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Ambetter RxEffect Provider Bonus Flyer

Date: 09/22/25

RxEffect® Incentive Payment for Adherence Measure

As part of a year-end push to improve medication adherence, Ambetter from Arizona CompleteHealth is offering an additional financial incentive (Incentive Payment Program) to its providerswho use RxEffect to identify and take action in the following medication therapy areas:

  • Diabetes
  • Blood Pressure
  • Cholesterol

This Program Description is the governing document regarding the bonus amounts that a provideris eligible to earn under this Incentive Program.

Definitions:

Adherence: is defined by the proportion of days covered (PDC). The PDC is “the proportion of days in themeasurement period ‘covered’ by prescription claims for the same medication or another in its therapeuticcategory.” It is the total number of days that a member has medications on hand, divided by the number ofdays in the measurement period. Members are defined as adherent if they have a PDC ≥ 80%.

  • In order to track treated days consistently, it is important that eligible members fill their medication at apharmacy or through home delivery using their health insurance card  

Missed Days: means the number of days an eligible member does not have prescription medication on handto treat their chronic disease because the eligible member did not refill their medication on time. The incentiveprogram uses “missed days” to measure adherence.

Bonus: means the additional reimbursement beyond the contract rates in the participation agreement aprovider may receive. This is a separate bonus program that supplements — but does not replace — any otherPlan programs or risk-based contracts in which providers may be enrolled.

Eligible Member: means a Plan member who meets the age, sex, and/or disease-specific criteria, and theenrollment and other technical criteria, set forth in the most recent Centers for Medicare & Medicaid Services(CMS) Health Insurance Exchange Quality Rating System (QRS) Measure Technical Specifications document.   

Medication Adherence Measures:

Diabetes* 

Common Medications include:

  • Glyburide.
  • Metformin.
  • Januvia.
  • Ozempic

*Members on insulin are not included.

Blood Pressure

ACE-I examples

  • Lisinopril
  • Zestril.

ARB examples:

  • Losartan.
  • Diovan.

DRI examples

  • Aliskiren

Cholesterol

  • Atorvastatin
  • Simvastatin.
  • Rosuvastatin.

Qualifying Member Therapy: means the three Medication Adherence Measures published in the most recentHealth Insurance Exchange Quality Rating System (QRS) Measure Technical Specifications Notes document,namely (1) diabetes medication; (2) hypertension (renin-angiotensin system; RAS Antagonists); and/or (3)cholesterol (statins).

Incentive Payment Program Criteria:

This Incentive Payment Program offers a pre-determined dollar amount per Qualifying Member Therapy,depending on market (maximum of per member depending on number of therapy areas andmarket). This program occurs August 2025 or date of program launch, through December 2025. The bonus is basedon eligible members getting their last medication fill for end-of-year adherence, and is broken into two categories:

  1. “90-Day Conversion” — The bonus icon will appear for member therapies converted from a 30-day fill toa 90-day fill that makes the eligible member adherent for that therapy in 2025.
  2. “Last Fill” — The bonus icon will appear for Eligible Member therapies that need one fill to meet the eligiblemember’s adherence goals for that therapy in 2025.

Bonus eligibility is dynamic and will be updated weekly. Please note: While a Qualifying Member Therapy may beeligible for each of the bonus types through year-end, only one bonus will be active at a time and therefore only onebonus will be paid per therapy.

Incentive Payment Program Eligibility

You must take the following steps to receive your bonus:

  • Visit RxEffect.com to review the Qualifying Member Therapies eligible to receive a bonus. The patient listmust be viewed while the therapy is eligible to receive a payment.
  • Help ensure the eligible member meets adherence criteria by filling out a pharmacy claim through theirprescription benefit (without a claim reversal) for that therapy area while eligible for the bonus (displayingthe bonus icon).

How to Identify Bonus Opportunities in RxEffect

The RxEffect features below will help you improve your adherence population and start earning incentives.

 

  • Priority List: The priority list ranks patients based on their likelihood of becoming adherent and responding toan intervention, bonus eligible opportunities and patients will exist in this list among other prioritized patients
  • Bonus Icon: Select high-priority patients who are eligible for an additional bonus will be represented by a dollarsign on the therapy tile. If a patient has a bonus icon on each adherence therapy, you can earn up to threebonuses for that eligible member.
  • Bonus List: Click on this list to show all bonus-eligible patients for the current calendar year.
  • Missed Days: Keep patients under their targeted number of missed days on each therapy tile and they will beadherent for 2025.

Incentive Payment Program Payout

Incentive Payment Program payout will be included as a separate line itemfor 2025 supplemental payments distributed in May, 2026

View your Progress.

Located in the Reports tab on RxEffect, this dashboard will show your completed Incentive Payment Programearnings and remaining potential. View these opportunities overall for a practice or filter to an individual provider.Reports will be updated daily as eligibility is updated.

Access to RxEffect

If you do not currently have access to RxEffect, please contact help@RxEffect.com. If you have questionsabout the bonus program, contact your health plan representative.The Incentive Payment

Program is for August, 2025 or date of program launch, through December, 2025.

Disclaimers:

  1. The Plan reserves the right to not pay any Bonus to a provider if the provider has received or retained anoverpayment (any money to which the provider is not entitled), as determined by the Plan. In the eventthe Plan determines a provider has an overpayment, the Plan may offset the overpayment by any Bonuspayment that may have otherwise been paid to the provider.
  2. The Plan will determine if the requirements of the Incentive Payment Program are satisfied, and Bonusespaid under the Incentive Payment Program will be paid solely at the Plan’s discretion. The IncentivePayment Program does not provide any right(s) to appeal a decision made in connection with theIncentive Payment Program.
  3. Plan shall make no specific payment, directly or indirectly under a physician incentive plan, to a provideras an inducement to reduce or limit medically necessary services to an enrollee. This Incentive PaymentProgram does not contain provisions that provide incentives, monetary or otherwise, for withholdingmedically necessary care.
  4. The Plan’s Incentive Payment Program is discretionary and subject to modification due to changes ingovernment health care program requirements, or otherwise.5. RxEffect® is a registered trademark of RxAnte, LLC.