Louisiana Department of Health Proposal for Integrated Pharmacy

Louisiana Medicaid Page 1

Louisiana Department of

Health

“The data contained in pages 16, 17, 18, 19, 30, 31, 38, 96, 113, 141, 142, and 143 of the

proposal have been submitted in confidence and contain trade secrets and/or privileged or

confidential information and such data shall only be disclosed for evaluation purposes, provided

that if a contract is awarded to this Proposer as a result of or in connection with the submission

of this proposal, the State of Louisiana shall have the right to use or disclose the data therein to

the extent provided in the contract. This restriction does not limit the State of Louisiana’s right

to use or disclose data obtained from any source, including the Proposer, without restrictions.”

Presented for your consideration by:

One CVS Drive

Woonsocket, Rhode Island 02895

Caremark.com

Proposal for

Integrated Pharmacy

Benefit Management

Services

Louisiana Medicaid Page 2

LOUISIANA MEDICAID

MARCH 2022

Section I Cover Letter

Section II Executive Summary

Section III Technical Proposal

Section IV Cost Proposal

Section V CVS Health Exhibits

Tab 1 CVS Health 2019 10-K

Tab 2 CVS Health 2020 10-K

Tab 3 Sample Implementation Timeline

Tab 4 CVS Health’s Business Continuity Plan

Tab 5 CVS Health’s List of Diverse Suppliers

Tab 6 Certification Statement

Tab 7 Officer’s Certificate of Authority

Tab 8 Certificate of Good Standing

Tab 9 Louisiana Secretary of State Certificate of Authority

Tab 10 Pricing Commitment Document

Tab 11 Limited Distribution Drugs With Access

Tab 12 Limited Distribution Drugs Without Access

Louisiana Medicaid Page 3

Germaine Becks-Moody March 30, 2022

Louisiana Department of Health

Medical Vendor Administration

P.O. Box 91030 Bin # 24

Baton Rouge, LA 70821-9030

Dear Germaine,

On behalf of CVS Health, I am pleased to present this proposal for pharmacy benefit management (PBM)

services to Louisiana Medicaid. Following your requested format, our proposal details the unique and

comprehensive services CVS Health can offer to help you achieve your goals.

This includes:

• A pharmacy benefits management (PBM) experience aligned to your commitments

• Smarter ways to control your costs

• Reduced spend and improved care for members with high-cost conditions

• Value beyond a traditional pharmacy benefits manager.

We look forward to the opportunity to discussing how we can be the best choice for the single Pharmacy Benefit

Manager for Louisiana’s Managed Care Organizations and their enrollees. If you have any questions or need

further information, please contact me at Michael.Jaeger@CVSHealth.com or call me at 469-524-7211. Thank

you for your consideration. We would be extremely pleased to enter into an agreement to provide pharmacy

benefit services to the five Managed Care Organizations in Louisiana.

Best regards,

Michael Jaeger

Director, Strategic Sales, CVS Health

Louisiana Medicaid Page 4

∙ Summary information about the Proposer's organization.

CVS Health provides a best-in-class Medicaid pharmacy benefit manager. We currently support 27 managed

Medicaid health plans, of which three are currently in Louisiana, with 135 unique lines of business,

representing more than 27 million enrollees, of which nearly one million are in Louisiana, across 37 states.

These plans cover children, nondisabled adults, pregnant women, individuals with disabilities, and seniors

eligible for both Medicaid and Medicare benefits.

DIFFERENTIATORS

Improved clinical and cost outcomes are achieved through our sophisticated programs. Our Medicaid-specific

clinical programs are geared toward reducing fraud, waste, and abuse; improving quality; managing costs;

and improving outcomes. When state-mandated formularies or preferred drug lists are required, we work with

our clients to ensure compliance. We have robust specialty programs, and our member engagement outreach

efforts are designed to provide high-quality clinical care. Further, we ensure members have access to the

most cost-effective and clinically appropriate medication through retail, specialty, and mail channels.

Our knowledge and expertise in managed Medicaid allow us to improve the per member per month (PMPM)

performance and operational efficiency of our managed Medicaid clients. We know plans are most successful

managing costs and meeting requirements when they have access to Medicaid experts who are dedicated to

helping them reach their goals. The clinical, account, and analytics experts in our managed Medicaid segment

provide detailed, consultative support to help our clients manage the complexities of their business.

• Encounter processing: We currently support Medicaid encounter submissions in 30 states. We maintain a

proprietary encounter processing system (EMS) that interfaces with our claims adjudication engine to extract

all adjudicated claims nightly. EMS prepares NCPDP encounter file transactions for submission to states in

the required formats.

• Formulary management: From closed formularies to therapeutic interchange programs, we have the

management expertise to develop the most appropriate level of formulary management. We developed a

Medicaid-specific formulary template to provide appropriate clinical and cost-effective formulary management

for managed Medicaid coverage providers.

• Fraud, waste, and abuse: We use comprehensive tools proven to solve fraud and abuse to effectively

control costs in relevant areas of a Medicaid environment.

• HEDIS scores: Through our comprehensive clinical solutions, we proactively engage members and their

prescribers with evidence-based clinical health improvement opportunities that support your efforts to meet or

exceed various HEDIS measures.

• NCQA accreditation: We support NCQA member connection standard MEM-4 by providing members the

information they need to understand and use their pharmacy benefits. This information is provided through

our website, Caremark.com, and over the phone.

• Network management: We offer multiple retail network options—including national, limited, and custom—to

provide optimal geographic coverage while allowing clients to manage their retail pharmacy spending. We will

develop a network with you that meets geo access requirements. We have successfully implemented

preferred network strategies in multiple states for our managed Medicaid clients.

Louisiana Medicaid Page 5

• PMPM performance: Our dedicated account teams provide ongoing analysis and consultation for a variety of

issues, including management of PMPM performance to meet client goals during challenging budgetary

times. We designed our PMPM trend forecasting tool specifically for health plan support, given the need to

evaluate opportunities at the therapeutic class level.

• Specialty medication management: Our specialty management capabilities address drug spending under

the pharmacy and medical benefits. We are the only specialty pharmacy that integrates rare disease

management—which is critical to controlling overall costs related to this small but high-cost population.

• State requirements: We maintain a dedicated Medicaid regulatory compliance support team that meets with

client staff to discuss the regulations and Medicaid requirements in a state with regard to PBM operations.

They review new requirements to advise clients on the impact of our operations and proactively identify new

and proposed requirements and communicate them to clients.

• Utilization management: We create Medicaid-specific criteria for prior authorization, step therapy, and

quantity limit programs to control high utilization, abuse, and access to high-cost drugs. We also provide

exception processing and member-level overrides, upon request.

∙ Location of Central Administrative Office with Full Time Personnel, including the address for all

office locations with full time personnel.

The following is a list of offices, locations, and primary functions of CVS Health and our prescription benefit

management affiliates:

Office

Function

Addresses

CVS Health

CVS Health Headquarters

One CVS Drive

Woonsocket, Rhode Island 02895

CVS Health

PBM Operations Centers

9501 E. Shea Boulevard

Scottsdale, Arizona 85260

750 West John Carpenter Freeway

Suite 1200

Irving, Texas 75039

CVS Caremark Medicare Part D

Medicare Part D Operations

Centers

9501 E. Shea Boulevard

Scottsdale, Arizona 85260

CVS Health

Data Services

Scottsdale Data Center

9501 E. Shea Boulevard.

Scottsdale, Arizona 85260

Back-up Site

One CVS Drive

Woonsocket, Rhode Island 02895

CVS Health Customer Care

Customer Care Facilities

800 NW Chipman Road, Suite 5830

Lee’s Summit, Missouri 64063

Louisiana Medicaid Page 6

6950 Alamo Downs Parkway

San Antonio, Texas 78238

2401 Cherahala Boulevard

Knoxville, Tennessee 37932

600 Penn Center Boulevard

Pittsburgh, Pennsylvania 15235

2700 W. Frye Road

Chandler, Arizona 85224

29300 Aurora Road

Solon, OH 44139

1451 Center Crossing Road

Las Vegas, NV 89144

CVS Health Mail Service

Program

Mail Service Pharmacies

Regional Order Creation Centers

(ROCCs)

620 Epsilon Drive

Pittsburg, Pennsylvania 15238-2808

1400 Business Center Drive

Mt. Prospect, Illinois 60056 - 6071

6935 Alamo Downs Parkway

San Antonio, Texas 78238 - 4501

Prescription Processing (Frontend)

Centers

Number 1 Great Valley Boulevard

Wilkes-Barre, Pennsylvania 18702

620 Epsilon Drive

Pittsburgh, PA 15238

7034 Alamo Downs Parkway

San Antonio, TX 78238

4121 E. Cotton Center Boulevard

Phoenix, AZ 85040

800 Biermann Court

Mount Prospect, IL 60056

10302 West Emerald Street

Boise, ID 83704

Dispensing Pharmacies

1780 Wall Street

Mount Prospect, Illinois 60056

Louisiana Medicaid Page 7

Number 1 Great Valley Boulevard

Wilkes-Barre, Pennsylvania 18702

Consumer Health Interactive

Consumer Website Developer

539 Bryant Street, Suite 200

San Francisco, California 94107

CVS Health specialty

Specialty Pharmacies

2700 West Frye Road

Chandler, Arizona 85224

9310 Southpark Center Loop

Orlando, Florida 32819

CVS Health Specialty Pharmacy

CareTeam - Accordant

4900 Koger Boulevard, Suite 100

Greensboro, North Carolina 27407-2710

CVS Health

Government Affairs

1300 I Street NW, Suite 525 West

Washington, District of Columbia 20005

∙ Name and address of principal officer.

CAREMARKPCS, L.L.C.

Following is the list of principal officers of CaremarkPCS, L.L.C.:

• John M. Conroy (President and Treasurer)

• Thomas S. Mofatt (Vice President and Secretary)

• Cheryl Baliey (Vice President)

• Melanie K. St Angelo (Assistant Secretary).

Note: Because it is a limited liability company, CaremarkPCS, L.L.C. does not have directors. The L.L.C. is managed by its sole member,

Caremark Rx, L.L.C.

∙ Name and address for purpose of issuing checks and/or drafts.

CVS Caremark

PO Box 848001

Dallas, TX 75284-8001

∙ For corporations, a statement listing name(s) and address(es) of principal owners who hold five

percent (5%) interest or more in the corporation.

The shareholder(s) that own 5% or more of the common stock of CVS Health Corporation include:

• The Vanguard Group, Inc. (8.1%)

Louisiana Medicaid Page 8

∙ If out-of-State Proposer, give name and address of local representative; if none, so state.

CT Corporation System

3867 Plaza Tower Dr.

Baton Rouge, LA, 70816-4378

∙ If the Proposer was engaged by LDH within the past twenty-four (24) months, indicate the

contract number and/or any other information available to identify the engagement; (if none, so

state).

Not Applicable.

∙ Proposer's state and Federal tax identification numbers.

Business Entity

Federal Tax ID #

CaremarkPCS Health, L.L.C.

75-2882129

Louisiana Medicaid Page 9

The cover letter should include a positive statement of compliance with the contract terms

defined herein. If the Proposer cannot comply with any of the contract terms, an explanation of

each exception should be supplied. The Proposer should indicate the specific section and

language in the RFP and submit exceptions or exact contract modifications that it may seek.

CVS Health confirms we can comply with the contract terms defined within the RFP unless otherwise stated

below:

Section

Language

Exception

Addendum 5 –

Section 5

Addendum 5 –

Section 12

Section 1.38

Record

Ownership

5. Record Ownership: All records, reports, documents, and

other material delivered or transmitted to Contractor by the

Department shall remain the property of the Department,

and shall be returned by Contractor to the Department, at

Contractor's expense, at termination or expiration of this

contract. All records, reports, documents, or other material

related to this Contract and/or obtained or prepared by

Contractor in connection with the performance of the

services contracted for herein shall become the property of

the Department, and shall, upon request, be returned by

Contractor to the Department, at Contractor's expense, at

termination or expiration of this contract.

12. Ownership of Proprietary Data: All non-third party

software and source code, records, reports, documents,

and other material delivered or transmitted to Contractor by

the State shall remain the property of the State, and shall

be returned by Contractor to the State, at Contractor's

expense, at termination or expiration of this contract. All

non-third party software and source code, records, reports,

documents, or other material related to this Contract and/or

obtained or prepared by Contractor in connection with the

performance of the services contracted for herein shall

become the property of the State, and shall be returned by

Contractor to the State, at Contractor's expense, at

termination or expiration of this contract.

1.38 Record Ownership

All records, reports, documents, or other material related to

any contract resulting from this RFP and/or obtained or

prepared by the Contractor in connection with the

performance of the services contracted for herein shall

become the property of the Department and shall, upon

request, be returned by the Contractor to the Department,

at the Contractor’s expense, at termination or expiration of

the contract.

CVS Health confirms with the exception of

any Contractor confidential information that

may be contained within them.

Addendum 5 –

Section 13

Section 1.22

Use of

Subcontractors

13. Subcontracting: Contractor shall not enter into any

subcontract for work or services contemplated under this

Contract without obtaining prior written approval of the

Department. Any subcontracts approved by the

Department shall be subject to conditions and provisions as

the Department may deem necessary; provided, however,

that notwithstanding the foregoing, unless otherwise

CVS Health confirms with the exception

that if LDH requires written approval of

subcontractors, there could be a cost

associated with holding permission.

Louisiana Medicaid Page 10

provided in this contract, such prior written approval shall

not be required for the purchase by Contractor of items and

services that are incidental but necessary for the

performance of the work required under this contract.

1.22 Use of Subcontractors

Unless provided for in the Contract, the prime Contractor

shall not contract with any other party for any of the

services herein contracted without the express prior written

approval of the State.

Addendum 5 –

Section 21

Section 1.32

Liability and

Indemnification

21. Indemnity: Contractor agrees to protect, indemnify, and

hold harmless the State of Louisiana and the Department

from all claims for damages, costs, expenses, and attorney

fees arising in Contract or tort from this Contract or from

any acts or omissions of Contractor's agents,

subcontractors, employees, officers, or clients, including,

but not limited to, premises liability and any claim based on

any theory of strict liability. This provision does not apply to

actions or omissions for which La. R.S. 40:1237.1, et seq.

provides malpractice coverage to Contractor, nor claims

related to treatment and performance of evaluations of

persons when such persons cause harm to third parties

(La. R.S. 13:5108.1(E)). Further, it does not apply to

premises liability when the services are being performed on

premises owned and operated by the Department.

We agree to indemnify and defend LDH

from any and all claims or losses that you

incur to the extent the claims or losses are

due to CVS Health negligence or breach of

our obligations or warranties as described

in the Prescription Benefit Management

Agreement. Our obligation to indemnify

you will be limited to the extent any claim or

loss is due to your negligence or actions.

We expect LDH to indemnify CVS Health

based on similar terms and will provide

contract language to reflect this

commitment.

Addendum 5 –

Section 42

42. Contractor must comply with the Office of Technology

Services (OTS) Information Security Policy,

https://www.doa.la.gov/Pages/ots/InformationSecurity.aspx.

b. Contractor must follow OTS Information Security Policy

for Data Sanitization requirements for any equipment

replaced during the Contract and at the end of the contract,

for all equipment which house confidential/restricted data

provided by the State.

d. If Contractor will have access to data originating from the

Centers for Medicare and Medicaid Services (CMS), then

Contractor must ensure their computer system is in

compliance with CMS latest version of the Minimum

Acceptable Risk Standards for Exchanges (MARS-E)

Document Suite, currently MARS-E 2.0. The CMS MARS-E

2.0 requirements include but are not limited to the below

listed requirements:

- Multi-factor authentication is a CMS requirement

for all remote users, privileged accounts and non-

privileged accounts. In this context, a “remote

user” is referencing staff accessing the network

from offsite, normally with a client virtual private

network with the ability to access CMS data.

- Perform criminal history check for all staff prior to

granting access to CMS data. All employees and

contractors requiring access to Patient Protection

CVS complies with its own Information

Security Policies and Control Standards

which are aligned with NIST, HIPAA, PCI-

DSS and CIS Benchmarks and comply with

legal and regulatory requirements.

CVS Complies with our own data

sanitization requirements which are

compliant with NIST-800-88.

We comply with the MFA requirement for

all remote users and privileged accounts.

We do not require Multi-factor

authentication for non-privileged accounts

that are not remote users.

We do not conduct reference checks as

part of our background checks. However,

we do conduct a criminal check.

Louisiana Medicaid Page 11

and Affordable Care Act (PL 111-148) sensitive

information must meet personnel suitability

standards. These suitability standards are based

on a valid need-to-know, which cannot be

assumed from position or title, and favorable

results from a background check. The background

checks for prospective and existing employees (if

not previously completed) should include, at a

minimum, contacting references provided by the

employee as well as the local law enforcement

agency or agencies.

1.8.10

Proposed Staff

Qualifications

Include full resumes of all proposed key personnel

identified for key roles. Each person identified for a role

above should be included in the resume section. Each

resume should demonstrate the qualifications and

experience relevant to the position proposed. Each resume

should include work history, the specific functions

performed, and how the experience relates to the assigned

role. Résumés of all known personnel working or

overseeing the LDH Pharmacy Program should be

included. Résumés of proposed personnel should include,

but not be limited to:

• Experience with Proposer.

• Previous experience in projects of similar scope

and size.

• Educational background, certifications, licenses,

special skills, etc.

Provide three (3) references for each proposed Key

Personnel candidate demonstrating experience in a similar

role on one or more projects similar to Section 2. Scope of

Work requirements. Each reference should include:

• Name of the person to be contacted.

• Contact phone number.

• Client name and address.

• Brief description of work.

• Dates (month and year) of employment.

These references should be able to attest to the

candidate’s specific qualifications.

CVS Health agrees in concept with the

staffing requirements as noted in the RFP.

At present we are not including names and

resumes. Given the highly competitive

nature of this procurement and the

Louisiana state-based requirement, the

hiring pool may be greatly reduced. Once

the award is announced bidders will have

an opportunity to assemble a team with the

best talent. As we work closely with the

state during subsequent stages of the

project and begin to better understand in

full scope the needed resources to fully

align objectives we will add individuals with

mutually agreeable backgrounds and

experience to ensure the business

outcomes are delivered.

1.30.1

Contractor’s

Insurance

If so requested, the Contractor shall also submit copies of

insurance policies for inspection and approval of the

Department before work is commenced.

CVS Health confirm with the exception that

policies are deemed to be proprietary and

therefore complete copies are not shared

externally.

1.30.2.2

Commercial

General

Liability

The Contractor shall maintain during the life of the contract

such Commercial General Liability Insurance which shall

protect Contractor, the Department, and any Subcontractor

during the performance of work covered by the contract

from claims or damages for personal injury, including

accidental death, as well as for claims for property

damages, which may arise from operations under the

CVS Health confirms with the exception

that subcontractors are not coved by our

CGL policy. We maintain Commercial

General Liability insurance with policy limits

of $4,500,000 per occurrence, $28,000,000

general aggregate. This policy is in excess

of a $500,000 self-insured retention. The

Louisiana Medicaid Page 12

contract, whether such operations be by the Contractor or

by a Subcontractor, or by anyone directly or indirectly

employed by either of them, or in such a manner as to

impose liability to the Department.

insurance carrier is ACE American

Insurance Company with policy effective

dates of January 1, 2022 through January

1, 2023. We maintain an Umbrella Liability

policy which provides coverage in excess

of $50,000,000. Subcontractors are not

covered by our Commercial General

Liability policy.

1.30.4.3 All

Coverage

All policies must be endorsed to require thirty (30) Calendar

Days written notice of cancellation to the Agency.

CVS Health confirms with the

understanding that our policies provide

notice to the named insured only. Our

insurance carriers are unable to endorse

each customer.

1.30.6

Verification of

Coverage

In addition to the Certificates, Contractor shall submit the

declarations page and the cancellation provision for each

insurance policy. The Agency reserves the right to request

complete certified copies of all required insurance policies

at any time.

CVS Health confirms with the exception

that policies are deemed to be proprietary

and therefore complete copies are not

shared externally.

2.1.8.1General

Requirements

The Contractor shall:

• Capture recoveries from other state or Federal

entities or third-party payers.

CVS Health does not confirm. We do not

provide any recoveries from State, federal,

or third-party payers.

Please refer to Section 1.86 of the

Technical Proposal for details on our

TPL/Subrogation capabilities.

2.1.9.1

General Drug

Claim

Adjudication

System

Requirements.

The Contractor’s Drug Claim Adjudication system shall:

• Comply with the latest version of the W3C Mobile Web

Application Best Practices for browser-based

components.

• Comply with the current Authoring Tool Accessibility

Guidelines (ATAG) as published by the Worldwide

Web Consortium (W3C).

CVS Health strives to comply with the

latest version of WCAG (2.1 currently) and

A/AA conformance levels. To that end, we

have an enterprise-wide policy which

establishes our organizational

standards and expectations for digital

accessibility. In addition, CVS Health has a

digital accessibility team dedicated to

empowering product teams to build

accessible products and support assets

that may require a remediation roadmap.

2.1.9.2

General Drug

Claim

Processing

Requirements.

• Process and reimburse Drug Claims without

inappropriate denials, delays, or recoupments.

• If the Contractor has a pattern, as determined by

the MCO, of inappropriately denying, delaying or

recouping Provider payments for services, the

Contractor may be subject to Monetary Penalties

equal to one and one-half (1.5) times the value of

the Drug Claims inappropriately denied, delayed,

or recouped, contract cancellation, or refusal to

contract in a future time period.

CVS Health confirms with the exceptions

that the criteria inappropriately deny,

delaying or recouping provider payments

shall be mutually determined prior to the

contract effective date.

Louisiana Medicaid Page 13

• If the Contractor has a pattern, as determined by

the MCO, of inappropriately denying, delaying, or

recouping Provider payments for services after

the termination of the Contract, the Contractor

may be subject Monetary Penalties equal to one

and one-half (1.5) times the value of the Drug

Claims inappropriately denied, delayed, or

recouped.

2.1.9.3

Drug Claims

Systems

Requirements

• Correct each deficiency by an effective date to be

determined by LDH.

CVS Health confirms with the exception

that deficiencies will be corrected by an

agreed upon date.

2.1.9.4

Information

Systems

Availability

• Notify designated LDH staff via phone and

electronic mail within fifteen (15) minutes of

discovery of a problem that results in delays in

report distribution or problems in online access to

critical systems functions and information, in order

for the applicable work activities to be rescheduled

or handled based on system unavailability

protocol.

CVS Health does not confirm. We can

notify LDH staff with 24 hours of discovery

of a problem.

2.1.9.4

Information

Systems

Availability

• Resolve and implement system restoration within

sixty (60) minutes of official declaration of

unscheduled system unavailability of critical

functions caused by the failure of system and

telecommunications technologies within the

Contractor’s span of control. Unscheduled system

unavailability to all other system functions caused

by system and telecommunications technologies

within the Contractor’s span of control shall be

resolved, and the restoration of services

implemented, within eight (8) hours of the official

declaration of system unavailability.

CVS Health does not confirm. Our standard

target restoration time for Priority 1 Events

is 3 hours.

2.1.9.13

Utilization

Management

• Provide the capability to produce an extract file of

procedure code drug pricing to be shared and

utilized by other stakeholders processing Drug

Claims for Provider administered pharmaceuticals

upon implementation by LDH.

CVS Health does not adjudicate claims

based on procedure codes. However, we

will share the pricing details of all claims

processed.

2.1.9.17 Third

Party Liability

• Verify and update its system within four (4) Business

Hours of receipt of an update request, if an Enrollee is

unable to access PBM Covered Services until the

update is made. This includes updates on coverage,

including removal of coverage that existed prior to the

Enrollee’s linkage to the MCO that impacts

Adjudication or Enrollee access to PBM Covered

Services.

CVS Health does not confirm. We will verify

and update the systems in a mutually

agreed upon timeframe.

2.1.9.17.2

Post-Payment

Recoveries

If TPL is identified after a Drug Claim has been

Adjudicated, the Contractor shall:

CVS Health does not confirm. Please refer

to Section 1.86 for our TPL/Subrogation

capabilities.

Louisiana Medicaid Page 14

2.1.9.17.3 LDH

Right to

Conduct

Identification

and Pursuit of

TPL

• Initiate recovery of reimbursement within sixty (60)

Calendar Days after the end of the calendar month in

which the TPL is identified.

• Not perform post-payment recovery for TPL from

Providers for Drug Claims with dates of service (DOS)

older than ten (10) months, except when the liable

third party is traditional Medicare, Tricare, or

CHAMPUS.

• Recover from the Provider if the liable third party is

traditional Medicare, Tricare or CHAMPUS, and more

than ten (10) months have passed since the DOS.

• Allow Providers sixty (60) Calendar Days from the

date stamp of the recovery letter to refute the recovery

with a one-time thirty (30) Calendar Day extension at

the Provider’s request.

• Refer pay and chase Drug Claims directly to the liable

third parties.

• Refer Point of Sale (POS) Drug Claims directly to the

carrier.

• Initiate an automatic recoupment at the expiration of

the sixty (60) Calendar Day time period if an extension

request is not received from the Network Provider and

at the expiration of the ninety (90) Calendar Day time

period if an extension is requested by the Network

Provider if the Network Provider has not remitted the

payment to the Contractor.

• Identify and track potential TPL recoveries. The

system shall produce reports indicating open

receivables, closed receivables, amounts collected,

amounts written off, and amounts avoided. These

reports shall be made available to LDH upon request.

• Identify the existence of potential TPL to pay for PBM

Covered Services through the use of trauma code

edits in accordance with 42 CFR §433.138(e).

• Seek reimbursement in accident/trauma related cases

when Drug Claims in the aggregate equal or exceed

five hundred dollars ($500.00) as required by the State

Plan and Federal Medicaid guidelines and may seek

reimbursement when Drug Claims in the aggregate

are less than five hundred dollars ($500.00). Failure to

seek reimbursement may result in Monetary Penalties

as specified in Attachment G, Table of Monetary

Penalties.

• Notify LDH when subpoenas duces tecum are

received and report the resulting recoveries to LDH.

• The amount of any recoveries collected by the

Contractor outside of the Drug Claims processing

system shall be treated by the Contractor as offsets to

medical expenses for the purposes of reporting.

• Obtain written approval from LDH prior to accepting a

TPL settlement on accident/trauma-related Drug

Claims equal to or greater than twenty-five thousand

dollars ($25,000.00).

• Upon receipt of a subpoena duces tecum, the

Contractor shall produce documents responsive to

said subpoena by the date of return indicated therein

(or shall contact the party who caused issuance of the

subpoena, in order to request additional time to

Louisiana Medicaid Page 15

respond) if the production is authorized under La. R.S.

13:3715.1. Upon receipt of a request for records not

sent via subpoena, the Contractor shall release PHI or

a response explaining why PHI cannot be released to

the individual or entity making the request, within

fifteen (15) Calendar Days of receipt of the request

and a written authorization, as set forth in La. R.S.

40:1165.1(A)(2)(c). The Contractor is solely

responsible for any sanctions and costs imposed by a

court of competent jurisdiction for failure to comply

with the requirements of La. R.S. 40:1165.1(A)(2)(c) or

for failure to respond Timely to a subpoena duces

tecum. Additionally, LDH may impose sanctions

against the Contractor for failure to properly or Timely

respond to requests for PHI.

• All records requests received by the Contractor shall

be investigated by the Contractor (or its vendor) for

possible TPL recoveries, resulting in issuance of a lien

statement (or notice of lack thereof) to the requesting

party, as provided for in La. R.S. 46:446.

• When the Contractor has actual knowledge that an

insurer or other risk bearing entity of an Enrollee has

filed for bankruptcy and the Network Provider files a

Drug Claim for reimbursement with the Contractor with

dates of service prior to the date the insurer or other

risk bearing entity filed bankruptcy, the Contractor

shall reimburse the Network Provider with the

Louisiana Medicaid Program as the primary insurer

only if the Enrollee was enrolled with the Contractor at

the time the service was provided and the Network

Provider has not been paid. The Contractor shall seek

reimbursement as a creditor in the bankruptcy

proceeding or from a liable third party. If the Network

Provider files a Drug Claim for reimbursement with the

Contractor with dates of service after the date the

insurer or other risk bearing entity filed for Chapter 11

bankruptcy, the insurer or other risk bearing entity

shall continue to be the primary insurer. If the Network

Provider files a Drug Claim for reimbursement with the

Contractor with dates of service after the date the

insurer or other risk bearing entity filed for Chapter 7

bankruptcy, the Louisiana Medicaid Program shall be

the primary insurer.

• Transfer one hundred percent (100%) of its TPL

recoveries to the appropriate MCO.

• Void encounters for Drug Claims for which the full

Louisiana Medicaid Program paid amount is being

recouped. For recoupments for which the full

Louisiana Medicaid Program paid amount is not being

recouped, the Contractor shall submit adjusted

encounters for the Drug Claims.

• Provide TPL information to the MCO in a format and

medium described in the MCO Manual and shall

cooperate in any manner necessary, as requested by

the MCO, with the MCO and/or its designee.

LDH Right to Conduct Identification and Pursuit of TPL

Louisiana Medicaid Page 16

LDH may invoke the Contractor’s right to pursue TPL

recoveries if the Contractor fails to recover reimbursement

from the liable third party to the limit of legal liability within

three hundred sixty-five (365) Calendar Days from date(s)

of service of the Drug Claim(s).

If the MCO determines that the Contractor is not actively

engaged in cost avoidance activities, the Contractor may

be subject to Monetary Penalties as set forth in Attachment

V, Table of Monetary Penalties.

2.1.14.1

Customer

Service Center

(CSC)

• Locate its primary CSC site in the State.

CVS Health confirms with the exception

that our customer care representatives will

be located in Louisiana but will work

virtually to support LDH. There will be no

physical call center located in Louisiana.

2.1.14.1

Customer

Service Center

(CSC)

• Handle emergent Provider issues twenty‐four (24)

hours per day, seven (7) days per week.

CVS Health does not confirm. Our Provider

Help Desk is open Monday through Friday

from 8 AM to 5:30 PM.

Attachment V:

Monetary

Penalties

Employment of Key Personnel: One thousand dollars

($1,000) per Calendar Day per key personnel position for

failure to have an individual serving in a full‐time acting or

permanent capacity in any key personnel position for more

than two (2) consecutive Calendar Days, for each Calendar

Day the key personnel has not been appointed.

CONFIDENTIAL

Attachment V:

Monetary

Penalties

Additional Personnel Requirements: One thousand dollars

($1,000) per appropriate staff person per meeting or event

for failure to provide subject appropriate staff member(s) to

attend a meeting or event when required.

One thousand dollars ($1,000) per appropriate staff person

per meeting or event for failure to attend a meeting or event

in person when required by the Contract or requested by

LDH.

CONFIDENTIAL

Attachment V:

Monetary

Penalties

Covered Outpatient Drugs: The actual cost incurred by an

Enrollee for obtaining Covered Outpatient Drugs from a

non-Medicaid source, as authorized by LDH, due to failure

of the Contractor to provide the service.

CONFIDENTIAL

Attachment V:

Monetary

Penalties

Enrollee Help Desk:

Five thousand dollars ($5,000) per Calendar Day for failure

to provide appropriate staff to answer calls from Enrollees

from 7:00 a.m. to 7:00 p.m. Central Time, Monday through

Friday.

Five thousand dollars ($5,000) per Calendar Day for failure

to provide a voice message system to receive calls outside

CONFIDENTIAL

Louisiana Medicaid Page 17

of 7:00 a.m. to 7:00 p.m. Central Time, Monday through

Friday.

Five thousand dollars ($5,000) for each thirty (30) second

time increment, or portion thereof, by which the daily

average hold time exceeds the maximum acceptable hold

time.

Five thousand dollars ($5,000) for each percentage point

for each standard that fails to meet the requirements for a

monthly reporting period.

Attachment V:

Monetary

Penalties

Drug Claims Data: Ten thousand dollars ($10,000) per

Calendar Day for failure to submit accurate and complete

Drug Claims data to the MCO.

In addition to the above, a quarterly offset equal to the

value of the rebate assessed on the disputed encounters

may be deducted from the Contractor.

CONFIDENTIAL

Attachment V:

Monetary

Penalties

Information Systems Availability

Fifteen thousand dollars ($15,000) per Calendar Day per

core eligibility and Claim’s processing system that is not

restored within seventy‐two (72) hours of declared disaster.

One thousand dollars ($1,000) per hour for failure to

restore system functions within the Contractor’s span of

control beyond the time limits provided in the Contract.

CONFIDENTIAL

Louisiana Medicaid Page 18

Attachment V:

Monetary

Penalties

CONFIDENTIAL

Louisiana Medicaid Page 19

CONFIDENTIAL

Louisiana Medicaid Page 20

With deep experience dating starting in 1969, CVS Health began the industry that came to be known as

pharmacy benefit management by creating more efficient and economical ways for members to receive

prescriptions. To keep pace with a rapidly changing health care market, we have evolved beyond the original

business of claims processing and administrative services to include new areas of health management and health

care information technology, as well as becoming deeply experienced in the Medicaid market.

We are URAC-accredited and have supported managed Medicaid clients since 1988. We currently support 27

managed Medicaid health plans, of which three are currently in Louisiana, with 135 unique lines of

business, representing more than 27 million Enrollees, of which nearly one million are in Louisiana,

across 37 states. Our Medicaid health plans cover children, nondisabled adults, pregnant women, individuals

with disabilities, and seniors eligible for both Medicaid and Medicare benefits. We’re always evolving to meet

changes in Medicaid program designs and regulations.

Prepared for Louisiana Department of Health | March 30, 2022

CVS Health will bring the Louisiana Department of Health best in class programs and

services:

• Unparalleled current experience providing pharmacy benefit management services in Louisiana

• Point of service claim adjudication system. CVS Health owns the source code to the system, RxClaim,

which enables us to make changes to the software based on client needs.

• Best in class technology and analytics to ensure drug dispensing accuracy and safety

• Guaranteed transparency to reduce costs and increase accountability

• Commitment to reducing opioid misuse in Louisiana

• Providing clinical programs that improve health outcomes

• Seamless transition and implementation

• Key personnel located in Louisiana and other dedicated resources

Louisiana Medicaid Page 21

Given we cover over half of managed Medicaid enrollees across the country, we recognize and understand their

unique needs. Many Medicaid enrollees have multiple co-occurring chronic conditions requiring complex drug

regimens. The top drug classes used by Medicaid enrollees demonstrate the chronic physical and mental health

conditions our enrollees have: antivirals, antiasthmatics, antipsychotics, antidiabetics, antidepressants,

anticonvulsants, analgesics, and antihyperlipidemics. To address the complex, need of the Medicaid population,

we have tailored our programs and services to meet our enrollees’ needs

Unparalleled current experience providing pharmacy benefit management services in

Louisiana

LDH will not have a more qualified respondent to the Single PBM request for proposals. As of the date of our

submission, more than 50% of Louisiana’s managed Medicaid enrollees who are enrolled in managed

Medicaid are being serviced on CVS Health’s systems through the three Managed Care Organizations we

support; Aetna Better Health Louisiana, Healthy Blue Louisiana (Anthem, Inc.) and Louisiana Healthcare

Solutions (Centene Corp.). This means that there will be minimum Enrollee and MCO disruption when the state

transitions to the Single PBM. CVS Health has experience working with state Medicaid agencies to implement

uniform preferred drug lists (PDLs), uniform clinical criteria, administrative edits, formulary grandfathering/prior

use exceptions, and National Average Drug Acquisition Cost (NADAC) plus FFS dispensing fee pricing with

lesser of methodologies. Because of this experience, we are well-placed to assume the contract with LDH and

continue to serve Louisiana’s Medicaid managed care organization (MCOs).

• Enrollees prior authorizations and medications for 50% of enrollees will seamlessly transfer, resulting in

full continuity of care. The initial implementation accuracy for go-live is at 100%. The maintenance of

business plan changes accuracy is at 99%.

• Because the CVS Health’s pharmacy network includes all of LDH’s pharmacies, no enrollee will have to

change pharmacies.

Louisiana Medicaid Page 22

• Our existing Medicaid clients in Louisianaalready follow the LDH preferred drug list (PDL) and we will be

able to quickly code and test the PDL,for the two additional plans

• Communications and data exchanges between three of the five MCOs and LDH will remain in place,

which will mean a more efficient implementation and less effort for LDH and MCOs.

• CVS Health completed approximately 194,000 prior authorizations for delegated services for the Medicaid

population.

As the PBM for three of the current five MCOs, we are experts in LDH’s policies, programs, and regulations. We

have developed Louisiana specific policies and regulations to address transparent pricing, maximum allowable

cost (MAC) requirements, and pharmacy network audit requirements among others.

Guaranteed transparency to reduce costs and increase accountability

CVS Health currently complies with Louisiana statutory requirements for pharmacy pricing for both local and chain

pharmacies. We will provide LDH with real-time and unredacted access to our claims adjudication engine,

RxClaim. With this access, LDH will be able to view and audit our claims adjudication to ensure we do not pay

the pharmacies amounts that are different from the LDH-established pricing methodology, including the LDH MAC

list and related pricing.

When we implement changes to the PDL or benefit design, LDH will have unfettered access to our pre-production

testing environment to develop testing scenarios. This will allow LDH to provide test scenarios and have a higher

level of comfort with 100% accuracy prior to moving the coding to production.

Best in class technology and analytics to ensure benefit set up accuracy, drug

dispensing and accuracy and safety it

CVS Health continually invests in technology to improve our performance and to provide our clients increased

accuracy in benefit set up, near real-time review of claims to identify drug utilization anomalies not caught at the

point of sale, and aberrant claims that may require auditing.

We use sophisticated algorithms and real-time claims surveillance to automatically identify benefits administration

issues. These rule-based and machine-learning algorithms detect potential issues with benefit coding during near

real-time claims adjudication. Our claims surveillance process runs multiple times a day. Because of the near

real-time reporting, we are able to conduct rapid response reviews of aberrant claims adjudication.

Our Drug Savings Review program provides a thorough review of a enrollee’s medication profile within 72 hours

after claim adjudication. When combined with our ongoing review of the enrollee’s prescription history, it helps us

identify those who might be at risk for drug interactions or drug-induced disease conditions, regardless of the

point of service. This can result in identification of opportunities to help reduce unnecessary prescriptions and

streamline enrollee therapy.

Our Pharmacy Performance Department believes that the best way to protect patient safety and the financial

resources of LDH is through rapid response desktop reviews. We developed a highly effective leading-edge

algorithm to review every claim submitted for reimbursement.

The algorithm contains a closely held set of rules that identifies claims that are potentially erroneous or unusual.

The claims flagged as erroneous undergo a secondary review by certified pharmacy technicians to spot claims in

need of correction. The claims are also flagged for the specific reason why the claim appears to be incorrect. If

the auditor feels there is an issue, they will call the pharmacy and review the claim over the phone.

Louisiana Medicaid Page 23

The rapid response process is invisible to the enrollee- only CVS Health and the Kentucky pharmacy know that

an error occurred on the claim, thereby preserving the Pharmacist-Patient bond. This reinforces the trust between

the pharmacist and patient, which is important to maintaining the pharmacist as a trusted member of the

enrollee’s health care team.

Commitment to reducing opioid misuse in Louisiana

CVS Health recognizes the importance of state Medicaid program efforts around drug safety and opioid misuse.

CVS Health will support conitue to support as it does today with it’s existing MCO client relationships in Lousiana,

the MCO compliance to the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment

for Patients and Communities (SUPPORT) Act. As a PBM one way we will help clients prevent opioid misuse and

abuse by implementing through our Prescription Safety Management Program (PSMP), which is a holistic

program to address opioids use and related drug safety. The SPMP is a single dynamic solution that can help

improve safety and utilization of prescribed controlled substances such as opioids, pain medications, and muscle

relaxants. Our PSMP consists of four pillars. This program can be tailored for LDH and MCOs needs. We

understand we will not implement this program without LDH approval and consistent with all LDH current opioid

review requirements.

Pillar 1 is integral helping LDH prevent opioid misuse and abuse for Medicaid enrollees. We use a combination of

prospective and retrospective drug utilization review edits to identify inappropriate prescriptions before they are

dispensed and within 72 hours post-dispensing.

• Point of sale safety messages. These safety alerts ensure that pharmacists are appropriately aware of

safety risks during dispensing. Safety messages help to reduce high dosage, and unsafe combinations.

Example safety messages related to Opioids are:

− Cumulative Morphine Milligram Equivalent Edit

− Buprenorphine/Opioid Edit

− Duplicate Long Acting Opioid Edit

Prescription

Safety

Management

Program

Prevention

Identification

Intervention

Investigation

Louisiana Medicaid Page 24

− Opioid/Benzodiazepine Edit

− Contains many of our CMS required edits for Medicare Part D enrollees

• Prior Authorizations/ UM – We also have a comprehensive set of utilization management edits, creating

“hard stops” to support prudent prescribing. These PA edits include:

− MME based quantity limits

− Post PA quantity limit durations

− Step therapy (e.g. IR before ER)

− Increased access to drugs to treat opioid use disorder (e.g. lifting PAs on buprenorphine/naloxone)

−

• Naïve therapy Opioids Days-Supply limits - We have instituted 7-day supply limits for adult new-to-therapy

enrollees, and also offer a 3-day supply limit for enrollees aged 19 and under.

− CMS Compliant with 7 Day initial opioid prescription for acute pain CMS Mandate for 2019 for opioid

naïve patients

• Retrospective Safety Review - Identifies opioid safety concerns for enrollees within 72 hours of adjudication

for medications and sends prescriber communication to prescriber. Examples of retrospective safety review

include:

− Neonatal Abstinence

− Opioid/Antipsychotic

Clinical programs that improve health outcomes

CVS Health will bring our Transform Care program which combines clinical expertise and data analytics to

enhance MCOs’ disease management strategies with targeted, comprehensive, plan enrollee support that bridges

the gap between their everyday lives and their physician’s office.

For example, our Transform Diabetes Care uses advanced analytics to assess enrollee pharmacy data, along

with biometric insights from a connected glucometer, to better understand their diabetes management and unique

needs. This enables our MCOs to develop personalized ‘interventions, delivered by health care professionals, to

help improve their medication management, blood glucose control, and condition management.

Our outcomes-based model focuses on improvements in blood glucose control, adherence and healthy

behaviors, while targeting an aggregate, one-point average decrease in A1C among the uncontrolled portion of a

diabetic population. Integrated systems enable collaboration between our program and providers, plans and

existing disease management programs to effectively extend the reach of the physician, support client goals and

align all points of care throughout enrollee therapy. This coordinated approach to diabetes management helps

drive the greatest improvements in care for enrollees with diabetes, while helping our clients better protect their

pharmacy investment.

Louisiana Medicaid Page 25

A seamless transition and implementation

Your dedicated implementation team will ensure a successful and timely transition for you and your members,

with our comprehensive approach. Over the past 10 years, CVS Health has built a track record of successfully

implementing new partnerships with our health plan clients. Our standardized processes and tools align

ownership and accountability for consistent results through a proven, stable, repeatable process with robust

testing that removes risk from transition to a new PBM. Our collaborative partnership leverages best practices that

help ensure our goals are aligned to your success.

To help ensure accuracy, we thoroughly test eligibility files in both the test and production environments during

the process of implementing a new client and benefit plans. Testing includes identifying and confirming

formatting, field values, and record counts. All results are documented and shared with the client for each test file

received. Our benefit accuracy is 100% upon implementation.

As noted, LDH and the MCO’s implementation process will be much more efficient than any other PBM

because of our significant presence today. We already implemented the LDH PDL and clinical criteria,

provider roster download, and claims payment to the LDH pharmacy network. This will limit primary areas of

testing to accepting the 834 file directly from LDH, loading LDH pricing methodologies, and sending the claims

encounter file on a weekly basis. We will only have to implement data exchanges and payment files between CVS

Health and AmeriHealth Caritas of Louisiana and United Healthcare Community Plan. Our. Our current presence

is a true value-added benefit for the smooth transition to the MCO PBM model.

Providing a skilled and effective local account team

We will ensure the LDH-assigned staff is tailored to the need of LDH, the MCOs, and Medicaid enrollees

Louisiana Medicaid Page 26

The CVS Health account team will provide the insights we have based upon local and national Medicaid

experience. On a quarterly basis we will meet with LDH to provide data insights and opportunities to improve

outcomes and reduce costs. These meetings will demonstrate why CVS holds the majority of managed Medicaid

business in the nation. We understand that not every MCO pharmacy management tool is available in FFS

programs, however, we are confident that we can help LDH drive better outcomes and cost savings through the

quarterly review.

Our goal is to provide you and your enrollees the best service, support, and strategies – with continued

innovation and investments in cost management, clinical solutions, and cutting-edge technology – to help

lower costs, improve outcomes, and increase satisfaction.

Thank you for your consideration.

Medicaid: Multi-state plan client case study

This Medicaid was concerned with helping enrollees meet their health challenges. Our data analysis showed that only

9% of enrollees had complex conditions, but they accounted for 72% of pharmacy spend, including nearly all of

specialty medication spend. These enrollees averaged 29 pharmacy visits per year, and 40% had 7 or more

maintenance therapies. Antidiabetics were a top category for these enrollees and for their chronic members as well.

Both the complex and chronic enrollees represented 17% of the plan’s enrollment and averaged 12 pharmacy visits

per year.

Based upon this MCOs input and population health-level data, we recommended a number of actions. Based on the

proposed actions, tight management in terms of formulary choices, step therapy and quantity limits helped this plan

save $720 million and kept gross trend in the low single digits. Prior authorization reduced wasteful spend; and

compounds, opioids, and hyperinflated drugs were also targeted. In addition, the plan implemented vaccination

services for this diverse population to support preventative care.

Key results over a 12-month period include:

• $720 million in pharmacy spend savings

• 2.3% gross trend

• $275 million wasteful spend savings, a reduction of 15%

• $445 million inefficient spend savings, a reduction of 23%

Louisiana Medicaid Page 27

1.8 Proposal Response Format

Proposers should respond, item by item, to each section under 1.8 Proposal Response Format.

There is no intent to limit the content of the proposals, and Proposers may include any additional

information deemed pertinent. Emphasis should be straightforward and concise statements,

summarizing the Proposer's ability to satisfy the requirements of the RFP and outlining the

exceptional qualities they bring to the proposal.

Proposals should include information that will assist the Department in determining the level of

quality and timeliness that may be expected. The Department shall determine, at its sole

discretion, whether or not the RFP provisions have been reasonably met. The proposal should

describe the background and capabilities of the Proposer, give details on how the services will

be provided, and shall include a breakdown of proposed costs. Work samples may be included

as part of the proposal.

Proposals should address how the Proposer intends to assume complete responsibility for

timely performance of all contractual responsibilities in accordance with Federal and State laws,

rules, regulations, policies, procedures, and manuals and the State Plan.

Proposals submitted for consideration should follow the format and order of presentation

described below:

1.8.1 Cover Letter

A cover letter should be submitted on the Proposer's official business letterhead explaining the

intent of the Proposer. Cover letter should contain the following information:

• Summary information about the Proposer's organization.

• Location of Central Administrative Office with Full Time Personnel, including the address for

all office locations with full time personnel.

• Name and address of principal officer.

• Name and address for purpose of issuing checks and/or drafts.

• For corporations, a statement listing name(s) and address(es) of principal owners who hold

five percent (5%) interest or more in the corporation.

• If out-of-State Proposer, give name and address of local representative; if none, so state.

• If the Proposer was engaged by LDH within the past twenty-four (24) months, indicate the

contract number and/or any other information available to identify the engagement; (if none,

so state).

• Proposer's state and Federal tax identification numbers.

The cover letter should include a positive statement of compliance with the contract terms

defined herein. If the Proposer cannot comply with any of the contract terms, an explanation of

each exception should be supplied. The Proposer should indicate the specific section and

language in the RFP and submit exceptions or exact contract modifications that it may seek.

Please refer to CVS Health’s Cover Letter.

1.8.2 Table of Contents

Louisiana Medicaid Page 28

The proposal should contain a table of contents, and each section in hard copy submissions

should be separated by a tabbed page that includes headings and numbering to match the

corresponding section of the RFP.

1.8.3 Executive Summary

This section serves to introduce the scope of the proposal. It shall include administrative

information including Proposer contact name and phone number, and the stipulation that the

proposal is valid for a time period of at least ninety (90) Calendar Days from the date of

submission. This section should also include a summary of the Proposer's qualifications and

ability to meet the State agency's overall requirements in the timeframes set by the agency.

Please refer to Section II for CVS Health’s Executive Summary.

1.8.4 Company Background and Experience

The Proposer should give a brief description of their organization or corporate entity including

brief history, corporate or organization structure, number of years in business. The Proposer

shall include copies of its latest three (3) years of audited financial statements. The proposal

should indicate the Proposer’s firm has a record of prior successful experience in the

implementation of the services sought through this RFP. Proposers should include statements

specifying the extent of responsibility on prior projects and a description of the projects’ scope

and similarity to the scope of services outlined in this RFP. All experience under this section

should be in sufficient detail to allow an adequate evaluation by the Department. The Proposer

should have, within the last thirty-six (36) months, implemented a similar type of project.

Proposers should identify at least two customer references for projects implemented in the last

twenty-four (24) months. References shall include the name, email address and telephone

number of each contact person.

The Proposer shall provide a brief statement if any of the following has occurred: Within the last

ten (10) years, Proposer’s Pharmacy Benefits Manager contract was (1) terminated or not

renewed for non‐performance or poor performance; and/or (2) terminated on a voluntary basis

prior to the contract end date. The Proposer must provide the name and contact information of

the lead program manager of the contracting entity.

The Proposer shall disclose all financial, legal, contractual, and other business interests of the

Proposer and any Subcontractor, affiliate, partner, parent, subsidiary, or other similar entity

related to the activities detailed in the Scope of Work. In this section, a statement of the

Proposer’s involvement in litigation that could affect this work should be included. If no such

litigation exists, the Proposer should so state.

Proposers should clearly describe their ability to meet or exceed the qualifications described in

the Mandatory Qualifications for Proposer section.

Proposers should clearly describe their ability to meet or exceed the desired qualifications

described in the Desirable Qualifications for Proposer section.

Ranked #4 on the Fortune 500 list, CVS Health Corporation is the largest health care provider in the United

States with integrated offerings across the entire spectrum of health care. Through our unique suite of assets,

Louisiana Medicaid Page 29

we are reinventing health to offer innovative solutions that help people on their path to better health. We are

focused on enhancing access to care, lowering overall health care costs for members and payors, and

improving health outcomes. We effectively manage health care costs and improve health care outcomes

through the following divisions and associated start dates:

• CVS Pharmacy: The retail segment of CVS Health Corporation is America’s leading retail pharmacy. The

first CVS Pharmacy store, selling health and beauty products, was founded in 1963 in Lowell, Mass. by

brothers Stanley and Sidney Goldstein and partner Ralph Hoagland. In 2015, CVS Health Corporation

acquired Target’s Pharmacy and Clinic business.

• CVS Caremark: The pharmacy benefit management (PBM) and mail service pharmacy segment of CVS

Health Corporation provides a full range of PBM services. Pharmaceutical Card System (PCS), a

predecessor of Caremark, was founded in 1969 in Scottsdale, Arizona, effectively launching the

pharmacy benefit management industry.

• CVS Specialty: The specialty pharmacy business of CVS Health Corporation (part of the PBM segment)

includes our specialty pharmacy services for patients who require treatment for rare or complex

conditions. We pioneered hemophilia home care and began supplying specialty medications in 1978, via

predecessor Baxter Health Care Corporation.

• Aetna: The medical business of CVS Health Corporation is one of the nation’s leading diversified health

care benefits companies with a broad range of traditional, voluntary and consumer-directed health

insurance products and related services. Founded in 1853 in Hartford, Connecticut, we entered the group

health insurance business in 1936.

• CVS MinuteClinic: The retail medical clinic business of CVS Health Corporation (part of the Retail

segment) is the leading retail medical clinic provider in the United States. The first QuickMedx centers

(the predecessor to MinuteClinic) opened in the Minneapolis-St. Paul area in May 2000 as a more

affordable alternative to ERs and urgent care centers.

• Omnicare: The long term care business of CVS Health Corporation (part of the Retail segment) is a

national provider of pharmacy services to the long-term care market, which includes skilled nursing

facilities and independent and assisted living communities. Acquired in 2015, it enhances our service

offerings to address the needs of an aging population across the continuum of senior care.

CVS Health Corporation, together with its subsidiaries, is the nation’s premier health innovation company

helping people on their path to better health. We have three reportable segments: Pharmacy Services,

Retail/LTC, and Corporate. These segments include our brands, which are outlined in the following high-level

organizational structure.

Louisiana Medicaid Page 30

CaremarkPCS Health, L.L.C. ("CVS Health") is a wholly-owned direct subsidiary of CaremarkPCS, L.L.C., a

subsidiary of Caremark Rx, L.L.C., whose ultimate parent company is CVS Health Corporation.

With roots dating back to 1969, CVS Health began the industry that came to be known as pharmacy benefit

management by creating more efficient and economical ways for Enrollees to receive prescriptions. To keep

pace with a rapidly changing health care market, we have evolved beyond the original business of claims

processing and administrative services to include new areas of health management and health care

information technology. CVS Health has provided PBM services in Louisiana to MCOs, and we currently

support over one million enrollees, covering more than 50% of all managed Medicaid lives within the State of

Louisiana.

We are URAC-accredited and have supported managed Medicaid clients since 1988. We currently support 27

managed Medicaid health plans, of which three are currently in Louisiana, with 135 unique lines of business,

representing more than 27 million Enrollees, of which nearly one million are in Louisiana, across 37 states.

Our Medicaid health plans cover children, nondisabled adults, pregnant women, individuals with disabilities,

and seniors eligible for both Medicaid and Medicare benefits. We’re always evolving to meet changes in

Medicaid program designs and regulations.

CONFIDENTIAL

CVS Health Corporation

Corporate

Executive

Mangaement

Corporate Relations

Legal

Compliance

Human Resources

Information

Technology

Finance

Pharmacy

Services

CVS Caremark

(PBM)

CVS Specialty

Retail/LTC

CVS Pharmacy

CVS MinuteClinic

Omnicare (LTC)

Health Care

Aetna

Louisiana Medicaid Page 31

CONFIDENTIAL

CVS HEALTH INVESTMENTS IN LOUISIANA

CVS Health has more than 2,400 Louisiana-based employees as of January 1, 2022. We have more than

80 CVS Pharmacy locations, including seven HealthHUB and seven MinuteClinic locations, within the State of

Louisiana, as well as a Coram specialty infusion suite.

MANDATORY AND DESIRABLE QUALIFICATIONS

As stated above, CVS Health has extensive experience as a PBM for MCOs in the Louisiana Medicaid

program. In addition, CVS Health continues to grow its business in other PBM Medicaid markets, as

exemplified by the addition of Anthem Incorporated and Centene Corporation.

Further, CVS Health confirms that its headquarters and offices are located inside the continental United

States, and it has provided the requested three years of audited financial statements as attachments to this

proposal response, to demonstrate the company’s strong financial standing.

As the current PBM for three MCOs serving the Louisiana Medicaid population, CVS Health confirms its

ability to accept, price, and process physician-administered Drug Claims, apply UM criteria as specified by

Louisiana Medicaid Page 32

LDH, maintain e-prescribing tools, and support the PDL, prior authorization program, and all coverage details

of the Louisiana Medicaid Program.

From time to time, CVS Health and its subsidiaries and affiliates have been subject to various legal

proceedings in the normal course of business. However, CVS Health is not aware of its involvement in any

litigation that could affect its work in meeting the activities details in the Scope of Work. Please refer to

Section V Tab 1 and 2 for CVS Health’s 10-K reports for 2019 and 2020. To view CVS Health’s 2021 10-K

report, please refer to the following link: https://d18rn0p25nwr6d.cloudfront.net/CIK-0000064803/d06cfa07-

b8f8-49c0-9f5c-552a41b68e5d.pdf

Over the last 5 years, we have not been provided notice of deficiency, non-compliance or terminations due to

defaults or with cause. We do not have any clients that have terminated with us due to the performance of

services. Clients who have terminated with us over the last 5 years have done so during a competitive RFP

process or due to changes within their own companies such as moving to an exchange, limiting their benefit

offering, or acquisitions and changes to business structure.

1.8.5 Approach and Methodology

Proposals should define the Proposer’s approach and methodology in providing services and

identify the tasks necessary to meet the RFP requirements of the provision of services, as

outlined in the RFP, and as specifically found in Section 1.8.6, Administrative Data, Section 1.8.7,

Word Plan/Project Execution; and Section 1.8.8, Detailed Scope Response. Proposals should

include enough information to satisfy evaluators that the Proposer has the appropriate

experience, knowledge and qualifications to perform the scope of services as described herein.

Proposers should respond to all requested areas.

CVS Health’s mature approach to project management and governance will be a key driver to our collective

success throughout this implementation.

PROJECT GOVERNANCE

The Figure below outlines a best practice starting point for how we will work with LDH to align resources and

responsibilities to ensure a strong one-to-one collaborative relationship throughout the implementation life

cycle. All functional areas will have a single, accountable owner from CVS Health. In addition to those

owners, we will incorporate key roles such as Implementation Program Managers and Enterprise Quality

Managers to provide cross-functional accountability around key items such as activity completion timeliness,

current and accurate project artifacts, all testing outcomes for all areas, and data integrity. Our goal is to

establish formal roles and responsibilities both at a workstream level and cross-functionally to ensure

appropriate oversight and accountability across the entire implementation process.

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Project Management Methodology

One of CVS Health’s key guiding principles is that we must execute against a single, integrated project plan.

Again, we will start with a best practice standard plan for this implementation and review it line by line jointly

to ensure that all activities are included. Each activity will ensure that we have tied in the appropriate

dependencies, that there is an appropriate amount of time for handoffs of work (examples: deliver test results,

review test results, provide feedback, clarify feedback, review final results, approve results) to set the

appropriate expectations. All tasks will be tied to one single, accountable owner rather than groups of people

or functional areas. The entire methodology around the plan is to ensure that it clearly states who will be

doing what through the entire implementation to ensure its success. Any need to adjust these activities after

they are agreed upon and baselined will be governed by a joint change control process.

We use a comprehensive project plan that outlines each implementation task and includes defined timelines

and deliverables around documenting and approving client requirements in time to fully configure and test

prior to the plan effective date. Because of diverse client needs, our implementation process is flexible

enough to allow focus on the unique requirements of each client’s implementation. The Implementation

Project Manager and Account Team will ensure that our management and implementation team work to

deliver a successful implementation and will manage escalations as needed.

Our project management methodology begins with an interrelated series of activities illustrated in the Figure

below; these activities enable and ultimately lead to:

• Development activities: Coordination of test and production eligibility files, review Enrollee

communications, build the benefit plan designs, and receipt of vendor transition files.

• Testing activities: unit, system integration, performance and user acceptance testing.

• Deployment activities: Coordination of Enrollee communications, receipt of final eligibility file, Customer

Care begins taking calls, and the website is available for Enrollees to access.

Louisiana Medicaid Page 34

• Maintenance activities: Monitoring all post effective activities including Customer Care, Enrollee

communications, and ensuring accuracy of claim adjudication.

Establishing and agreeing upon a formal escalation process early in the life of a project is key to its success.

As such we will work with the MCOs to establish a successful project escalation structure. In our experience,

the structure illustrated in the below Figure has proven effective.

Louisiana Medicaid Page 35

Each MCO’s dedicated Account Team will be involved with all aspects of Implementation to help ensure

seamless service and accountability. Each MCO’s Implementation Project Manager will be the single point of

contact and will lead and drive the implementation process from start to finish. Our proven experience in

health plan implementations has shown that the strategic advisory role of our dedicated Implementation

Project Manager is central to securing an efficient transition with minimal disruption.

CVS Health subject matter experts will be assigned to various project workstreams. We have a proven

process that tracks all the important milestones and timeframes, including standard templates for project

status reports. We propose holding weekly project status and issue management meetings with the LDH team

and each of the MCOs.

Change, Risk, Action, Issue and Decision (CRAID) Management

We have successfully implemented hundreds of clients, including many Medicaid MCOs, by utilizing proven

project management tools such as our integrated Change, Risk, Action, Issue and Decision (CRAID) log,

illustrated in the below Figure. This artifact combined with the expertise and knowledge of our implementation

team, we will demonstrate highly consultative capabilities when it comes to risk mitigation, issue resolution,

and contingency planning. Our CRAID log is designed to gather key information tied to a risk or issue – a

single accountable owner, an actionable mitigation plan for risks, a clear outline of activities for the resolution

of issues, and a clear understanding of contingency plans should an agreed upon mitigation approach fail. We

will work together through our management of activities within the project plan to identify these items and

have the CVS Health team lead the joint discussion around the establishment of a clear, joint problem

statement, owner, due date, and mitigation planning.

Louisiana Medicaid Page 36

Examples of actual risks we have encountered on our PBM implementation, as well as solutions we have

found successful, include:

Risk 1: Dependence on the incumbent vendor to provide accurate refill, prior authorization, claims, and/or

account balance files. Resolution: We will work with LDH and the incumbent PBMs to establish a

comprehensive PBM transition plan, including an extensive routine of testing protocols. We will also host

weekly meetings to monitor timeframes and key deliverables.

Risk 2: Transferring prior authorizations. Resolution: Because prior authorization coding differs among

PBMs, we thoroughly review the prior authorization information from the incumbent PBM in order to determine

the most appropriate translation method for loading the other PBM’s prior authorization data into our system.

This is typically done by either identifying a one-to-one match of the prior authorization codes or by analyzing

the drug categories supplied on the file to determine which benefit structures need to be overridden under the

new plan design. This will help ensure the prior authorizations load correctly into our system.

Risk 3: Notifying Enrollees of their new PBM vendor. Resolution: We believe in proactive communication to

Enrollees to help ensure successful implementations. We will develop a phased communication strategy

using various communication vehicles to communicate to Enrollees the change in vendors. Sample strategies

can include a welcome message using IVR, access to all of the necessary information through

Caremark.com, benefit fair participation, incumbent vendor messaging, and pre-enrollment Customer Care

support.

1.8.6 Administrative Data

This section should:

• State Proposer’s knowledge and understanding of the needs and objectives of LDH

Pharmacy and the MCOs as related to the scope of this RFP.

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LDH will not have a more qualified respondent to the Single PBM request for proposals. As of the date of

our submission, more than 50% of Louisiana managed Medicaid Enrollees who are enrolled in

managed Medicaid are being serviced on CVS Health’s systems through the three Managed Care

Organizations we support: Aetna Better Health Louisiana, Health Blue Louisiana (Anthem, Inc.)

and Louisiana Healthcare Solutions (Centene Corp.). This means that there will be minimum Enrollee

and MCO disruption when the state transitions to the Single PBM.

• Enrollee prior authorizations and medications for more than 50% of Enrollees will seamlessly transfer,

resulting in full continuity of care. The initial implementation accuracy for go-live is at 100%. The

maintenance of business plan changes accuracy is at 99%.

• Because CVS Health’s pharmacy network includes all of LDH’s pharmacies, no Enrollee will have to

change pharmacies.

• Communications and data exchanges between three of the five MCOs and LDH will remain in place,

which will mean a more efficient implementation and less effort for LDH and MCOs.

• In 2021, CVS Health completed approximately 200,000 prior authorizations for the book of business

delegated services for the Medicaid population.

As the PBM for three of the current five MCOs, we are experts in LDH’s policies, programs, and

regulations. We have developed Louisiana specific policies and processes to address plan requirements,

as needed, and are prepared to continue to do so as part of the single PBM program.

Our approach to becoming the MCO PBM will be to continue the same work we do today and when the

new MCO contracts are implemented:

• Point of service claims adjudication including coordination of benefits

• Transparent pricing

• Point of service drug utilization review

• Pharmacy payments

• Fraud waste, and abuse monitoring

• Prior authorization

• Retrospective drug utilization review programs

• Our gold standard network audit program

• Our opioid program that has reduced use and misuse

• Enrollee and provider support

Accountability

We know that price transparency is a State priority. CVS Health will be a fully accountable partner to LDH.

We will provide LDH with unredacted access to our claims adjudication engine results through

our Client Online Services portal. With this access, LDH will be able to view and audit our claims

adjudication to ensure claims are paid appropriately and in accordance with LDH-established pricing

methodology, including the LDH MAC list and related pricing.

When we implement changes to the PDL or benefit design, LDH will have unfettered access to our pre-

production testing environment to develop testing scenarios. This will allow LDH to provide test scenarios

and have a higher level of comfort with 100% accuracy prior to moving the coding to production.

Best in class technology and analytics to ensure benefit set up accuracy, drug

dispensing and accuracy and safety

CVS Health continually invests in technology to improve our performance and to provide our clients

increased accuracy in benefit set up, near real-time review of claims to identify drug utilization anomalies

not caught at the point of sale, and aberrant claims that may require auditing.

Louisiana Medicaid Page 38

LDH will have the same technology and analytics that their Louisiana MCOs have today. We use

sophisticated algorithms and real-time claims surveillance to automatically identify benefits administration

issues. These rule-based and machine-learning algorithms detect potential issues with benefit coding

during near real-time claims adjudication. Our claims surveillance process runs multiple times a day.

Because of the near real-time reporting, we are able to conduct rapid response reviews of aberrant claims

adjudication.

Our Drug Savings Review program is an enhanced, buy-up option available should Louisiana or any of

the MCOs be interested, and provides a thorough review of a Enrollee’s medication profile within 72

hours after claim adjudication. When combined with our ongoing review of the Enrollee’s prescription

history, it helps us identify those who might be at risk for drug interactions or drug-induced disease

conditions, regardless of the point of service. This can result in identification of opportunities to help

reduce unnecessary prescriptions and streamline Enrollee therapy.

Best in Class Pharmacy Network Audit

As a company staffed with hundreds of pharmacist-employees, we understand the need to minimize

pharmacist provider abrasion during the auditing process. We use CVS Health employees to audit our

pharmacy network to help ensure that covered drugs are filled in accordance with the provider

agreement.

Additionally, our Pharmacy Performance Department believes that the best way to protect patient safety

and the financial resources of LDH is through rapid response desktop reviews. We developed a highly

effective leading-edge algorithm to review every claim submitted for reimbursement.

The algorithm contains a closely held set of rules that identifies claims that are potentially erroneous or

unusual. The claims flagged as erroneous undergo a secondary review by certified pharmacy technicians

who may call the pharmacy and review the claim over the phone.

The rapid response process is invisible to the Enrollee – if the technician reviews the claims with the

pharmacy, only CVS Health and the pharmacy know that a review occurred on the claim, thereby

preserving the Pharmacist-Patient bond. This reinforces the trust between the pharmacist and patient,

which is important to maintaining the pharmacist as a trusted member of the Enrollee’s health care team.

CONFIDENTIAL

Clinical programs that improve health outcomes

CVS Health can offer our enhanced Transform Care program if LDH or the MCOs are interested, which

combines clinical expertise and data analytics to enhance MCOs’ disease management strategies with

targeted, comprehensive, Enrollee support that bridges the gap between their everyday lives and their

physician’s office.

For example, our Transform Diabetes Care uses advanced analytics to assess Enrollee pharmacy data,

along with biometric insights from a connected glucometer, used by some Enrollees, to better understand

their diabetes management and unique needs. This enables our MCOs to develop personalized

‘interventions, delivered by health care professionals, to help improve their medication management,

blood glucose control, and condition management.

Our outcomes-based model focuses on improvements in blood glucose control, adherence and healthy

behaviors, while targeting an aggregate, one-point average decrease in A1C among the uncontrolled

portion of a diabetic population. Integrated systems enable collaboration between our program and

providers, plans and existing disease management programs to effectively extend the reach of the

physician, support client goals and align all points of care throughout Enrollee therapy. This coordinated

approach to diabetes management helps drive the greatest improvements in care for Enrollees with

diabetes, while helping our clients better protect their pharmacy investment.

Louisiana Medicaid Page 39

A seamless transition and implementation

As noted, LDH’s and the MCO’s implementation process with CVS Health will be much more

efficient than any other PBM because of our significant presence today. We will already have

implemented the LDH PDL and clinical criteria, provider roster download, and claims payment to the LDH

pharmacy network. This will limit primary areas of testing to accepting the 834 file directly from LDH,

loading LDH pricing methodologies, and sending the claims encounter file on a weekly basis. We will only

have to implement data exchanges and payment files between CVS Health and AmeriHealth Caritas of

Louisiana and United Healthcare Community Plan. Our current presence is a true value-added benefit for

the smooth transition to the Single PBM model.

Post-Payment Recoveries

CVS Health provides a number of services to assist Medicaid in their post-service recoveries and cost-

avoidance strategies for drug reimbursement claims.

CVS Health maintains a dedicated Third-Party Liability (TPL) and Subrogation team for the processing of

Medicaid TPL/Subrogation claims (e.g. Pay & Chase) per applicable state and federal law. This same

team maintains direct working relationships with all US states, and national service providers for Third-

Party Liability and Subrogation services.

CVS Health maintains several services to identify and process Medicaid TPL & Subrogation claims

including direct connections to service providers and many US States. These direct connections allow

for the adjudication of digitally presented claims within 72 hours of receipt. CVS Health remits payments

to the appropriate state and/or Managed Medicaid Organization within 21 calendars days.

• In 2021 – CVS Health processed 36M TPL/Subrogation Medicaid Claims with 99.99% presented

digitally. 96% adjudicated within 7 days, and 99.999% within 60 days.

CVS Health also maintains a series of services to assist Medicaid with their cost avoidance

strategies. CVS Health will reject a drug claim submitted with Medicaid as primary when CVS Health is

aware of alternative coverage legally responsible to provide payment ahead of Medicaid.

CVS Health also offers a new premier service to maximize the effectiveness of Medicaid’s post-service

recovery and avoidance strategies. In instances where Medicaid pays primary for a member with

primary coverage on a CVS Health administered and delegated plan, CVS Health can initiate a

TPL/Subrogation claim when directed on behalf of the Medicaid plan. This enhanced service allows the

Medicaid plan to recovery post-service payments in under 30 days.

** This service is exclusively provided by CVS Health. The service provides both an cost effective

solution in recovering service fees from the appropriate primary payor, while also avoiding the

commissions and/or fees charged by all national service providers for TPL/Subrogation services.

All TPL/Subrogation activities, including reimbursements, are recorded in our system of record, and is

made available to Medicaid and/or Managed Medicaid Organizations. CVS Health will make available

the required reports and files, in a format acceptable to Medicaid or national format, to assist Medicaid in

their administration of the plan and financial reconciliations.

Where required by Medicaid, or federal and/or state law, CVS Health will assist the Medicaid with post-

service recovery, the identification of alternative coverage/eligibility, respond timely to all valid legal

inquiries, audits, or similar.

Louisiana Medicaid Page 40

While CVS Health does not expect to be presented settlements or otherwise be presented with requests

that would result in Medicaid recovering all the funds for which Medicaid is entitled, CVS Health will

provide proper notification to Medicaid if such instances arise in our performance of our responsibilities.

• Provide a written explanation of the Proposer’s organizational structures of both operations

and program administration, and a description of how the components communicate and

work together in both an administrative and functional capacity from the top down.

Ensuring LDH’s, MCOs’, and Medicaid Enrollees’ satisfaction is the core of our Client Service Team

philosophy. Our model will allow the LDH and MCOs Service Teams the flexibility, innovation, and

collaboration needed to achieve outstanding results on behalf of LDH.

The Client Services’ vision is to achieve exceptional client loyalty by delivering unparalleled service

through effective communication and coordination. We aim to achieve client loyalty through:

• Greater face-to-face collaboration processes among internal team members

• An emphasis on quality, turnaround times, and LDH convenience

• More rigorous processes to track and deliver on LDH and MCO day-to-day needs

• A streamlined team approach, ensuring delivery and accuracy of LDH benefit plan changes on or

before deadlines

• A collaborative focus on the effective execution of the LDH’s strategies.

• We are focused on continuously adapting our support philosophy to stay in line with the evolving

needs of LDH.

Louisiana Medicaid Page 41

MCO SERVICE TEAMS

In addition to supporting LDH, all Louisiana MCOs will have access to the expertise of the LDH Service

Team. Each team member has extensive experience supporting Medicaid Enrollees. Every state is

unique in their requirements and we will ensure continuity of the current account teams assisting the

Louisiana MCOs we service today. For the MCOs we don’t serve today, we will take pride in selecting

team members with backgrounds and experiences with significant Medicaid experience.

CHANGES IN ACCOUNT TEAM ASSIGNMENT

We will agree not to change the assigned Executive Director, Account Director, or Audit Pharmacist

without LDH’s consent, except in the case of a promotional opportunity, request for reassignment,

employee termination, or other reasonable justification to manage the business.

We recognize the importance of continuity and consider client relationships a top priority. We strive to

minimize changes to account teams whenever possible. LDH and the MCOs will be notified immediately

in the event of a key personnel change. We will create a comprehensive and thorough succession plan to

support the transfer of knowledge and responsibility from your key contact to their replacement.

In addition, account team members have access to our customer relationship management tool. This

central repository stores specific contact and account information to ensure continuous support of the

client relationship.

Your satisfaction is paramount, and we carefully choose account team members based on your unique

requirements. We are driven to achieve 100% client satisfaction and retention. Our account team

members’ individual employee evaluations and overall CVS Health evaluations are based on client

feedback regarding service performance and overall satisfaction.

Louisiana Medicaid Page 42

If you are not completely satisfied with your account team and request a replacement, we will address

your concerns and make changes as necessary.

LDH ACCESS TO SUBJECT MATTER EXPERTS

One of the responsibilities of your account team is to engage subject matter experts across our company

including doctors, pharmacists, nurses, IT, reporting and more. This engagement may be initiated by the

account team or in response to an LDH request. Each member of your account team makes it a priority to

remain informed with the most up-to-date information to assist you in all areas.

TRAINING

Our implementation and account teams will work to ensure that Customer Care Representatives are

trained on any Louisiana-specific information via computer-based training, bulletin postings to the internal

proprietary online tool, and through desk-based reference information.

LDH-specific training will be administered to focus on the overall business culture and unique needs of

Louisiana Medicaid Enrollees. This training is designed to help Customer Care Representatives fully

understand the unique plan design parameters and culture of Louisiana Medicaid. Our goal is to serve as

an extension of your benefits offices, and LDH-specific training provides our representatives with the

information they need to achieve that goal.

• Contain a brief summary setting out the Proposer’s management philosophy including, but

not limited to, the role of Quality Control, Professional Practices, Supervision, Distribution of

Work and Communication System.

To serve our health plan client base we staff our account service team with knowledgeable, experienced

professionals whose focus is providing the highest level of customer service for our clients. Customer

service excellence starts at the top of our organization and every colleague is responsible and

accountable to work collaboratively with others across our organization from Customer Care, Mail,

Specialty, Marketing, Plan Design, Analytics and more to support your goals and align your strategic

direction with our capabilities. We take pride in selecting team members with background and experience

that best meet your unique needs. Customer satisfaction is a key performance metric across our

enterprise and while your account team is the front line, they have the backing of our entire organization

in ensuring the success of your programs.

Our consultative services play a major role in supporting our clients’ strategic goals for managing

pharmacy and total health care trend, while working together to improve health outcomes.

Your account services team will include dedicated account management resources with managed

Medicaid expertise. These resources include clinical, account, and client services teams. We will also

include management of per member per month (PMPM) performance to meet client goals during

challenging budgetary times. And, of course, we can help ensure our compliance with policy and

legislative tracking activities associated with Medicaid regulations at the state level.

Our “management philosophy” is one of service excellence for all constituents. Our Caremark Service

Excellence team, is a cross functional group that oversees the issues management process, instituting

core operational discipline and leading the culture transformation. They create visibility to trends and high

priority issues; drive accountability; and ensure issue prevention through better collaboration. This is

comprised of leaders across account management, benefits, client services, data operations, analytics,

finance, IT, product, human resources, and Medicare operations that meets weekly to address client and

member issues. Our focus is to ensure that we address issues as they arise, so we can align the right

resources to resolve issues, do a thorough root cause analysis, and then take action. This philosophical

approach applies not just in high priority events but also in smaller teams across the organization as we

have transformed how we think about continuous improvement.

Louisiana Medicaid Page 43

We will work collaboratively with LDH to ensure our team is fully trained on all aspects this program. To

start, the identified team members all have deep Medicaid experience including in Louisiana. As we

respond to this RFP and in the subsequent months, will work diligently to ensure all of our team members

are fully oriented to the LDH and this program.

CVS Health provides employees working within the Medicaid space the foundational skills and expertise

to be successful in meeting our clients specific needs. Our Medicaid educational approach is

multipronged. We provide our Medicaid internal stakeholders with detailed Medicaid trainings that cover

both internal and external market information. For example, these trainings cover the following topics:

• Foundation in how the federal government works with states to fund and administer Medicaid

• Overview of enrollment, eligibility and coverage (mandatory & optional benefits)

• Overview of quality and incentive programs

• Understanding of care delivery models including managed care and managed care organizations

(MCOs)

• Highlight of key policy developments impacting the program, including trends in drug benefit

management and future payment reform options

We also realize that each state is unique, and to that end, we generate regularly updated market profiles

on each Managed Medicaid state that we operate in – including the State of Louisiana. We also regularly

review and share local, state and federal Medicaid news and information with key Medicaid market

stakeholders on a daily, weekly and monthly schedule. Taken together, this foundational and ongoing

educational support in Medicaid ensures not only the success of our employees but also the success of

our clients who operate in this complex and rapidly changing market.

In addition, department programs are supported by full-time, dedicated professional Learning and

Development teams that deliver educational programs specific to their individual department, job function,

and professional development needs.

We design onboarding and learning programs tailored to the roles of our colleagues serving our clients.

Tracks are designed specifically for Sales, Strategic Account Executives, Clinical Advisors, and Account

Managers. We benchmark against and leverage other learning professionals and tools, including

Corporate Executive Board, XBInsight, Huthwaite, and Salesforce.

Our account management new-hire training program, a three-week onboarding program, employs a

blended solution with instructor-led, online and on-the-job training for technical system proficiency and

soft-skill building. On-the-job activities alongside an assigned mentor supplement structured training for

autonomy and immediate application of knowledge to support adult learning principles. Learning guidance

and feedback throughout training elicits performance to identify additional development opportunities. A

final assessment is required to transition into the role and interface with clients. Account Managers enter

the position with a range of experience, from recent college graduates to experienced customer service

professionals. Pre- and post-assessments show an average 65% increase in learning objective

knowledge. Customer retention and loyalty surveys, a measure of level four evaluation, show only a 3%

differential in overall performance ratings between new and tenured Account Managers, an indication that

new-hire training effectively prepares students to serve clients at a comparable level to tenured Account

Managers.

Ongoing education opportunities for sales professionals are delivered throughout the year through office

hours, Investing in You, and Learning Exchange virtual trainings. All learning curricula and content are

indefinitely accessible on Max+, a sales collateral library and knowledge portal that can be accessed by

account team members (online or by mobile) in the client relationship management tool that is central to

their job functions.

Louisiana Medicaid Page 44

All new hires and contingent workers must complete the courses below within 30 days of employment.

Additionally, all employees and contingent workers must complete these same courses on an annual

basis. All courses listed have been delivered over the past 12 months.

• Integrity Training (Code of Conduct) – New hire and annual

• HIPAA Privacy and Security – New hire and annual

• Medicare Fraud Waste and Abuse – New hire (all employees) and annual (those who are directly or

indirectly involved with the benefit).

CVS Health also provides the following training to CVS Health Clinical Advisors and Service Team

members.

Objective: Enable team members with key strategic & background information on the health plan

Medicaid market

Proposed Scope of Training:

• Foundation in how the federal government works with states to fund and administer Medicaid

• Overview of enrollment, eligibility and coverage (mandatory and optional benefits)

• Overview of quality and incentive programs

• Understanding of care delivery models including managed care and MCOs

• Highlight of key policy developments impacting the program, including trends in drug benefit

management and future payment reform options

• Understanding of Medicaid clients’ needs and expectations

• Louisiana Medicaid policies, key regulations, and compliance

Once account team members complete orientation, they are exposed to a variety of additional in-depth

classes, workshops, and webinars related to their positions and job responsibilities.

ACCOUNT MANAGERS

New Account Managers are required to complete a new-hire course focusing on operational processes,

system functionality, our programs and services, and internal departments. Throughout class, new hires

work on client activities and complete additional courses focusing on value-added services and soft-skills

development (e.g., communication, relationship building, critical thinking). These courses are designed to

set their knowledge foundation and build successful client relationships.

ACCOUNT TEAM CONTINUING DEVELOPMENT

Developmental training is ongoing for all Account Team members. Regularly scheduled offerings provide

additional training for all colleagues, along with comprehensive consultative and professional skill

building, including:

• Interaction and communication skills;

• Louisiana Medicaid regulations

• Presentation skills

• Time management.

• Medicaid Clinical advisors weekly meetings

• Regulatory Affairs Committee monthly meetings

• Regulatory Affairs, compliance and legal weekly meetings

• Medicaid Operations and Strategy meetings - monthly

• Department Specific Medicaid training i.e. Encounters team, Finance team, Government Services

team, Clinical Teams, Account Management

Louisiana Medicaid Page 45

Medicaid Ongoing Best Practice Training:

• Recurring MCO/PBM – joint operations meetings

• Recurring MCO/PBM- Pharmacy trends/performance meetings

Mentoring programs are provided for all levels of Account Services team members to promote an

environment of open communication, continuous growth, and best practice/knowledge sharing. Product

training and upskilling are communicated and delivered by various methods, including weekly electronic

sales briefings, quarterly sales calls, e-learning modules, recorded conference calls, regional meetings,

and an annual national sales meeting.

Our Implementation and Account teams will work to ensure that Customer Care Representatives are

trained on any client-specific information via computer-based training, bulletin postings to the internal

proprietary online tool, updates to Client Information Forms, and through desk-based reference

information.

CVS Health will ensure that all trained employees with the appropriate qualifications, or other personnel

as approved by LDH, are available for all claims administration services as outlined in the proposal.

1.8.7 Work Plan/Project Execution

The Proposer should articulate an understanding of, and ability to, effectively implement

services as identified in Section 2. Scope of Work. In this section, the Proposer should state the

approach it intends to use in achieving each objective of the scope as outlined, including a

project work plan and schedule for implementation.

The Proposer should:

• Provide a written explanation of how the operations and program administration components

of the Proposer’s organizational structures will support service implementation. Individual

components should include plans for supervision, training, technical assistance, as well as

collaboration as appropriate.

Your executive-led account services team will be responsible for executing a smooth and seamless

implementation. The team works together to provide a highly consultative and well-coordinated transition,

bringing all necessary subject matter experts together to support your program start-up, and help ensure

all program requirements are fully defined and met.

IMPLEMENTATION – A COLLABORATIVE PROCESS

An implementation project manager will be responsible for assembling and leading a team of experts in

the areas of eligibility, benefit design, provider networks, clinical programs, member communications,

vendor transition, and technology and customer service, as needed. Our team meets with your team

members in their respective areas to guide them through gathering and documenting your specific

requirements and confirm understanding through a rigorous review and approval process that will include

outlining how each set of requirements will be tested.

During the implementation process, we will continue to meet with you to help ensure full understanding of

requirements, address any questions, and resolve issues that may arise throughout the process. Your

account services team will also conduct ongoing post-implementation meetings to help ensure that all

aspects of the program are in place and are operating to your requirements.

Louisiana Medicaid Page 46

MAINTAINING CLIENT COMMUNICATION

Following implementation, account service personnel will be available, as required, to effectively manage

all aspects of your account. Client support, as well as clinical experts, will be available by telephone or

for on-site meetings, as needed, over the course of a plan year.

ONGOING COLLABORATION

Our experienced account management team is focused on executing on your initiatives through

proactive, professional collaboration. We employ a tenured team with analytic and clinical experience.

Our insights and recommendations help you control costs, maintain high employee satisfaction, achieve

your health and wellness goals and accomplish your business objectives. We do this through strategic

meetings, formulary and specialty management strategy discussions, operational tools for tracking and

training and regulatory support for topics such as retiree benefit options and ACA compliance.

• Demonstrate an ability to hire staff with the necessary experience and skill set that will

enable them to effectively meet the needs of Enrollees.

CVS Health has a deep bench of internal talent and our plan is to leverage those resources to staff our

team. We are confident that by the award deadline we can have our team in place at that time. We will

provide written notification to LDH and the MCOs of anticipated vacancies of Key Management Staff

within two (2) business days of receiving the individual’s resignation notice, our notice to terminate an

individual, or the position becomes vacant. CVS Health will work with LDH to fill Key Management

Personnel positions should any vacancies remain open at the time of contract award.

Your satisfaction is paramount, and we carefully choose account team members based on your unique

requirements. We are driven to achieve 100% client satisfaction and retention. Our account team

members’ individual employee evaluations and overall CVS Health evaluations are based on client

feedback regarding service performance and overall satisfaction.

If you are not completely satisfied with your account team and request a replacement, we will address

your concerns and make changes as necessary. CVS Health will not substitute or exchange Key

Management Personnel without the LDH’s written approval.

We recognize the importance of continuity and consider client relationships a top priority. We strive to

minimize changes to account teams whenever possible. LDH will be notified immediately in the event of a

key personnel change. Within ten (10) business days of receiving the resignation, we will create a

comprehensive and thorough succession plan to support the transfer of knowledge and responsibility

from your key contact to their replacement. LDH reserves the right to approve or reject the plan.

In addition, account team members have access to our customer relationship management tool. This

central repository stores specific contact and account information to ensure continuous support of the

client relationship.

CVS Health will provide resumes of proposed replacement candidates to LDH within thirty (30) calendar

days after vacancy occurs. If a suitable replacement candidate has not been identified within that time

period, CVS Health will provide weekly updates to LDH.

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• Demonstrate an understanding of, and ability to implement, the various types of

organizational strategies to be integrated within the day-to-day operations.

We have extensive experience in implementing clients with complex pharmacy benefits. These

implementations typically consist of the receipt of multiple eligibility feeds, the building of hundreds of

different benefit plan designs, and the delivery of complex communications to members. As a testament

to our configurable setups, in a recent welcome season we implemented 330 clients of which 259 were

new clients – serving 3.2 million members.

We handled more than 14,209 mailing projects, 1832 inbound member data transition files, and deployed

approximately 54,000 plan benefit changes. We had 387 million test claims processed. On January 7

the busiest day of the year, we processed over 11.3 million claims and a record 249.5 million claims in the

month of January. We are pleased to report our client satisfaction rating is 97%.

We use our claims processing system as the backbone of our primary operations for pharmacy benefit

administration and claims processing. This will enable a smooth transition for current downstream clients,

as we have great depth of experience with all of the functionality and architecture. In addition, we have

created an environment where we run rigorous test scenarios to help ensure all possible combinations of

edits and criteria are correctly executed.

IMPLEMENTATION TEAM

You will be supported by an experienced, dedicated Implementation team, led by your Implementation

Project Manager. Your Implementation Project Manager will be the single point of contact and will

oversee the implementation process from start to finish. The strategic advisory role of our dedicated

Implementation Project Manager is central to securing an efficient transition with minimal disruption. We

are committing dedicated individuals to manage your account both during your implementation and

throughout your relationship with us.

Your executive-led account services team, in conjunction with your dedicated Implementation Project

Manager, will be responsible for executing a smooth and seamless implementation.

• Collaboration through the discovery process at the kick off meeting

− Open communication to determine and document shared terminology

− Obtain client requirements around plan design, hierarchy, reporting, etc. and help ensure these

are thoughtfully documented in the Client Requirements Document

− Define the timeline using the Project Plan and identify specific tasks needing client sign-off

− Proactively anticipate and document any obstacles that may occur by using the Issues/Risk log

• Experienced implementation professionals

− Matrix of subject matter experts (SMEs) matching your structure and SMEs

− Oversight of end-to-end certification testing and client test environment

− Establish responsibility on both sides for critical decisions

• Governance of the Process

− Follow our proven methodology for managing a successful implementation

− Establish escalation process for quick issue resolution for risk and issue resolution

− Agreed upon timeframes for thorough review and testing.

To align with your complex pharmacy benefit needs, the implementation process is very detailed. Subject

matter experts are assigned and all implementations are managed with a detailed project plan. We have

a proven process that tracks all of the important milestones and timeframes.

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• Discover: Understanding your lines of business and priorities. Bring key decision makers to

meetings, provide all necessary information and data files and execute timely review and approval of

requirement documents to support the gathering process. Discuss the implementation guide which

provides a roadmap for the process. Document your requirements and provide our recommendations

on plan design, hierarchy, and reporting needs. Determine frequency of communications and

meetings

• Build: Continue attending weekly meetings and completing key client milestones as we execute

activities to implement your requirements

• Test: Support testing and quality assurance activities by continuing to attend weekly meetings,

providing timely approval of test results and supporting vendor collaboration.

• Deploy: Participate in final implementation activities involving preparation, coordination, and quality

checks driven by the CVS Health Implementation Manager leading up to and including the effective

date.

• Maintenance: Monitoring all post effective activities including Customer Care, member

communications, and ensuring accuracy of claim adjudication. Resolution of any identified gaps or

plan design elements from the plan effective date.

BENEFIT TESTING

Our unique and proprietary testing capabilities are key to minimizing operational impacts to plans during

an implementation. Key features include:

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All of our testing is conducted in a pre-production environment, allowing for plan design changes as

needed until the expected outcome is reached. When test results are confirmed as satisfactory, the plan

design will be moved to our production environment. Client Benefits conducts comprehensive testing that

includes three steps: processing claims (test scenarios), reviewing the data, and verifying/validating the

results.

• Processing Claims – During the claims processing step, claims are created and run against the

benefit design. The test scenarios are built around the client’s benefit design. Typically, a drug is

tested from every category based on the client’s benefit design. While testing for coverage or

exclusion, we will also include testing for pricing, quantity versus time , age limits, contingent

therapy/prior use exceptions, and accumulation testing which includes deductible, out of pocket, and

maximum allowable benefit. Accumulation testing is handled manually to help ensure claims

calculate correctly before the accumulation level, the crossover claim, and after the accumulation

level is reached.

• Reviewing the Data – The second step requires Client Benefits to review their testing outcomes. In

this step we review our test results to confirm that claims accepted or rejected as expected, based on

the client’s benefit design. For rejected claims, we confirm the reject is valid. If the reject is not

related to drug exclusion, it is reviewed to determine if plan and/or macro modifications are

needed. If plan and/or macro modifications are made, retesting will occur to confirm changes provide

the valid drug coverage or exclusion outcomes before moving to the third step in the testing process.

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• Verifying/Validating Results – The last step of the testing process is to confirm the outcomes are as

expected. We validate drug coverages and exclusions against client documentation. When

reviewing the outcomes, we also confirm the member's copay is correct and the claim calculated as

expected based on the contracted prices. If we find any discrepancies during this step, we will

identify what caused the issue, make any required plan modifications, and process a new set of

claims for review. All test cases and results are reviewed.

CLIENT IMPLEMENTATION TESTING FOR CLIENTS

After benefit testing is completed in the pre-production environment, the client’s data is promoted to the

Client Test Environment (CTE), which is a production-like environment; to perform further testing that

includes production, eligibility, plan, utilization management rules, prior authorizations, and pricing. Test

claims or production claims can be used for testing. After the claims are processed, claim files are

produced which can be reconciled to financials and available to be loaded into client’s Data

Warehouse. Also, an invoice from our billing system will be generated for your review. You will have the

ability to not only reconcile the financials but also the formats should you elect to load these files into your

system(s). Testing can take four to eight weeks to complete before going live, assuming no re-tests are

needed.

TOOLS FOR SUCCESS

We document the implementation status with proprietary tools, including a Project Plan, Implementation

Guide, Status Reports, and Risk/Issues Log. Together, these four tools will help ensure business units

are provided with the correct information, allowing sufficient time to execute on key tasks.

Our Implementation Project Plan monitors the progress of the implementation by outlining tasks,

responsible parties, and targeted completion dates, with a focus on the following key components:

• Plan Design

• Eligibility

• Management Reports

• Benefit Communications

• Finance

• Vendor Transition.

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We can incorporate executive summaries and dashboard reports, if desired, to provide the progress of

the implementation to your upper management. Project Plan updates occur in real-time throughout the

process and are shared with you on a weekly basis or more frequently if needed. In addition, the

Implementation Project Manager will provide an action log throughout the process detailing conversations

and any needed issue resolution.

We recommend a minimum of weekly meetings to review the current Implementation Project Plan and

Open Action Items. In addition, weekly meetings can occur at the executive level to provide a briefing on

implementation status and identified risks or issues.

• Demonstrate knowledge of services to be provided and effective strategies to achieve

objectives and effective service delivery.

CVS Health provides a best-in-class Medicaid pharmacy benefit manager. We currently support 27

managed Medicaid health plans, of which three are currently in Louisiana, with 135 unique lines of

business, representing more than 27 million Enrollees, of which nearly one million are in Louisiana,

across 37 states. Our Medicaid health plans cover children, nondisabled adults, pregnant women,

individuals with disabilities, and seniors eligible for both Medicaid and Medicare benefits. We’re always

evolving to meet changes in Medicaid program designs and regulations.

DIFFERENTIATORS

We recognize and understand the uniqueness of the Medicaid population. With more than half of

Medicaid members managing multiple conditions, the complexity of drug regimens is a major factor in

nonadherence. As the level of complexity goes up, the rate of adherence goes down. Mental illness,

which has a high incidence among this population, can affect a member’s ability to understand and/or

remember treatment regimens. Communication challenges also exist, as there is generally a low level of

health literacy, which can affect a member’s lifestyle choices. Language barriers, including lower literacy

levels and non-English-speaking members, may create challenges for effective communication between

members and providers. And limited mobility and/or access to transportation make it difficult for members

to get to the pharmacy to refill prescriptions or to providers for appropriate care. Among the Medicaid

population, disease states and utilization patterns may vary by state, but typically the top drug classes in

our book of business are antivirals, antiasthmatics, antipsychotics, antidiabetics, antidepressants,

anticonvulsants, analgesics, and antihyperlipidemics.

Improved clinical and cost outcomes are achieved through our sophisticated programs. Our Medicaid-

specific formulary and clinical programs are geared toward reducing fraud, waste, and abuse; improving

quality; managing costs; and improving outcomes. When state-mandated formularies or preferred drug

lists are required, we work with our clients to ensure compliance. We have robust specialty programs, and

our member engagement outreach efforts are designed to provide high-quality clinical care. Further, we

ensure members have access to the most cost-effective and clinically appropriate medication through

retail, specialty, and mail channels.

Our knowledge and expertise in managed Medicaid allow us to improve the per member per month

(PMPM) performance and operational efficiency of our managed Medicaid clients. We know plans are

most successful managing costs and meeting requirements when they have access to Medicaid experts

who are dedicated to helping them reach their goals. The clinical, account, and analytics experts in our

managed Medicaid segment provide detailed, consultative support to help our clients manage the

complexities of their business.

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• Encounter processing: We currently support Medicaid encounter submissions in 30 states. We

maintain a proprietary encounter processing system (EMS) that interfaces with our claims

adjudication engine to extract all adjudicated claims nightly. EMS prepares NCPDP encounter file

transactions for submission to states in the required formats.

• Formulary management: From closed formularies to therapeutic interchange programs, we have the

management expertise to develop the most appropriate level of formulary management. We

developed a Medicaid-specific formulary template to provide appropriate clinical and cost-effective

formulary management for managed Medicaid coverage providers.

• Fraud, waste, and abuse: We use comprehensive tools proven to solve fraud and abuse to

effectively control costs in relevant areas of a Medicaid environment.

• HEDIS scores: Through our comprehensive clinical solutions, we proactively engage members and

their prescribers with evidence-based clinical health improvement opportunities that support your

efforts to meet or exceed various HEDIS measures.

• NCQA accreditation: We support NCQA member connection standard MEM-4 by providing

members the information they need to understand and use their pharmacy benefits. This information

is provided through our website, Caremark.com, and over the phone.

• Network management: We offer multiple retail network options—including national, limited, and

custom—to provide optimal geographic coverage while allowing clients to manage their retail

pharmacy spending. We will develop a network with you that meets geo access requirements. We

have successfully implemented preferred network strategies in multiple states for our managed

Medicaid clients.

• PMPM performance: Our dedicated account teams provide ongoing analysis and consultation for a

variety of issues, including management of PMPM performance to meet client goals during

challenging budgetary times. We designed our PMPM trend forecasting tool specifically for health

plan support, given the need to evaluate opportunities at the therapeutic class level.

• Specialty medication management: Our specialty management capabilities address drug spending

under the pharmacy and medical benefits. We are the only specialty pharmacy that integrates rare

disease management—which is critical to controlling overall costs related to this small but high-cost

population.

• State requirements: We maintain a dedicated Medicaid regulatory compliance support team that

meets with client staff to discuss the regulations and Medicaid requirements in a state with regard to

PBM operations. They review new requirements to advise clients on the impact of our operations and

proactively identify new and proposed requirements and communicate them to clients.

• Utilization management: We create Medicaid-specific criteria for prior authorization, step therapy,

and quantity limit programs to control high utilization, abuse, and access to high-cost drugs. We also

provide exception processing and member-level overrides, upon request.

Customer feedback and our knowledge of industry trends have resulted in the following best practices

in our managed Medicaid segment.

CLINICAL SUPPORT

A clinical pharmacist with managed Medicaid experience is assigned to each account. Your clinical

pharmacist will provide comprehensive clinical solutions and online reporting to help you meet HEDIS

standards. They can also provide insight into how you can implement evidence-based interventions to

improve member health. Our clinical support can target health management programs for the Medicaid

population, including an emphasis on disease states/conditions such as HIV and behavioral health. You

can also take advantage of the managed Medicaid drug list that can save you time and money.

• Describe approach and strategy for project oversight and management.

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One of CVS Health’s key guiding principles is that we must execute against a single, integrated project

plan. Again, we will start with a best practice standard plan for this implementation and review it line by

line jointly to ensure that all activities are included. Each activity will ensure that we have tied in the

appropriate dependencies, that there is an appropriate amount of time for handoffs of work (examples:

deliver test results, review test results, provide feedback, clarify feedback, review final results, approve

results) to set the appropriate expectations. All tasks will be tied to one single, accountable owner rather

than groups of people or functional areas. The entire methodology around the plan is to ensure that it

clearly states who will be doing what through the entire implementation to ensure its success. Any need

to adjust these activities after they are agreed upon and baselined will be governed by a joint change

control process.

We use a comprehensive project plan that outlines each implementation task and includes defined

timelines and deliverables around documenting and approving client requirements in time to fully

configure and test prior to the plan effective date. Because of diverse client needs, our implementation

process is flexible enough to allow focus on the unique requirements of each client’s implementation. The

Implementation Project Manager and Account Team will ensure that our management and

implementation team work to deliver a successful implementation and will manage escalations as

needed.

Our project management methodology begins with an interrelated series of activities illustrated in the

Figure below; these activities enable and ultimately lead to:

• Development activities: Coordination of test and production eligibility files, review Enrollee

communications, build the benefit plan designs, and receipt of vendor transition files.

• Testing activities: unit, system integration, performance and user acceptance testing.

• Deployment activities: Coordination of Enrollee communications, receipt of final eligibility file,

Customer Care begins taking calls, and the website is available for Enrollees to access.

• Maintenance activities: Monitoring all post effective activities including Customer Care, Enrollee

communications, and ensuring accuracy of claim adjudication.

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Establishing and agreeing upon a formal escalation process early in the life of a project is key to its

success. As such we will work with the MCOs to establish a successful project escalation structure. In our

experience, the structure illustrated in the below Figure has proven effective.

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Each MCO’s dedicated Account Team will be involved with all aspects of Implementation to help ensure

seamless service and accountability. Each MCO’s Implementation Project Manager will be the single

point of contact and will lead and drive the implementation process from start to finish. Our proven

experience in health plan implementations has shown that the strategic advisory role of our dedicated

Implementation Project Manager is central to securing an efficient transition with minimal disruption.

CVS Health subject matter experts will be assigned to various project workstreams. We have a proven

process that tracks all the important milestones and timeframes, including standard templates for project

status reports. We propose holding weekly project status and issue management meetings with the LDH

team and each of the MCOs.

• Articulate the need for, and the ability to implement, a plan for continuous quality

improvement. This includes (but is not limited to) reviewing the quality of services provided

and staff productivity.

CVS Health and its integrated services including CVS Health is committed to continuous efforts to deliver

the best products and services to meet the needs of customers, including patients/plan members, clients,

and prescribers. CVS Health’s culture of continuous quality improvement is based on identifying

innovative solutions to pharmacy and health care delivery challenges. Our leaders must be the driving

force behind a high-performance culture created to help ensure the service and care provided to our

customers exceeds expectations. CVS Health colleagues embrace continuous quality improvement as

part of their everyday work responsibilities. Our front-line colleagues are encouraged to identify

opportunities to improve processes within their work environment and to bring forward larger ideas for

CVS Health to remain a market leader in pharmacy care innovation. It is this collaboration between

leaders and front-line staff that identifies opportunities to help improve quality and deliver the highest-level

quality of care and service to our customers.

Within each core business unit (BU), quality measures and goals are established and pursued to meet

the vision and mission of the individual BU, as well as the overall Program. These measures and goals

include:

• Alignment of governance, leadership, structures, and processes that drive results and drive

accountability throughout the organization

• Utilization of an organized, systematic approach to help improve and optimize quality, and to ensure

consistency of performance across service channels

• Provision of clear, concise messages to members and clients about our commitment to quality and

how we operationalize it to meet their needs and goals

• Development and sharing of organization-wide, best tools, practices, and methodologies to optimize

process-driven results

• Alignment of actions and measurements with CVS Health strategic imperatives and business

initiatives

• Alignment of/coordination between specific BU performance improvement initiatives based upon

recommendations from the Executive Leadership Team (ELT)

CVS Health PBM Services specifically strives for continuous quality improvement in the following areas:

• Medication (Drug Therapy) Management – safe, effective, and appropriate use of medications to

help increase adherence and deliver improved health outcomes.

• Operations Excellence – continuous high-quality execution in PBM and pharmacy processes and

human performance.

• Value and Affordability – process improvements that directly impact the cost to deliver quality

services to our customers.

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• Client and Member Satisfaction – identification of opportunities to measure and improve key

stakeholder experiences

QUALITY AT CVS HEALTH

The Program scope covers areas within CVS Health, including, but not limited to, CVS Health

Mail

Service Pharmacy, Customer Care, CVS Specialty

Pharmacy, Client/Account Management Services,

Drug Therapy Management, Health Call Center, Medicare Part D, Clinical and Professional Services, and

Accordant

Specifically, CVS Health provides quality service and care to our customers by utilizing consistent quality

improvement methodologies, cross departmental communication, and cross functional representation on

projects. CVS Health employs various evidence-based quality tools and methodologies (e.g., Lean Six

Sigma) to support continuous quality improvement. To evaluate the effectiveness of processes and

services:

• Key quality indicators are identified

• Data are collected

• Quantifiable performance metrics and goals are defined

• Baseline measurements and reporting timelines are established

For these performance goal(s), re-measurements are taken at established time frames (e.g., quarterly),

and if a measurement indicates a meaningful variation from the performance goal(s), the data are

analyzed; a root-cause matrix is completed; and a process improvement is identified, developed and

implemented, as needed. The new and revised processes are then monitored for effectiveness and

updated to maintain new performance levels. Ineffective process improvements are evaluated and

revised accordingly. Periodic re-measurement of performance metrics continues as long as necessary to

ensure defined goals are maintained.

PBM QUALITY SERVICES COMMITTEE (MAIL PHARMACY OPERATIONS,

SPECIALTY PHARMACY OPERATIONS, AND CUSTOMER CARE)

• Provides an annual report to the Quality Management Committee (QMC) on the effectiveness of the

Operations Quality management program

• Accurately tracks and reports on non-conformances for Mail and Specialty Operations and Clinical

Operations

• Provides ongoing analysis of non-conformance root causes

• Directly links into the various processes within the business for ongoing process improvement

initiatives

• Reviews credible safety literature, at least annually, for recommendations and application of best

practices regarding medication safety, risk-reduction tools, and error-prevention strategies

• Performs call monitoring to ensure effective, courteous, and accurate communication to members

regarding medications and pharmacy services

• Provides call mentoring to ensure appropriate communication to prescribers

CLINICAL QUALITY COMMITTEE (CQC)

• Oversee the clinical quality measurement/improvement activities of PBM clinical programs and

provide regular reports to the CMO concerning those activities

• Track ongoing accreditation activities and review indicators associated with various programs to

include, but not limited to, NCQA, URAC, and Medicare Part D

• Review the DTM Program quality indicators associated with the program

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• Oversee the annual review and update of clinical policies and other documents such as the UM

Program Description, Annual UM Program Evaluation and the CQC Charter

• Review quality dashboard results on a quarterly basis and provide an annual review to the QMC of

the effectiveness of the PBM’s clinical quality programs

• Provide oversight and monitor performance of UM programs, appeals, and Medicare Part D Quality,

and general clinical consistency by way of the following subgroups:

− UM Subgroup: Provide reporting of UM program activities, including operational metrics, audit

metrics, UM Annual Program Description and UM Annual Program Evaluation, and applicable

policies and procedures

− Vendor Subgroup: Manage all activities related to required quality oversight for Independent

Review Organization (IRO) vendors and internal clinicians and medical directors including the

quality of clinical appeal decisions, operational metrics, and relevant policies and procedures.

Subgroup also collaborates with internal Vendor Audits and Procurement regarding effective use

of external IRO vendors

− Medicare Part D Quality Subgroup: Monitor clinical outcomes, both effectiveness and quality, of

key enterprise clinical programs (e.g., MTM, concurrent and retroactive DUR) for CVS Health

Medicare Part D Enrollees. Subgroup also performs oversight of these clinical programs for

compliance with Centers for Medicare & Medicaid (CMS) regulations and guidance

− Clinical Consistency Committee: Evaluate and recommend the primary clinical guidelines to be

used as references across the enterprise in clinical communications and programs using an

analytical framework to ensure reproducibility as well as consistent clinical messages

ACCREDITATION

As a component of the Program, CVS Health monitors its compliance with various accreditation standards

that either directly or indirectly impact business operations. These include, but are not limited to, National

Committee for Quality Assurance (NCQA), URAC, Joint Commission, Drug Distributor Accreditation

(formerly VAWD), and Digital Pharmacy Accreditation (formerly VIPPS). If gaps are identified in processes

relative to standards, recommendations are made and plans are created and implemented to achieve full

compliance.

QUALITY MANAGEMENT PROCESS

LEAN SIX SIGMA

Colleagues are trained on continuous quality improvement methodologies, where applicable. One such

training program focuses on Lean Six Sigma. This training and mentoring program emphasizes the

following topics:

• Reduction/elimination of defects and/or waste from a process

• Timely flow of a process

• Reduction of variation using statistical tools

• Ongoing process control and continuous process improvement

• Yielding of dramatic results for the organization

• Define, Measure, Analyze, Improve, Control (DMAIC) model

Colleagues utilize the skills learned when leading and/or participating in improvement initiatives. There

are Six Sigma-certified Master Black Belts, Black Belts, and Green Belts available within CVS Health to

provide support for newly trained colleagues. Additionally, these Six Sigma-certified individuals are

utilized to broaden the skill depth of various business units when an opportunity for improvement has

been identified and an initiative is launched, including appropriate identification of metrics, data, and

more.

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TOTAL QUALITY MANAGEMENT (TQM) - QUALITY IMPROVEMENT

METHODOLOGIES

There are various process improvement methodologies that we utilize to support the quality framework

essential to building and re-enforcing a culture of continuous quality improvement. TQM emphasizes the

DMAIC process as a framework for identifying and investigating areas of the PBM for process/outcome

improvements. Teams using TQM frequently collaborate with and borrow techniques from the staff

trained in Lean Six Sigma.

REPORTING

The final component of the Program framework is the ongoing measurement and tracking of key

performance metrics/indicators. To ensure continuous quality, the enterprise has identified measurable

and data-driven key indicators. CVS Health uses this quantifiable data to identify significant quality

improvement opportunities and to design necessary corrective action plans.

A data-driven approach is also used to measure the effectiveness of these initiatives on business

practices and outcomes. Effectiveness is benchmarked against internal data (e.g., set quality goals and

year-over-year comparisons) and external performance data (e.g., URAC annual measures reporting)

where available. A data management program is in place to ensure the integrity of the key quality metrics

prior to the collection and analysis of work processes and subsequent evaluation of identified

performance initiatives.

In addition, CVS Health measures performance through other modalities, including satisfaction surveys,

consultant feedback, service warranties and performance related to client performance guarantees.

Information is tracked, analyzed, and utilized to identify gaps and opportunities for improvement for the

development of performance/quality improvement initiatives. Results of these activities are communicated

to relevant staff through the QMC.

• Demonstrate an understanding of and ability to implement data collection, as needed.

Data is derived from multiple sources depending on the program. In addition to pharmacy claims, data

may be self-reported by the patient, captured and reported by the CareTeam, or provided to us by the

medical vendor.

PATIENT REPORTED

Patient reported data can be captured through our specialty digital communication tools. This can also be

captured through our patient engagement points that happen as part of our standard specialty fill process,

through CVS Specialty Pharmacy, as well as when patients are engaged by the Accordant nurse team.

CLINICAL PROGRAM CAPTURE

We collect outcomes as part of our clinical program engagement with the prescriber. One example of this

is when we obtain lab value/results as part of the Specialty Guideline Management program and the

clinical review of a drug within the prior authorization process.

MEDICAL DATA

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We can often determine certain outcomes based on the prescription claims and history of the patient. For

example, if we see the start of a secondary treatment option it can indicate that the primary therapy did

not provide the overall intended outcome.

INTEGRATION AND REPORTING

Medical (ICD-10) data elements are captured and stored in the CVS Health Data Warehouse and our

fully-integrated technology system. This data streamlines processes because evaluations and outcomes

analysis can be made electronically, not requiring manual intervention. This data is also available to

clients for on demand reporting using our web-enabled reporting tool, RxNavigator.

Our RxClaim suite of systems offers a comprehensive set of automated reports that provide key financial

and utilization statistics essential to analyzing your pharmacy benefit program. Example reports include:

• Drug usage;

• Management activity;

• Enrollee utilization; and

• Pharmacy providers.

Unlike many pharmacy benefit managers, we use a hierarchy to set up eligibility. .

Custom Reporting

In addition to automated reports, our claims processing suite of systems has direct interface with our

proprietary RxNavigator reporting tool, which lets you manipulate your mail, retail, and specialty

prescription claims data and design custom reports with hundreds of variables. RxNavigator provides

secure access to pharmacy claims data using a Web browser, software upgrades are transparent to the

user, and no special software is needed to access the program. RxNavigator is user-friendly, allowing

flexible formatting and interactive dashboard capabilities.

DATA WAREHOUSING AND DECISION SUPPORT

Our Analytic Consultants and your designated representatives will have access to our Enterprise Data

Warehouse (EDW) repository. The EDW facilitates storage, linkage, and rapid retrieval of prescription

information and other health data and advanced tools, such as statistical analysis system software, which

allows large amounts of data to be accessed faster than ever before. While traditional reporting gives the

user a historical perspective, we provide intelligent reporting—reports with built-in interactive features that

enable users to manipulate data with future projections and understand how to influence and shape those

developments.

Our data warehousing technology employs a combination of proprietary and third-party-developed

software systems in a client/server environment. This system provides access to ad hoc queries and

reports (e.g., clinical, administrative, financial). Highlights of our data warehousing systems include:

• More than 220,000 pharmacy entities with name, address, and classification information;

• Multiple therapeutic classification systems;

• Online data resources that currently include nearly 16 million drug pricing records with historical

information spanning more than seven years;

• Oracle, Teradata and Hadoop

• Proprietary enhancement data sets.

Coordinating Data with MCOs

CVS Health works together with MCOs to coordinate care for their Enrollees through detailed activity

reporting, data integration and coordination of clinical services, where appropriate. We have accrued vast

experience working directly with medical health plans and payors to coordinate patient care as part of our

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focused campaign to connect and integrate care for Enrollees. We will provide full pharmacy claims data

and pharmacy insight reports to LDH and MCOs, and we offer clients a number of medication adherence

and care improvement products such as Pharmacy Advisor®, Transform Diabetes Care and Enrollee

targeting. These programs are designed to complement programs offered by a Enrollee’s medical

provider.

Our programs support providers by helping high-risk Enrollees address a multitude of drug-related

problems in an effort to improve overall health outcomes. We think long-term by continuing to work with

Enrollees post-hospital discharge to help prevent hospital readmission. All of these targeted efforts with

Enrollees are communicated to the provider and care managers to facilitate coordinated care.

ENROLLEE-LEVEL ACTIVITY REPORTING

We are committed to supporting LDH and MCOs through fact-based decision making, which is why we’ve

developed key clinical reporting tools that provide LDH and MCOs access to the information and insight

LDH and MCOs need to better understand and slow the growth of drug spending. Our clinical

management reports provide timely summary information, derived from the system’s detail-level data, to

answer management and operational questions more completely and facilitate decision-making

processes.

We have developed Enrollee-level activity data files in order to better coordinate with LDH’s and MCOs’

care management teams. These files arm the MCOs’ care manager with Enrollee-specific interventions,

based on the Enrollee’s most current treatment scenario.

The Adherence Activity Report provides detailed tangible measures of adherence such as persistency

curves, first-fill drop-off rates, medication possession ratio, and optimal adherence rates. The report was

designed to provide additional detailed adherence metrics within several commonly utilized therapeutic

classes.

DATA INTEGRATION

We coordinate with our clients’ disease management programs to help improve Enrollee identification and

predictive modeling to help boost engagement through targeted outreach. For example, we can send the

MCO biweekly first-fill maintenance reports. Also, our online reporting tool, RxNavigator, can be used by

the MCO to access patient-specific pharmacy data in near real-time to help optimize treatment plans,

including identifying and addressing gaps in care.

We currently have an integrated, enterprise data warehouse that integrates both medical and pharmacy

claims, and this integrated data set can be used across a number of programs that provide a longitudinal

view of Enrollee’s medical and pharmacy history.

Examples of how we have integrated this data include:

• Assessment of opportunities to better manage drugs that are delivered through both the medical and

pharmacy benefit, including support for rebates on medical specialty pharmacy, medical claims

repricing, site-of-care alignment, integrated prior authorization programs between medical and

pharmacy benefits, and drug benefit alignment. Uses include opportunity assessment and sizing,

program operations, and ongoing reporting and tracking.

• Collaboration with clients on scientific investigations into topics of interest such as total medical cost

for non-adherent populations as well as the appropriate use of medications with black-box warnings

in their population 65+ years of age

• Evaluation of the impact of an intervention such as a pharmacy benefit design change on the future

total cost of care (pharmacy and medical care costs)

• Integration of medical claims history as part of ‘smart coding/smart edits’ capability for prior

authorization programs. With smart PA, a prescription is submitted directly to the pharmacy. The

system reviews medical, lab and pharmacy data (provided by the client on a regular basis) to answer

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the clinical criteria. If met, the request is approved and drug dispensed with no Enrollee or physician

disruption.

CLINICAL SERVICE COORDINATION

Several clinical solutions utilize a collaborative case management approach that has proven successful in

effectively coordinating care and prevention with our MCO clients.

Our clinical pharmacists will work collaboratively with LDH and MCOs, their care coordination/case

management departments, and physicians to coordinate care for high-risk Enrollees. Through programs

such as closing gaps in medication therapy, Safety and Monitoring, and Retrospective DUR, we

communicate with both primary care physicians and case managers regarding pertinent Enrollee-specific

health care opportunities. These activities prompt physicians to act upon relevant information, while

looping in the case manager to update the Enrollee’s care plan and avoid duplicative efforts.

• Demonstrate an understanding of fiduciary duty, and knowledge of all applicable Louisiana

legislative requirements.

CVS Health will accept limited fiduciary responsibility for the purpose of adjudicating claims and

processing appeals related to prescription drug benefits provided by client.

Serving the Medicare and Medicaid markets is one of our corporate priorities. We have invested heavily

in both the infrastructure and personnel required to effectively serve the needs of health plans in the

complex and evolving government programs arena, and we will continue such investments to support

clients’ success.

The Government Services organization includes Regulatory Affairs, Client Advisors, and Operations

teams. Responsibilities include working closely with our Government Affairs team to influence CMS and

state policy decisions; reviewing, interpreting, communicating, and implementing new regulations; as

aligning our programs with quality measures; monitoring client performance; and driving improvement

initiatives.

Government Services Regulatory Affairs serves as the single source for all regulatory research and is

supported by both internal and external legal counsel when necessary. When regulatory issues become

known, the team works with the affected operational areas for implementation, including project

management and policy and procedures support. Government Services staff participate in PCMA and

NCPDP workgroups and coordinate with the Medicaid Health Plans of America and the Association for

Community Affiliated Plans.

During initial conversations related to implementation, the Government Services Medicaid Client Advisor

and Implementation Manager will meet with you to discuss the regulations and Medicaid requirements in

a particular state as they relate to PBM operations. Ongoing, Government Services and our legal team

will review new requirements to advise you on the impact to our operations. We will also proactively

identify new and proposed requirements and communicate them to you.

Government Services Regulatory Affairs will take the lead on developing regulatory crosswalks for the

Medicaid requirements in the dual demonstrations. We understand that state Medicaid agencies will have

significant oversight in the dual demonstrations, and we will build from the relationships we have with our

current clients, many of which participate.

• Define its functional approach in providing the services.

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CVS Health has extensive experience with applying state Medicaid uniform preferred drug lists (PDLs)

accurately and timely. Over half of the states where we have Medicaid MCO clients have state required

PDLs. We have experience applying state required benefit designs in the following states: Arizona,

Arkansas, Delaware, Florida, Illinois, Iowa, Kansas, Louisiana, Massachusetts, Michigan, Minnesota,

Mississippi, Nebraska, New Hampshire, Ohio, Pennsylvania, Rhode Island, Texas, Virginia and

Washington.

We routinely meet and exceed 95% PDL adherence in these states and will do so in Louisiana.

OUR APPROACH TO IMPLEMENTING BENEFIT CHANGES

CVS Health will provide LDH and the five MCOs with consistent, ongoing support regarding benefit

design changes by assigning a Benefit Relationship Manager (BRM) to your dedicated CVS Health

Service Team. The BRM will work to help make sure all benefit design changes are made on a timely

basis. The BRM also helps ensure quality delivered through - among other things - extensive plan change

testing.

When LDH provides notice with a benefit change, we will facilitate a requirements analysis documentation

meeting and draft a Requirements Analysis Document (RAD) subject to approval. We will provide LDH

and/or the MCOs with the tools to request benefit changes. We provide two routes for requesting benefit

changes. First, LDH and/or the MCOscan send a written request to your assigned BRM who completes a

benefit change request and forwards it to the Client Benefit department to input the change. We can also

provide LDH and/or the MCOs access to Salesforce.com for you to submit the request directly. This will

be a Single Sign On link available via Client Care Access (CCA), and the link will display as “CLIENT

CENTER”.

We use Salesforce.com to track and report benefit changes to track and report benefit changes to our

clients. This state-of-the-art Customer Relationship Management (CRM) tool enables us to track end-to-

end benefit changes and offers real-time monitoring. This technology enables you to keep track of the

status of its benefit changes. After all appropriate quality checks have been executed, we will send

confirmation to LDH and/or the MCOs confirming the change has been completed.

Once the Client Benefit department receives the change request, the benefits coding team will

immediately implement the change to ensure that the change is completed with one business day. If the

Benefits team identifies that more time is needed, they will provide the information related to an extension

to the CVS Health Account Director detailed to each

MCO. The Account Director will notify and request

permission to extend the implementation timeframe.

Extended timeframes may be needed when there are

complex clinical criteria for coding and testing; this may

be discussed and agreed upon as needed. The initial

implementation accuracy for go-live is at 100%. The maintenance of business plan changes

accuracy is at 99%.

The following is the process for benefit set-up and changes:

• LDH or the MCOs submits a benefit change request to CVS Health

• The Benefits team codes the change in a pre-production environment

• The Benefits team conducts testing using mock claims

• The BRM reviews the results with LDH and/or the MCOs.

• The approved benefit change coding is promoted to production

BENEFITS TESTING

In the past 12 months, CVS Health has

processed over 100,000 benefit change

requests with an average of 99%

accuracy.

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CVS Health tests benefits set up in a production-like environment that will include LDH and/or the MCO

Enrollee information for the greatest accuracy in identifying issues. After we code the benefit, we

conduct a detailed testing protocol to ensure 100% accuracy prior to production. LDH will have

complete access to review and conduct your own testing through the Client Test Environment (CTE)

portal. We find that this testing transparency has led to collaboratively identifying issues with initial

requirements gathering in addition to coding. The below table 1 details CVS Health’s testing protocol.

CVS Health Benefits Set Up Testing Protocol

Software

Quality

Assurance

Create test strategies and plans to help ensure software changes will

undergo comprehensive testing

Create test scenarios that map to each requirement within functional

specifications document

Benefit Plan

Testing

Review and create test scenarios that will map to requirement within the

Client Requirements Document (CRD)

Quality review of the testing encompasses the review of each unique

component CRD before promoting into production

Requirements: PDL, clinical criteria, administrative edits, pricing/network

and non-adjudication items

Benefit plans are tested by functional area based on plan set up and

components

Query

Validation

Predefined queries will be run in both a production-like and a production

environment to compare benefits coded vs. expected results, as

documented in CRD

The test results are reviewed with the benefits coding team to help ensure

that all discrepancies are addressed or validated with the client

Client

Implementation

Testing

Assesses real-time test scenarios focused on Enrollee experiences in a

production-like environment and validates their benefits coded and

compares the results with client requirements

Test results are reviewed and shared with business partners and the client

Client Testing

Clients are provided access to the CTE, which is a production-like

environment to perform their own testing with their Enrollees and benefit

plans

Clients can work with their Account Managers to obtain access to this

environment. Clients also may coordinate with their Account Managers to

receive additional training on CTE and the claim adjudication application.

If issues or errors arise, we take the following steps to quickly address and resolve:

• Proactive and Early Reviews - Live claim reviews are conducted beginning midnight of the effective

date of implementation. These live claim reviews continue at an established frequency throughout the

first few days and then taper-off over the next couple weeks until we both concur that no further

review at this level is needed.

• Prompt Prioritization - Errors are prioritized so that the corrections are updated in the system as

quickly as possible. Assessments are then made to determine if the error resulted in rejected claims.

If so, pharmacies are contacted to reprocess the claim and the Enrollee is contacted advising their

prescription is ready for pick up. If the error resulted in paid claims, but incorrectly paid, then a

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request is submitted to our Finance department to conduct the impact analysis and determine the

financial reconciliation needed.

• Financial Reconciliation Process - Once an error is identified and corrected in the system, the

issue is then sent to our Finance team for resolution and financial reconciliation of the incorrectly

processed claim(s). The Finance team researches the reported issue and confirms that the

appropriate corrections have been made in the system. The team then queries and analyzes claims

for the identified timeframe to determine the financial impact to the affected parties (e.g., Enrollee,

client, etc.) and then calculates any adjustments needed to make all parties whole for the impacted

transaction and initiates financial restitutions.

• Root Cause Analysis (RCA) - Benefits coding defects are assigned to an Advisor level resource to

perform and document the root cause of the defect and identify the defect prevention method (DPM).

Based on the RCA and DPM, the issues are fixed so they are not repeated again. Standard Test

Beds are updated accordingly to test for these defects going forward.

CVS Health’s Continuous Testing Processes

CVS Health uses sophisticated algorithms and real-time claims surveillance to automatically identify

benefits administration issues. These rule-based and machine-learning algorithms detect potential issues

with benefit coding during near real-time claims adjudication. Our claims surveillance process runs

multiple times a day. Because of the near real-time reporting, we are able to conduct rapid response

reviews of aberrant claims adjudication. If an actual issue is identified, the Claims Manager will notify LDH

and/or the MCO, and the benefits set up will be corrected within one business day.

We will document any benefit coding errors that resulted in the accuracy of implementing and maintaining

the PDL. We will report PDL adherence percentage to LDH on a monthly basis. The LDH-assigned Chief

Operational Officer will attest to the accuracy of the measurement. If the accuracy rate falls below 95%,

we will initiate a root cause analysis (described above) immediately to determine if the inaccuracy was

due to unusual circumstances or whether there is a systemic issue that must be corrected.

During its continuous testing and surveillance, CVS Health may identify opportunities for policy changes

that could benefit LDH and reduce provider administrative burden. When potential opportunities are

identified, we will conduct an analysis of the potential impact on providers, Enrollees, MCOs, and LDH to

ensure the change does not adversely impact any group, provides a measurable benefit such as

administrative simplification, and will not inadvertently compromise the administration of the LDH

pharmacy program. Opportunities for change will be presented to LDH at least quarterly.

Encounter Data

Following adjudication, claims are stored in the RxClaim platform. On a weekly basis, or more frequently if

needed, CVS Health will provide LDH (or designee) a full adjudicated claim encounter file. Whenever

claims are adjusted, the encounter files will be updated to reflect the adjustments. This encounter data file

will be designed to meet LDH specifications and can be altered to meet LDH’ changing needs. Any

changes to the encounter file will be implemented within 30 days of after LDH notifies CVS Health of a

change.

• Define its functional approach in identifying the tasks necessary to meet requirements.

We have implemented thousands of clients and structured the implementation process around proven

project management tools and methodology. We use a comprehensive project plan that outlines each

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implementation task and includes defined timelines and deliverables around documenting and approving

client requirements in time to fully configure and test prior to the plan effective date. Because of diverse

client needs, our implementation process is flexible enough to allow focus on the unique requirements of

each client’s implementation. The Implementation Project Manager and Account Team will ensure that

our management and implementation team work to deliver a successful implementation and will intervene

if necessary.

We currently support Medicaid encounter submissions in 37 states, including DC. Our proprietary system

prepares NCPDP encounter file transactions for submission to the states in the required formats. We also

receive response files from the state that identify rejected encounters and the corresponding rejection

codes. We can correct rejected encounters and resubmit them based on a LDH or the five MCOs agreed-

upon process. We also provide a reporting package that allows for health plan monitoring of the

delegated encounter function.

WORKING WITH STATES

Because our clients are the contract holders with state agencies, we typically have limited direct

involvement with the states. In a few instances, we had the opportunity to work directly with a state,

include California, New York, and South Carolina.

HISTORY AND EXPERIENCE

We have been processing encounter data for our clients that delegate this function to us since the

inception of our Medicaid business. We have successfully submitted encounters on all iterations of

NCPDP file format, and we validate each file in accordance with the individual state and/or CMS

requirements. Additional charges may apply for any custom formatting. We will work with LDH or the five

MCOs to define the frequency of file submissions and align all reporting, operational processes, and

tracking with state and/or CMS submission requirements.

IMPLEMENTATION TESTING

Encounter file testing is included in new client implementations if LDH or the five MCOs delegates the

encounter function to CVS Health and if the state has a testing environment available. We may need 120

days to implement testing if we have not worked with the state on encounter files previously.

We will establish file timeline dates and frequency with LDH or the five MCOs prior to implementation. In

all cases, we use state requirements as a guide for timeliness of submissions and resubmissions.

ENCOUNTER STATISTICS

Encounter Accuracy

Our encounter accuracy rate for Medicaid clients has been above 99.0%.

Encounter Data Acceptance and Rejection

Our encounter data acceptance/rejection rate across all of our Medicaid clients has been 98.1%.

Quality Reports

Across our clients and states, we average over 97% initial acceptance. We work with our clients and

internal partners to drive final rejection rates to under 1% within our control (excludes retro-eligibility

issues and value-added services).

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• Describe the approach to Project Management and Quality Assurance.

Please refer to the response above regarding CVS Health’s approach to Project Management during

implementation and through the life of the contract, as well as our Continuous Quality Assurance Program

that is utilized in all facets of our PBM service model.

• Provide a proposed Project Work Plan that reflects the approach and Agile project

management methodology, tasks and services to be performed, deliverables, timetables, and

staffing.

Our implementation process is aligned with LDH’s complex pharmacy benefit management needs.

Subject matter experts are assigned, and implementations managed based on a detailed project plan and

proven systems used to track timeframes and critical milestones.

For context, an illustrative high-level implementation timeline is provided below in Figure 4. This timeline

represents workstreams associated with a wide variety of CVS Health PBM implementations; this timeline

– and the underlying detailed implementation work plan – will be tailored to include the work streams

specific to LDH’s implementation.

Figure 4. High-Level Model Implementation Timeline

The detailed implementation work plan requested is included in Section IV Tab 4. Our work plan reflects

key work streams within our solution implementation, including:

• Plan Design

• Eligibility

• Management Reports

• Enrollee Communications

Business Area Month 1 Month 2 Month 3 Month 4 Month 5 Pre-Imp.

Discovery

(post-award tasks)

Define Account Structure (CAG)

Underwriting & Network Pricing

Vendor Transition

Clinical

Benefits

Specialty

Mail Ops

Eligibility

Consumer Driven Health***

Customer Care

Member Communication

Finance

Claims File

eBusiness

Encounter File

Integration Testing***

Effective

Date

Collect

Build

Collect Build

Collect Build Test

C Build

Build

Test

Collect Build Test

Collect

Build

Collect Build

Test

Collect Test

BCollect T

Deploy

Collect Build Test

Deploy

Kick-Off Meeting

T Deploy

Deploy

C TestBuild

Collect Build Test Deploy

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• Clinical

• Finance

• Enrollee Data Transition

We wanted to note the following assumptions that went into the construction of this plan:

1. Given that this plan must be jointly owned by CVS Health and LDH, any scope changes post baseline

will require joint change control.

2. Requirements will be finalized and jointly signed off in an appropriate, mutually agreed upon

timeframe after project kickoff.

3. The plan accounts for appropriate client review and sign off of key documents (requirements, test

results, etc.).

4. The plan establishes a “pencils-down” period prior to go live to ensure that no late activities introduce

changes in the solution that could adversely impact solution deployment.

Please refer to Section V Tab 3 for the Sample Implementation Timeline

• Provide approach and detail the methodology/formula in defining the applicable transaction

fee.

Transaction fee was calculated by incorporating all costs associated with requested and required services

in this request for proposal. Transaction fee will apply to all paid claims

• Explain processes to implement in order to complete all tasks and phases of the project in a

timely manner, as outlined within Section 2. Scope of Work.

We are committed to providing you with a smooth and detail-focused implementation process. We are

aware that every health plan is unique in its service delivery infrastructure, lines of business, and

membership. Our long history of supporting health plans has given us the knowledge to understand

health plan complexities, forecast obstacles, and mitigate risks of member disruption during

implementation. You will benefit from our extensive experience implementing and supporting complex

and varied plan designs, including options such as CDH, accumulators, multiple deductibles, and more.

We have extensive experience in implementing clients with complex pharmacy benefits. These

implementations typically consist of the receipt of multiple eligibility feeds, the building of hundreds of

different benefit plan designs, and the delivery of complex communications to members. As a testament

to our configurable setups, in the 2020 welcome season we implemented 371 clients of which 280 were

new clients – serving 4.3 million members.

We handled more than 14,209 mailing projects, 1832 inbound member data transition files, and deployed

approximately 54,000 plan benefit changes. We had 387 million test claims processed. On January 7

the busiest day of the year, we processed over 11.3 million claims and a record 249.5 million claims in the

month of January. We are pleased to report our client satisfaction rating is 97%.

We use our claims processing system as the backbone of our primary operations for pharmacy benefit

administration and claims processing. This will enable a smooth transition for current Blue clients, as we

have great depth of experience with all of the functionality and architecture. In addition, we leverage

Artificial Intelligence and Machine Learning technologies to perform several levels of testing, to help

ensure all possible combinations of edits and criteria are correctly executed.

CRUCIAL STEPS FOR A SUCCESSFUL IMPLEMENTATION

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At the initial planning meeting, the Strategic Account Executive, Account Manager, Implementation

Program Manager, and your designated benefit personnel will meet to identify a comprehensive list of all

tasks and timeframes that need to be completed by each party. We believe that a successful

implementation hinges on the completion of each identified task. Based on our experience in

implementing clients, the following factors prove critical for a smooth implementation: