Lowest net cost standard and book of business comparison

No evidence quotation was recorded for this finding.

Recorded reference: No page reference recorded

Published rationale. I looked for a lowest net cost standard, an annual book of business comparison and disclosure of drugs placed above cheaper equivalents in Exhibit 7 Sections 1 through 4 on pages 43 and 44, the Drug List and Utilization Management definitions on pages 48 and 49, and the rebate disclosures in Exhibit 3 Sections 4 and 5 on pages 27 and 28. The text says Prime provides Drug List management in accordance with NCQA and URAC standards (page 43), which is a process accreditation and not a cost standard, and it discloses that rebate arrangements are based on formulary status and market share (page 43), which describes the incentive without constraining it. The Expected Rebates projection on page 28 is a revenue forecast for the Claim Administrator, not a net cost comparison for the plan. No lowest net cost obligation, comparison report or placement disclosure appears anywhere, so missing.

“Not addressed” is this published review’s conclusion about the produced text, not proof that a provision is absent from every version or withheld document.

No evidence quotation was recorded for this finding.

Recorded reference: No page reference recorded

Published rationale. I examined the Drug List and formulary provisions on Pages 43 through 49, as well as the administrative services descriptions on Pages 18 through 20 of the document. The text contains no commitment to a lowest net cost standard for this Plan, no annual comparative analysis against the PBM book of business, and no required disclosures when a higher cost product is placed ahead of an equivalent therapy. Because these standards are entirely absent, this item is missing.

“Not addressed” is this published review’s conclusion about the produced text, not proof that a provision is absent from every version or withheld document.

No evidence quotation was recorded for this finding.

Recorded reference: No page reference recorded

Published rationale. I reviewed the drug list and manufacturer contracting provisions on pages 43 and 44, the pharmacy network provision on page 44, and drug list and utilization management definitions on pages 48 and 49. Nothing makes lowest net cost to this city an enforceable formulary standard, requires an annual comparison to the administrator's or Prime's whole book, or mandates disclosure of each placement above a cheaper therapeutic equivalent with a reason. Page 44 even describes rebate arrangements based on formulary status or market share, without a countervailing net cost rule. The benefit application and fee addendum are absent, but the particular standard and comparative report are not addressed in the produced formulary provisions.

“Not addressed” is this published review’s conclusion about the produced text, not proof that a provision is absent from every version or withheld document.

No evidence quotation was recorded for this finding.

Recorded reference: No page reference recorded

Published rationale. I looked in the Exhibit 7 drug list and rebate sections on Pages 43 and 44, in the formulary promotion sentence, and in the reporting services on Pages 18 and 19. Nothing requires formulary decisions to meet a lowest net cost standard for this plan. Nothing requires an annual comparison against Claim Administrator's or Prime's whole book of business. Nothing requires disclosure, with a reason, when a drug is placed above a cheaper equivalent. Page 43 says rebate arrangements are based on formulary status, market share, or similar manufacturer arrangements, and that those contracts are for the vendor's benefit. That describes the vendor's incentive. It is not a lowest net cost standard and it is not a book of business report. The model contract requires the standard, the annual comparison, and disclosure of a higher cost placement with the reason. None of those terms is addressed in the produced text, and none is identified as living in an omitted attachment. This item is missing.

“Not addressed” is this published review’s conclusion about the produced text, not proof that a provision is absent from every version or withheld document.

No evidence quotation was recorded for this finding.

Recorded reference: No page reference recorded

Published rationale. The model term requires formulary decisions to meet a lowest net cost standard for this specific plan, an annual comparison against the vendor's whole book of business, and disclosure with reasons when a drug is placed above a cheaper equivalent. I looked at Exhibit 7 sections 3 and 4 on pages 43 and 44 covering Drug List services and rebate management, the Drug List definition on page 48, and the pricing terms on pages 45 and 46. Page 43 mentions only that the Claim Administrator may promote dispensing consistent with the selected Drug List, and page 44 acknowledges rebate arrangements are based on formulary status and market share, which points toward rebate driven placement rather than net cost. No lowest net cost standard, no book of business comparison, and no placement disclosure appears anywhere in the document.

“Not addressed” is this published review’s conclusion about the produced text, not proof that a provision is absent from every version or withheld document.