Orange County NC Website
Browse       Search
DocuSign Envelope ID:E8C538EF-9595-4E36-A4C9-2CA66C7BE34A <br /> COVERAGE DETERMINATION AND APPEALS PROCESS ADDENDUM <br /> This Coverage Determination and Appeals Process Addendum (hereinafter "Addendum") is <br /> entered into by and between Envision Pharmaceutical Services, LLC (hereinafter "Envision") <br /> and (hereinafter "Plan Sponsor") as follows. This Addendum is effective <br /> (hereinafter the "Effective Date"). <br /> BACKGROUND <br /> Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement <br /> dated (hereinafter "Agreement") under which Envision provides PBM Services to <br /> Plan Sponsor. Plan Sponsor wishes for Envision to provide additional services under the <br /> Agreement as set forth below. <br /> NOW THEREFORE,Envision and Plan Sponsor agree as follows: <br /> 1. Initial Coverage Determinations and Appeals: Envision shall administer a Coverage <br /> Determination and Appeals Process under Plan Sponsor's direction as described in Exhibit 1-A. <br /> The Coverage Determination and Appeals Process will include: (i) Real-time adjudication to <br /> determine coverage/non-coverage status of a Claim; (ii) Initial Determinations '(including <br /> Clinical Prior Authorizations); and (iii) Redeterminations ("Internal Appeals"). The Coverage <br /> Determination and Appeals Process will meet the requirements of the Department of Labor's <br /> Internal Claims and Appeals and External Review Processes under 29 CFR §2590.715-2719. <br /> 2. Compensation: Plan Sponsor shall pay Envision the following fees: <br /> Provided Internally by Envision <br /> Coverage Determinations (including Clinical Prior $35.00 per request <br /> Authorizations) <br /> Redeterminations (Internal Appeals) $125 per request <br /> Postage <br /> 100%pass-through of all postage <br /> 3. All other terms and conditions of the Agreement not modified by this Addendum or any <br /> prior amendment or addenda shall remain unchanged. <br /> [SIGNATURE PAGE FOLLOWS] <br /> Wass-through PBMSA(041917) ©Envision Pharmaceutical Services,LLC Page 37 of 41 <br />