          

        

      

      
        6

        
          


      

      
        
          	

                	ii.	
                  Patient has experienced a serious adverse reaction to the alternative drugs that appear in the FMC; or

                


        

      

      
        
          	

                	iii.	
                  Therapeutic failure of all available alternatives on the FMC, either because these alternatives were ineffective or would adversely affect the health or condition of the
                      patient.

                


        

      

      

      

      If the physician is requesting an alternative not listed on FMC or LME:

      
        
          	

                	i.	
                  All FMC and LME alternatives for the requested drugs are contraindicated with drugs that the patient is already taking. The MCO must request that the patient’s medical
                      records to show such contraindication, or that the prescribing physician provide scientific literature showing the strong possibility of serious adverse health effects as a result of taking the FMC and LME alternatives; or

                


        

      

      
        
          	

                	ii.	
                  Patient has experienced a serious adverse reaction to the alternative drugs that appear in the FMC and LME; or

                


        

      

      
        
          	

                	iii.	
                  Therapeutic failure of all available alternatives on the FMC and LME, either because these alternatives were ineffective or would adversely affect the health or condition
                      of the patient.

                


        

      

      

      

      
        
          	

                	2.	
                  If a physician provides an oral supporting statement to set forth the medical necessity of the drug, the MCO shall require the physician to submit this oral statement in
                      writing. This written supporting statement must be submitted within 72 hours.

                


        

      

      

      

      
        
          	

                	3.	
                  During the evaluation process, the MCO clinical reviewer will conduct an in-depth review of all available documentation submitted as part of the exception request
                      including, but not limited to:

                


        

      

      
        
          	

                	a.	
                  The supporting statement and other documentation submitted with the exception request by the prescribing physician

                


        

      

      
        
          	

                	b.	
                  Internal information such as medication utilization history from PBM’s adjudication system

                


        

      

      
        
          	

                	c.	
                  Diagnosis reported for the condition the requested drug is treating, from the claims system

                


        

      

      
        
          	

                	d.	
                  Any special condition(s) the patient may have which may have qualified him or her for special coverage.

                


        

      

      

      

      
        
          	

                	4.	
                  If a discrepancy in the available documentation is found during the review of the information indicated in Section D.3 above, the prescribing physician shall be contacted
                      by phone to clarify the discrepancy. The MCO clinical reviewer must document this contact, including the content of what was discussed and the results of that discussion.

                


        

      

      

      

      
        
          	

                	5.	
                  The MCO clinical reviewer should also consider whether other utilization management measures for either the FMC or LME alternative drugs, such as dose

                


           

          

        

      

      
        7

        
          


      

      restrictions to limit the number of doses available, or alternative forms of the drug, e.g. liquid versus pill, or oral versus injected
          or infused, could be appropriate.

      

      

      
        
          	

                	6.	
                  The MCO will make a determination, with the available information, before expiration of the applicable timeframes set forth in Section B.

                


        

      

      

      

      
        
          	E.	
                  Notification of Decision

                


        

      

      

      

      
        
          	

                	1.	
                  If the exception request does not fully meet the established clinical criteria or protocol for the medication, it will be denied by the MCO’s authorized
                      clinician-reviewer.

                


        

      

      
        
          	

                	a.	
                  The prescribing physician, pharmacy and patient will be verbally notified by the MCO ́s representatives within the applicable timeframes required in the preceding
                      sections.

                


        

      

      
        
          	

                	b.	
                  A denial letter also will be mailed within three (3) business days of verbal notification to the patient in accordance with Section 14.4.3 of the MCO Contract, including
                      an explanation of the reasons for the denial and a description of the appeal process. This same denial letter will be sent via fax or email to the prescribing physician and pharmacy.

                


        

      

      
        
          	

                	c.	
                  The denial determination will be documented in the PBM PA Management Application.

                


        

      

      
        
          	

                	2.	
                  If the request is approved, the MCO will document the determination and the date and time approved in the PBM PA Management Application. The pharmacy will then process
                      and dispense the requested medication. The dispensing pharmacy representatives will verbally notify the beneficiary and prescribing physician of the approval. An approval letter also will be mailed within three (3) business days of
                      verbal notification to the patient. This same letter will be sent via fax or email to the prescribing physician and pharmacy.

                


        

      

      

      

      
        
          	

                	3.	
                  If a requested medication is approved through an exception, that approval will be valid for the duration indicated by the prescribing physician or the period specified in
                      the clinical protocol, but in any case, no longer than twelve (12) months. The MCOs may use information on record to re-approve a non-FMC or LME medication as long as the information remains accurate and complies with current clinical
                      protocols. The approval is also valid as long as:

                


        

      

      
        
          	

                	a.	
                  The patient remains enrolled in MI Salud, and

                


        

      

      
        
          	

                	b.	
                  The prescribing physician continues to prescribe the drug, and

                


        

      

      
        
          	

                	c.	
                  The drug continues to be safe for the treatment of the patient’s condition.

                


        

      

      

      

      
        
          	

                	4.	
                  The determination (approval or denial) and supporting evidence will be documented and filed as per MCOs’ internal process.

                


        

      

      

      

      

      

      
        8

      

       

    

  








  
    Attachment 28

    

  

   

  

  
    ATTACHMENT 28 – HCHN Rate Cells

    

    

    HCHN Rate Cell Assignment

    

    

    Starting on November 1, 2018 each enrollee in the GHP will be assigned to one of 37 distinct rate cells. Appendix A lists each rate cell by eligibility group. The rate cell assignment is a function of the enrollee’s Category Of Eligibility (COE) including Federal, Dual Eligible, CHIP, and State-funded
        (Commonwealth) enrollees, Age, Gender, Medicare status, and Domestic Abuse and Foster Children (formerly Virtual region) and select High Cost High Need (HCHN) condition categories. Each of the 37 rate cells will have a distinct premium that will be
        paid to the Contractor for each enrollee.

    

    

    Rate Cell Assignment Prior to November 1, 2018

    

    

    Prior to November 1, 2018 ASES will identify the HCHN conditions using the carrier reported claims data according to the methodology described below. The
        Contractor will receive an enrollment data file (.sus) (please refer to Attachment 09) that will contain the enrollees assigned to the Contractor according to the auto-enrollment algorithm. The file will contain fields that identify the rate cell
        and if applicable the specific HCHN condition(s) for each enrollee. In addition, the file will include date of initial diagnosis, date of last encounter with the diagnosis, and end date of HCHN rate cell eligibility (12 months after the date of
        last encounter).

    

    

    Rate Cell Assignment after November 1, 2018

    

    

    By the 15th day of each month the Contractor shall submit a HCHN Registry Report
        that will contain the roster of all enrollees and the HCHN conditions identified. The file shall be formatted in the data layout contained in Appendix C.

    

    

    If the Contractor provides all required information in a timely manner ASES will disburse the premium for each enrollee according to HCHN Registry Report
        in the subsequent month. If the report is not received with the required information or in the specified timeline, ASES will disburse the premium for each enrollee according to the HCHN Eligibility Report received in the previous month. No
        retroactive premium will be paid due to reports that do not comply with the procedures established in this attachment.

    

    

    The Contractor can internally identify enrollees with the specific HCHN conditions with methods other than claims data (Clinical Review, Behavioral health
        data, Pharmacy data, Care Management, and referrals etc.). However, it is the responsibility of the Contractor to report the enrollee’s encounter with the specific diagnosis codes that qualify for a HCHN rate cell. (See below for specific
        diagnostic codes that qualify as a HCHN rate cell)

    

    

    Retroactive Review of HCHN Registry Report

    

    

    ASES reserves the right to retroactively review the assignment of any enrollee into a HCHN condition rate cell. In addition, ASES can at any time request
        information regarding the diagnosis, supporting documentation, revised HCHN registry report, and care management plan of the enrollee. In the case that ASES determines that the member should not have been enrolled into a HCHN rate cell, premium
        will be retroactively recovered in the amount equal to the difference of the HCHN premium and the corresponding lower hierarchy HCHN premium or Age Gender premium, for each eligible month.

    

    

    
      
        


    

    The retroactive review will be performed but not limited to the methodology the HCHN identification described in this attachment, such as:

    

    

    
      
        	

              	1.	
                Review of enrollee’s medical claims history based on the diagnosis codes contained in Appendix



                      B, with appropriate exclusions.

              


      

    

    
      
        	

              	2.	
                Direct contact with enrollee’s PCP, specialist or physician directing the enrollee HCHN care plan.

              


      

    

    
      
        	

              	3.	
                Review of enrollee behavioral health data

              


      

    

    
      
        	

              	4.	
                Review of enrollee pharmacy data

              


      

    

    
      
        	

              	5.	
                Referrals

              


      

    

    

    

    The Contractor will not be allowed to submit any adjustment to the medical claims data submitted to ASES modifying diagnosis codes, procedure codes or any
        other claim information to evidence HCHN diagnosis.

    

    

    ASES can at any time review policies and efforts undertaken by the MCO to adjust claims or alter data for diagnosis codes to evidence enrollment into a HCHN
        rate cell. This practice can result in recoupment of premium and possible additional sanctions.

    

    

    HCHN Rate Cell Assignment Methodology

    

    

    The assignment of HCHN condition rate cells is based on specific diagnosis codes contained in Appendix B for cancer, diabetes, renal, cardiologic, and pulmonary conditions reported in the medical claims data. Claims that are not billed by an Inpatient hospital facility and contain a laboratory or radiology
        procedure code are excluded from the identification process.

    

    

    An enrollee is assigned to a HCHN rate cell if in the previous 12 months they had an encounter flagged for one or more HCHN conditions. In the case where the
        enrollee had more than one HCHN condition the assignment is according to the condition hierarchy as follows:

    

    

    
      
        	

              	1.	
                Federal

              


      

    

    
      
        	

              	i.	
                Enrollee with a HCHN flag for cancer

              


      

    

    
      
        	

              	ii.	
                Enrollee with a HCHN flag for medium, very high, and extra high Renal Disease

              


      

    

    
      
        	

              	iii.	
                Enrollee with a HCHN flag for very high and medium cardiovascular disease

              


      

    

    
      
        	

              	iv.	
                Enrollee with a HCHN flag for diabetes and/or low and extra low cardiovascular disease

              


      

    

    
      
        	

              	v.	
                Enrollee with a HCHN flag for pulmonary disease

              


      

    

    
      
        	

              	vi.	
                Enrollee with none of the above HCHN condition flag by age and gender

              


      

    

    
      
        	

              	·	
                Male 14-18

              


      

    

    
      
        	

              	·	
                Male 19-44

              


      

    

    
      
        	

              	·	
                Male 45+

              


      

    

    
      
        	

              	·	
                Female 14-18

              


      

    

    
      
        	

              	·	
                Female 19-44

              


      

    

    
      
        	

              	·	
                Female 45+

              


      

    

    
      
        	

              	·	
                Age 0-1

              


         

        

        
          
            


        

      

    

    
      
        	

              	·	
                Age 1-6

              


      

    

    
      
        	

              	·	
                Age 7-13

              


      

    

    

    

    
      
        	

              	2.	
                State-funded (Commonwealth)

              


      

    

    
      
        	

              	i.	
                Enrollee with a HCHN flag for cancer

              


      

    

    
      
        	

              	ii.	
                Enrollee with a HCHN flag for medium, very high, and extra high Renal Disease

              


      

    

    
      
        	

              	iii.	
                Enrollee with a HCHN flag for very high and medium cardiovascular disease

              


      

    

    
      
        	

              	iv.	
                Enrollee with a HCHN flag for diabetes and/or low and extra low cardiovascular disease

              


      

    

    
      
        	

              	v.	
                Enrollee with a HCHN flag for pulmonary disease

              


      

    

    
      
        	

              	vi.	
                Enrollee with none of the above HCHN condition flag by age and gender

              


      

    

    
      
        	

              	·	
                Male 14-18

              


      

    

    
      
        	

              	·	
                Male 19-44

              


      

    

    
      
        	

              	·	
                Male 45+

              


      

    

    
      
        	

              	·	
                Female 14-18

              


      

    

    
      
        	

              	·	
                Female 19-44

              


      

    

    
      
        	

              	·	
                Female 45+

              


      

    

    
      
        	

              	·	
                Age 0-1

              


      

    

    
      
        	

              	·	
                Age 1-6

              


      

    

    
      
        	

              	·	
                Age 7-13

              


      

    

    

    

    
      
        	

              	3.	
                CHIP

              


      

    

    
      
        	

              	i.	
                Enrollee with HCHN flag for pulmonary disease

              


      

    

    
      
        	

              	ii.	
                Enrollee with HCHN flag for diabetes

              


      

    

    
      
        	

              	iii.	
                Enrollee with none of the above HCHN condition flag by age and gender

              


      

    

    
      
        	

              	·	
                Age 0-1

              


      

    

    
      
        	

              	·	
                Age 1-6

              


      

    

    
      
        	

              	·	
                Age 7-13

              


      

    

    
      
        	

              	·	
                Age 14+

              


      

    

    

    

    Appendix A: Rate Cell List

    

    

    	 	
            Elegibility Group

          	 	
            Rate Cell Group

          	 	
            Category

          
	 	
            Federal

          	 	
            Domestic Abuse and Foster Children

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Domestic Abuse and Foster Children

          	 	
            Other

          
	 	
            CHIP

          	 	
            Domestic Abuse and Foster Children

          	 	
            Other

          
	 	
            Federal

          	 	
            A only

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            A only

          	 	
            Other

          
	 	
            Federal

          	 	
            A and B

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            A and B

          	 	
            Other

          
	 	
            Federal

          	 	
            Cancer

          	 	
            HCHN

          
	 	
            Federal

          	 	
            Renal

          	 	
            HCHN

          
	 	
            Federal

          	 	
            Cardio

          	 	
            HCHN

          
	 	
            Federal

          	 	
            Cardio and/or Diabetes

          	 	
            HCHN

          


    

    

    
      
        


    

    	 	
            Federal

          	 	
            Pulmonary

          	 	
            HCHN

          
	 	
            Federal

          	 	
            Male 14-18

          	 	
            Other

          
	 	
            Federal

          	 	
            Male 19-44

          	 	
            Other

          
	 	
            Federal

          	 	
            Male 45+

          	 	
            Other

          
	 	
            Federal

          	 	
            Female 14-18

          	 	
            Other

          
	 	
            Federal

          	 	
            Female 19-44

          	 	
            Other

          
	 	
            Federal

          	 	
            Female 45+

          	 	
            Other

          
	 	
            Federal

          	 	
            Age 0-1

          	 	
            Other

          
	 	
            Federal

          	 	
            Age 1-6

          	 	
            Other

          
	 	
            Federal

          	 	
            Age 7-13

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Cancer

          	 	
            HCHN

          
	 	
            Commonwealth

          	 	
            Renal

          	 	
            HCHN

          
	 	
            Commonwealth

          	 	
            Cardio

          	 	
            HCHN

          
	 	
            Commonwealth

          	 	
            Cardio and/or Diabetes

          	 	
            HCHN

          
	 	
            Commonwealth

          	 	
            Pulmonary

          	 	
            HCHN

          
	 	
            Commonwealth

          	 	
            Male 14-18

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Male 19-44

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Male 45+

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Female 14-18

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Female 19-44

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Female 45+

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Age 0-1

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Age 1-6

          	 	
            Other

          
	 	
            Commonwealth

          	 	
            Age 7-13

          	 	
            Other

          
	 	
            CHIP

          	 	
            Pulmonary

          	 	
            HCHN

          
	 	
            CHIP

          	 	
            Diabetes

          	 	
            HCHN

          
	 	
            CHIP

          	 	
            Age 0-1

          	 	
            Other

          
	 	
            CHIP

          	 	
            Age 1-6

          	 	
            Other

          
	 	
            CHIP

          	 	
            Age 7-13

          	 	
            Other

          
	 	
            CHIP

          	 	
            Age 14+

          	 	
            Other

          


     

      

    

    
      
        


    

    Appendix B: Diagnosis Codes Used to Identify HCHN Rate Cells

    

    	
            Rate Cell

          	
            CDPS Condition Category

          	
            Diagnosis Codes

          
	
            Cancer

          	
            Cancer, high

          	
            150, 1500, 1501, 1502, 1503, 1504, 1505, 1508,

            1509, 151, 1510, 1511, 1512, 1513, 1514, 1515,

            1516, 1518, 1519, 155, 1550, 1551, 1552, 156,

            1560, 1561, 1562, 1568, 1569, 158, 1580, 1588,

            1589, 162, 1620, 1622, 1623, 1624, 1625, 1628,

            1629, 163, 1630, 1631, 1638, 1639, 183, 1830,

            1832, 1833, 1834, 1835, 1838, 1839, 191, 1910,

            1911, 1912, 1913, 1914, 1915, 1916, 1917, 1918,

            1919, 192, 1920, 1921, 1922, 1923, 1928, 1929,

            20030, 20031, 20032, 20033, 20034, 20035,

            20036, 20037, 20038, 20040, 20041, 20042,

          


    

    

    
      
        


    

    
      	
              Rate Cell

            	
              CDPS Condition Category

            	
              Diagnosis Codes

            


    

    	 	 	
            20043, 20044, 20045, 20046, 20047, 20048,

            20050, 20051, 20052, 20053, 20054, 20055,

            20056, 20057, 20058, 20060, 20061, 20062,

            20063, 20064, 20065, 20066, 20067, 20068,

            20070, 20071, 20072, 20073, 20074, 20075,

            20076, 20077, 20078, 2020, 20200, 20201, 20202,

            20203, 20204, 20205, 20206, 20207, 20208, 2021,

            20210, 20211, 20212, 20213, 20214, 20215,

            20216, 20217, 20218, 20270, 20271, 20272,

            20273, 20274, 20275, 20276, 20277, 20278, 204,

            2040, 20400, 20401, 20402, 2041, 20410, 20411,

            20412, 2042, 20420, 20421, 20422, 2048, 20480,

            20481, 20482, 2049, 20490, 20491, 20492, 205,

            2050, 20500, 20501, 20502, 2051, 20510, 20511,

            20512, 2052, 20520, 20521, 20522, 2053, 20530,

            20531, 20532, 2058, 20580, 20581, 20582, 2059,

            20590, 20591, 20592, 206, 2060, 20600, 20601,

            20602, 2061, 20610, 20611, 20612, 2062, 20620,

            20621, 20622, 2068, 20680, 20681, 20682, 2069,

            20690, 20691, 20692, 207, 2070, 20700, 20701,

            20702, 2071, 20710, 20711, 20712, 2072, 20720,

            20721, 20722, 2078, 20780, 20781, 20782, 208,

            2080, 20800, 20801, 20802, 2081, 20810, 20811,

            20812, 2082, 20820, 20821, 20822, 2088, 20880,

            20881, 20882, 2089, 20890, 20891, 20892, 20900,

            20901, 20902, 20903, 20910, 20911, 20912,

            20913, 20914, 20915, 20916, 20917, 20920,

            20921, 20922, 20923, 20924, 20925, 20926,

            20927, 20929, 20930, 20931, 20932, 20933,

            20934, 20935, 20936, 20970, 20971, 20972,

            20973, 20974, 20975, 20979, 23877, 99685, C153,

            C154, C155, C158, C159, C160, C161, C162,

            C163, C164, C165, C166, C168, C169, C220,

            C221, C222, C223, C224, C227, C228, C229, C23,

            C240, C241, C248, C249, C33, C3400, C3401,

            C3402, C3410, C3411, C3412, C342, C3430,

            C3431, C3432, C3480, C3481, C3482, C3490,

            C3491, C3492, C384, C450, C451, C480, C481,

            C482, C488, C4A0, C4A10, C4A11, C4A12,

            C4A20, C4A21, C4A22, C4A30, C4A31, C4A39,

            C4A4, C4A51, C4A52, C4A59, C4A60, C4A61,

            C4A62, C4A70, C4A71, C4A72, C4A8, C4A9,

            C561, C562, C569, C5700, C5701, C5702, C5710,

            C5711, C5712, C5720, C5721, C5722, C573,

            C574, C700, C701, C709, C710, C711, C712,

            C713, C714, C715, C716, C717, C718, C719,

            C720, C721, C7220, C7221, C7222, C7230,

            C7231, C7232, C7240, C7241, C7242, C7250,

            C7259, C729, C7A00, C7A010, C7A011, C7A012,

            C7A019, C7A020, C7A021, C7A022, C7A023,

          


    

    

    
      
        


    

    
      	
              Rate Cell

            	
              CDPS Condition Category

            	
              Diagnosis Codes

            


    

    	 	 	
            C7A024, C7A025, C7A026, C7A029, C7A090,

            C7A091, C7A092, C7A093, C7A094, C7A095,

            C7A096, C7A098, C7A1, C7A8, C7B00, C7B01,

            C7B02, C7B03, C7B04, C7B09, C7B1, C7B8,

            C8200, C8201, C8202, C8203, C8204, C8205,

            C8206, C8207, C8208, C8209, C8210, C8211,

            C8212, C8213, C8214, C8215, C8216, C8217,

            C8218, C8219, C8220, C8221, C8222, C8223,

            C8224, C8225, C8226, C8227, C8228, C8229,

            C8230, C8231, C8232, C8233, C8234, C8235,

            C8236, C8237, C8238, C8239, C8240, C8241,

            C8242, C8243, C8244, C8245, C8246, C8247,

            C8248, C8249, C8260, C8261, C8262, C8263,

            C8264, C8265, C8266, C8267, C8268, C8269,

            C8280, C8281, C8282, C8283, C8284, C8285,

            C8286, C8287, C8288, C8289, C8290, C8291,

            C8292, C8293, C8294, C8295, C8296, C8297,

            C8298, C8299, C8310, C8311, C8312, C8313,

            C8314, C8315, C8316, C8317, C8318, C8319,

            C8331, C8332, C8333, C8334, C8335, C8336,

            C8337, C8338, C8339, C8380, C8381, C8382,

            C8383, C8384, C8385, C8386, C8387, C8388,

            C8389, C8400, C8401, C8402, C8403, C8404,

            C8405, C8406, C8407, C8408, C8409, C8440,

            C8441, C8442, C8443, C8444, C8445, C8446,

            C8447, C8448, C8449, C8460, C8461, C8462,

            C8463, C8464, C8465, C8466, C8467, C8468,

            C8469, C8470, C8471, C8472, C8473, C8474,

            C8475, C8476, C8477, C8478, C8479, C8520,

            C8521, C8522, C8523, C8524, C8525, C8526,

            C8527, C8528, C8529, C884, C9100, C9101,

            C9102, C9110, C9111, C9112, C9130, C9131,

            C9132, C9150, C9151, C9152, C9160, C9161,

            C9162, C9190, C9191, C9192, C91A0, C91A1,

            C91A2, C91Z0, C91Z1, C91Z2, C9200, C9201,

            C9202, C9210, C9211, C9212, C9220, C9221,

            C9222, C9230, C9231, C9232, C9240, C9241,

            C9242, C9250, C9251, C9252, C9260, C9261,

            C9262, C9290, C9291, C9292, C92A0, C92A1,

            C92A2, C92Z0, C92Z1, C92Z2, C9300, C9301,

            C9302, C9310, C9311, C9312, C9330, C9331,

            C9332, C9390, C9391, C9392, C93Z0, C93Z1,

            C93Z2, C9400, C9401, C9402, C9420, C9421,

            C9422, C9430, C9431, C9432, C9480, C9481,

            C9482, C9500, C9501, C9502, C9510, C9511,

            C9512, C9590, C9591, C9592, D45, D47Z1,

            T8600, T8601, T8602, T8603, T8609, V4281,

            V580, V581, V5811, V5812, Z510, Z5111, Z5112,

            Z9481

          


    

    

    
      
        


    

    
      	
              Rate Cell

            	
              CDPS Condition Category

            	
              Diagnosis Codes

            


    

    	
            Cancer

          	
            Cancer, low

          	
            140, 1400, 1401, 1403, 1404, 1405, 1406, 1408,

            1409, 141, 1410, 1411, 1412, 1413, 1414, 1415,

            1416, 1418, 1419, 142, 1420, 1421, 1422, 1428,

            1429, 143, 1430, 1431, 1438, 1439, 144, 1440,

            1441, 1448, 1449, 145, 1450, 1451, 1452, 1453,

            1454, 1455, 1456, 1458, 1459, 146, 1460, 1461,

            1462, 1463, 1464, 1465, 1466, 1467, 1468, 1469,

            147, 1470, 1471, 1472, 1473, 1478, 1479, 148,

            1480, 1481, 1482, 1483, 1488, 1489, 149, 1490,

            1491, 1498, 1499, 160, 1600, 1601, 1602, 1603,

            1604, 1605, 1608, 1609, 161, 1610, 1611, 1612,

            1613, 1618, 1619, 172, 1720, 1721, 1722, 1723,

            1724, 1725, 1726, 1727, 1728, 1729, 173, 1730,

            17300, 17301, 17302, 17309, 1731, 17310, 17311,

            17312, 17319, 1732, 17320, 17321, 17322, 17329,

            1733, 17330, 17331, 17332, 17339, 1734, 17340,

            17341, 17342, 17349, 1735, 17350, 17351, 17352,

            17359, 1736, 17360, 17361, 17362, 17369, 1737,

            17370, 17371, 17372, 17379, 1738, 17380, 17381,

            17382, 17389, 1739, 17390, 17391, 17392, 17399,

            174, 1740, 1741, 1742, 1743, 1744, 1745, 1746,

            1748, 1749, 175, 1750, 1759, 179, 180, 1800,

            1801, 1808, 1809, 181, 182, 1820, 1821, 1828,

            184, 1840, 1841, 1842, 1843, 1844, 1848, 1849,

            185, 186, 1860, 1869, 187, 1871, 1872, 1873,

            1874, 1875, 1876, 1877, 1878, 1879, 188, 1880,

            1881, 1882, 1883, 1884, 1885, 1886, 1887, 1888,

            1889, 189, 1890, 1891, 1892, 1893, 1894, 1898,

            1899, 190, 1900, 1901, 1902, 1903, 1904, 1905,

            1906, 1907, 1908, 1909, 193, 195, 1950, 1951,

            1952, 1953, 1954, 1955, 1958, C000, C001, C002,

            C003, C004, C005, C006, C008, C009, C01, C020,

            C021, C022, C023, C024, C028, C029, C030,

            C031, C039, C040, C041, C048, C049, C050,

            C051, C052, C058, C059, C060, C061, C062,

            C0680, C0689, C069, C07, C080, C081, C089,

            C090, C091, C098, C099, C100, C101, C102,

            C103, C104, C108, C109, C110, C111, C112,

            C113, C118, C119, C12, C130, C131, C132, C138,

            C139, C140, C142, C148, C300, C301, C310,

            C311, C312, C313, C318, C319, C320, C321,

            C322, C323, C328, C329, C430, C4310, C4311,

            C4312, C4320, C4321, C4322, C4330, C4331,

            C4339, C434, C4351, C4352, C4359, C4360,

            C4361, C4362, C4370, C4371, C4372, C438,

            C439, C4400, C4401, C4402, C4409, C44101,

            C44102, C44109, C44111, C44112, C44119,

            C44121, C44122, C44129, C44191, C44192,

            C44199, C44201, C44202, C44209, C44211,

            C44212, C44219, C44221, C44222, C44229,

          


    

    

    
      
        


    

    
      
        	
                Rate Cell

              	
                CDPS Condition Category

              	
                Diagnosis Codes

              


      

    

    	 	 	
            C44291, C44292, C44299, C44300, C44301,

            C44309, C44310, C44311, C44319, C44320,

            C44321, C44329, C44390, C44391, C44399,

            C4440, C4441, C4442, C4449, C44500, C44501,

            C44509, C44510, C44511, C44519, C44520,

            C44521, C44529, C44590, C44591, C44599,

            C44601, C44602, C44609, C44611, C44612,

            C44619, C44621, C44622, C44629, C44691,

            C44692, C44699, C44701, C44702, C44709,

            C44711, C44712, C44719, C44721, C44722,

            C44729, C44791, C44792, C44799, C4480, C4481,

            C4482, C4489, C4490, C4491, C4492, C4499,

            C457, C50011, C50012, C50019, C50021, C50022,

            C50029, C50111, C50112, C50119, C50121,

            C50122, C50129, C50211, C50212, C50219,

            C50221, C50222, C50229, C50311, C50312,

            C50319, C50321, C50322, C50329, C50411,

            C50412, C50419, C50421, C50422, C50429,

            C50511, C50512, C50519, C50521, C50522,

            C50529, C50611, C50612, C50619, C50621,

            C50622, C50629, C50811, C50812, C50819,

            C50821, C50822, C50829, C50911, C50912,

            C50919, C50921, C50922, C50929, C510, C511,

            C512, C518, C519, C52, C530, C531, C538, C539,

            C540, C541, C542, C543, C548, C549, C55, C577,

            C578, C579, C58, C600, C601, C602, C608, C609,

            C61, C6200, C6201, C6202, C6210, C6211,

            C6212, C6290, C6291, C6292, C6300, C6301,

            C6302, C6310, C6311, C6312, C632, C637, C638,

            C639, C641, C642, C649, C651, C652, C659,

            C661, C662, C669, C670, C671, C672, C673,

            C674, C675, C676, C677, C678, C679, C680,

            C681, C688, C689, C6900, C6901, C6902, C6910,

            C6911, C6912, C6920, C6921, C6922, C6930,

            C6931, C6932, C6940, C6941, C6942, C6950,

            C6951, C6952, C6960, C6961, C6962, C6980,

            C6981, C6982, C6990, C6991, C6992, C73, C760,

            C761, C762, C763, C7640, C7641, C7642, C7650,

            C7651, C7652, C768, D030, D0310, D0311,

            D0312, D0320, D0321, D0322, D0330, D0339,

            D034, D0351, D0352, D0359, D0360, D0361,

            D0362, D0370, D0371, D0372, D038, D039, V524,

            Z4430, Z4431, Z4432, Z45811, Z45812, Z45819

          
	
            Cancer

          	
            Cancer, medium

          	
            152, 1520, 1521, 1522, 1523, 1528, 1529, 153,

            1530, 1531, 1532, 1533, 1534, 1535, 1536, 1537,

            1538, 1539, 154, 1540, 1541, 1542, 1543, 1548,

            164, 1640, 1641, 1642, 1643, 1648, 1649, 165,

            1650, 1658, 1659, 170, 1700, 1701, 1702, 1703,

            1704, 1705, 1706, 1707, 1708, 1709, 171, 1710,

            1712, 1713, 1714, 1715, 1716, 1717, 1718, 1719,

          


    

    

    
      
        


    

    
      
        
          	
                  Rate Cell

                	
                  CDPS Condition Category

                	
                  Diagnosis Codes

                


        

      

    

    	 	 	
            194, 1940, 1941, 1943, 1944, 1945, 1946, 1948,

            1949, 196, 1960, 1961, 1962, 1963, 1965, 1966,

            1968, 1969, 199, 1990, 1991, 1992, 200, 2000,

            20000, 20001, 20002, 20003, 20004, 20005,

            20006, 20007, 20008, 2001, 20010, 20011, 20012,

            20013, 20014, 20015, 20016, 20017, 20018, 2002,

            20020, 20021, 20022, 20023, 20024, 20025,

            20026, 20027, 20028, 2008, 20080, 20081, 20082,

            20083, 20084, 20085, 20086, 20087, 20088, 201,

            2010, 20100, 20101, 20102, 20103, 20104, 20105,

            20106, 20107, 20108, 2011, 20110, 20111, 20112,

            20113, 20114, 20115, 20116, 20117, 20118, 2012,

            20120, 20121, 20122, 20123, 20124, 20125,

            20126, 20127, 20128, 2014, 20140, 20141, 20142,

            20143, 20144, 20145, 20146, 20147, 20148, 2015,

            20150, 20151, 20152, 20153, 20154, 20155,

            20156, 20157, 20158, 2016, 20160, 20161, 20162,

            20163, 20164, 20165, 20166, 20167, 20168, 2017,

            20170, 20171, 20172, 20173, 20174, 20175,

            20176, 20177, 20178, 2019, 20190, 20191, 20192,

            20193, 20194, 20195, 20196, 20197, 20198, 202,

            2022, 20220, 20221, 20222, 20223, 20224, 20225,

            20226, 20227, 20228, 2023, 20230, 20231, 20232,

            20233, 20234, 20235, 20236, 20237, 20238, 2024,

            20240, 20241, 20242, 20243, 20244, 20245,

            20246, 20247, 20248, 2025, 20250, 20251, 20252,

            20253, 20254, 20255, 20256, 20257, 20258, 2026,

            20260, 20261, 20262, 20263, 20264, 20265,

            20266, 20267, 20268, 2028, 20280, 20281, 20282,

            20283, 20284, 20285, 20286, 20287, 20288, 2029,

            20290, 20291, 20292, 20293, 20294, 20295,

            20296, 20297, 20298, C170, C171, C172, C173,

            C178, C179, C180, C181, C182, C183, C184,

            C185, C186, C187, C188, C189, C19, C20, C210,

            C211, C212, C218, C37, C380, C381, C382, C383,

            C388, C390, C399, C4000, C4001, C4002, C4010,

            C4011, C4012, C4020, C4021, C4022, C4030,

            C4031, C4032, C4080, C4081, C4082, C4090,

            C4091, C4092, C410, C411, C412, C413, C414,

            C419, C452, C459, C470, C4710, C4711, C4712,

            C4720, C4721, C4722, C473, C474, C475, C476,

            C478, C479, C490, C4910, C4911, C4912, C4920,

            C4921, C4922, C493, C494, C495, C496, C498,

            C499, C49A0, C49A1, C49A2, C49A3, C49A4,

            C49A5, C49A9, C7400, C7401, C7402, C7410,

            C7411, C7412, C7490, C7491, C7492, C750,

            C751, C752, C753, C754, C755, C758, C759,

            C770, C771, C772, C773, C774, C775, C778,

            C779, C800, C801, C802, C8100, C8101, C8102,

            C8103, C8104, C8105, C8106, C8107, C8108,

          


    

    

    
      
        


    

    
      
        
          	
                  Rate Cell

                	
                  CDPS Condition Category

                	
                  Diagnosis Codes

                


        

      

    

    	 	 	
            C8109, C8110, C8111, C8112, C8113, C8114,

            C8115, C8116, C8117, C8118, C8119, C8120,

            C8121, C8122, C8123, C8124, C8125, C8126,

            C8127, C8128, C8129, C8130, C8131, C8132,

            C8133, C8134, C8135, C8136, C8137, C8138,

            C8139, C8140, C8141, C8142, C8143, C8144,

            C8145, C8146, C8147, C8148, C8149, C8170,

            C8171, C8172, C8173, C8174, C8175, C8176,

            C8177, C8178, C8179, C8190, C8191, C8192,

            C8193, C8194, C8195, C8196, C8197, C8198,

            C8199, C8250, C8251, C8252, C8253, C8254,

            C8255, C8256, C8257, C8258, C8259, C8300,

            C8301, C8302, C8303, C8304, C8305, C8306,

            C8307, C8308, C8309, C8330, C8350, C8351,

            C8352, C8353, C8354, C8355, C8356, C8357,

            C8358, C8359, C8370, C8371, C8372, C8373,

            C8374, C8375, C8376, C8377, C8378, C8379,

            C8390, C8391, C8392, C8393, C8394, C8395,

            C8396, C8397, C8398, C8399, C8410, C8411,

            C8412, C8413, C8414, C8415, C8416, C8417,

            C8418, C8419, C8490, C8491, C8492, C8493,

            C8494, C8495, C8496, C8497, C8498, C8499,

            C84A0, C84A1, C84A2, C84A3, C84A4, C84A5,

            C84A6, C84A7, C84A8, C84A9, C84Z0, C84Z1,

            C84Z2, C84Z3, C84Z4, C84Z5, C84Z6, C84Z7,

            C84Z8, C84Z9, C8510, C8511, C8512, C8513,

            C8514, C8515, C8516, C8517, C8518, C8519,

            C8580, C8581, C8582, C8583, C8584, C8585,

            C8586, C8587, C8588, C8589, C8590, C8591,

            C8592, C8593, C8594, C8595, C8596, C8597,

            C8598, C8599, C860, C861, C862, C863, C864,

            C865, C866, C9140, C9141, C9142, C960, C962,

            C964, C969, C96A, C96Z

          
	
            Cancer

          	
            Cancer, very high

          	
            157, 1570, 1571, 1572, 1573, 1574, 1578, 1579,

            197, 1970, 1971, 1972, 1973, 1974, 1975, 1976,

            1977, 1978, 198, 1980, 1981, 1982, 1983, 1984,

            1985, 1986, 1987, 1988, 19881, 19882, 19889,

            203, 2030, 20300, 20301, 20302, 2031, 20310,

            20311, 20312, 2038, 20380, 20381, 20382, C250,

            C251, C252, C253, C254, C257, C258, C259,

            C7800, C7801, C7802, C781, C782, C7830,

            C7839, C784, C785, C786, C787, C7880, C7889,

            C7900, C7901, C7902, C7910, C7911, C7919,

            C792, C7931, C7932, C7940, C7949, C7951,

            C7952, C7960, C7961, C7962, C7970, C7971,

            C7972, C7981, C7982, C7989, C799, C882, C883,

            C888, C889, C9000, C9001, C9002, C9010,

            C9011, C9012, C9020, C9021, C9022, C9030,

            C9031, C9032

          


    

    

    
      
        


    

    
      
        
          
            	
                    Rate Cell

                  	
                    CDPS Condition Category

                  	
                    Diagnosis Codes

                  


          

        

      

    

    	
            Low Cardio

          	
            Cardiovascular, extra low

          	
            401, 4010, 4011, 4019, 402, 4020, 40200, 4021,

            40210, 4029, 40290, 403, 4030, 40300, 4031,

            40310, 4039, 40390, 404, 4040, 40400, 4041,

            40410, 4049, 40490, 405, 4050, 40501, 40509,

            4051, 40511, 40519, 4059, 40591, 40599, I10,

            I119, I129, I1310, I150, I151, I152, I158, I159, I160,

            I161, I169, N262

          
	
            Low Cardio

          	
            Cardiovascular, low

          	
            410, 4100, 41000, 41001, 41002, 4101, 41010,

            41011, 41012, 4102, 41020, 41021, 41022, 4103,

            41030, 41031, 41032, 4104, 41040, 41041, 41042,

            4105, 41050, 41051, 41052, 4106, 41060, 41061,

            41062, 4107, 41070, 41071, 41072, 4108, 41080,

            41081, 41082, 4109, 41090, 41091, 41092, 411,

            4110, 4111, 4118, 41181, 41189, 412, 413, 4130,

            4131, 4139, 414, 4140, 41400, 41401, 41402,

            41403, 41404, 41405, 41406, 4141, 41410, 41411,

            41412, 41419, 4142, 4143, 4144, 4148, 4149, 420,

            4200, 4209, 42090, 42091, 42099, 421, 4211,

            4219, 422, 4220, 4229, 42290, 42291, 42292,

            42293, 42299, 423, 4230, 4231, 4232, 4233, 4238,

            4239, 42511, 42518, 426, 4260, 4261, 42610,

            42611, 42612, 42613, 4262, 4263, 4264, 4265,

            42650, 42651, 42652, 42653, 42654, 4266, 4267,

            4268, 42681, 42682, 42689, 4269, 427, 4270,

            4271, 4272, 4273, 42731, 42732, 4274, 42741,

            42742, 4275, 4276, 42760, 42761, 42769, 4278,

            42781, 42789, 4279, 4293, 441, 4410, 44100,

            44101, 44102, 44103, 4411, 4412, 4413, 4414,

            4415, 4416, 4417, 4419, 442, 4420, 4421, 4422,

            4423, 4428, 44281, 44282, 44283, 44284, 44289,

            4429, 443, 4430, 4431, 4432, 44321, 44322,

            44323, 44324, 44329, 4438, 44381, 44382, 44389,

            4439, 444, 4440, 44401, 44409, 4441, 4442,

            44421, 44422, 4448, 44481, 44489, 4449, 445,

            4450, 44501, 44502, 4458, 44581, 44589, 446,

            4460, 4461, 4462, 44620, 44621, 44629, 4463,

            4464, 4465, 4466, 4467, 451, 4510, 4511, 45111,

            45119, 4512, 4518, 45181, 45182, 45183, 45184,

            45189, 4519, 452, 453, 4530, 4531, 4532, 4533,

            4534, 45340, 45341, 45342, 45350, 45351, 45352,

            4536, 45371, 45372, 45373, 45374, 45375, 45376,

            45377, 45379, 4538, 45381, 45382, 45383, 45384,

            45385, 45386, 45387, 45389, 4539, 4540, 4542,

            4548, 745, 7450, 7451, 74510, 74511, 74512,

            74519, 7452, 7453, 7454, 7455, 7456, 74560,

            74561, 74569, 7457, 7458, 7459, 746, 7460,

            74600, 74601, 74602, 74609, 7461, 7462, 7463,

            7464, 7465, 7466, 7467, 7468, 74681, 74682,

            74683, 74684, 74685, 74686, 74687, 74689, 7469,

            747, 7470, 7471, 74710, 74711, 7472, 74720,

            74721, 74722, 74729, 7473, 74731, 74732, 74739,

          


    

    

    
      
        


    

    
      
        
          
            	
                    Rate Cell

                  	
                    CDPS Condition Category

                  	
                    Diagnosis Codes

                  


          

        

      

    

    	 	 	
            7474, 74740, 74741, 74742, 74749, 7475, 7476,

            74760, 74761, 74762, 74763, 74764, 74769, 7478,

            74781, 74782, 74783, 74789, 7479, 9960, 99600,

            99601, 99602, 99603, 99604, 99609, 99661,

            99671, 99672, I200, I201, I208, I209, I2101, I2102,

            I2109, I2111, I2119, I2121, I2129, I213, I214, I220,

            I221, I222, I228, I229, I240, I241, I248, I249, I2510,

            I25110, I25111, I25118, I25119, I252, I253, I2541,

            I2542, I255, I256, I25700, I25701, I25708, I25709,

            I25710, I25711, I25718, I25719, I25720, I25721,

            I25728, I25729, I25730, I25731, I25738, I25739,

            I25750, I25751, I25758, I25759, I25790, I25791,

            I25798, I25799, I25810, I25811, I2582, I2583,

            I2584, I2589, I259, I300, I301, I308, I309, I310,

            I311, I312, I313, I314, I318, I319, I32, I339, I400,

            I401, I408, I409, I41, I421, I422, I440, I441, I442,

            I4430, I4439, I444, I445, I4460, I4469, I447, I450,

            I4510, I4519, I452, I453, I454, I455, I456, I4581,

            I4589, I459, I462, I468, I469, I470, I471, I472, I479,

            I480, I481, I482, I483, I484, I4891, I4892, I4901,

            I4902, I491, I492, I493, I4940, I4949, I495, I498,

            I499, I517, I670, I7100, I7101, I7102, I7103, I711,

            I712, I713, I714, I715, I716, I718, I719, I720, I721,

            I722, I723, I724, I725, I726, I728, I729, I7300,

            I7301, I731, I7381, I7389, I739, I7401, I7409,

            I7410, I7411, I7419, I742, I743, I744, I745, I748,

            I749, I75011, I75012, I75013, I75019, I75021,

            I75022, I75023, I75029, I7581, I7589, I7770, I7771,

            I7772, I7773, I7774, I7775, I7776, I7777, I7779,

            I790, I791, I798, I8000, I8001, I8002, I8003, I8010,

            I8011, I8012, I8013, I80201, I80202, I80203,

            I80209, I80211, I80212, I80213, I80219, I80221,

            I80222, I80223, I80229, I80231, I80232, I80233,

            I80239, I80291, I80292, I80293, I80299, I803, I808,

            I809, I81, I820, I821, I82210, I82211, I82220,

            I82221, I82290, I82291, I823, I82401, I82402,

            I82403, I82409, I82411, I82412, I82413, I82419,

            I82421, I82422, I82423, I82429, I82431, I82432,

            I82433, I82439, I82441, I82442, I82443, I82449,

            I82491, I82492, I82493, I82499, I824Y1, I824Y2,

            I824Y3, I824Y9, I824Z1, I824Z2, I824Z3, I824Z9,

            I82501, I82502, I82503, I82509, I82511, I82512,

            I82513, I82519, I82521, I82522, I82523, I82529,

            I82531, I82532, I82533, I82539, I82541, I82542,

            I82543, I82549, I82591, I82592, I82593, I82599,

            I825Y1, I825Y2, I825Y3, I825Y9, I825Z1, I825Z2,

            I825Z3, I825Z9, I82601, I82602, I82603, I82609,

            I82611, I82612, I82613, I82619, I82621, I82622,

            I82623, I82629, I82701, I82702, I82703, I82709,

            I82711, I82712, I82713, I82719, I82721, I82722,

          


    

    

    
      
        


    

    
      
        
          
            
              	
                      Rate Cell

                    	
                      CDPS Condition Category

                    	
                      Diagnosis Codes

                    


            

          

        

      

    

    	 	 	
            I82723, I82729, I82811, I82812, I82813, I82819,

            I82890, I82891, I8290, I8291, I82A11, I82A12,

            I82A13, I82A19, I82A21, I82A22, I82A23, I82A29,

            I82B11, I82B12, I82B13, I82B19, I82B21, I82B22,

            I82B23, I82B29, I82C11, I82C12, I82C13, I82C19,

            I82C21, I82C22, I82C23, I82C29, I83001, I83002,

            I83003, I83004, I83005, I83008, I83009, I83011,

            I83012, I83013, I83014, I83015, I83018, I83019,

            I83021, I83022, I83023, I83024, I83025, I83028,

            I83029, I83201, I83202, I83203, I83204, I83205,

            I83208, I83209, I83211, I83212, I83213, I83214,

            I83215, I83218, I83219, I83221, I83222, I83223,

            I83224, I83225, I83228, I83229, I83811, I83812,

            I83813, I83819, I83891, I83892, I83893, I83899,

            M300, M301, M302, M303, M308, M310, M311,

            M312, M3130, M3131, M314, M315, M316, M317,

            M3212, P293, Q200, Q201, Q202, Q203, Q204,

            Q205, Q206, Q208, Q209, Q210, Q211, Q212,

            Q213, Q214, Q218, Q219, Q220, Q221, Q222,

            Q223, Q224, Q225, Q226, Q228, Q229, Q230,

            Q231, Q232, Q233, Q234, Q238, Q239, Q240,

            Q241, Q242, Q243, Q244, Q245, Q246, Q248,

            Q249, Q250, Q251, Q252, Q2521, Q2529, Q253,

            Q254, Q2540, Q2541, Q2542, Q2543, Q2544,

            Q2545, Q2546, Q2547, Q2548, Q2549, Q255,

            Q256, Q2571, Q2572, Q2579, Q258, Q259, Q260,

            Q261, Q262, Q263, Q264, Q265, Q266, Q268,

            Q269, Q270, Q271, Q272, Q2730, Q2731, Q2732,

            Q2733, Q2734, Q2739, Q274, Q278, Q279, Q280,

            Q281, Q282, Q283, Q288, Q289, R001, T8201XA,

            T8202XA, T8203XA, T8209XA, T82110A,

            T82111A, T82118A, T82119A, T82120A, T82121A,

            T82128A, T82129A, T82190A, T82191A, T82198A,

            T82199A, T82211A, T82212A, T82213A, T82218A,

            T82221A, T82222A, T82223A, T82228A, T82512A,

            T82518A, T82519A, T82522A, T82528A, T82529A,

            T82532A, T82538A, T82539A, T82592A, T82598A,

            T82599A, T826XXA, T827XXA, T82817A,

            T82827A, T82837A, T82847A, T82857A, T82867A,

            T82897A, T829XXA, V422, Z953, Z954

          
	
            High 

            Cardio

          	
            Cardiovascular, medium

          	
            40201, 40211, 40291, 40401, 40411, 40491, 416,

            4160, 4161, 4162, 4168, 4169, 417, 4170, 4171,

            4178, 4179, 4210, 425, 4250, 4251, 4252, 4253,

            4254, 4255, 4257, 4258, 4259, 428, 4280, 4281,

            4282, 42820, 42821, 42822, 42823, 4283, 42830,

            42831, 42832, 42833, 4284, 42840, 42841, 42842,

            42843, 4289, 4295, 4296, 449, 7825, 7826, 78261,

            78262, 7827, I110, I130, I234, I235, I270, I271,

            I272, I2781, I2782, I2789, I279, I280, I281, I288,

            I289, I330, I420, I423, I424, I425, I426, I427, I428,

            I429, I43, I501, I5020, I5021, I5022, I5023, I5030,

            I5031, I5032, I5033, I5040, I5041, I5042, I5043,

            I509, I511, I512, I76, R230, R231, R232, R233,

            V450, V4500, V4501, V4502, V4509, V533, V5331,

            V5332, V5339, Z45010, Z45018, Z4502, Z4509,

            Z950, Z95810, Z95818, Z959

          


    

    

    
      
        


    

    
      
        
          
            
              	
                      Rate Cell

                    	
                      CDPS Condition Category

                    	
                      Diagnosis Codes

                    


            

          

        

      

    

    	
            High Cardio

          	
            Cardiovascular, very high

          	
            41407, 9961, 99662, 99674, 99683, I25760,

            I25761, I25768, I25769, I25812, T82310A,

            T82311A, T82312A, T82318A, T82319A, T82320A,

            T82321A, T82322A, T82328A, T82329A, T82330A,

            T82331A, T82332A, T82338A, T82339A, T82390A,

            T82391A, T82392A, T82398A, T82399A, T8241XA,

            T8242XA, T8243XA, T8249XA, T82510A,

            T82511A, T82513A, T82514A, T82515A, T82520A,

            T82521A, T82523A, T82524A, T82525A, T82530A,

            T82531A, T82533A, T82534A, T82535A, T82590A,

            T82591A, T82593A, T82594A, T82595A, T82818A,

            T82828A, T82838A, T82848A, T82858A, T82868A,

            T82898A, T8620, T8621, T8622, T8623, T86290,

            T86298, T8630, T8631, T8632, T8633, T8639,

            V421, V4322, Z941, Z95812

          
	
            Diabetes

          	
            Diabetes, type 1 high

          	
            25021, 25023, 25031, 25033, 25041, 25043,

            99686, E1011, E1021, E1022, E1029, E10641,

            V4283, Z9483

          
	
            Diabetes

          	
            Diabetes, type 1 medium

          	
            25001, 25003, 2501, 25010, 25011, 25012, 25013,

            25051, 25053, 25061, 25063, E1010, E10311,

            E10319, E10321, E103211, E103212, E103213,

            E103219, E10329, E103291, E103292, E103293,

            E103299, E10331, E103311, E103312, E103313,

            E103319, E10339, E103391, E103392, E103393,

            E103399, E10341, E103411, E103412, E103413,

            E103419, E10349, E103491, E103492, E103493,

            E103499, E10351, E103511, E103512, E103513,

            E103519, E103521, E103522, E103523, E103529,

            E103531, E103532, E103533, E103539, E103541,

            E103542, E103543, E103549, E103551, E103552,

            E103553, E103559, E10359, E103591, E103592,

            E103593, E103599, E1036, E1037X1, E1037X2,

            E1037X3, E1037X9, E1039, E1040, E1041, E1042,

            E1043, E1044, E1049, E1051, E1052, E1059,

            E10610, E10618, E10620, E10621, E10622,

            E10628, E10630, E10638, E10649, E1065, E1069,

            E108, E109

          
	
            Diabetes

          	
            Diabetes, type 2 low

          	
            24900, 24901, 24980, 24981, 24990, 24991, 250,

            2500, 25000, 25002, 2507, 25070, 25071, 25072,

            25073, 2508, 25080, 25081, 25082, 25083, 2509,

            25090, 25091, 25092, 25093, 3620, 36201, 36203,

            36204, 36205, E08618, E08620, E08621, E08622,

            E08628, E08630, E08638, E08649, E0865, E0869,

            E088, E089, E09618, E09620, E09621, E09622,

            E09628, E09630, E09638, E09649, E0965, E0969,

            E098, E099, E1151, E1152, E1159, E11618,

            E11620, E11621, E11622, E11628, E11630,

            E11638, E11649, E1165, E1169, E118, E119,

            E13618, E13620, E13621, E13622, E13628,

            E13630, E13638, E13649, E1365, E1369, E138,

            E139

          


    

    

    
      
        


    

    
      
        
          
            
              
                	
                        Rate Cell

                      	
                        CDPS Condition Category

                      	
                        Diagnosis Codes

                      


              

            

          

        

      

    

    	
            Diabetes

          	
            Diabetes, type 2 medium

          	
            24910, 24911, 24920, 24921, 24930, 24931,

            24940, 24941, 24950, 24951, 24960, 24961,

            24970, 24971, 2502, 25020, 25022, 2503, 25030,

            25032, 2504, 25040, 25042, 2505, 25050, 25052,

            2506, 25060, 25062, 36202, 36206, 36207, E0800,

            E0801, E0810, E0811, E0821, E0822, E0829,

            E08311, E08319, E08321, E083211, E083212,

            E083213, E083219, E08329, E083291, E083292,

            E083293, E083299, E08331, E083311, E083312,

            E083313, E083319, E08339, E083391, E083392,

            E083393, E083399, E08341, E083411, E083412,

            E083413, E083419, E08349, E083491, E083492,

            E083493, E083499, E08351, E083511, E083512,

            E083513, E083519, E083521, E083522, E083523,

            E083529, E083531, E083532, E083533, E083539,

            E083541, E083542, E083543, E083549, E083551,

            E083552, E083553, E083559, E08359, E083591,

            E083592, E083593, E083599, E0836, E0837X1,

            E0837X2, E0837X3, E0837X9, E0839, E0840,

            E0841, E0842, E0843, E0844, E0849, E0851,

            E0852, E0859, E08610, E08641, E0900, E0901,

            E0910, E0911, E0921, E0922, E0929, E09311,

            E09319, E09321, E093211, E093212, E093213,

            E093219, E09329, E093291, E093292, E093293,

            E093299, E09331, E093311, E093312, E093313,

            E093319, E09339, E093391, E093392, E093393,

            E093399, E09341, E093411, E093412, E093413,

            E093419, E09349, E093491, E093492, E093493,

            E093499, E09351, E093511, E093512, E093513,

            E093519, E093521, E093522, E093523, E093529,

            E093531, E093532, E093533, E093539, E093541,

            E093542, E093543, E093549, E093551, E093552,

            E093553, E093559, E09359, E093591, E093592,

            E093593, E093599, E0936, E0937X1, E0937X2,

            E0937X3, E0937X9, E0939, E0940, E0941, E0942,

            E0943, E0944, E0949, E0951, E0952, E0959,

            E09610, E09641, E1100, E1101, E1121, E1122,

            E1129, E11311, E11319, E11321, E113211,

            E113212, E113213, E113219, E11329, E113291,

            E113292, E113293, E113299, E11331, E113311,

            E113312, E113313, E113319, E11339, E113391,

            E113392, E113393, E113399, E11341, E113411,

            E113412, E113413, E113419, E11349, E113491,

            E113492, E113493, E113499, E11351, E113511,

            E113512, E113513, E113519, E113521, E113522,

            E113523, E113529, E113531, E113532, E113533,

            E113539, E113541, E113542, E113543, E113549,

            E113551, E113552, E113553, E113559, E11359,

            E113591, E113592, E113593, E113599, E1136,

            E1137X1, E1137X2, E1137X3, E1137X9, E1139,

            E1140, E1141, E1142, E1143, E1144, E1149,

            E11610, E11641, E1300, E1301, E1310, E1311,

            E1321, E1322, E1329, E13311, E13319, E13321,

            E133211, E133212, E133213, E133219, E13329,

            E133291, E133292, E133293, E133299, E13331,

            E133311, E133312, E133313, E133319, E13339,

            E133391, E133392, E133393, E133399, E13341,

            E133411, E133412, E133413, E133419, E13349,

            E133491, E133492, E133493, E133499, E13351,

            E133511, E133512, E133513, E133519, E133521,

            E133522, E133523, E133529, E133531, E133532,

            E133533, E133539, E133541, E133542, E133543,

            E133549, E133551, E133552, E133553, E133559,

            E13359, E133591, E133592, E133593, E133599,

            E1336, E1337X1, E1337X2, E1337X3, E1337X9,

            E1339, E1340, E1341, E1342, E1343, E1344,

            E1349, E1351, E1352, E1359, E13610, E13641

          


    

    

    
      
        


    

    
      
        
          
            
              
                	
                        Rate Cell

                      	
                        CDPS Condition Category

                      	
                        Diagnosis Codes

                      


              

            

          

        

      

    

    	
            Pulmonary

          	
            Pulmonary, high

          	
            4820, 4821, 4822, 494, 4940, 4941, 7991, J14,

            J150, J151, J470, J471, J479, R092

          
	
            Pulmonary

          	
            Pulmonary, low

          	
            07982, 476, 4760, 4761, 480, 4800, 4801, 4802,

            4803, 4808, 4809, 481, 482, 4823, 48230, 48231,

            48232, 48239, 4824, 48240, 48241, 48242, 48249,

            4828, 48281, 48282, 48283, 48284, 48289, 4829,

            483, 4830, 4831, 4838, 484, 4841, 4843, 4845,

            4846, 4847, 4848, 485, 486, 488, 4880, 48801,

            48802, 48809, 4881, 48811, 48812, 48819, 4888,

            48881, 48882, 48889, 491, 4910, 4911, 4912,

            49120, 49121, 49122, 4918, 4919, 492, 4920,

            4928, 493, 4930, 49300, 49301, 49302, 4931,

            49310, 49311, 49312, 4932, 49320, 49321, 49322,

            4938, 49381, 49382, 4939, 49390, 49391, 49392,

            496, 511, 5110, 5111, 5118, 51181, 51189, 5119,

            5191, 51911, 51919, 5192, 5193, 5194, 7863,

            78630, 78631, 78639, 7866, A481, B9721, J09X1,

            J09X2, J09X3, J09X9, J120, J121, J122, J123,

            J1281, J1289, J129, J13, J1520, J15211, J15212,

            J1529, J153, J154, J155, J156, J157, J158, J159,

            J160, J168, J17, J180, J181, J188, J189, J370,

            J371, J410, J411, J418, J42, J430, J431, J432,

            J438, J439, J440, J441, J449, J4520, J4521,

            J4522, J4530, J4531, J4532, J4540, J4541, J4542,

            J4550, J4551, J4552, J45901, J45902, J45909,

            J45990, J45991, J45998, J90, J910, J918, J920,

            J929, J940, J941, J942, J948, J949, J9801, J9809,

            J985, J9851, J9859, J986, R042, R0481, R0489,

            R049, R091

          


    

    

    
      
        


    

    
      
        
          
            
              
                	
                        Rate Cell

                      	
                        CDPS Condition Category

                      	
                        Diagnosis Codes

                      


              

            

          

        

      

    

    	
            Pulmonary

          	
            Pulmonary, medium

          	
            507, 5070, 5071, 5078, 512, 5120, 5121, 5122,

            5128, 51281, 51282, 51283, 51284, 51289, 515,

            516, 5160, 5161, 5162, 5163, 51630, 51631,

            51632, 51633, 51634, 51635, 51636, 51637, 5164,

            5165, 5166, 51661, 51662, 51663, 51664, 51669,

            5168, 5169, 517, 5171, 5172, 5173, 5178, 518,

            5180, 5181, 5182, 5183, 5184, 5185, 51851,

            51852, 51853, 5186, 5187, 5188, 51881, 51882,

            51883, 51884, 51889, 748, 7480, 7481, 7482,

            7483, 7484, 7485, 7486, 74860, 74861, 74869,

            7488, 7489, B4481, J690, J691, J698, J80, J810,

            J82, J8401, J8402, J8403, J8409, J8410, J84111,

            J84112, J84113, J84114, J84115, J84116, J84117,

            J8417, J842, J8481, J8482, J8483, J84841,

            J84842, J84843, J84848, J8489, J849, J930,

            J9311, J9312, J9381, J9382, J9383, J939, J951,

            J952, J953, J95811, J95812, J95821, J95822,

            J9584, J9600, J9601, J9602, J9610, J9611, J9612,

            J9620, J9621, J9622, J9690, J9691, J9692, J9811,

            J9819, J982, J983, J984, J99, M3213, M3301,

            M3311, M3321, M3391, M3481, M3502, Q300,

            Q301, Q302, Q303, Q308, Q309, Q310, Q311,

            Q312, Q313, Q315, Q318, Q319, Q320, Q321,

            Q322, Q323, Q324, Q330, Q331, Q332, Q333,

            Q334, Q335, Q336, Q338, Q339, Q340, Q341,

            Q348, Q349

          
	
            Pulmonary

          	
            Pulmonary, very high

          	
            2770, 27700, 27701, 27702, 27703, 27709, 5190,

            51900, 51901, 51902, 51909, 99684, E840, E8411,

            E8419, E848, E849, J9500, J9501, J9502, J9503,

            J9504, J9509, T86810, T86811, T86812, T86818,

            T86819, V426, V440, V460, V461, V4611, V4612,

            V462, V550, Z430, Z930, Z942, Z990, Z9911,

            Z9912, Z9981

          
	
            Renal

          	
            Renal, extra high

          	
            45821, 99656, 99668, 99673, I953, T85611A,

            T85621A, T85631A, T85691A, T8571XA, V451,

            V4511, V4512, V56, V560, V561, V562, V563,

            V5631, V5632, V568, Z4901, Z4902, Z4931,

            Z4932, Z9115, Z992

          
	
            Renal

          	
            Renal, medium

          	
            40301, 40311, 40391, 40402, 40403, 40412,

            40413, 40492, 40493, 580, 5800, 5804, 5808,

            58081, 58089, 5809, 581, 5810, 5811, 5812, 5813,

            5818, 58181, 58189, 5819, 583, 5830, 5831, 5832,

            5834, 5836, 5837, 5838, 58381, 58389, 5839,

            5880, 5881, 59381, 99681, I120, I1311, I132,

            M3214, M3215, M3504, N000, N001, N002, N003,

            N004, N005, N006, N007, N008, N009, N010,

            N011, N012, N013, N014, N015, N016, N017,

            N018, N019, N020, N021, N022, N023, N024,

            N025, N026, N027, N028, N029, N040, N041,

            N042, N043, N044, N045, N046, N047, N048,

            N049, N050, N051, N052, N053, N054, N055,

            N056, N057, N058, N059, N060, N061, N062,

            N063, N064, N065, N066, N067, N068, N069,

            N070, N071, N072, N073, N074, N075, N076,

            N077, N078, N079, N08, N140, N141, N142, N143,

            N144, N150, N158, N159, N16, N250, N251, N280,

            T8610, T8611, T8612, T8613, T8619, V420, V445,

            V4450, V4451, V4452, V4459, V446, V555, V556,

            Z435, Z436, Z9350, Z9351, Z9352, Z9359, Z936,

            Z940

          


    

    

    
      
        


    

    
      
        
          
            
              
                	
                        Rate Cell

                      	
                        CDPS Condition Category

                      	
                        Diagnosis Codes

                      


              

            

          

        

      

    

    	
            Renal

          	
            Renal, very high

          	
            585, 5851, 5852, 5853, 5854, 5855, 5856, 5859,

            N181, N182, N183, N184, N185, N186, N189

          


     

      

    Appendix C: HCHN Registry Report Data Layout

    

    

    
      Each month the Contractor will provide the HCHN Registry Report with the following information:

       

        

      	

            	(i)	
              the name of the enrollee,

            


       

      

    

    
      
        	

              	(ii)	
                the MPI number of the enrollee,

              


         

        

      

    

    
      
        	

              	(iii)	
                the HCHN condition(s) of the enrollee by ICD-10 code,

              


         

        

      

    

    
      
        	

              	(iv)	
                provider name, address and NPI rendering the service, and

              


         

        

      

    

    
      
        	

              	(v)	
                date of initial diagnosis.

              


         

        

      

    

    
      
        	

              	(vi)	
                Date of last diagnosis

              


         

        

      

    

    
      
        	

              	(vii)	
                Month of HCHN eligibility expiration

              


         

        

      

    

    
      
        	

              	(viii)	
                Method of identification

              


         

        

      

    

    
      
        	

              	a.	
                PCP or Specialist visit

              


         

        

      

    

    
      
        	

              	b.	
                Inpatient or Outpatient Hospital visit

              


         

        

      

    

    
      
        	

              	c.	
                Positive laboratory result

              


         

        

      

    

    
      
        	

              	d.	
                Positive radiological test

              


         

        

      

    

    
      
        	

              	e.	
                Clinical Review

              


         

        

      

    

    
      
        	

              	f.	
                Care Management Review

              


         

        

      

    

    
      
        	

              	g.	
                (Other)

              


         

        

         

        

         

      

    

  








  
    Attachment 29

    

  

   

  

  
    
      ATTACHMENT 29 – MATERNITY KICK PAYMENT
        


    

     

      

    This attachment provides the methodology that ASES will use in determining maternity deliveries for reimbursement by ASES. This payment is in addition to
        the monthly capitation payment process.

    

    

    Reporting Template

    

    

    On a monthly basis, Contractor must submit the claims and encounter files included at Attachment 9 unless a different frequency is specified by ASES. These
        files will be the primary source for the maternity kick payment.

    

    

    ASES will use the encounter/ claims data submitted by the Contractor, which shall be auditable by ASES, to determine number of deliveries. Only one payment
        is made per delivery per pregnancy per member. If a member has multiple births delivered for the same pregnancy, only one (1) maternity kick payment will be issued. The Contractor shall receive $4,641.59 for each delivery that is reported to and
        validated by ASES. If during a validation process, the data or audit does not provide evidence of the reported delivery(ies), ASES may retroactively recoup the maternity kick payment. Each delivery claim must be evidenced with the following
        parameters.

     

      

    
      
        


    

    
    
      
        Maternity Kick Payment
          


      

    

     

      

    The following procedure codes must be accompanied by a revenue code for hospital facility or Professional claims:

    

    

    	
            CPT

             Procedure 

            Code

          	
            Description

          
	
            59400

          	
            Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

          
	
            59409

          	
            Vaginal delivery only (with or without episiotomy and/or forceps)

          
	
            59410

          	
            Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care

          
	
            59412

          	
            External cephalic version, with or without tocolysis

          
	
            59414

          	
            Delivery of placenta (separate procedure)

          
	
            59510

          	
            Routine obstetric care including antepartum care, cesarean delivery, and postpartum care

          
	
            59514

          	
            Cesarean delivery only

          
	
            59515

          	
            Cesarean delivery only; including postpartum care

          
	
            59610

          	
            Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous
                cesarean delivery

          
	
            59612

          	
            Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps)

          
	
            59614

          	
            Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care

          
	
            59618

          	
            Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean
                delivery

          
	
            59620

          	
            Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery

          
	
            59622

          	
            Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care

          


    

    

    
      Page 2 of 4

      
        


    

    
      
        
          Maternity Kick Payment
            


        

      

       

      And ICD-10 Diagnosis codes in either the first or second reported diagnosis code of:

    

    

    	
            ICD10

             Diagnosis

             Code

          	
            Description

          
	
            Z370

          	
            Single live birth

          
	
            Z371

          	
            Single stillbirth

          
	
            Z372

          	
            Twins, both liveborn

          
	
            Z373

          	
            Twins, one liveborn and one stillborn

          
	
            Z374

          	
            Twins, both stillborn

          
	
            Z3750

          	
            Multiple births, unspecified, all liveborn

          
	
            Z3751

          	
            Triplets, all liveborn

          
	
            Z3752

          	
            Quadruplets, all liveborn

          
	
            Z3753

          	
            Quintuplets, all liveborn

          
	
            Z3754

          	
            Sextuplets, all liveborn

          
	
            Z3759

          	
            Other multiple births, all liveborn

          
	
            Z3760

          	
            Multiple births, unspecified, some liveborn

          
	
            Z3761

          	
            Triplets, some liveborn

          
	
            Z3762

          	
            Quadruplets, some liveborn

          
	
            Z3763

          	
            Quintuplets, some liveborn

          
	
            Z3764

          	
            Sextuplets, some liveborn

          
	
            Z3769

          	
            Other multiple births, some liveborn

          
	
            Z377

          	
            Other multiple births, all stillborn

          
	
            Z379

          	
            Outcome of delivery, unspecified

          


     

    

    
      Page 3 of 4

      
        


    

    Maternity Kick Payment

    
      
        
          


      

    

     

    Timeliness of Payment

    

    

    The Maternity Kick Payment will be paid only for services incurred on or after November 1,
          2018. The first maternity kick payment shall be issued no later than February 28, 2019 for claims paid by the Contractor during the month of November 2018 and reported to ASES no later than December 15, 2018. Payments will thereafter be performed
          on a monthly basis for claims paid three months prior and reported no later than the 15th of the second
          to last month. The final maternity kick payment will be performed no later than the close of the quarter following the Termination of this Contract. Contractor shall have thirty (30) days to object to a payment. Any objection submitted past this
          term shall be deemed waived.

    

    

    

    

    Page 4 of 4

     

  








  
    Attachment 30

    

  

  
    

    

    TRANSACTION STANDARD TRADING PARTNER

    AGREEMENT/ADDENDUM

    

    

    This Trading Partner Agreement (TPA) is entered into between Administración de Seguros de Salud de Puerto Rico (ASES or PRHIA), represented by its
        Executive Director, Angela Avila, of legal age, married, and resident of Guaynabo, Puerto Rico, and Triple-S Salud, Inc., a Billing Agent, Health Care
        Clearinghouse, and/or managed Care Organization who transmits any health information in electronic form in connection with a transaction covered by 45 C.F.R. Parts 160 and 162 (“Trading Partner”), represented by Madeline Hernández Urquiza.

    

    

    WHEREAS, the Trading Partner agrees to perform certain functions or activities that are subject to certain transaction standards;

    

    

    WHEREAS, the Trading Partner agrees to conduct these transactions according to the limitations set forth in this TPA;

    

    

    NOW, THEREFORE, ASES and the Trading Partner agree as follows:

    

    

    ARTICLE I. Definitions

    

    

    1.1 Billing Agent: A Billing Agent is an
        entity that has a contract with a Provider(s) to submit claims to ASES on behalf of a Provider(s).

    

    

    1.2 Puerto Rico Medicaid Program: The
        subdivision of the Puerto Rico Department of Health that conducts eligibility determinations under GHP for Medicaid, CHIP, and State Populations.

    

    

    1.3 HHS Transaction Standard Regulation: The
        HHS Transaction Standard Regulation means the Code of Federal Regulations at Title 45, Parts 160 and 162.

    

    

    1.4 Health Care Clearinghouse: The Health Care
        Clearinghouse has the same meaning as the term “Health care clearinghouse” as defined in 45 C.F.R. §160.103.

    

    

    1.5 Individual: The Individual is the person
        who is the subject of the PHI and has the same meaning as the term “individual” as defined in 45 C.F.R. §160.103.

     

      

    
      
        


    

    1.6 Parties: The Parties are ASES and the
        Trading Partner.

    

    

    1.7 Protected Health Information: Protected
        Health Information (“PHI”) has the same meaning as the term “protected health information” as defined in 45 C.F.R. §160.103.

    

    

    1.8 Provider: The Provider is an individual,
        entity or facility that has an approved Provider Enrollment Agreement with ASES.

    

    

    1.9 Provider Enrollment Agreement: The
        Provider Enrollment Agreement is the agreement entered into between ASES and Providers participating in the Puerto Rico Medicaid Program.

    

    

    1.10 Standard transaction: Standard
        transaction (“Standard”) means a transaction that complies with the applicable standard adopted by 45 C.F.R. Part 162.

    

    

    1.11 Transactions: Transactions means the
        transmission of information between two entities to carry out financial or administrative activities related to health care, as defined in 45 C.F.R. §160.103.

    

    

    ARTICLE II. Term

    

    

    The term of this TPA shall commence as of the date of Execution (the “Effective Date”).

    

    

    ARTICLE III. Trading Partner Obligations

    

    

    The Trading Partner agrees to the following:

    

    

    3.1 Trading Partner hereby agrees that it will not change any definition, data condition or use of a data element or segment as
        proscribed in the HHS Transaction Standard Regulation (45 C.F.R. § 162.915(a)).

    

    

    3.2 Trading Partner hereby agrees that it will not add any data elements or segments to the maximum data set as proscribed in the HHS
        Transaction Standard Regulation (45 C.F.R. §162.915(b)).

    

    

    3.3 Trading Partner hereby agrees that it will not use any code or data elements that are either marked “not used” in the Standard’s
        implementation specifications or are not in the Standard’s implementation specifications. (45 C.F.R. §162.915(c)).

     

      

    
      
        


    

    3.4 Trading Partner hereby agrees that it will not change the meaning or intent of any of the Standard’s implementation specifications.
        (45 C.F.R. §162.915(d)).

    

    

    3.5 Trading Partner hereby understands and agrees to submit Puerto Rico Medicaid Program-specific data elements in accordance with the
        Puerto Rico Medicaid Companion Guides to the extent that the Puerto Rico Medicaid Program-specific data elements do not change the meaning or intent of any of the Standard’s implementation specifications (45 C.F.R. §162.915(d)) or do not change any
        definition, data condition or use of a data element or segment as proscribed in the HHS Transaction Regulation (45 C.F.R. §162.915(a)).

    

    

    3.6 Trading Partner who is a Provider hereby agrees to adequately test all business rules appropriate to its types and specialties.
        Trading Partner who is a Billing Agent or a health care clearinghouse hereby agrees to adequately test all business rules appropriate to each and every provider type and specialty for which it provides billing or health care clearinghouse services.

    

    

    3.7 Trading Partner agrees to cure Transactions errors or deficiencies identified by ASES, and Transactions errors or deficiencies
        identified by a Provider if the Trading Partner is acting as a Billing Agent or a health care clearinghouse for that Provider. When Trading Partner is a Billing Agent or a health care clearinghouse, Trading Partner agrees to properly communicate
        deficiencies and other pertinent information regarding electronic transactions to enrolled providers to which they provide services as a Billing Agent or a health care clearinghouse.

    

    

    3.8 Trading Partner agrees and understands that, from time to time, the federal Department of Health and Human Services (“HHS”) may
        modify and set compliance dates for its Standards. Trading Partner agrees to incorporate by reference into this TPA any such modifications or changes. (45 C.F.R. §160.104).

    

    

    3.9 Trading Partner and ASES understand and agree to keep open code sets being processed or used in this TPA for at least the current
        billing period or any appeal period, whichever is longer. (45 C.F.R. §162.925(c)(2)).

    

    

    3.10 Trading Partner agrees to meet all state and federal laws and regulations pertaining to confidentiality, privacy and security that
        are applicable to the Parties and to maintain and safeguard, in accordance with all state and federal laws and regulations, the confidentiality of ASES data and the’ personal, financial and medical information of ASES’s beneficiaries.

     

      

    
      
        


    

    ARTICLE IV. Transactions

    

    

    Standards

    

    

    Selected ASC X12N standards include, as applicable, all data dictionaries, segment dictionaries, code sets and transmission controls referenced in those
        standards, but include only the Transaction Sets selected below.

    

    

    Documents

    

    

    Trading Partner will send to ASES the following documents:

    

    

    	 	
            Transaction Set

          	 	
            Document Name/Description

          	 	
            Version

          	 	
            Check those that apply

          
	 	
            X12N 837 I

          	 	
            Health Care Claim/Encounter: Institutional

          	 	
            5010X223A3

          	 	 
	 	
            X12N 837 P

          	 	
            Health Care Claim/Encounter: Professional

          	 	
            5010X222A2

          	 	 
	 	
            X12N 837 D

          	 	
            Health Care Claim/Encounter: Dental

          	 	
            5010X224A3

          	 	 
	 	
            NCPDP D.0

          	 	
            Pharmacy Post-Adjudication Transaction

          	 	
            V4.2

          	 	 


    

    

    ASES will send the Trading Partner the following documents:

    

    

    X12N TA1 Interchange Acknowledgement

    

    

    X12N 999 Acknowledgement of Sent Transactions

    

    

    PRMMIS Encounter Error Report

     

      

    
      
        


    

    ARTICLE V. Termination

    

    

    This TPA shall remain in effect until terminated by either party with not less than thirty (30) days prior written notice to the other Party. Such notice
        shall specify the effective date of termination. In the event of a material breach of this TPA by either Party, the non-breaching Party may terminate the TPA by giving written notice to the breaching Party. The breaching Party shall have thirty
        (30) days to fully cure the breach. If the breach is not cured within thirty (30) days after the written notice is received by the breaching party, this TPA shall automatically and immediately terminate. Nothing herein shall limit ASES’s power or
        authority to impose intermediate sanctions, liquidated damages, and/or fines against the other Party in the event of an uncured material breach of this TPA by that other Party pursuant to Puerto Rico Act No. 72-1993 and ASES Regulation No. 8446,
        and/or as indicated in Articles 19 and 20 of the Contract between the Parties for the Provision of Physical and Behavioral Health Services under the Government Health Plan.

    

    

    ARTICLE VI. Assignment of the TPA

    

    

    This TPA is binding on the Parties hereto and their successors and assigns, but neither Party may assign this TPA without the prior written consent of the
        other, which consent shall not be unreasonably withheld.

    

    

    ARTICLE VII. Contact Information for the Parties

    

    

    Administración de Seguros de Salud de Puerto Rico

    1549 Calle Alda,

    Urbanización Caribe

    San Juan, Puerto Rico 00926-2712

    

      TRADING PARTNER

     

      

    
      	
              Name: 

              

            	
              Triple-S Salud, Inc.

            
	
              Address:

            	
              1441 F.D. Roosevelt Ave., San Juan, P.R. 00920

            
	
               

            	
              P.O. Box 363628, San Juan, P.R. 00936-3628

            
	
              Contact Name:

            	
               Madeline Hernández Urquiza

            
	
              Telephone Number: 

              

            	
              (787)749-4001

            
	
              E-mail Address: 

              

            	
              
                murquiza@ssspr.com

              

            


    

    

    

    
      
        


    

    IN WITNESS WHEREOF, ASES and Trading Partner have caused this TPA to be signed and delivered by their duly authorized representatives as of the date set
        forth above.

     

      

    ASES

    
      	
              By:

            	
              s/Angela M. Avila Marrero

            
	
              Print Name:  

              

            	
              Angela M. Avila Marrero

            
	
               

            	
              Executive Director

            
	
              Date:   

              

            	
              9/21/2018

            


    

    

    TRADING PARTNER

     
      	
              By:

            	
              s/Madeline Hernández Urquiza

            
	
              Print Name: 

              

            	
               Madeline Hernández Urquiza

            
	
              Title:

            	
              President

            
	
              Date:

            	
              9/21/2018