data file and may be used for identification purposes only and not disclosed or used for any other purpose. CONTRACTORS must always keep record of Social Security numbers for providing data and other reports to the DEPARTMENT or its authorized vendors and track the eight (8)-digit unique member identification number that is assigned by the DEPARTMENT. Provide coverage for PARTICIPANTS deemed eligible and enrolled by the DEPARTMENT. Have legal and technical staff available to the DEPARTMENT for advice and consultation as needed for program administration, and for assistance with any appeals processes. The CONTRACTOR shall monitor the development of and provide notification, information and advice to the DEPARTMENT in a timely manner concerning state or federal regulations or legislation that may affect the PHARMACY benefits PLAN. Shall not use or disclose names, addresses, or other data for any purpose other than specifically provided for in the CONTRACT. Comply with all applicable requirements and provisions of the . Evidence of compliance with ADA shall be made available to the DEPARTMENT upon request. The DEPARTMENT must be notified of any changes to the CONTRACTOR’S administrative and/or operative systems 120 Board Authority , provides authority for the BOARD to enter into contracts with insurers authorized to transact insurance business in this state for the purpose of providing the group insurance plans, or, provide any group insurance plan on a self-insured basis in which case the board shall approve a written description setting forth the terms and conditions of the plan, and may contract directly with providers of HOSPITAL, medical or ancillary services to provide eligible and enrolled EMPLOYEES with the benefits. The BOARD shall establish enrollment periods, known as the IT’S YOUR CHOICE OPEN ENROLLMENT period, which shall permit eligible EMPLOYEES, ANNUITANTS, and CONTINUANTS to enroll or transfer coverage to any benefit plan offered by the BOARD as required by . Unless otherwise provided by the BOARD, the IT’S YOUR CHOICE OPEN ENROLLMENT period shall be held once annually in the fall of each year with coverage effective the following January 1. The BOARD reserves the right to change to a fiscal year or to some other schedule that it deems appropriate. In cases where data submitted by the CONTRACTOR is deemed to be inadequate by the BOARD, the DEPARTMENT, or the BOARD’S consulting actuary, the BOARD may take any action up to and including limiting new enrollment into the PHARMACY BENEFIT PROGRAM administered by the CONTRACTOR.
In the event a CONTRACTOR becomes, or is at risk for becoming insolvent, experiences a significant event or significant loss of PARTICIPATING PHARMACIES, or if the BOARD so directs due to a significant event as described in the BOARD may do any of the following, including any combination of the following: Terminate the CONTRACT upon any notice it deems appropriate, including no notice. Close the PHARMACY BENEFIT PROGRAM administered by the CONTRACTOR to any new enrollments for the remainder of the CONTRACT period. Take no action. The BOARD may forfeit a SUBSCRIBER'S rights to the PHARMACY BENEFIT PLAN if a PARTICIPANT fraudulently or inappropriately assigns or transfers rights to an ineligible individual(s), or aids any other person in obtaining BENEFITS to which they are not entitled, or otherwise fraudulently attempts to obtain BENEFITS. The DEPARTMENT may at any time request such documentation as it deems necessary to substantiate SUBSCRIBER or DEPENDENT eligibility. Failure to provide such documentation upon request shall result in the suspension of BENEFITS. The BOARD may initiate disenrollment efforts in situations where a PARTICIPANT has committed acts of physical or verbal abuse, or is unable to establish/maintain a satisfactory physician-patient relationship with the current or alternate primary care provider. The SUBSCRIBER'S disenrollment is effective the first of the month following completion of the grievance process and approval of the BOARD. The BOARD may limit re-enrollment options in the PHARMACY BENEFITS PROGRAM. The BOARD shall determine all policy for the PHARMACY BENEFIT PLAN. In the event that the CONTRACTOR requests, in writing, that the BOARD issue program policy determinations or operating guidelines required for proper performance of the AGREEMENT, the DEPARTMENT shall acknowledge receipt of the request in writing and respond to the request within a mutually agreed upon time frame. . 125 Eligibility 125A General For PHARMACY BENEFIT PLAN purposes, per , eligible EMPLOYEES include: General state EMPLOYEES: active state and university EMPLOYEES participating in the Wisconsin Retirement System (WRS). Elected state officials. Members or EMPLOYEES of the legislature. Any blind EMPLOYEES of the Beyond Vision (aka WISCRAFT) authorized under .
The CONTRACTOR shall submit the following information to the DEPARTMENT, in the format as determined by the DEPARTMENT, for inclusion in the communications from the DEPARTMENT for the IT’S YOUR CHOICE OPEN ENROLLMENT period: CONTRACTOR information, including address, toll-free customer service telephone number, and website address. CONTRACTOR’s content for the pharmacy benefit related information page, including available features. Information for PARTICIPANTS to access the CONTRACTOR’s pharmacy network directory on its web site, including a link to the pharmacy network directory. The CONTRACTOR shall submit all informational materials intended for distribution to PARTICIPANTS during the IT’S YOUR CHOICE OPEN ENROLLMENT period to the DEPARTMENT for review and approval. The CONTRACTOR shall submit three (3) hard copies of all IT’S YOUR CHOICE OPEN ENROLLMENT materials in final format to the DEPARTMENT at least two (2) weeks prior to the start of the IT’S YOUR CHOICE OPEN ENROLLMENT period. 135C Required Member and Prescriber Outreach When making any changes to the formulary, the CONTRACTOR will be required to send notification a minimum 90 days prior to the change to all PARTICIPANTS who are currently prescribed drugs affected by the change. The notification should include the drug affected, the tier/cost-share level of the drug prior to change, the tier/cost-share level of the drug after change, the cost difference, contact information for the CONTRACTOR’s customer service, and information on members’ rights to appeal. This does not preclude the CONTRACTOR from implementing the formulary change immediately for PARTICIPANTS who have a new prescription written for the affected drug. The CONTRACTOR will also be required to contact PRESCRIBERS and PARTICIPATING PHARMACIES to notify these organizations of formulary change. Notification should be made no less than 90 days prior to the change in formulary. 140 Information Systems The CONTRACTOR’S systems must have the capability of adapting to any future changes that become necessary as a result of modifications to the state and LOCAL programs and their requirements. The CONTRACTOR’S systems shall be scalable and flexible so they can be adapted as needed, within negotiated timeframes, as requirements may change. If the CONTRACTOR has plans to migrate to a different data or web platform, the DEPARTMENT must be notified no less than six (6) months in advance of the migration.
300 305 Reporting Requirements As required by the CONTRACT, the CONTRACTOR must submit reports to the DEPARTMENT. Reports must be submitted by SECURE email to the DEPARTMENT, the DEPARTMENT’S sFTP site, or other method as specified by the DEPARTMENT, in the format and timeframe specified by the DEPARTMENT. The DEPARTMENT reserves the right to modify reporting requirements as deemed necessary to monitor the CONTRACT and programs. Instructions and specific due dates will be provided by the DEPARTMENT annually. Unless otherwise requested by the DEPARTMENT, each report must be specific to data from the PHARMACY BENEFIT PLAN, not general data from the CONTRACTOR’S book of business. Report Description Frequency Claims Invoicing Pharmacy Claims Reimbursement The CONTRACTOR notifies the DEPARTMENT twice monthly during the term of this AGREEMENT and informs the DEPARTMENT in writing by submission of an invoice showing the amount due from the DEPARTMENT to the CONTRACTOR. See , 1, . (1) Cycle I: Encompasses prescription claims processed day one (1) through day fifteen (15). CONTRACTOR will electronically send an invoice to DEPARTMENT two (2) DAYS after the end of the cycle. Cycle II: Encompasses prescription claims processed day sixteen (16) through the last day of the month. CONTRACTOR will electronically send an invoice to DEPARTMENT two (2) DAYS after the end of the cycle. Semi-Monthly Claims Invoicing Member Claims Reimbursement The CONTRACTOR notifies the DEPARTMENT monthly during the term of this AGREEMENT and informs the DEPARTMENT in writing by submission of an invoice showing the amount due from the DEPARTMENT to the CONTRACTOR. See , , . (2) Each cycle consists of one month, always ending on the last day of the month. The CONTRACTOR will electronically send an invoice to the DEPARTMENT two (2) DAYS after the end of the cycle Monthly
Statement of Standard for Attestation Engagements (SSAE) 16 Report The CONTRACTOR agrees to an audit conducted by an independent CPA firm at the CONTRACTOR’S expense that is in accordance with the SSAE 16 and provides a copy of the CPA’s report to the DEPARTMENT. Annually 310 Deliverables As required by the CONTRACT, the CONTRACTOR must provide deliverables specified in the sections below. 310A Deliverables to the Department Instructions on submitting the deliverable and specific due dates will be provided by the DEPARTMENT annually. Deliverable Description Frequency Implementation Plan The CONTRACTOR submits an updated implementation plan in a mutually agreed upon format and timeline to the DEPARTMENT Program Manager or designee. Within ten (10) BUSINESS DAYS of execution of this CONTRACT Emergency Contact Numbers The CONTRACTOR provides the DEPARTMENT with an emergency contact number for the Implementation Manager and Account Manager or backup in case issues arise that need to be resolved outside of the aforementioned business hours. Within ten (10) BUSINESS DAYS of execution of this CONTRACT Fraud and Abuse Review Plan The CONTRACTOR submits a fraud and abuse review plan to the DEPARTMENT. Within thirty (30) DAYS of execution of this CONTRACT Identification (ID) Card Issuance Delays The CONTRACTOR notifies the DEPARTMENT Program Manager of any delays with issuing the ID CARDS. Upon identification of issue ID CARD Confirmation The CONTRACTOR sends a written confirmation to the DEPARTMENT Program Manager indicating the date(s) the ID CARDS were issued. January Key Contacts Listing (ET-1728) The CONTRACTOR provides the DEPARTMENT with contact information for the key staff, which the DEPARTMENT will share with EMPLOYERS. April August PARTICIPATING PHARMACY Submission for Upcoming Benefit Period The CONTRACTOR provides an annual submission to the DEPARTMENT containing their network for the upcoming benefit period June
Medicare Enrollment Denial The CONTRACTOR notifies the DEPARTMENT in writing if Medicare does not allow an enrollment due to a PARTICIPANT’S residence in a given area. The notification must be provided within five (5) BUSINESS DAYS of the later of receipt of the DEPARTMENT’S enrollment file or notification by Medicare. See . See description Transition Plan The CONTRACTOR provides a comprehensive transition plan in a mutually agreed upon format that provides a timeline of major tasks, activities, and information that will be provided to the succeeding vendor when relinquishing responsibilities at termination of the CONTRACT. See . During the implementation period, upon DEPARTMENT request, and prior to CONTRACT termination 310B Deliverables to Participants Deliverable Description Frequency ID CARDS The CONTRACTOR provides PARTICIPANTS with ID CARDS indicating, at a minimum, the EFFECTIVE DATE of coverage, and the emergency room and office visit copayment amounts. Upon enrollment and BENEFIT changes that impact the information printed on the ID CARDS Participant Enrollment Information The CONTRACTOR provides the following information, at a minimum, to PARTICIPANTS upon enrollment: Information about PARTICIPANT requirements, including PRIOR AUTHORIZATIONS and referrals. The directory or directions on how to request a printed copy of the provider directory. Directions on how to access the directory on the CONTRACTOR’S website. The CONTRACTOR’S contact information, including the dedicated toll-free customer service phone number, business hours, twenty-four (24)-hour nurse line, and website address. Upon enrollment SUBSCRIBER Notification of Changes The CONTRACTOR issues written notice to PARTICIPANTS enrolled in its benefit plan(s) prior to the IT’S YOUR CHOICE OPEN ENROLLMENT period identifying those that will not be in-network for the upcoming benefit period and including any language directed by the DEPARTMENT summarizing any BENEFIT or other changes. September
PARTICIPANT Notification of Terminated Agreement At least thirty (30) DAYS prior to the termination of a agreement during the benefit period, the CONTRACTOR sends written notification, as approved by the DEPARTMENT, to all PARTICIPANTS who have had services from that in the past twelve (12) months that includes the following information: How to find a new IN-NETWORK , The continuity of care provision as it relates to this situation, and Contact information for questions. See description PARTICIPANT Notification of Grievance Rights The CONTRACTOR provides the PARTICIPANT with notice of their grievance rights and a period of one hundred eighty (180) calendar DAYS to file a grievance after written denial of a BENEFIT or other occurrence of the cause of the grievance along with the Uniform Benefit contractual provision(s) upon which the denial is based. See . See description PARTICIPANT Notification of DEPARTMENT Administrative Review Rights In the final grievance decision letters, the CONTRACTOR informs PARTICIPANTS of their right to request a DEPARTMENT review of the grievance committee’s final decision and their right to request an HHS-administered federal external review in accordance with federal law, using the language approved by the DEPARTMENT. See . See description 315 Performance Standards and Penalties Performance standards are specific to data from the HEALTH BENEFIT PROGRAM, not general data from the CONTRACTOR’S book-of-business. The CONTRACTOR must track performance using the template provided by the DEPARTMENT. The CONTRACTOR must submit reports and supporting documentation for validation as mutually agreed upon with the DEPARTMENT. The CONTRACTOR shall notify the DEPARTMENT upon realization that a standard will not be met, prior to the deadline. The penalties assessed shall not exceed twenty-five (25%) percent of the CONTRACTOR’S total administrative fee in any given quarter. After implementation, all performance standards will be measured by the DEPARTMENT on a QUARTERLY basis and assessed based on PARTICIPANT counts as of the first calendar DAY of the quarter, as determined by
Performance Standards Penalties Enrollment File: The CONTRACTOR must accept an enrollment file update on a daily basis and accurately process the enrollment file additions, changes, and deletions within two (2) BUSINESS DAYS of the file receipt. Delays in processing the 834 file must be communicated to the DEPARTMENT Program Manager or designee within one (1) BUSINESS DAY. See One thousand ($1,000) dollars per DAY for which the standard is not met Enrollment Discrepancies: The CONTRACTOR must resolve all enrollment discrepancies (any difference of values between the DEPARTMENT’S database and the CONTRACTOR’s database) as identified within one (1) BUSINESS DAY of notification by the DEPARTMENT or identification by the CONTRACTOR. See . ID CARDS: The CONTRACTOR shall issue ID CARDS within five (5) BUSINESS DAYS of the generation date of the enrollment file containing the addition or enrollment change, except as noted in item 4) below. See , 1. ID CARDS for elections made during the IT’S YOUR CHOICE OPEN ENROLLMENT Period: The CONTRACTOR shall issue ID CARDS by December 15 for enrollment additions or changes effective the following January 1 calendar year, as submitted on enrollment files generated on the first DAY of the IT’S YOUR CHOICE OPEN ENROLLMENT period through December 10. See , 2. One thousand ($1,000) dollars per DAY for which the standard is not met 315G Other The total penalties for this performance category shall not exceed three (3%) percent of the total administrative fee for the quarter. Performance Standards Penalties Audit: The CONTRACTOR shall address any areas of improvement as identified in the audit in the timeframe as determined by the DEPARTMENT One thousand ($1,000) dollars per DAY for which the standard is not met Grievance Resolution: Investigation and resolution of any grievance will be initiated within five (5) BUSINESS DAYS of the date the grievance is filed by the complainant for a timely resolution of the problem. Grievances related to an urgent health concern will be handled within seventy-two (72) hours of the CONTRACTOR'S receipt of the grievance. Major System Changes and Conversions: The CONTRACTOR shall verify and commit that during the length of the contract, it shall not undertake a major system change or conversion for, or related to, the system used to deliver services for the HEALTH BENEFIT One thousand ($1,000) dollars per DAY for which the standard is not met
After DEDUCTIBLE, subject to copays below, to OOPL. See Note, below, for exceptions on preventive prescription drugs. Under no circumstances will YOU pay beyond the federal Maximum Out-of-Pocket (MOOP) limit which is $6,850 single / $13,700 family for federally required essential health benefits. 1 Level 3 prescription drug COINSURANCE will continue to be paid by YOU past the OOPL, to the federal MOOP, see more information below. 2Federally required preventive services are covered at 100%. 3 State of Wisconsin MEDICARE eligible annuitants and their MEDICARE eligible dependents are limited to participation under the MEDICARE Prime Uniform Benefits SCHEDULE OF BENEFITS. Benefit: Participating Wisconsin Public Employer’s (WPE) WPE eligible PARTICIPANTS in (Program Option PO 2 and MEDICARE eligible and enrolled in PO 6 and PO 7) WPE eligible PARTICIPANTS in PO 6 who are not eligible for nor enrolled in MEDICARE as the primary payor3 WPE eligible PARTICIPANTS in PO 4 including MEDICARE eligible and enrolled High DEDUCTIBLE Health Plan WPE eligible (PO 7) PARTICIPANTS 3 Annual Medical DEDUCTIBLE applies to (OOPL). None $250 Individual/$500 Family When an individual within a family plan meets the $250 DEDUCTIBLE, COINSURANCE will apply to covered medical services. Medical DEDUCTIBLE does not apply to office visit COPAYMENTS or prescription drugs. $500 Individual/ $1,000 Family When an individual within a family plan meets the $500 DEDUCTIBLE, COINSURANCE will apply to covered medical services. Medical DEDUCTIBLE does not apply to prescription drugs. The DEDUCTIBLE must be met before coverage begins. The DEDUCTIBLES are: $1,500 per individual plan $3,000 per family plan. DEDUCTIBLE includes prescription drugs.
Annual Medical COINSURANCE 100% except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to (OOPL). After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to (OOPL) except as described below. 100% except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. After DEDUCTIBLE: 90%/10% applies to medical services except for office visits, and as described below. COINSURANCE applies to (OOPL) except as described below. Benefit: Participating Wisconsin Public Employer’s (WPE) WPE eligible PARTICIPANTS in (Program Option PO 2 and MEDICARE eligible and enrolled in PO 6 and PO 7) WPE eligible PARTICIPANTS in PO 6 who are not eligible for nor enrolled in MEDICARE as the primary payor3 WPE eligible PARTICIPANTS in PO 4 including MEDICARE eligible and enrolled High DEDUCTIBLE Health Plan WPE eligible (PO 7) PARTICIPANTS 3 Annual Medical OOPL (OOPL) None except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 $1,250 aggregate family limit except as described below.1 After $500 per individual $1,000 aggregate per family DEDUCTIBLE, none except as described below for: DURABLE MEDICAL EQUIPMENT, cochlear implants and hearing aids. Then, 80% to OOPL. 1 After DEDUCTIBLE: $2,500 per individual plan $5,000 per family plan except as described below. Routine, preventive services as required by federal law 100% 100% 100% 100% Primary Care Office Visit COPAYMENT applies to: No medical COPAYMENTs $15, DEDUCTIBLE need not be met first No medical COPAYMENTs After DEDUCTIBLE: $15
Family Practice General Practice Internal Medicine Midwives Nurse Practitioners Physician Assistants Chiropractic Mental Health Physical Therapy Occupational Therapy Speech Therapy COPAYMENT applies towards meeting the annual OOPL, but not the DEDUCTIBLE Primary Care Office Visit COPAYMENT applies towards meeting the annual OOPL Benefit: Participating Wisconsin Public Employer’s (WPE) WPE eligible PARTICIPANTS in (Program Option PO 2 and MEDICARE eligible and enrolled in PO 6 and PO 7) WPE eligible PARTICIPANTS in PO 6 who are not eligible for nor enrolled in MEDICARE as the primary payor3 WPE eligible PARTICIPANTS in PO 4 including MEDICARE eligible and enrolled High DEDUCTIBLE Health Plan WPE eligible (PO 7) PARTICIPANTS 3 Specialist COPAYMENT Applies to: Specialists URGENT CARE No medical COPAYMENTs $25 per visit, DEDUCTIBLE need not be met first COPAYMENTS count towards meeting the OOPL, but not the DEDUCTIBLE No medical COPAYMENTs After DEDUCTIBLE: $25 per visit COPAYMENT applies towards meeting the annual OOPL ILLNESS/INJURY related services beyond the office visit COPAYMENT (if applicable) 100% After DEDUCTIBLE: 90% (10% member cost to OOPL) 100% After DEDUCTIBLE: 90% (10% member cost to OOPL) EMERGENCY Room Copay (Waived if admitted as an inpatient directly from the EMERGENCY room or for $60 $75 COPAYMENT to OOPL. After COPAYMENT, DEDUCTIBLE and (10% member cost to OOPL) $60 After DEDUCTIBLE, $75 to OOPL. After DEDUCTIBLE and copay 90% (10% member cost to OOPL)