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[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"form revised 8/8/2019"]
[]
[]
[null,"MANAGED CARE SYSTEMS"]
[null,"P.O. Box 64975, St. Paul, MN 55164-0975"]
[null,"Telephone: 651-201-5100"]
[null,"Email:",null,"health.managedcare@state.mn.us"]
[]
[null,"Pharmacy Benefit Manager Request for Waiver"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,"Plan Year:"]
[]
[null,"Please ensure that information contained on this waiver request coincides with information provided on the"]
[null,"geographical access maps and provider file."]
[]
[null,"1.","Name and Title of Person Submitting this Document:"]
[]
[null,null,"PBM Corporate Name",null,null,null,null,null,null,null,null,"PBM Network Name",null,null,null,null,null,null,null,null,"PBM Network ID",null,null,null,null,null,"Reason Code 4: Network Structure*-Leave blank"]
[null,null,"<enter carrier>",null,null,null,null,null,null,null,null,"<enter network name>",null,null,null,null,null,null,null,null,"<enter network id starts with PBM>",null,null,null,null,null,"<select one>"]
[null,null,"Contact Name",null,null,null,null,null,null,null,null,"Contact Title",null,null,null,null,null,null,null,null,"Date",null,null,null,null,null,"Reason Code 4: Enrollees in Network*-Leave blank"]
[null,null,"<enter name>",null,null,null,null,null,null,null,null,"<enter title>",null,null,null,null,null,null,null,null,"<enter date in month/day/year>"]
[]
[null,"2.","By submitting this form, the above-referenced confirms:"]
[]
[null,null,"A.","That person submitting this request has personal knowledge of the network contracting process involved in this submission; and"]
[]
[null,null,"B.","That access cannot be met for the following provider type(s). Include the county and reason(s) for not meeting the requirements.  "]
[]
[]
[null,null,"Provider Type",null,null,null,null,null,null,null,null,"County",null,null,"Reason Code",null,"Notes",null,null,null,null,null,null,null,null,null,"Affected Enrollees*-Leave Blank",null,null,"Percent Not Covered*-Leave Blank"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,"<select one>",null,null,null,null,null,null,null,null,"<select all that apply>",null,null,"<select one>"]
[null,null,null,"Please use additional sheet if needed"]
[]
[null,null,null,null,"As part of this waiver request for all reason codes, a Pharmacy Benefit Manager must (1) demonstrate with specific data why the pharmacy benefit manager is "]
[null,null,null,null,"not able to meet the requirements; and (2) include information as to the steps that were and will be taken to address network adequacy. "]
[null,null,null,null,"(MN Statutes § 62W.05, subdivision 2)."]
[]
[null,null,null,"Reason Codes:"]
[null,null,null,"1.","Pharmacy Benefit Manager has conducted a good faith search for pharmacy providers and determined that there are no providers physically present."]
[null,null,null,null,"MDH will not grant a waiver for this reason code unless the Pharmacy Benefit Manager demonstrates, with specific information, in the service area. "]
[null,null,null,null,"that there are no providers physically present in the part(s) of the service area for which the waiver is sought."]
[null,null,null,null,"Specific information may include provider directories and sources consulted, physical geography that affects the location of providers,"]
[null,null,null,null,"or other information that affects the availability and location of providers. State what steps will be taken to address the network inadequacy."]
[]
[null,null,null,"2.","Pharmacy Benefit Manager made a good faith effort to contract with provider and provider refused to accept a contract. "]
[null,null,null,null,"State what steps were and will be taken to address the network inadequacy.  "]
[null,null,null,null," "]
[]
[]
[null,null,null,null,null,"                                                                Attestation for the Request for Waiver"]
[]
[null,null,null,null,null,"The undersigned attests that he/she is a representative of the applicant Pharmacy Benefit Manager with personal knowledge of the network  "]
[null,null,null,null,null,"and reasons for the above waiver requests, and that the waiver requests meet the requirements for the waiver, "]
[null,null,null,null,null,"as outlined above. The undersigned also attests that good faith efforts have been made to locate and contract with providers,"]
[null,null,null,null,null,"as outlined above, and that if providers become available in the service area, the PBM will make a good faith effort to contract with "]
[null,null,null,null,null,"said providers.  "]
[]
[]
[null,null,null,null,null,"_____________________________________     _____________________________________________"]
[null,null,null,null,null,"Name, Company, Title                                                 Date Attestation Signed"]

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[]
["MANAGED CARE SYSTEMS"]
["P.O. Box 64975, St. Paul, MN 55164-0975"]
["Telephone: 651-201-5100"]
["Email: health.managedcare@state.mn.us"]
["Please review the following instructions prior to filling in the Pharmacy Benefit Management Request for Waiver form"]
["1) File format: MS Excel."]
["2) Download the Request for Waiver form. Open document. If you receive a security warning, click enable content. Save as, Excel Macro-Enabled workbook (*.xlsm). "]
["3) Enter the pharmacy benefit manager entity name, network name, and network ID. "]
["4) Enter the contact name and title of the person submitting the form. Complete the date field as MM/DD/YYYY.  "]
["5) Pick a pharmacy type from the drop down menu. "]
["6) Pick the county that pertains to the pharmacy type from the drop down menu."]
["7) Pick a reason code from the drop down menu. List one reason code per line."]
["8) Please do not alter the form by adding rows. If you need to add a page, click the Additional tab at the bottom."]
["9) If you have any problems, send an email to health.managedcare@state.mn.us."]

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["Provider Type",null,null,null,null,null,null,null,"County",null,null,"Reason Code",null,"Notes",null,null,null,null,null,null,null,null,null,null,null,"Affected Enrollees*",null,null,"Percent Not Covered*"]
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