Common use of Part D Rewards and Incentives Programs Structure and Content Clause in Contracts

Part D Rewards and Incentives Programs Structure and Content. A. If the Part D Sponsor is implementing a Part D RI Program under the Model, the parties acknowledge that Part D Sponsor has submitted as part of its application for participation in the Part D Senior Savings Model, a proposal to offer one or more Part D RI Programs to Targeted Enrollees. B. Part D Sponsor shall identify Targeted Enrollees for the Part D RI Program without discrimination and using objective criteria that comply with the terms of the Addendum, including this Appendix 2, and are specified in the Approved Proposal or are otherwise approved in writing, in advance by CMS. Such objective criteria must identify the subset of enrollees who would receive the greatest health care value from receiving the benefits or participating in the activities associated with the particular reward or incentive in the Part D RI Program and must include that the enrollee have Diabetes or Pre-diabetes. C. The Part D Sponsor acknowledges that for each Part D RI Program the Approved Proposal contains the following: i. The goals of the Part D RI Program; ii. The list of Model PBPs in which the Part D RI Program will be implemented; iii. The nature and scope of the Part D RI Program, including the criteria for identifying Targeted Enrollees and the beneficiary engagement methodology; iv. The eligibility criteria that must be met for an individual Targeted Enrollee to qualify to receive the reward or incentive, including the healthcare activity that must be completed for the reward or incentive to be available, and, if eligibility includes an adherence metric, the specific criteria for measuring adherence and the evidence base to support the clinical appropriateness of the adherence criteria; v. The type and per unit value of each reward or incentive and the method for providing the reward or incentive to eligible Targeted Enrollees; vi. The maximum number and frequency of the rewards and incentives that may be obtained by an eligible Targeted Enrollee per year; and vii. The evidence base and theory of change used to develop the reward or incentive and the expected outcomes of the Part D RI Program(s). D. The Part D Sponsor shall: i. Provide the rewards and incentives only to eligible Targeted Enrollees and only in accordance with the Approved Proposal and this Addendum; ii. Comply with the standards for Rewards and Incentives as outlined in the Medicare Managed Care Manual Ch. 4 § 100 issued and effective April 22, 2016 at available at ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/Regulations-and- Guidance/Guidance/Manuals/Downloads/mc86c04.pdf except as waived or otherwise modified by the Addendum, including Appendix 1 or this Appendix 2; iii. Not provide any reward or incentive if its value exceeds the value of the expected impact on enrollee behavior or the expected benefit of the healthcare service or activity on which receipt of the reward or incentive is based, except that (notwithstanding the Rewards and Incentives provisions in the Medicare Managed Care Manual Ch. 4 § 100), the value of the individual reward or incentive may exceed the cost of the health- related service or activity itself, so long as the cost of the health-related service or activity is less than the expected benefit of the health care item or service on which receipt of the reward is based; iv. Ensure that Part D RI Programs are complete by the end of a plan year. Part D RI programs may allow the enrollee to carry over unspent value of rewards and incentives from one contract year to the next for the enrollee’s use, but the Part D Sponsor must not require additional actions by the enrollee in the next plan year to receive that reward or incentive; v. Ensure that Rewards and incentives are tangible items that align with the purpose of the Part D RI program and must directly benefit the enrollee; and, vi. Limit the provision of rewards and incentives to each enrollee to a maximum annual aggregate amount of $600.00 for all rewards and incentives in this Model and the MA- VBID Model, and include the per unit value of each reward and incentive it offers to a Targeted Enrollee under the MA-VBID Model when determining whether a reward or incentive to such Targeted Enrollee would exceed the annual aggregate amount on the total value of rewards and incentives that the Part D Sponsor can provide to a Targeted Enrollee under this Model. E. Part D Sponsor shall ensure that any rewards and incentives in its Part D RI Programs are furnished in accordance with the goals of the program set forth in the Approved Proposal, which must reward or incentivize one or more of the following: i. Participation of Targeted Enrollees in a disease state management programs specifically for individuals with Pre-diabetes or Diabetes. ii. Participation in a Part D Sponsor’s medication therapy management (MTM) program that includes a focus on a Pre-diabetes or Diabetes. iii. Receipt by the Targeted Enrollee of preventative health services, such as receiving Part D covered vaccines. iv. Participation in educational activities designed to enable Targeted Enrollees to better understand their Part D plan benefit, costs, and clinically appropriate coverage alternatives, including biosimilars and generics. F. In offering any reward or incentive for participation in an MTM program, the Part D Sponsor shall comply with existing CMS requirements for MTM programs, as set forth in 42 C.F.R. § 423.153. G. In offering any reward or incentive for participation in preventive health services, the Part D Sponsor may design a program with the overall goal of improving medication adherence, however the Part D Sponsor shall not condition any such reward or incentive solely on prescription fills or clinical outcomes, and shall not furnish any such reward or incentive for a service that is not clinically indicated for the beneficiary. H. In implementing and operating its Part D RI Program, the Part D Sponsor shall not: i. Provide a reward or incentive to a Medicare beneficiary who is not enrolled in a Model PBP. ii. Provide a reward or incentive to an enrollee in a Model PBP who does not have a Diabetes or Pre-diabetes. iii. Provide a reward or incentive to an enrollee in a Model PBP in connection with the same healthcare activity or service that the enrollee completed to be eligible for a reward or incentive under the MA-VBID Model. iv. Structure a Part D RI Program to discourage clinically indicated medication use. v. Use a Part D RI Program largely to market a PBP or encourage beneficiaries to remain with a specific plan. vi. Use a Part D RI Program to, in any way, choose or solicit healthier enrollees over enrollees who the sponsors believe may be less healthy. vii. Create a Part D RI Program that discriminates against enrollees based on race, national origin, limited English proficiency, gender, disability, chronic disease, whether a person resides or receives services in an institutional setting, frailty status, health status, or other prohibited basis. viii. Provide rewards or incentives in the form of cash, cash equivalents, or other monetary rebates, or use rewards or incentives to decrease cost-sharing or plan premium; ix. Identify Targeted Enrollees based on the identity of their pharmacy provider. x. Use a Part D RI Program that is designed to allow for rewards and incentives to be won based on probability; xi. Use prescription fills or adherence as the sole basis for providing a reward or incentive. xii. Incentivize enrollees to use mail service pharmacies, preferred pharmacies, or any other specific network providers. xiii. Receive or use funding, in-kind resources, or any kind of remuneration provided directly or indirectly by a drug manufacturer. This includes, but is not limited to, the use of personnel affiliated with a drug manufacturer, or manufacturer-financed coupons or discounts provided to a beneficiary. xiv. Receive or use funding, in-kind resources, or any kind of remuneration provided directly or indirectly by a pharmacy or entity that owns or operates pharmacies. This includes use of personnel affiliated with a pharmacy, or pharmacy-financed coupons or other discounts provided to a beneficiary.

Part D Rewards and Incentives Programs Structure and Content. A. 1. If the Part D Sponsor is implementing a Part D RI Program under the Model, the parties acknowledge that Part D Sponsor has submitted as part of its application for participation in the Part D Senior Savings Model, a proposal to offer one or more Part D RI Programs to Targeted Enrollees. B. 2. Part D Sponsor shall identify Targeted Enrollees for the Part D RI Program without discrimination and using objective criteria that comply with the terms of the Addendum, including this Appendix 2, and are specified in the Approved Proposal or are otherwise approved in writing, in advance by CMS. Such objective criteria must identify the subset of enrollees who would receive the greatest health care value from receiving the benefits or participating in the activities associated with the particular reward or incentive in the Part D RI Program and must include that the enrollee have Diabetes or Pre-diabetes. C. The 3. Part D Sponsor acknowledges that for each Part D RI Program the Approved Proposal contains the following: i. The goals of the Part D RI Program; ii. The list of Model PBPs in which the Part D RI Program will be implemented; iii. The nature and scope of the Part D RI Program, including the criteria for identifying Targeted Enrollees and the beneficiary engagement methodology; iv. The eligibility criteria that must be met for an individual Targeted Enrollee to qualify to receive the reward or incentive, including the healthcare activity that must be completed for the reward or incentive to be available, and, if eligibility includes an adherence metric, the specific criteria for measuring adherence and the evidence base to support the clinical appropriateness of the adherence criteria; v. The type and per unit value of each reward or incentive and the method for providing the reward or incentive to eligible Targeted Enrollees. Part D Sponsor must reasonably establish value for each healthcare-related service or activity for which Part D sponsor is providing rewards and incentives; vi. The maximum number and frequency of the rewards and incentives that may be obtained by an eligible Targeted Enrollee per year; and vii. The evidence base and theory of change used to develop the reward or incentive and the expected outcomes of the Part D RI Program(s). D. The 4. Part D Sponsor shall: i. Provide the rewards and incentives only to eligible Targeted Enrollees and only in accordance with the Approved Proposal and this Addendum; ii. Comply with the standards for Rewards rewards and Incentives incentives as outlined in the Medicare Managed Care Manual Ch. 4 § 100 issued and effective April 22, 2016 at available at ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/Regulations-and- Guidance/Guidance/Manuals/Downloads/mc86c04.pdf except as waived or otherwise modified by the Addendum, including Appendix 1 or this Appendix 2; iii. Not provide any reward or incentive if its value exceeds the value of the expected impact on enrollee behavior or the expected benefit of the healthcare service or activity on which receipt of the reward or incentive is based, except that (notwithstanding the Rewards and Incentives provisions in the Medicare Managed Care Manual Ch. 4 § 100), the value of the individual reward or incentive may exceed the cost of the health- health-related service or activity itself, so long as the cost of the health-related service or activity is less than the expected benefit of the health care item or service on which receipt of the reward is based; iv. Ensure that Part D RI Programs are complete by the end of a plan year. Part D RI programs may allow the enrollee to carry over unspent value of rewards and incentives from one contract year to the next for the enrollee’s use, but the Part D Sponsor must not require additional actions by the enrollee in the next plan year to receive that reward or incentive; v. Ensure that Rewards rewards and incentives are tangible items that align with the purpose of the Part D RI program and must directly benefit the enrollee; and, vi. Limit the provision of rewards and incentives to each enrollee to a maximum annual aggregate amount of $600.00 for all rewards and incentives in this Model and the MA- VBID Model, and include the per unit value of each reward and incentive it offers to a Targeted Enrollee under the MA-VBID Model when determining whether a reward or incentive to such Targeted Enrollee would exceed the annual aggregate amount on the total value of rewards and incentives that the Part D Sponsor can provide to a Targeted Enrollee under this Model. E. 5. Part D Sponsor shall ensure that any rewards and incentives in its Part D RI Programs are furnished in accordance with the goals of the program set forth in the Approved Proposal, which must reward or incentivize one or more of the following: i. Participation of Targeted Enrollees in a disease state management programs specifically for individuals with Pre-diabetes or Diabetes. ii. Participation in a Part D Sponsor’s medication therapy management (MTM) program that includes a focus on a Pre-diabetes or Diabetes. iii. Receipt by the Targeted Enrollee of preventative health services, such as receiving Part D covered vaccines. iv. Participation in educational activities designed to enable Targeted Enrollees to better understand their Part D plan benefit, costs, and clinically appropriate coverage alternatives, including biosimilars and generics. F. 6. In offering any reward or incentive for participation in an MTM program, the Part D Sponsor shall comply with existing CMS requirements for MTM programs, as set forth in 42 C.F.R. CFR § 423.153. G. 7. In offering any reward or incentive for participation in preventive health services, the Part D Sponsor may design a program with the overall goal of improving medication adherence, however the Part D Sponsor shall not condition any such reward or incentive solely on prescription fills or clinical outcomes, and shall not furnish any such reward or incentive for a service that is not clinically indicated for the beneficiary. H. 8. In implementing and operating its Part D RI Program, the Part D Sponsor shall not: i. Provide a reward or incentive to a Medicare beneficiary who is not enrolled in a Model PBP. ii. Provide a reward or incentive to an enrollee in a Model PBP who does not have a Diabetes or Pre-diabetes. iii. Provide a reward or incentive to an enrollee in a Model PBP in connection with the same healthcare activity or service that the enrollee completed to be eligible for a reward or incentive under the MA-VBID Model. iv. Structure a Part D RI Program to discourage clinically indicated medication use. v. Use a Part D RI Program largely to market a PBP or encourage beneficiaries to remain with a specific plan. vi. Use a Part D RI Program to, in any way, choose or solicit healthier enrollees over enrollees who the sponsors believe may be less healthy. vii. Create a Part D RI Program that discriminates against enrollees based on race, national origin, limited English proficiency, gender, disability, chronic disease, whether a person resides or receives services in an institutional setting, frailty status, health status, or other prohibited basis. viii. Provide rewards or incentives in the form of cash, cash equivalents, or other monetary rebates, or use rewards or incentives to decrease cost-sharing or plan premium;. ix. Identify Targeted Enrollees based on the identity of their pharmacy provider. x. Use a Part D RI Program that is designed to allow for rewards and incentives to be won based on probability; xi. Use prescription fills or adherence as the sole basis for providing a reward or incentive. xii. Incentivize enrollees to use mail service pharmacies, preferred pharmacies, or any other specific network providers. xiii. Receive or use funding, in-kind resources, or any kind of remuneration provided directly or indirectly by a drug manufacturer. This includes, but is not limited to, the use of personnel affiliated with a drug manufacturer, or manufacturer-financed coupons or discounts provided to a beneficiary. xiv. Receive or use funding, in-kind resources, or any kind of remuneration provided directly or indirectly by a pharmacy or entity that owns or operates pharmacies. This includes use of personnel affiliated with a pharmacy, or pharmacy-financed coupons or other discounts provided to a beneficiary. xv. Provide RI that can be used for the purchase of alcohol, tobacco, gambling, or firearms.

Part D Rewards and Incentives Programs Structure and Content. A. If the Part D Sponsor is implementing a Part D RI Program under the Model, the parties acknowledge that Part D Sponsor has submitted as part of its application for participation in the Part D Senior Savings Model, a proposal to offer one or more Part D RI Programs to Targeted EnrolleesPrograms. B. Part D Sponsor shall identify Targeted Enrollees for the each Part D RI Program without discrimination and using objective criteria that comply with the terms of the Addendum, including this Appendix 2, and are specified in the Approved Proposal or are otherwise approved in writing, in advance writing by CMS. Such objective criteria must identify the subset of enrollees who would receive the greatest health care value from receiving the benefits or participating in the activities associated with the particular reward or incentive in the Part D RI Program and must include that the enrollee have Diabetes or Pre-diabetes. C. The Part D Sponsor acknowledges that for each Part D RI Program the Approved Proposal contains the following: i. The goals of the Part D RI Program; ii. The list of Model PBPs in which the Part D RI Program will be implemented; iii. The nature and scope of the Part D RI Program, including the criteria for identifying Targeted Enrollees and the beneficiary engagement methodology; iv. The eligibility criteria that must be met for an individual Targeted Enrollee targeted enrollee to qualify to receive the reward or incentive, including the associated healthcare activity that must be completed for the reward or incentive to be available, and, if eligibility includes an adherence metric, the specific criteria for measuring adherence and the evidence base to support the clinical appropriateness of the adherence criteria; v. The type and per unit value of each reward or incentive and the method for providing the reward or incentive to eligible Targeted Enrollees; vi. The maximum number and frequency of the rewards and incentives that may be obtained by an eligible Targeted Enrollee per year; and vii. The evidence base and theory of change used to develop the reward or incentive and the expected outcomes of the Part D RI Program(s)Program. D. The Part D Sponsor shall: i. Provide the rewards and incentives only to eligible Targeted Enrollees and only in accordance with the Approved Proposal and this Addendum; ii. Not provide any individual reward or incentive the value of which exceeds the value of the expected impact on enrollee behavior or benefit of the healthcare activity on which receipt of the reward or incentive is based, but notwithstanding, the Rewards and Incentives provisions in the Medicare Managed Care Manual Ch. 4 § 100, may provide an individual reward or incentive the value of which exceeds the cost of the health- related service or activity itself; iii. Limit the provision of rewards and incentives to each enrollee to a maximum annual aggregate amount of $600.00 for all rewards and incentives in this Model; and iv. Comply with the standards for Rewards and Incentives as outlined provisions in the Medicare Managed Care Manual Ch. 4 § 100 issued and effective April 22, 2016 at available at ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/Regulations-and- Guidance/Guidance/Manuals/Downloads/mc86c04.pdf except as waived or otherwise modified by the Addendum, including Appendix 1 or this Appendix 2; iii. Not provide any reward or incentive if its value exceeds the value of the expected impact on enrollee behavior or the expected benefit of the healthcare service or activity on which receipt of the reward or incentive is based, except that (notwithstanding the Rewards and Incentives provisions in the Medicare Managed Care Manual Ch. 4 § 100), the value of the individual reward or incentive may exceed the cost of the health- related service or activity itself, so long as the cost of the health-related service or activity is less than the expected benefit of the health care item or service on which receipt of the reward is based; iv. Ensure that Part D RI Programs are complete by the end of a plan year. Part D RI programs may allow the enrollee to carry over unspent value of rewards and incentives from one contract year to the next for the enrollee’s use, but the Part D Sponsor must not require additional actions by the enrollee in the next plan year to receive that reward or incentive; v. Ensure that Rewards and incentives are tangible items that align with the purpose of the Part D RI program and must directly benefit the enrollee; and, vi. Limit the provision of rewards and incentives to each enrollee to a maximum annual aggregate amount of $600.00 for all rewards and incentives in this Model and the MA- VBID Model, and include the per unit value of each reward and incentive it offers to a Targeted Enrollee under the MA-VBID Model when determining whether a reward or incentive to such Targeted Enrollee would exceed the annual aggregate amount on the total value of rewards and incentives that the Part D Sponsor can provide to a Targeted Enrollee under this Model. 2 E. Part D Sponsor shall ensure that any rewards and incentives in its Part D RI Programs are furnished in accordance with the goals of the program set forth in the Approved Proposal, which must reward or incentivize one or more of the following: i. Participation of Targeted Enrollees with Pre-diabetes or Diabetes in a disease state management programs specifically for individuals with Pre-diabetes or Diabetes. ii. Participation in a Part D Sponsor’s medication therapy management (MTM) program that includes include a review of all of the Targeted Enrollee’s medications and a focus on a Pre-Pre- diabetes or Diabetes. iii. Receipt by the Targeted Enrollee with Pre-Diabetes or Diabetes of preventative health services, such as receiving Part D covered vaccines. iv. Participation in educational activities designed to enable Targeted Enrollees with Pre- diabetes or Diabetes to better understand their Part D plan benefit, costs, and clinically clinically- appropriate coverage alternatives, including biosimilars and generics. F. In offering any reward or incentive for participation in an MTM program, the Part D Sponsor shall comply with existing CMS requirements for MTM programs, as set forth in 42 C.F.R. § 423.153. G. In offering any reward or incentive for participation in preventive health services, the Part D Sponsor may design a program with the overall goal of improving medication adherence, however the Part D Sponsor shall not condition any such reward or incentive solely on prescription fills or clinical outcomes, and shall not furnish any such reward or incentive for a service that is not clinically indicated for the beneficiary. H. In implementing and operating its Part D RI Program, the Part D Sponsor shall not: i. Provide a reward or incentive to a Medicare beneficiary who is not enrolled in a Model PBP. ii. Provide a reward or incentive to an enrollee in a Model PBP who does not have a Diabetes or Pre-diabetes. iii. Provide a reward or incentive to an enrollee in a Model PBP in connection with the same healthcare activity or service that the enrollee completed to be eligible for a reward or incentive under the MA-VBID Model. iv. Structure a Part D RI Program to discourage clinically indicated medication use. v. Use a Part D RI Program largely to market a PBP or encourage beneficiaries to remain with a specific plan. vi. Use a Part D RI Program to, in any way, choose or solicit healthier enrollees over enrollees who the sponsors believe may be less healthy. vii. Create a Part D RI Program that discriminates against enrollees based on race, national origin, limited English proficiency, gender, disability, chronic disease, whether a person resides or receives services in an institutional setting, frailty status, health status, or other prohibited basis. viii. Provide rewards or incentives in the form of cash, cash equivalents, or other monetary rebates, or use rewards or incentives to decrease cost-sharing or plan premium; ix. Identify Targeted Enrollees based on the identity of their pharmacy provider. x. Use a Part D RI Program that is designed to allow for rewards and incentives to be won based on probability; xi. Use prescription fills or adherence as the sole basis for providing a reward or incentive. xii. Incentivize enrollees to use mail service pharmacies, preferred pharmacies, or any other specific network providers. xiii. Receive or use funding, in-kind resources, or any kind of remuneration provided directly or indirectly by a drug manufacturer. This includes, but is not limited to, the use of personnel affiliated with a drug manufacturer, or manufacturer-financed coupons or discounts provided to a beneficiary. xiv. Receive or use funding, in-kind resources, or any kind of remuneration provided directly or indirectly by a pharmacy or entity that owns or operates pharmacies. This includes use of personnel affiliated with a pharmacy, or pharmacy-financed coupons or other discounts provided to a beneficiary.