Client Approved Medication List for Go-Live Date

Will there be an infertility Maximum Allowable Benefit on Go-Live Date?	Yes No
Will there be an open HIV network on Go-Live Date?	Yes No
The CVS/Aetna Account Manager should contact benefits assistance to determine if a Preventive Drug List (PDL) that is OUTSIDE of the standard ACA Preventive Drug List is in place for the PrudentRx eligible CAGs at go-live. If there is a PDL outside the standard ACA Preventive Drug List that will impact the PrudentRx eligible CAGs at go-live, select Yes.	Yes No
Does the client have an Onsite Pharmacy that has been approved by CVS & PrudentRx management for use outside of the exclusive specialty requirement of the PrudentRx Program?	Yes No
If the client is including fertility, does the client's plan cover injectable fertility medications?	Yes No N/A
In making the selections below, is the client's intention to keep the current drug list in place or to change it at go-live?	Keep Change

Please select the desired Drug List at Go-Live.

	Category	Not included on go-live date	Included on go-live date
	Select high-cost Limited Distribution Drugs (LDDs) are included in the PrudentRx Program*
	CVS Specialty (Formulary is standard with below options available)
	Hepatitis B, Ocular Disorder & Transplant (Must be moved together)
	HIV. Not available if open network**
	Infertility. Not available with infertility MAB (Maximum Allowable Benefit) in place***

Program code:

Program name:

Drug List Link:

Program description:

*	To obtain a list of the LDDs, contact your PrudentRx rep.
**	If the plan has an open HIV network, you cannot include HIV. If you checked open network above, HIV would automatically default to not included on the formulary.
***	If the plan has an infertility Maximum Allowable Benefit (MAB) it cannot have infertility drugs in the approved drug list as the PrudentRx Program is always $0 out of pocket cost to the member. If you checked MAB above, infertility would automatically default to not included on the formulary.

Please enter the Go-Live Date:
Is this is a CVS or Aetna Client:	CVS Aetna
Does the drug list provided above match the drug list on the client's CRD/BPS?	Yes No
I will request to have the CRD/BPS updated. Use the report generated from this app as the client's drug list and disregard the CRD/BPS until the new one is provided.	I agree
Please enter the name of the Client representative who provided the information for this form:
Please enter the Client representative title:
Please enter the Client representative email address:
Please enter the CVS/Aetna representative name:		email:
Please enter the Client's legal business name:
Please enter any additional notes or comments :
Please choose the PrudentRx account manager:
Please enter the authorization code:

* Button is enabled when all selections have been made and valid authorization code is provided