What: AVAP Council Meeting Date & Time: February 20, 2019; 11:00 A.M.-12:30 P.M., AKST Where: BP Energy Center, 900 E Benson

2019-02-20 AVAP Council Meeting Page 1 of 86 c/o KidsVax.org® P.O. Box 1885 • Concord, NH 03302-1885 tel 1.855.KidsVax (543.7829) fax 1.855.KidsFax (543.7329)

What: AVAP Council Meeting Date & Time: February 20, 2019; 11:00 a.m.-12:30 p.m., AKST Where: BP Energy Center, 900 E Benson Blvd, Anchorage, AK 99508 Public Access: Please register for the AVAP Council Meeting on February 20, 2019, 11:00 am to 12:30 pm EST at: https://attendee.gotowebinar.com/register/3084090928410617089, Webinar ID: 380-757-811 After registering, you will receive a confirmation email containing information about joining the webinar. Audio PIN: Shown after joining the webinar

AVAP Agendas are subject to revision up to and including the time of the meeting.

Approx. Time Topic/[Anticipated Action] Presented by: 11:00-11:05 a.m. 1. Welcome J. McLaughlin a. Notification of Recording b. Introductions/Finalization of Agenda

11:05-11:10 a.m. 2. Items for Council Consent J. McLaughlin * a. Approval of Sept. 20, 2018 Council Meeting Minutes

11:10- 11:25 a.m. 3. DHSS Updates M. Bobo a. Regulations b. CDC Vaccination Coverage Award c. 2019-2024 CDC Vaccine for Children Cooperative Agreement d. Enrolling Village Clinics into the Immunization Program e. DHSS Staffing

11:25-11:40 a.m. 4. Legislative Update M. Bobo a. SB 037 (review language of bill) i. Original Bill ii. February 13, 2019 Amendment b. Senate Health Committee Materials c. Senate Finance Committee Materials

11:40-11:50 a.m. 5. KidsVax Updates * a. Financial Update F. Potter/C. Roberge * b. Status (ED) Report F. Potter c. TRICARE F. Potter * i. Summary Memo * ii. Past Due Notice * iii. FLP email to Sharon Seelmeyer

11:50-11:55 a.m. 6. Other Items (if any) from Council Members

7. Public Comment Any

12:00 p.m. 8. Closing J. McLaughlin (Tentative) 9. Reference Materials * a. Proposed Form of Votes * b. 2019 Meeting Calendar * c. AVAP Contact Directory 2019 * d. BP Energy Center Map 2019-02-20 AVAP Council Meeting Page 2 of 86

1 Alaska Vaccine Assessment Program Council Meeting 2 September 20, 2018; 10:00 a.m.-12:30 p.m., AKDT 3 In-person Meeting 4 BP Energy Center, 900 E, Benson Rd., Anchorage, AK 99503 5 6 I. Participating in all or part of the meeting in person or by telephone (T) were the following individuals:

Council Members Joe McLaughlin, MD, Chairman – Division of Epidemiology Sarah Bailey – Alaska Division of Insurance Fred Brown, Esq. – Health Care Cost Management Corporation of Alaska Jody Butto, MD – Anchorage Pediatric Group Kara King – Alaska Native Tribal Health Consortium (T) Rosalyn Singleton, MD, MPH – Alaska Native Medical Center Lydia Bartholomew, MD – Senior Medical Director, Aetna Mike Patton - Premera Blue Cross

Department of Health and Social Services Jay Butler, MD –Chief Medical Officer/Director Matthew Bobo – Immunization Program Manager Kelsey Pistotnik – Deputy Program Manager Alicia Weber – Vaccine Depot Manager

Absent Jill Lewis – Deputy Director, Juneau

KidsVax® Fred L. Potter – Managing Member Nicole G. Price – Northeast Region, CEO (T) Claire Roberge, Controller (T) Heather Veen – Sr. Executive Assistant, Paralegal Norm Roberge, Assessment Monitoring/Internal Control (T) Matt Miller – Client Services Coordinator (T)

Others Julia Zell (T) Katrina Anderson (T) Denyse Bayer (T) Amy Walker (T)

7 II. Summary of Actions Taken and/or Recommended 8 A. Actions Taken (votes adopted) 9 1. To approve the May 24, 2018, Council meeting minutes. 10 2. To pass a resolution to request the legislation to reauthorize AVAP with additional sunset periods. 11 3. To recommend 2019 Assessment Rates. 12 4. To approve AVAP’s 2019 Meeting Calendar. 13

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1 III. Minutes 2 3 Welcome and Introductions 4 At approximately 10:00 a.m., a quorum having been established, Chairman Joe McLaughlin called the meeting to 5 order. Chairman McLaughlin announced that the meeting was being recorded for the benefit of the minute-taker 6 and the recording would be deleted following the final approval of the minutes. Following introductions, Chairman 7 McLaughlin proceeded to the Consent Calendar Items. 8 9 Consent Calendar Items 10 Chairman McLaughlin asked for comments and edits to the May 24, 2018, Council meeting minutes. 11 12 Upon motion duly made and seconded, it was unanimously 13 14 VOTED: To approve the May 24, 2018 Council meeting minutes as submitted. 15 16 DHSS Updates 17 18 Matt Bobo reported that the final AVAP regulations had gone through open notice, however, the senior regulation 19 reviewer noticed that a plan of operation had not been attached to the actual open notice post. Matt stated that a 20 supplemental open notice should be completed next week and is hoping regulations will be finalized by the end of 21 the month. 22 23 Mr. Bobo discussed the transition of the vaccine depot. He reported DHSS will be out of the current vaccine depot 24 by the end of October. The vaccine depot will now be in the Frontier Building near the section of epidemiology on 25 the fifth floor. McKesson is a third-party distributor and can’t ship to some of the more rural locations, so going 26 forward the DHSS epidemiology section will maintain a “mini depot” and ship to those more rural areas. 27 28 Mr. Bobo went on to discuss the reauthorization of AVAP. When the Senate Bill passed there was a clause saying 29 the bill sunsets January 1, 2021. Mr. Bobo reported there is a 90-day legislative session starting in January usually 30 after Martin Luther King Day and continuing through April. DHSS is now gathering data and getting everything 31 together for the legislative session. Chairman McLaughlin informed the Council that they are seeking 32 reauthorization at the commencement of the legislature’s two-year cycle due to inevitable uncertainty inherent in 33 any legislative process. He then opened the floor for comment. 34 35 Mr. Potter praised the Council for their diligent work which had fully implemented best practices and brought 36 AVAP to a remarkably stable operating condition. Fred Brown made a motion to recommend to the legislature the 37 reauthorization of AVAP, with a three-year sunset. There was no second to that motion. At that point, another 38 motion was made and seconded to recommend to the legislature the reauthorization of AVAP without a sunset. 39 After much discussion, the matter was put to vote. 40 41 Upon motion duly made and seconded, 42 43 VOTED: To recommend to the legislature reauthorization of AVAP without a sunset. 44 45 There was only one vote in opposition; that was Mr. Brown’s. Mr. Brown confirmed that he is favorable toward the 46 reauthorization of AVAP, that his vote in opposition was not in opposition to AVAP’s reauthorization, but was 47 based upon his general view that every government agency is best subject to periodic sunset reviews. 48 49 Rate Setting Workshop 50 51 Mr. Potter thanked Mr. Bobo and his team for pulling the numbers together. The Council engaged in extensive 52 discussion of the Annual Assessment Setting Workbook and examination of each of the applicable control points. 53 Mr. Potter noted it was KidsVax®’s recommendation to release approximately one-third of excess reserves. It was 2

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1 the sense of the Council that that approach seemed appropriately measured and equitable to all payers. Chairman 2 McLaughlin opened the phones for public comment. There was none. 3 4 Upon motion duly made and seconded, it was unanimously 5 6 VOTED: To adopt recommend 2019 assessment rates of $7.44 per month per child and $.53 per month per 7 adult. 8 9 KidsVax® Updates 10 Mr. Potter informed the Council that Julia Zell is now living in Boise, Idaho and has moved on to full-time work for 11 the Washington Vaccine Association. Mr. Potter thanked Ms. Zell for her work with AVAP. Chairman 12 McLaughlin added his personal commendation of Julia’s work for AVAP as well. 13 14 Mr. Potter gave a brief overview of his ED report. He updated the Council regarding TRICARE stating AVAP has a 15 seven percent reduction in rates due to TRICARE’s commitment of regular quarterly payments in August. He noted 16 with the $1.5 million TRICARE arrearages collected to date, together with its commencement of regular quarterly 17 payments, KidsVax® is aware of no payer in this market that is not paying its equitable share as determined by the 18 Council. Mr. Potter again thanked the Council members for their diligent work. Chairman McLaughlin thanked Mr. 19 Potter and Ms. Zell for their tremendous work and dedication in obtaining such a positive outcome with regard to 20 TRICARE arrearages. Dr. Singleton echoed Chairman McLaughlin’s thanks and inquired about Medicare and 21 Medicaid. Mr. Bobo stated DHSS has begun talks with Medicare and Medicaid and is hoping to have answers in 22 that regard in the fall. Further discussion ensued. 23 24 Mr. Potter gave a further TRICARE update and summary of TRICARE 2018 collections. He reported that he and 25 Ms. Zell met with DHA in Colorado and have been able to resolve numerous remaining issues, all in favor of the 26 state vaccine programs. Mr. Potter informed the Council he recently received a memo from DHA stating they were 27 willing to pay monies toward the assessment rate and allow the balance to be recovered over future months through 28 a supplemental TRICARE assessment. He stated it should take approximately one year for TRICARE to make up 29 for its arrearages. Mr. Potter recommends the Council proceed with a supplemental assessment as suggested by 30 TRICARE. Further discussion ensued. 31 32 Upon motion duly made and seconded, it was unanimously 33 34 VOTED: To recommend a supplemental assessment for TRICARE to recover any (i) underpayments of 35 assessments, or (ii) interest for past due payments as allowed by federal law, such assessments 36 to be established on such terms as may be worked out by DHSS, TRICARE and KidsVax®. 37 38 Mr. Potter mentioned the cost recovery letter AVAP received from WVA. Chairman McLaughlin shared that the 39 letter suggested a $150,451 contribution. Chairman McLaughlin noted that the amount seemed reasonable, but 40 informed the Council DHSS will be looking into whether Alaska law allows such a contribution by AVAP. 41 42 Mr. Potter recommended the retention of the same auditor AVAP used last year. It was the sense of the Council to 43 proceed. Mr. Bobo indicated he would proceed with the audit engagement for AVAP program year 2018. 44 45 Council Development 46 There was discussion of AVAP’s Council of Members, terms & positions. Mr. Potter suggested to the Council that 47 someone possibly volunteer to be moved to the 2019 class in order balance the classes of membership. It was 48 opened for discussion. Chairman McLaughlin asked for one volunteer to have his/her first term end in 2019. 49 50 The 2019 meeting calendar was brought before the Council. After discussion, approval of the 2019 meeting 51 calendar was put to vote. 52

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1 Upon motion duly made and seconded, it was unanimously 2 3 VOTED: To approve the 2019 meeting calendar with the suggested changes. 4 5 Public Comment 6 There was no public comment. 7 8 Closing 9 After asking if there were any final comments or questions Chairman McLaughlin adjourned the meeting at 11:20 10 a.m. AKST.

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31-LS0162\A

SENATE BILL NO. 37

IN THE LEGISLATURE OF THE STATE OF ALASKA

THIRTY-FIRST LEGISLATURE - FIRST SESSION

BY SENATOR GIESSEL

Introduced: 1/25/18 Referred: Health and Social Services, Finance

A BILL

FOR AN ACT ENTITLED

1 "An Act relating to the statewide immunization program."

2 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA:

3 * Section 1. AS 18.09.200(b) is amended to read: 4 (b) The commissioner shall 5 (1) establish a procedure [TO PHASE IN THE PROGRAM OVER A 6 THREE-YEAR PERIOD] that provides for participation by an assessable entity; 7 (2) maintain a list of recommended vaccines for inclusion in the 8 program; 9 (3) for each included vaccine, establish the initial vaccine assessment 10 for the first year of the program and thereafter make annual assessments based on the 11 determinations made by the council established under AS 18.09.210; 12 (4) notify assessable entities and other program participants of the 13 annual vaccine assessment for each vaccine included in the program; 14 (5) devise a method for crediting to assessable entities and other 15 program participants overpayments of vaccine assessments made for reasons related to

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1 administrative error, program termination, or lower than anticipated actual usage of 2 the program by covered individuals; 3 (6) coordinate collective purchases of included vaccines; 4 (7) establish a procedure for statewide distributions of vaccines 5 purchased under the program; and 6 (8) review vaccine assessment appeals for error. 7 * Sec. 2. AS 18.09.220(a) is amended to read: 8 (a) An assessable entity and other program participant shall [, AFTER BEING 9 PHASED INTO THE PROGRAM UNDER PROCEDURES APPROVED BY THE 10 COMMISSIONER,] 11 (1) pay to the department the annual combined vaccine assessments as 12 determined under the program for the included vaccines covered by the assessable 13 entity or other program participant for each covered individual on a schedule adopted 14 by the council; 15 (2) provide information requested by the council to determine the 16 number of covered individuals, actual vaccine usage under the program, and other data 17 necessary to calculate and monitor compliance with the vaccine assessment; and 18 (3) provide audited financial statements upon request of the council. 19 * Sec. 3. AS 18.09.220(e) is repealed. 20 * Sec. 4. Section 5, ch. 30, SLA 2014, is repealed.

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STATE OF ALASKA SENATE FINANCE COMMITTEE SB 37 Renewal of Vaccine Assessment Program Hearing Held 2/6/2019

DOCUMENT INDEX

SB37 AVAP Renewal vsn A 1-25-19 ...... 1 SB37 Sponsor Statement 1-28-19.cg ...... 2 SB37 Letter of Support AK Pediatric Grp 1-24-19 ...... 3 SB37 Letter of Support American Academy of Pediatrics – AK 1-24-19 ...... 4 SB37 Supporting Document WA Post Anti Vaccine NC outbreak 11-18 ...... 5 SB37 Supporting Document Alaska Public Health Advisory 1-29-19 ...... 6 SB37 Supporting Document AVAP Annual Report 2018 ...... 7 SB37 Supporting Document AVAP Status Update 2017 ...... 8 SB37 Sectional Analysis 2-3-19 ...... 9 SB37 Supporting Document NPR 2-2-19 ...... 10 SB37 Supporting Document DHSS Vaccine Formulary 2019 ...... 11 SB37 Letter of Support Premera 1-29-19 ...... 12 SB37 Fiscal Note Div of Public Health Epidemiology 1.29.19 ...... 13 SB37 Supporting Document AVAP Payers ...... 14 SB37 Supporting Document AVAP Providers ...... 15 SB37 Supporting Document Status Update 2018 ...... 16 SB37 Supporting Document Who Pays AVAP ...... 17 SB37 Supporting Document PPt AVAP DPH 2-5-19 ...... 18 SB37 Aetna Support 2.5.19 ...... 19 SB37 Supporting Document Measles Info CDC ...... 20 SB37 Supporting Document Vaccination Rate Trends 2013-17 ...... 21 SB37 Supporting Document Measles Info DHSS ...... 22 SB37 Letter of Support AK Ped Partnership 2-6-19 ...... 23 2019-02-20 AVAP Council Meeting Page 9 of 86

31-LS0162\A

SENATE BILL NO. 37

IN THE LEGISLATURE OF THE STATE OF ALASKA

THIRTY-FIRST LEGISLATURE - FIRST SESSION

BY SENATOR GIESSEL

Introduced: 1/25/18 Referred: Health and Social Services, Finance

A BILL

FOR AN ACT ENTITLED

1 "An Act relating to the statewide immunization program."

2 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA:

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2019-02-20 AVAP Council Meeting Page 10 of 86 31-LS0162\A

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2019-02-20 AVAP Council Meeting ALASKA STATE LEGISLATURE Page 11 of 86

1500 W. Benson Boulevard Alaska State Capitol Anchorage AK 99503 Juneau AK 99801 907-269-0181 907-465-4843 800-892-4843 800-892-4843

North to the Future

Senator Cathy Giessel Senate District N

Sponsor Statement Senate Bill 37: Renewal of the Alaska Vaccine Assessment Program

Senate Bill 37 reauthorizes the statewide immunization program in the Department of Health and Social Services, which is scheduled for repeal January 1, 2021. Established in 2014, via Senate Bill 169, the program monitors, purchases and distributes all childhood vaccines and select adult vaccines to providers, making access to vaccines universal for all Alaskans. By 2018, the program covered more than 333,000 Alaskans, 45% of the total population. Next to clean drinking water and good nutrition, vaccines have saved more lives than any other public health intervention.

The statewide immunization program is fully funded by the state Vaccine Assessment Account through assessments (upfront fees) from health plans and insurers. There are no undesignated general funds needed for this program. The state leverages its buying power to purchase vaccines in bulk using the fees collected from healthcare payers. The state distributes that vaccine to providers who then administer them at no charge, improving health and wellbeing while lowering overall vaccine costs by 20 -30%.

Through the statewide immunization program, Alaska continues to demonstrate leadership in creating innovative solutions for difficult public health issues. Out of the 11 universal vaccine purchase programs in the United States, Alaska is the only state to allow providers to receive state- supplied vaccine for uninsured adults, enabling greater vaccine access for Alaska adults.

Alaska’s immunization program is an example of a successful public-private partnership that ensures Alaskans a healthier future at the lowest possible cost. The department reduces vaccine - preventable diseases, and providers have improved health outcomes for their patients and easier vaccine stock management. The insurers pay less to vaccinate individuals; we all save more money in the long run due to decreased medical costs from vaccine-preventable diseases.

[email protected]

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GROWING HEALTHY ALASKANS

3340 Providence Drive, Suite 500-Building A, Anchorage, AK 99508 / T. 907-562-2423 / F. 907-563-1170

1/24/19

Anchorage Pediatric Group 3340 Providence Dr #500 Anchorage AK 99508 (907)562-2423 The Honorable Cathy Giessel Alaska State Senate State Capitol Room 111, Juneau AK, 99801 Phone: 907-465-4843

Dear Senator Giessel:

I am writing in support of AVAP’s reauthorization (LS-0162). As you know, Alaska was a universal vaccine provider until 2010 when Federal funding was reduced and a cumbersome, expensive 2-tier system took its place. In 2015 we successfully developed the AVAP (Alaska Vaccine Assessment Program), a consortium of public and private funding that once again provides universal access of vaccines to Alaska’s children. The program has been incredibly successful in providing efficiency in procurement and distribution while simultaneously offering significant financial savings. Reauthorization of this important legislation is key to continued success in Alaska continuing to be a universal vaccine provider.

Sincerely, Jody Butto MD FAAP [email protected]

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Alaska Chapter

Alaska Chapter Executive Committee To: The Honorable Senator Cathy Giessel State Capitol, Room 111 President Lily J. Lou, MD, FAAP Juneau, Alaska 99801 3200 Providence Drive Anchorage, AK 99508 RE: LS0162 – Letter of Support for AVAP Reauthorization Phone: 907/632-4378 Fax: 907/212-5834 E-mail: [email protected] Date: January 24, 2019

Vice President Dear Senator Giessel, Anna Ogena, MD, FAAP 15700 Southpark Loop Anchorage, AK 99516 I speak for the pediatricians of Alaska, as a fellow pediatrician and the president of Phone: 907/250-8427 the American Academy of Pediatrics-Alaska Chapter. I am writing in enthusiastic E-mail: [email protected] support of reauthorization of the Alaska Vaccine Assessment Program (AVAP), which was created with bipartisan support in 2015, with plans to sunset in January of Secretary/Treasurer 2021. Jody Butto, MD, FAAP 10101 Hampton Cir Anchorage, AK 99507 Vaccine preventable disease is one area of health care where there are clear E-mail: [email protected] cost-effective savings demonstrated. All Alaskans benefit from high

immunization rates. AVAP has operated effectively for the past four years, Chapter Executive Director establishing a workable process, saving Alaskans money on state purchase of Dale Knutsen vaccines, keeping pace with evidence-based recommendations, and even Phone: 907-317-1397 E-mail:[email protected] navigating the recent mumps outbreak with provision of additional MMR doses. After a phased opt-out option ended, there is near universal

participation in this successful program, and TRICARE is participating as Chapter Web site www/aapalaska.org well. In fact, Alaska was recognized by the CDC in 2018 with an award for most improved coverage for teen vaccines.

AAP Headquarters 345 Park Blvd. I believe it is essential to continue to support AVAP, and the pediatric Itasca, IL 60143 Phone: 630-626-6000 community is grateful for your leadership on this issue from the very Fax: 874-434-8000 beginning. I feel this program should be reauthorized, with strong E-mail: [email protected] www.aap.org consideration for reauthorization without a scheduled sunset date.

Thank you for considering my views. Please let me know if there is anything I can do to help you further on this or any other children’s health issue.

Best regards,

Lily J. Lou, MD, FAAP AAP-AK Chapter President

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Washington Post, November 19, 2018 Anti-vaccination stronghold in N.C. hit with state’s worst chickenpox outbreak in 2 decades

Mother taking care of a girl with chickenpox disease. (iStock) (Mixmike/iStock) By Isaac Stanley-Becker November 19 Chickenpox has taken hold of a school in North Carolina where many families claim religious exemption from vaccines.

Cases of chickenpox have been multiplying at the Asheville Waldorf School, which serves children from nursery school to sixth grade in Asheville, N.C. About a dozen infections grew to 28 at the beginning of the month. By Friday, there were 36, the Asheville Citizen- Times reported. The outbreak ranks as the state’s worst since the chickenpox vaccine became available more than 20 years ago. Since then, the two-dose course has succeeded in limiting the highly contagious disease that once affected 90 percent of Americans — a public health breakthrough.

The school is a symbol of the small but strong movement against the most effective means of preventing the spread of infectious diseases. The percentage of children under 2 years old who haven’t received any vaccinations has quadrupled since 2001, according to the Centers for Disease Control and Prevention. 2019-02-20 AVAP Council Meeting Page 15 of 86

Like the Disneyland measles outbreak in 2015, the flare-up demonstrates the real-life consequences of a shadowy debate fueled by junk science and fomented by the same sort of Twitter bots and trolls that spread misinformation during the 2016 presidential election. And it shows how a seemingly fringe view can gain currency in a place like Asheville, a funky, year- round resort town nestled between the Blue Ridge and Smoky Mountains.

“The school follows immunization requirements put in place by the state board of education, but also recognizes that a parent’s decision to immunize their children happens before they enter school,” the school explained in a statement to Blue Ridge Public Radio.

Jennifer Mullendore, the medical director of Buncombe County, N.C., was unambiguous: “We want to be clear: Vaccination is the best protection from chickenpox.”

“When we see high numbers of unimmunized children and adults, we know that an illness like chickenpox can spread easily throughout the community — into our playgrounds, grocery stores, and sports teams,” she said in a news release.

But not all parents seemed to grasp the gravity of the outbreak. Nor does everyone see the rationale behind vaccines, which some believe — contrary to scientific evidence — cause more severe health issues than they’re meant to cure. The claim of an autism risk, though it has been debunked, has remained a rallying cry of the anti-vaccine movement.

“What’s the big deal with chickenpox?” one city resident, Amy Gordon, told the Citizen-Times. Chickenpox is serious, warns the CDC, “even life-threatening, especially in babies, adolescents, adults, pregnant women and people with weakened immune systems.”

A person can spread the disease one to two days before the rash appears, increasing the risk of broad transmission of the virus before it is detected. That was before a two-dose vaccination program was introduced in the United States in 1995.

The virus used to crop up in about 4 million cases annually in the United States, causing more than 10,000 hospitalizations and between 100 and 150 deaths. Children were especially susceptible, as schools seemed to incubate the blisterlike rash, which appears first on the stomach, back and face and can extend over the entire surface of the body, creating as many as 500 itchy blisters.

The vaccine, which the CDC says is about 90 percent effective, hasn’t eliminated the varicella zoster virus, which causes chickenpox. But since the regimen became commercially available, it has reduced the number of cases, as well as their severity. A 14-year prospective study published in Pediatrics in 2013 found that the incidence of infection was nine- to 10-times lower than in the pre-vaccine era.

Still, the vaccine’s clearly documented merits remain unconvincing to some. Asheville Waldorf has one of the highest religious vaccination exemption rates in the state, according to data maintained by the state’s Department of Health and Human Services.

The private school has a higher rate of exemption on religious grounds than all but two other North Carolina schools, the Citizen-Times reported. During the 2017-18 school year, 19 of 28 kindergartners were exempt from at least one vaccine required by the state. Of the school’s 152 students, 110 had not received the chickenpox vaccine, the newspaper reported. 2019-02-20 AVAP Council Meeting Page 16 of 86

North Carolina requires all students in the state to receive certain immunizations. Among the vaccines required for kindergarten-aged children are two doses for chickenpox, two for measles and two for mumps. Seventh graders must again submit to immunization.

But the state also permits exemptions based on the advice of a physician — as well as on religious grounds.

“If the bona fide religious beliefs of an adult or the parent, guardian or person in loco parentis of a child are contrary to the immunization requirements contained in this Part, the adult or the child shall be exempt from the requirements,” state statute allows.

Recent efforts to tighten the rules have foundered. In 2015, state legislators withdrew a bill that would have all but eliminated the religious exemption after their efforts were met with strident protest. Protesters picketed the state’s General Assembly in Raleigh, warning of “Medical Terrorism.”

Meanwhile, the county’s medical director has been exhorting residents to immunize their children. “What happens when we lack community immunity? Measles is what happens,” Mullendore this fall told commissioners of the county, which had the highest rate of religious exemptions last year.

The friction between medical experts and the residents in their care is not unique to Buncombe County, where the parents of 5.7 percent of kindergartners claimed a religious exemption, or even to North Carolina, where the rate was 1.2 percent.

Forty-seven states allow religious exemptions to vaccine requirements, according to the National Conference of State Legislatures. CDC data shows that the median percentage of kindergartners with an exemption from one or more required vaccine was highest in Oregon.

2019-02-20 AVAP Council Meeting Page 17 of 86 Alaska Public Health Advisory January 29, 2019

Measles Outbreak in Washington State — What Alaskans Should Know

All suspected or confirmed measles cases must be reported immediately to the Alaska Section of Epidemiology at (907) 269-8000 or 800-478-0084 (after hours).

The purpose of this health alert network message is to raise awareness about the measles outbreak in Washington State, to encourage Alaskans to be up-to-date with MMR vaccination, and to inform people about measles signs and symptoms and what to do if they think that they have measles.

On January 25, 2019, the Governor of Washington State declared an emergency in all counties in response to more than two dozen confirmed measles cases in the state. The statewide case count for the measles outbreak since January 1, 2019 is available on the Washington State Department of Health (DOH) website and is updated daily. As of January 29, 2019, DOH is reporting 35 confirmed cases in Clark County and one confirmed case in King County. The Oregon Health Authority has confirmed a case of measles in a resident of Multnomah County that is linked to the outbreak in Clark County.

Persons who have recently traveled to or have visited various public venues within Washington State and Portland, Oregon may be at risk of contracting measles if they are not up-to-date on their measles-mumps- rubella (MMR) vaccination. Additional information about the outbreak is available at the following websites: Public Health – Seattle & King County and Clark County Public Health.

As of January 29, 2019, there have been no cases in Alaska.

Measles Basics

Measles is a highly infectious viral respiratory disease that spreads via the airborne route and through direct contact with respiratory secretions. Measles typically starts with a fever, runny nose, cough, and red eyes. Two or three days after symptoms begin, tiny white spots (Koplik spots) may appear inside the mouth. Three to five days after symptoms begin, a rash breaks out. It usually begins as flat red spots that appear on the face at the hairline and spread downward to the neck, trunk, arms, legs, and feet.

Small raised bumps may also appear on top of the flat red spots. The spots may become joined together as they spread from the head to the rest of the body. When the rash appears, a person’s fever may spike to more than 104° Fahrenheit. After a few days, the fever subsides and the rash fades. About 30% of people who get measles will develop one or more complications including pneumonia, ear infections, or diarrhea. More serious complications, including death, can occur. Complications are more common in young children, adults, and pregnant women.

Incubation period: Symptoms typically start to appear 8–12 days (range: 7–21 days) after exposure, with rash onset typically occurring around 14 days after exposure.

Infectious period: 4 days before rash onset through 4 days after rash onset

• Clinicians should advise persons who might have measles to call ahead before arriving at the clinic or emergency department and arrange a time and place to meet with medical staff that will minimize the risk of exposing others. 2019-02-20 AVAP Council Meeting Page 18 of 86 • Clinicians should ensure that persons with suspected measles should avoid exposing other people during the entire infectious period.

Laboratory Diagnosis

• Contact the Alaska Section of Epidemiology (SOE) immediately to facilitate testing: 907-269-8000, or 800-478-0084 after hours. • Obtain a throat or nasopharyngeal swab on a synthetic collection swab (e.g., Dacron, no natural fibers such as wood or cotton) and place into viral transport media (other media types can reduce virus stability). • Draw 7–10 mL of blood in a red-top or serum separator tube; spin down serum if possible. o Capillary blood (finger or heel stick) can be used for pediatric patients, if necessary (e.g., in infants); approximately 3–5 capillary tubes are needed to yield 100 μl of serum. • Collect 20–100 mL of urine in a clean/sterile, leak-proof container. • See Alaska Section of Laboratories Test Directory, Rubeola (Measles) on page 56: http://dhss.alaska.gov/dph/Labs/Documents/LaboratoryTests.pdf.

Vaccination Recommendations

• CDC recommends routine vaccination with a 2-dose series of MMR, the first dose at 12–15 months and the second dose at 4–6 years. • One dose of MMR vaccine is approximately 93% effective for the prevention of measles; two doses are approximately 97% effective. • Accepted presumptive evidence of immunity against measles includes one of the following: o Written documentation of adequate vaccination ▪ One or more valid doses of a measles-containing vaccine for pre-school age children and adults not at high risk ▪ Two valid doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers; or o Laboratory confirmation of measles; or o Laboratory evidence of immunity*; or o Birth in the United States before 1957 ▪ Adults born during or after 1957 who do not have evidence of immunity against measles should get at least one dose of MMR vaccine. *Serologic testing for immunity to measles is not necessary for persons documented to be appropriately vaccinated or who have other acceptable evidence of prior infection (see CDC Pink Book: https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html#diagnosis).

Surveillance and Reporting

• Health care providers should report suspected measles cases immediately by calling the Alaska Section of Epidemiology at (907) 269-8000 or (800) 478-0084 after hours. • Suspected cases should be promptly isolated.

2019-02-20 AVAP Council Meeting Page 19 of 86 Resources

• CDC. Measles – Healthcare Professionals, https://www.cdc.gov/measles/hcp/index.html • IAC. Ask the Experts – MMR, http://immunize.org/askexperts/experts_mmr.asp • CDC. MMWR: Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013, https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm • Alaska Section of Epidemiology – Measles webpage, http://dhss.alaska.gov/dph/Epi/id/Pages/measles/default.aspx

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2019-02-20 AVAP Council Meeting Page 20 of 86 ANNUAL REPORT 2017-2018

Dear Friends What is a Universal Purchase Program? The universal vaccine purchase program implemented in Alaska allows the state to and Colleagues, purchase recommended vaccines for all children and select vaccines for limited adults. As AVAP continues to mature Alaska’s universal vaccine purchase program ensures that every child and some adults programmatically, we are pleased to who enter a participating doctor’s office or hospital can receive recommended vaccines report another great year of carrier at no cost. Therefore, more healthcare providers can offer vaccination services because participation. Thanks to the efforts they have less up-front costs to finance out of their own pockets for vaccines, reducing of AVAP stakeholders – insurers & staff burdens required to separate private and public vaccine stock and lessening the TPAs, providers, and the Department operational overhead of complex ordering systems. This approach allows the State of Health and Social Services – AK’s to manage the supply of vaccines, thereby lowering providers’ administrative costs and ensuring that the state can quickly supply vaccines to vulnerable patient groups vaccine assessment mechanism during emergencies or vaccine shortages. Alaska is one of only 11 states that has a has become even more equitable universal childhood vaccine program and one of only 3 states that offers adult vaccines. as no private payers opted out of the Additionally, it is the only state that offers healthcare providers the option of purchasing Program for 2017. This collaborative state-supplied vaccine to serve uninsured adults. effort serves all Alaskans by lowering direct and long-term healthcare costs and yields numerous public How Does the Universal Purchase health benefits. Program Lower Health Care Costs? As a universal purchase state, Alaska qualifies to purchase vaccines at substantially Through AVAP, Alaska continues to discounted bulk contract rates from vaccine manufacturers. Federal dollars fund vaccines demonstrate leadership in creating for low-income and other federally-eligible children, while AVAP covers vaccine costs for innovative solutions for difficult public privately insured children and some adults through assessments collected from insurance health issues. Out of the 11 universal carriers. This approach allows the state to leverage bulk purchasing with vaccine vaccine purchase programs in the manufacturers instead of requiring every provider office to purchase from the private United States, Alaska is the only state market, thereby lowering overall vaccine costs by 20%–30%. to allow providers to receive state- supplied vaccine for uninsured adults, COST TO FULLY VACCINATE A PERSON THROUGH 18 YEARS enabling increased vaccine access for Alaskan adults. The cost to fully vaccinate a $3,500 Thank you for supporting AVAP, and person through 18 years of AVAP Bulk Contract age increased by $427 (23%) we look forward to another great year $3,000 in public health for Alaskans. Private Sector on the AVAP Bulk Contract from 2015 to 2018 compared $2,500 to a $722 (30%) increase in the private sector. $2,000 Joe McLaughlin, MD Chairman $1,500 State Epidemiologist and Chief, Section of Epidemiology, Division of Public Health, $1,000 Department of Health and Social Services

$500

$0 2015 2016 2017 2018

WWW.AKVACCINE.ORG

June 2018 2019-02-20 AVAP Council Meeting Page 21 of 86

AVAP Council Members Joe McLaughlin, MD, Chairman State Epidemiologist and Chief, Section AVAP: A Critical Component of Alaska’s of Epidemiology, Division of Public Health, Award Winning Vaccine Program Department of Health and Social Services Alaska’s universal vaccine purchase program is a private-public vaccine partnership GOVERNMENT REPRESENTATIVES funded through federal dollars, healthcare providers paying into the program to gain Sarah Bailey, AIE access to state-supplied vaccine for uninsured adults, and payers’ assessment dollars. Supervisor The Alaska Department of Health and Social Services’ (DHSS) Immunization Program Life / Health Filings & Market Conduct was recognized at the National Immunization Conference in Atlanta, GA in May for Division of Insurance

its efforts in increasing pediatric vaccine uptake rates. At the conference, DHSS was HEALTH CARE PROVIDER honored with the “Most Improved Coverage Amongst Adolescents Award”. Federal REPRESENTATIVES funding, along with AVAP partners, has enabled DHSS to deploy public health’s Jodyne Butto, MD resources in a way that makes a meaningful difference in the lives of Alaskan residents Pediatrician who would not otherwise have access to the full spectrum of recommended vaccines. Anchorage Pediatric Group Rosalyn Singleton, MD MPH Creating Solutions for Government Payer Participation Research Physician This year, the AVAP Council and DHSS took one more step towards guaranteeing payer Alaska Native Tribal Health Consortium

equity and ensuring that all Alaskan residents remain eligible for state-supplied vaccine. HEALTH CARE INSURER REPRESENTATIVES After multi-year negotiations with TRICARE, the US military’s health insurance program, Lydia Bartholomew, MD DHSS received a partial assessment payment for past-due amounts and has been Senior Director assured by TRICARE that it will participate in the program going forward. The Council’s Pacific NW Medical Health Services willingness to offer guidance and send letters of support helped make this achievement Aetna possible. DHSS continues to work with state Medicaid and research options for Mike Patton Medicare participation to resolve the issue of carve-out populations from Alaska’s Director of Large Group Underwriting universal vaccine supply programs. Premera

Fred Brown Executive Director Health Care Cost Management Corporation FINANCIALS January - December, 2017 of Alaska

TRIBAL REPRESENTATIVE Revenues Expenses Kara King $10,582,848 $10,582,848 Pharmacy Manager Alaska Native Medical Center Consortium

WWW.AKVACCINE.ORG

ADMINISTRATOR:

PHONE: 1-855-KidsVax (543-7829) FAX: 1-855-KidsFax (543-7329) 81.3% Child Assessments 45.3% Child Vaccines WEBSITE: www.KidsVax.org 16.4% Adult Assessments 19.4% Adult Vaccines 2.3% Provider Opt-in Payments 27.9% Reserves KIDSVAX® STAFF 2.2% KidsVax Admin Services Fred L. Potter, MBA, Esq. Peter Smith Managing Member Financial Analyst 2.5% DHSS Admin Fee Julia G. Zell, MA, Esq. Claire M. Roberge Other 2.7% Executive Director of AVAP Controller

For illustrative purposes for January – December 2017. AVAP revenues are actuals. Other numbers are from various sources. These charts will be updated when accounting policies are finalized and the audited financials for 2017 are released. This is expected to be prior to September 30, 2018.

June 2018 2019-02-20 AVAP Council Meeting Page 22 of 86

2017 Status Update (January 1, 2017 through December 31, 2017)

2017 Assessment Rate: Children: $8.62 Adult: $0.60

2017 Coverage Numbers:

Children (23% of all covered lives)  Filed average child covered lives = 83,649

Adults (77% of all covered lives)  Filed average adult covered lives = 242,884  Provider Opt in for uninsured adults (monthly) =30,233  Total average adult lives = 273,117

Total Covered (46.43 % of total population)  Filed average covered lives = 326,533 (92%)  Provider Opt in for uninsured adults (monthly) = 30,233 (8%)  Total average lives = 356,766 (100%)

2017 Total Assessments: $10,401,409

2019-02-20 AVAP Council Meeting ALASKA STATE LEGISLATURE Page 23 of 86

1500 W. Benson Boulevard Alaska State Capitol Anchorage AK 99503 Juneau AK 99801 907-269-0181 907-465-4843 800-892-4843 800-892-4843

North to the Future

Senator Cathy Giessel Senate District N

Senate Bill 37 Renewal of Alaska Vaccine Assessment Program

Sectional Analysis (vsn A)

Section 1: Amends AS 18.09.200(b) by removing the “phase in” language from statute as the Alaska Vaccine Assessment Program is now fully implemented.

Section 2: Amends AS 18.09.220(a) by removing the “phase in” language from statute as the Alaska Vaccine Assessment Program is now fully implemented.

Section 3: Repeals AS 18.09.220(e) by removing the opt out option for assesses since the program is no longer in the “phase-in” stage

Section 4: Repeals the sunset provisions (to repeal the program in 2021) that were in section 5 of the original bill, SB 169 in 2014.

[email protected]

2019-02-20 AVAP Council Meeting Page 24 of 86 NPR Beyond Rash And Fever: How Measles Kills 100,000 Children A Year February 2, 20197:00 AM ET

MICHAELEEN DOUCLEFF

Writer Roald Dahl and his wife, actress Patricia Neal, with two of their children, Theo and Chantel Sophia "Tessa." The photo was taken a few years after oldest daughter, Olivia, died of measles. Hulton Archive/Getty Images Editor's note: This story was originally published in 2015 and has been updated.

In 1962, children's book author Roald Dahl lost his oldest daughter, Olivia, to measles. She was 7 years old.

Twenty-six years later, Dahl wrote a letter to parents about what happened:

"As the illness took its usual course I can remember reading to her often in bed and not feeling particularly alarmed about it. Then one morning, when she was well on the road to recovery, I was sitting on her bed showing her how to fashion little animals out of coloured pipe-cleaners, and when it came to her turn to make one herself, I noticed that her fingers and her mind were not working together and she couldn't do anything.

" 'Are you feeling all right?' I asked her. 2019-02-20 AVAP Council Meeting Page 25 of 86 " 'I feel all sleepy,' she said.

"In an hour, she was unconscious. In twelve hours she was dead." Olivia had what's called measles encephalitis. The virus had spread to her brain. Her immune system rushed in to fight it. Her brain swelled up. At the time, Dahl wrote, "a reliable measles vaccine had not been discovered."

Today there is a vaccine for this extremely contagious disease. But certain groups of parents opt not to vaccinate their children — and that has led to outbreaks in countries like Italy and Israel and recently in Washington state, where the governor has declared a state of emergency with 41 confirmed cases.

"A lot of folks feel measles isn't a big deal. It just causes a rash and a fever," says Dr. Alice Ackerman, professor emeritus at Virginia Tech Carilion School of Medicine. "In the majority of cases, that's true." But in about 1 in 1,000 cases, the infection becomes systemic and moves to the brain.

"This causes behavioral changes, potential brain swelling and convulsions," Ackerman says. There's little doctors can do. Children can be left deaf, blind or with mental retardation — if they recover.

In some cases the brain infection can set in quickly, as with Dahl's daughter. But there's a small chance, Ackerman says, that 7 to 10 years after a child has the measles, subacute sclerosing panencephalitis, or SSPE, can occur. "Through my four decades of practice I saw children admitted to my ICU with horrible brain occurrences where they might start having seizures, started drooling, lost their ability to interact," she says. "It's heartbreaking."

The only way to prevent these potential problems, she says, "is to prevent yourself from getting measles in the first case" with the vaccine.

SSPE is very rare: Only about 1 in 5,000 people with the measles will develop it, a study found. But other serious complications from measles aren't so rare. The most common is pneumonia.

Measles typically infects the upper respiratory tract, like the flu or common cold does. But when measles moves to the lower respiratory, it becomes pneumonia — and much more problematic.

"Pneumonia impairs the body's ability to harness oxygen in the air," says Dr. Amesh Adalja, an infectious disease specialist at the Johns Hopkins Center for Health Security. "Children don't get enough oxygen in their lungs to supply the body. Some end up on a ventilator."

Up to 1 in 20 children worldwide who catch measles gets pneumonia, the Centers for Disease Control and Prevention says. It's one of the most common ways that measles killed 110,000 children worldwide in 2017, most of them under age 5.

And there's no way to predict which children will develop severe complications to measles, Adalja says. "For all [intents and] purposes, anyone can get pneumonia from the measles or encephalitis."

But people with weak immune systems are at higher risk, Adalja says. That includes those undergoing some cancer treatments, organ donor recipients, the elderly and babies.

Malnourished children in poor countries are also vulnerable to measles encephalitis and pneumonia, says Ackerman. "Their immune systems can't build an appropriate response against the virus."

In many instances, the parents of these children don't have access to vaccines or treatments for measles complications. These parents experience what Dahl and his family faced a half-century ago: losing a child to measles.

2019-02-20 AVAP Council Meeting Page 26 of 86

Vaccine Formulary

Pediatric Vaccines Brand Name® Manufacturer NDC Code DT (Diphtheria/ Tetanus) No trade name Sanofi Pasteur 49281-0225-10 DTaP (Diphtheria/ Tetanus/acellular Pertussis) Infanrix® GlaxoSmithKline 58160-0810-11 DTaP/ Hepatitis B/ IPV Pediarix® GlaxoSmithKline 58160-0811-52 DTaP/ IPV Kinrix® GlaxoSmithKline 58160-0812-52 Hepatitis A Havrix® GlaxoSmithKline 58160-0825-52 00006-4981-00 (vial) Recombivax HB® Merck Hepatitis B 00006-4093-02 (syringe) Engerix-B® GlaxoSmithKline 58160-0820-52 Hib (Haemophilus influenzae type b) PedvaxHIB® Merck 00006-4897-00 9vHPV (Human Papillomavirus 9-valent) Gardasil®9 Merck 00006-4121-02 Influenza Varies: Influenza Vaccines IPV (Inactivated poliovirus) IPOL® Sanofi Pasteur 49281-0860-10 MCV4 (Meningococcal conjugate) Menactra® Sanofi Pasteur 49281-0589-05 MVC4O (Meningococcal conjugate) Menveo® GlaxoSmithKline 46028-0208-01 58160-0976-06 (1 pack) MenB (Serogroup B Meningococcal) Bexsero® GlaxoSmithKline 58160-0976-20 (10 pack) MMR (Measles/ Mumps/ Rubella) M-M-R®II Merck 00006-4681-00 PCV13 (Pneumococcal conjugate) Prevnar 13™ Pfizer 00005-1971-02 PPSV23 (Pneumococcal polysaccharide) Pneumovax®23 Merck 00006-4943-00 RV5 (Rotavirus) RotaTeq® Merck 00006-4047-41 Td (Tetanus/ diphtheria) No trade name Grifols 13533-0131-01 Tdap (Tetanus/ Diphtheria/acellular Pertussis) Boostrix® GlaxoSmithKline 58160-0842-11 Varicella (Chickenpox) Varivax® Merck 00006-4827-00

Adult Vaccines age restrictions may apply Brand Name® Manufacturer NDC Code 9vHPV (Human papillomavirus 9-valent) Gardasil®9 Merck 00006-4121-02 Influenza Varies: Influenza Vaccines MCV4 (Meningococcal conjugate) Menactra® Sanofi Pasteur 49281-0589-05 58160-0976-06 (1 pack) MenB (Serogroup B Meningococcal) Bexsero® GlaxoSmithKline 58160-0976-20 (10 pack) PPSV23 (Pneumococcal polysaccharide) Pneumovax®23 Merck 00006-4943-00 Td (Tetanus/ diphtheria) No trade name Grifols 13533-0131-01 Tdap (Tetanus/ Diphtheria/acellular Pertussis) Boostrix® Sanofi Pasteur 58160-0842-11 58160-0819-12 (1 pack) Zoster (Shingles) Shingrix GlaxoSmithKline 58160-0823-11 (10 pack)

Related CDC links Vaccine for Children Vaccine Price List CDC Current Vaccine Shortages and Delays Immunization Information Systems (IIS) Code Sets

Alaska Immunization Helpline: Anchorage: 907-269-8088 | Toll Free: 888-430-4321 | Email: [email protected]

Rev. 11/18/18 2019-02-20 AVAP Council Meeting Page 27 of 86 2019-02-20 AVAP Council Meeting Fiscal Note Page 28 of 86 State of Alaska Bill Version: SB 37 2019 Legislative Session Fiscal Note Number: () Publish Date: Identifier: SB037-DHSS-E-2-1-2019 Department: Department of Health and Social Services Title: RENEWAL OF VACCINE ASSESSMENT Appropriation: Public Health PROGRAM Allocation: Epidemiology Sponsor: GIESSEL OMB Component Number: 296 Requester: HSS Expenditures/Revenues Note: Amounts do not include inflation unless otherwise noted below. (Thousands of Dollars) Included in FY2020 Governor's Appropriation FY2020 Out-Year Cost Estimates Requested Request OPERATING EXPENDITURES FY 2020 FY 2020 FY 2021 FY 2022 FY 2023 FY 2024 FY 2025 Personal Services Travel Services Commodities 10,500.0 10,500.0 10,500.0 10,500.0 10,500.0 10,500.0 Capital Outlay Grants & Benefits Miscellaneous Total Operating 0.0 10,500.0 10,500.0 10,500.0 10,500.0 10,500.0 10,500.0

Fund Source (Operating Only) 1238 VaccAssess (DGF) 10,500.0 10,500.0 10,500.0 10,500.0 10,500.0 10,500.0 Total 0.0 10,500.0 10,500.0 10,500.0 10,500.0 10,500.0 10,500.0

Positions Full-time Part-time Temporary

Change in Revenues None Total 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Estimated SUPPLEMENTAL (FY2019) cost: 0.0 (separate supplemental appropriation required) Estimated CAPITAL (FY2020) cost: 0.0 (separate capital appropriation required) Does the bill create or modify a new fund or account? No (Supplemental/Capital/New Fund - discuss reasons and fund source(s) in analysis section) ASSOCIATED REGULATIONS Does the bill direct, or will the bill result in, regulation changes adopted by your agency? No If yes, by what date are the regulations to be adopted, amended or repealed? n/a Why this fiscal note differs from previous version/comments: Not applicable, initial version based on the 12/15/2018 Governor's FY2020 request.

Prepared By: Merry Carlson, Director Phone: (907)269-2042 Division: Public Health Date: 01/29/2019 03:41 PM Approved By: Sana Efird Administrative Services Director Date: 02/01/19 Agency: Office of Management and Budget

Printed 2/4/2019 Page 1 of 2 Control Code: RVFeT 2019-02-20 AVAP Council Meeting Page 29 of 86 FISCAL NOTE ANALYSIS

STATE OF ALASKA BILL NO. SB037(HSS) 2019 LEGISLATIVE SESSION

Analysis

This bill reauthorizes the statewide immunization program in the Department of Health and Social Services, which is scheduled to sunset January 1, 2021.

Established in 2014, the Alaska Vaccine Assessment Program is a public-private partnership that monitors, purchases and distributes all childhood and select adult vaccines to providers, making access to vaccines universal for all Alaskans at no cost to the state. In 2018, the program covered more than 333,000 Alaskans, 45 percent of the total population.

The Alaska Vaccine Assessment Program is fully funded by the state Vaccine Assessment Account through mandatory assessments from health plans and insurers. The Department of Health and Social Services manages the program and provides support to the Vaccine Assessment Council. The Council determines the assessment rate.

Private health insurers, third party administrators, and other program participants pay an assessment to the state based on the number of beneficiaries they cover. The State uses the assessments to purchase pediatric and adult vaccines at discounted rates off a bulk contract. The State then distributes the vaccines directly to healthcare providers at no additonal charge to their patients. This program improves health and well-being while lowering overall vaccine costs by 20 to 30 percent.

Current budgeted authorization in the FY2020 Governor's Budget is $10,500.0 from the Vaccine Assessment Account.

(Revised 9/05/18 OMB/LFD) Page 2 of 2

SB037-DHSS-E-2-1-2019 Page 2 of 2 Control Code: RVFeT 2019-02-20 AVAP Council Meeting Page 30 of 86

2018 Alaska Vaccine Assessment Program (AVAP) Participating Payers

2018 AVAP Participating Payers 4 Ever Life Insurance Company Aetna AK Carpenters Health & Welfare Trust Fund AK Hotel, Restaurant and Camp Employees Health & Welfare Plan AK Laborers Health and Secuirty Plan AK Pipe Trades Assoc - UA Local No. 375 Health and Secuirty Trust Fund AK UFCW Health & Welfare Trust Alaska Electrical Health & Welfare Fund ALASKA HOUSING FINANCE CORP Alaska Teamster-Employer Welfare Trust Alaska UFCW Retiree Health & Welfare Trust All Alaska Longshore Health & Welfare Trust Allied Benefit Systems, Inc. ALSCO EMPLOYEE BENEFIT PLAN AmeriHealth Administrators, Inc. Anthem Blue Cross Life and Health Insurance Company Anthem Health Plans of KY Anthem Health Plans of Maine, Inc. Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of Virginia, Inc. Anthem Health Plans, Inc. Anthem Insurance Companies, Inc. APEA-AFT Health and Welfare Trust ARM, LTD ASRM Automated Benefit Services, Inc. BCS Insurance Company Benefit & Risk Management Services BLOOD BANK OF ALASKA, INC Blue Benefit Administrators of Massachusetts Blue Cross & Blue Shield of Rhode Island Blue Cross and Blue Shield of Alabama Blue Cross and Blue Shield of Georgia, Inc. Blue Cross and Blue Shield of Kansas City Blue Cross and Blue Shield of Minnesota 2019-02-20 AVAP Council Meeting Page 31 of 86

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Blue Cross Blue Shield of Arizona Blue Cross Blue Shield of FL Blue Cross Blue Shield of Massachusete, Inc. BLUE CROSS BLUE SHIELD OF NEBRASKA Blue Cross Blue Shield of Wisconsin Blue Cross of California Blue Shield of CA BOON ADMINISTRATIVE SERVICES, INC Capital Advantage Assurance Company Capital BlueCross CareFirst BlueCross BlueShield CBA Blue Central United Life Insurance Company CFA, LLC Chesterfield Resources, Inc. CHG COMPANIES, Inc. Christian Brothers Employee Benefit Trust Cigna Health and Life Insurance Company CollectiveHealth Administrators, LLC Commercial Roofing Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield Compcare Health Services Insurance Corporation Comprehensive Care Services, Inc Connecticut General Life Insurance Company Consolidated Health Plans, Inc. Core and Main CoreSource, Inc. CU GME CUSTOMER ENGINEERING SERVICES Delaware American Life Insurance Company EBMS, Inc. EBMS, LLC EBSO, Inc. Empire HealthChoice Assurance, Inc. Excellus Health Plan, Inc. Fairbanks North Star Borough Fairbanks North Star School District First Choice Health Administrators Gilsbar, LLC 2019-02-20 AVAP Council Meeting Page 32 of 86

GOLDEN RULE INSURANCE COMPANY Group & Pension Administrators, Inc. Group Health Program of NTCA and Its Members HCSC HD SUPPLY, INC Health Net Life Insurance Company Health Plan of Nevada, Inc. Health Plans Inc Healthcare Management Administrators, Inc. HealthFirst TPA, Inc. HealthKeepers, Inc. HealthSCOPE Benefits HealthSmart Benefit Solutions, Inc. Healthy Alliance Life Insurance Company Highmark Highmark Delaware Highmark West Virginia HMO Colorado, Inc. Horizon Healthcare Services Inc Humana Health Plan, Inc. Humana Insurance Company Independence American Insurance Company Inlandboatmens Union of the Pacific Health Plan Integrity Administrators, Inc. Jackson National Life Insurance Company JBS USA Food Company Holdings JP HEALTH PLAN Key Benefit Administrators, Inc. LifeWise Assurance Company LifeWise Health Plan of Oregon LifeWise Health Plan of Washington Local 302 & 612 Intl Union of Operating Engineers Const. Ind. Health and Secuirty Plan MAMSI Life and Health Insurance Company ManhattanLife Assurance Company of America Matthew Thornton Health Plan, Inc. Medical Benefits Administrators, Inc. Medova Healthcare Financial Group, LLC Meritain Health, Inc. MMSI INC Moda Health Plan, Inc. 2019-02-20 AVAP Council Meeting Page 33 of 86

Nationwide Life Insurance Company Newell Brand Nicholas Gismondi Nippon Life Insurance Company of America NORTH SLOPE BOROUGHS SCHOOL DIST Northwest Fire Fighters Benefits Trust NW Insulation Workers Welfare Trust NW Ironworkers Health and Security Plan Oxford Health Insurance, Inc. Oxford Health Plans LLC Planned Administrators, Inc. Premera Blue Cross Prime Therapeutics LLC QCC Insurance Company Regence BlueCross BlueShield of Oregon Regence BlueCross BlueShield of Utah Regence BlueShield Regence BlueShield of Idaho Regional Care, Inc. Rehn & Associates Rocky Mountain Hospital and Medical Service, Inc. Seafarers Health & Benefits Plan Security Health Plan of Wisconsin, Inc. SelectHealth - Finance Dept Self Insured Services Company Sierra Health and Life Insurance Company, Inc. Significa Benefit Services, Inc. SPORTSMAN'S WAREHOUSE INC Standard Security Life Insurance Company of New Yor State Farm Mutual Automobile Insurance Company Symetra Life Insurance Company TECK AMERICAN INCORPORATED Transamerica Premier Life Insurance Company TRAX INTERNATIONAL CORPORATION Trusteed Plans Service Corporation UMR, Inc. UniCare Life & Health Insurance Company Unimerica Insurance Company United Healthcare Insurance Company United Healthcare Services, Inc. 2019-02-20 AVAP Council Meeting Page 34 of 86

UnitedHealthcare Inc. UnitedHealthcare Life Insurance Co. Unity Health Insurance Corporation USAble Mutual Insurance Company WebTPA LLC WellCare Prescription Insurance, Inc. Wellmark, Inc. d/b/a Wellmark Blue Cross and Blue Shield of Iowa Zenith American Solutions

2019-02-20 AVAP Council Meeting Page 35 of 86

Where to go for childhood and adolescent immunizations

Children in Alaska may receive vaccines at no cost to them from medical providers enrolled to receive vaccine through the Alaska Immunization Program.

While medical providers are not permitted to charge for the cost of vaccines they receive through the Alaska Immunization Program, they may charge for vaccine they privately purchase and may bill for visit or office fees. (For information regarding vaccine and vaccine administration fees, see this chart.)

Parents/guardians seeking immunization services are encouraged to contact clinics to: • Ensure vaccine availability and • Find out if clinics take walk-in patients or if appointments are needed

Local Public Health Centers and the providers listed below receive vaccines through the Alaska Immunization Program:

Provider/Facility Name City

ALASKA CENTER FOR PEDIATRICS ANCHORAGE ALASKA FAMILY CARE ASSOCIATES ANCHORAGE ALASKA NATIVE MEDICAL CENTER ANCHORAGE ALASKA REGIONAL HOSPITAL (Imm. clinic third Saturday each month) ANCHORAGE ALASKA REGIONAL MYHEALTH CLINIC ANCHORAGE ALASKA URGENT CARE ANCHORAGE ALLERGY ASTHMA & IMMUNOLOGY CLINIC ANCHORAGE ALYESKA FAMILY MEDICINE ANCHORAGE ANCHORAGE NEIGHBORHOOD HEALTH CENTER ANCHORAGE ANCHORAGE PEDIATRIC GROUP ANCHORAGE BRIGGS JAMES D MD ANCHORAGE CAPSTONE FAMILY MEDICINE ANCHORAGE CHILDRENS CLINIC ANCHORAGE CORNERSTONE MEDICAL CLINIC ANCHORAGE DESCHWEINITZ ELIZABETH MD ANCHORAGE FIRST CARE MEDICAL CENTER LLC ANCHORAGE FULL SPECTRUM PEDIATRICS PC ANCHORAGE INDEPENDENCE PARK MEDICAL SERVICES ANCHORAGE JACOB MARY ANN MD ANCHORAGE LATOUCHE PEDIATRICS LLC ANCHORAGE LEMON TREE FAMILY MEDICINE LLC ANCHORAGE MUNICIPALITY OF ANCHORAGE - DHHS ANCHORAGE NORTHWEST MEDICAL ANCHORAGE PATIENTS FIRST MEDICAL CLINIC ANCHORAGE POLAR PEDIATRICS ANCHORAGE PROVIDENCE FAMILY MEDICINE CENTER ANCHORAGE PROVIDENCE IMMUNIZATION CLINIC, (First Saturday of each month) ANCHORAGE BETHEL HEALTH CLINIC BETHEL YUKON KUSKOKWIM HEALTH CORPORATION BETHEL EKLUTNA VILLAGE CLINIC CHUGIAK COPPER RIVER NATIVE ASSOCIATION REGIONAL HEALTH CLINIC COPPER CENTER CORDOVA COMMUNITY MEDICAL CENTER CORDOVA ILANKA HEALTH CENTER CORDOVA PEACEHEALTH MEDICAL GROUP CRAIG FAMILY MEDICAL CENTER DELTA JUNCTION

Rev. 6/20/2018 2019-02-20 AVAP Council Meeting Provider/Facility Name City Page 36 of 86 INTERIOR ALASKA MEDICAL CLINIC DELTA JUNCTION BRISTOL BAY AREA HEALTH CORPORATION DILLINGHAM CAPSTONE FAMILY MEDICINE EAGLE RIVER GAUPP MONICA MD EAGLE RIVER LATOUCHE PEDIATICS LLC EAGLE RIVER CHIEF ANDREW ISAAC HEALTH CENTER FAIRBANKS FAIRBANKS CLINIC INC FAIRBANKS INTERIOR COMMUNITY HEALTH CENTER FAIRBANKS TANANA VALLEY CLINIC FAIRBANKS UNIVERSITY OF ALASKA FAIRBANKS FAIRBANKS YUKON FLATS HEALTH CENTER FORT YUKON NORTH COUNTRY CLINIC GAKONA GIRDWOOD HEALTH CLINIC GIRDWOOD CROSS ROAD MEDICAL CENTER GLENNALLEN GUSTAVUS CLINIC GUSTAVUS HAINES HEALTH CENTER HAINES HOMER MEDICAL CENTER HOMER HOMER MEDICAL OB AND WELL BABY CLINIC HOMER KACHEMAK BAY MEDICAL CLINIC HOMER SELDOVIA VILLAGE TRIBE HEALTH CENTER HOMER HOONAH HEALTH CENTER HOONAH NILAVENA SUBREGIONAL CLINIC ILIAMNA ETHEL LUND MEDICAL CENTER JUNEAU FAMILY PRACTICE PHYSICIANS JUNEAU GLACIER PEDIATRICS JUNEAU RAINFOREST PEDIATRIC CARE JUNEAU VALLEY MEDICAL CARE JUNEAU CENTRAL PENINSULA FAMILY PRACTICE KENAI DENA'INA WELLNESS CENTER KENAI PENINSULA COMMUNITY HEALTH SERVICES KENAI KETCHIKAN INDIAN COMMUNITY KETCHIKAN PEACEHEALTH PRIMARY CARE KETCHIKAN PEACEHEALTH PEDIATRIC CLINIC KETCHIKAN KODIAK AREA NATIVE ASSOCIATION KODIAK KODIAK COMMUNITY HEALTH CENTER KODIAK KODIAK ISLAND AMBULATORY CARE CLINIC KODIAK MANIILAQ ASSOCIATION KOTZEBUE MCGRATH HEALTH CENTER MCGRATH ANNETTE ISLAND SERVICE UNIT METLAKATLA CAMAI COMMUNITY HEALTH CENTER NAKNEK NINILCHIK COMMUNITY CLINIC NINILCHIK NORTON SOUND HEALTH CORPORATION NOME CLIFT BRUCK MD LLC PALMER IDEAL FAMILY MEDICINE PALMER PALMER FAMILY MEDICINE PALMER THE FAMILY HEALTH CENTER PALMER JOY JANSSEN CLINIC PETERSBURG ST GEORGE HEALTH CENTER SAINT GEORGE ISLAND ST PAUL HEALTH CENTER SAINT PAUL ISLAND

Rev. 6/20/2018 2019-02-20 AVAP Council Meeting Provider/Facility Name City Page 37 of 86 CHUGACHMIUT NORTH STAR HEALTH CLINIC SEWARD GLACIER FAMILY MEDICINE CLINIC SEWARD SEWARD COMMUNITY HEALTH CENTER SEWARD MOUNTAINSIDE FAMILY HEALTHCARE SITKA MT. EDGECUMBE HOSPITAL SITKA SITKA MEDICAL CENTER SITKA DAHL MEMORIAL CLINIC SKAGWAY CENTRAL PENINSULA FAMILY PRACTICE AND PEDIATRICS SOLDOTNA DEEDE MARCUS MD SOLDOTNA FAMILY MEDICAL CLINIC SOLDOTNA FLORES KATHRYN FNP SOLDOTNA PENINSULA COMMUNITY HEALTH SERVICES SOLDOTNA SHERIDAN KATY MD SOLDOTNA UPSTREAM FAMILY MEDICINE SOLDOTNA LIFE HOUSE COMMUNITY HEALTH CENTER SUTTON SUNSHINE COMMUNITY HEALTH CENTER TALKEETNA ILIULIUK FAMILY AND HEALTH SERVICES UNALASKA OONALASKA WELLNESS CENTER UNALASKA NORTH SLOPE BOUROUGH DEPARTMENT OF HEALTH AND SOCIAL SERVICES UTQIAGVIK SAMUEL SIMMONDS MEMORIAL HOSPITAL UTQIAGVIK VALDEZ MEDICAL CLINIC VALDEZ ADVENTURES IN PEDIATRICS WASILLA ALL SEASONS FAMILY HEALTH CARE WASILLA CAPSTONE FAMILY MEDICINE WASILLA COHO FAMILY MEDICINE WASILLA FRONTIER FAMILY MEDICINE WASILLA HERITAGE FAMILY MEDICINE LLC WASILLA MAT-SU COMMUNITY PEDIATRICS WASILLA MAT-SU HEALTH SERVICES WASILLA MAT-SU MIDWIFERY WASILLA MAT-SU REGIONAL URGENT CARE WASILLA MAT-SU REGIONAL URGENT CARE SETTLERS BAY WASILLA NORTHWOODS FAMILY MEDICINE WASILLA PTARMIGAN PEDIATRICS LLC WASILLA SOLSTICE FAMILY CARE WASILLA VALLEY NATIVE PRIMARY CARE CENTER WASILLA WILD IRIS FAMILY MEDICINE & MATERNITY CARE WASILLA SUNSHINE COMMUNITY HEALTH CENTER WILLOW ALASKA ISLAND COMMUNITY SERVICES TLCD WRANGELL YAKUTAT COMMUNITY HEALTH CENTER YAKUTAT

Questions? Alaska Immunization Helpline 269-8088 (Anchorage) or 1-888-430-4321; email [email protected]

Rev. 6/20/2018 2019-02-20 AVAP Council Meeting Page 38 of 86

2018 Status Update (January 1, 2018 through December 31, 2018)

2018 Assessment Rate: Children: $8.61 per covered life per month Adult: $0.88 per covered life per month

2018 Coverage Numbers:

Children (44% of child population)  Average child covered lives reported = 85,964 (24% of total covered lives)

Adults (52% of adult population)  Average adult covered lives reported = 247,517  Provider Opt‐in for uninsured adults (monthly) = 32,056  Total average adult lives = 279,573 (76% of total covered lives)

Total Covered (50% of total population)  Filed average covered lives = 333,482 (91% of total covered lives)  Provider Opt in for uninsured adults (monthly) = 32,056 (9% of total covered lives)  Total average lives = 365,538

2018 Total Assessments: $12,477,155

Source: Alaska Division of Public Health, Alaska Vaccine Assessment Program and Department of Labor and Workforce Development, Research and Analysis. Children are under age 19. Adults are 19 years of age or older. The Alaska Vaccine Assessment Program is authorized under Alaska Statute 18.09. Who Pays for Vaccine in Alaska?

Alaska Vaccine Assessment Privately Privately Insured, Program Insured, Policy Policy Does Not Covers Cover Uninsured TRICARE Immunizations Immunizations Medicaid AI/AN VA Medicare

Children Aged 0‐18 Years State supplies at no cost to provider Not Applicable

Provider Provider Adults Aged 19 Years State supplies at no cost to Provider purchases or Provider Purchases purchases or and Older provider Purchases can opt in* state supplies† 2019-02-20

AI/AN = American Indian/Alaska Native

*Providers can opt in annually for their uninsured population AVAP †IHS beneﬁciary status or coverage through the VA is not considered insurance under the AVAP adult vaccine program. AVAP eligibility for these adults is dependent on a

secondary insurance status or if the provider has opted in. Council Page

Alaska Division of Public Health, Alaska Vaccine Assessment Program January 2019 39 Meeting of 86 SB 37 Renewal of Vaccine Assessment Program

SENATE HEALTH AND SOCIAL SERVICES COMMITTEE FEBRUARY 6, 2019

Alaska Division of Public Health 2019-02-20 AVAP Council Page 40 Meeting of 86 SB 37 • Reauthorizes the statewide Alaska Vaccine Assessment Program in the Department of Health and Social Services, scheduled for sunset January 1, 2021. • Eliminates a temporary phase‐in period that ended in 2017. • Uses the state Vaccine Assessment Account to fully fund the program. o No unrestricted general funds 2019-02-20 are involved. AVAP Council Page 41 Meeting

AS 18.09.200‐18.09.990 Statewide Health Care, Statewide Immunization Program. of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 2 What is the Alaska Vaccine Assessment Program? Established in 2014, AVAP is a public‐private partnership making access to vaccines universal for all Alaskans at no cost to the state. • Provides all childhood and certain adult vaccines for privately insured children and some adults. • Covers vaccine costs through assessments collected from private health insurers, third party administrators, and other program participants. • Purchases vaccines at discounted rates off a bulk contract. 2019-02-20 • Distributes vaccine directly to healthcare providers at no charge who administer the vaccines to their patients. AVAP Council Page 42 Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 3 What is the Alaska Vaccine Assessment Program?

• Through AVAP, Alaska continues to demonstrate leadership in creating innovative solutions for difficult public health issues. • Alaska is one of only 11 states that has a universal childhood vaccine program and one of only 3 states that offers adult vaccines. • Alaska is the only state that offers healthcare providers the option of purchasing state‐supplied vaccine to serve uninsured adults. 2019-02-20 AVAP Council Page 43 Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 4 Alaska Vaccine Assessment Council sets the annual assessment rate

Payers pay into the The Division of Public assessment quarterly Health provides data to based on their reported the Council for rate setting covered lives

Providers report The Division of Public administered vaccines to Health purchases vaccine the Division of Public off a discounted bulk Health contract 2019-02-20 Providers vaccinate The Division of Public covered patients, only Health ships vaccine at no billing payers for office cost to providers or AVAP

visit through the Vaccine Depot Council Page 44 Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 5 Vaccine Cost

COST TO VACCINATE A PERSON THROUGH 18 YEARS OF AGE Overall vaccine Savings costs $940 lowered by 20%‐30%. Cost Cost $2,379 $3,319 2019-02-20 AVAP Council Page 45 AVAP PRIVATE SECTOR Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 6 Vaccine Coverage

2018 • 366,000 Alaskans covered • 50% of the population • 86,000 children • 44% of all children • 280,000 adults • 52% of all adults 2019-02-20 AVAP Council Page 46 Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 7 Successes

• The Division of Public Health reduces vaccine preventable diseases. • Providers have improved health outcomes for vaccinated individuals and easier vaccine stock management. • The health insurance industry pays less to vaccinate

individuals. 2019-02-20 • All Alaskans save more money in the long run due to fewer medical costs from vaccine‐preventable diseases. AVAP Council Page 47 Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 8 Return on Health

Lowers direct and long‐term healthcare costs and yields numerous public health benefits: • Ensures that every child and some adults who enter a participating doctor’s office or hospital can receive recommended vaccines at no cost. • More healthcare providers can offer vaccination services • less up‐front costs to finance out of their own pockets for vaccines, and • reduces staff burdens required to separate private and public vaccine stock. 2019-02-20 • Allows the State to manage the supply of vaccines, • ensuring that the state can quickly supply vaccines to vulnerable AVAP Council patient groups during emergencies or vaccine shortages, and Page 48 Meeting

• reducing waste through centralized inventory management. of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 9 (Diphtheria, Tetanus, (Measles, Mumps, and Pertussis) and Rubella) 2019-02-20 AVAP Council Page 49 Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 10 In Closing…

Reauthorizing the Alaska Vaccine Assessment Program ensures a healthier future for all Alaskans at the lowest possible cost. 2019-02-20 AVAP Council Page 50 Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 11 Thank You

Department of Health and Social Services Division of Public Health

Lily J. Lou, MD, FAAP Jill Lewis Chief Medical Officer Deputy Director 2019-02-20 907‐269‐6680 907‐465‐8617

[email protected] [email protected] AVAP Council Page 51 Meeting of 86

SB037 RENEWAL OF VACCINE ASSESSMENT PROGRAM ALASKA DIVISION OF PUBLIC HEALTH 12 2019-02-20 AVAP Council Meeting Page 52 of 86 2019-02-20 AVAP Council Meeting Page 53 of 86 Measles IT ISN’T JUST A LITTLE RASH

Measles can be dangerous, especially for babies and young children.

MEASLES SYMPTOMS TYPICALLY INCLUDE

• High fever (may spike to more than 104° F)

• Cough

• Runny nose

• Red, watery eyes

• Rash breaks out 3-5 days after symptoms begin

Measles Can Be Serious

About 1 out of 4 1 out of every 1,000 1 or 2 out of 1,000 people who get measles people with measles people with measles will be hospitalized. will develop brain will die, even with swelling due to infection the best care. (encephalitis), which may lead to brain damage.

You have the power to protect your child.

Provide your children with safe and long-lasting protection against measles by making sure they get the measles-mumps-rubella (MMR) vaccine according to CDC’s recommended immunization schedule. CS254521-A

WWW.CDC.GOV/MEASLES 2019-02-20 AVAP Council Meeting Page 54 of 86

Alaska Vaccination Rate, Selected Vaccines, 2013‐2017

≥ 1 Tdap ≥ 1 MenACWY ≥ 1 HPV HPV1‐F HPV UTD‐F HPV1‐M HPV UTD‐M Combined 7 Vaccine Series Pneumococcal vaccine 100% Alaska Vaccine 90% Assessment Program begins January 2015 80%

70%

60%

50%

40%

30%

20%

10%

0% 2013 2014 2015* 2016 2017

Alaska Vaccination Rate, Selected Vaccines, 2013‐2017 Age Group^ Vaccine 2013 2014 2015* 2016 2017 ≥ 1 Tdap 74% 74% 70% 79% 80% ≥ 1 MenACWY 55% 56% 56% 67% 68% ≥ 1 HPV 61% 65% Adolescents aged 13‐17 HPV1‐F 52% 49% 57% 62% 61% HPV UTD‐F 27% 34% 37% 48% 46% HPV1‐M 28% 38% 42% 60% 68% HPV UTD‐M 9% 13% 19% 39% 40% Children under age 2 Combined 7 Vaccine Series 64% 67% 66% 69% 68%

Adults age 65+ Pneumococcal vaccine 63% 61% 63% 70% 70%

Notes: ^Adolescent vaccination coverage among adolescents 13 through 17 years old for Tdap, MenACWY, and HPV percent vaccination coverage, 2013‐2017, National Immunization Survey Combined 7‐vaccine series (≥4 DTaP, ≥3 Polio, ≥1 MMR, 3 Hib, ≥3 HepB, ≥1 Varicella, and ≥4 PCV) coverage among children 19 through 35 months in Alaska, 2013‐2017, National Immunization Survey Pneumococcal vaccination coverage among adults 65 years and greater, 2013‐2017, BRFSS *Alaska Vaccine Assessment Program began operations in January, 2015. Source: Alaska Division of Public Health, February 2019 Measles Page 1 of 2 2019-02-20 AVAP Council Meeting Page 55 of 86 myAlaska My Government Resident Business in Alaska Visiting Alaska State Employees

Home Divisions and Agencies Services News Contact Us

Health and Social Services > Public Health > Epidemiology > Infectious Disease > Measles

Measles (Rubeola) Section of Epidemiology Home Measles is a highly contagious viral respiratory illness. Symptoms Conditions Reportable include fever, cough, runny nose, and red watery eyes followed by a Epidemiology Bulletins rash over most of the body. Contact Us Measles can be serious. Programs Environmental Public Health About 1 in 4 people in the U.S. who get measles will be hospitalized Health Impact Assessment 1 out of every 1,000 people with measles will develop brain HIV/STD swelling, which could lead to brain damage Immunization 1 or 2 out of 1,000 people with measles will die, even with the best Infectious Disease care Injury Surveillance Measles is very contagious.

Measles spreads through the air when an infected person coughs or Infectious Disease sneezes. It is so contagious that if one person has it, 9 out of 10 Home people around him or her will also become infected if they are not Food and Waterborne Diseases protected. Your child can get measles just by being in a room where a Healthcare Associated Infections person with measles has been, even up to two hours after that person Hepatitis Prevention has left. An infected person can spread measles to others even before Influenza knowing he/she has the disease—from four days before developing the Syndromic Surveillance measles rash through four days afterward. Tuberculosis Control Some people think of measles as just a little rash and fever that clears Vaccine-Preventable Diseases up in a few days, but measles can cause serious health complications, (VPD) especially in children younger than 5 years of age. There is no way to Epi Procedure Manual tell in advance the severity of the symptoms your child will experience.

A highly effective vaccine has resulted in a dramatic reduction in measles cases and deaths worldwide. However, outbreaks and deaths continue to occur, primarily related to overseas travel and unvaccinated individuals.

Alaska Surveillance Data

After an absence of almost 15 years, a confirmed case of measles was diagnosed in Fairbanks on June 9, 2015. The case-patient had recent travel history to central Asia. Providers are reminded to always ask about travel history in patients with acute rash illness and be aware of measles as a possibility. Multiple states are currently experiencing measles outbreaks including New York State, New York City, and Washington.

Providers must report suspected measles cases immediately to the Alaska Section of Epidemiology at (907) 269-8000.

View the latest U.S. surveillance data from the CDC.

Resources for the General Public

'About the Disease' - CDC's comprehensive measles website, with information on risk factors, causes, signs and symptoms, diagnosis, treatment, prevention, and photographs of disease Measles Fact Sheet from the Alaska Division of Public Health Frequently Asked Questions about Measles in the U.S. from the CDC Measles Vaccination: Who Needs It? Measles Vaccine Information

http://dhss.alaska.gov/dph/Epi/id/Pages/measles/default.aspx 2/5/2019 Measles Page 2 of 2

Vaccines do not cause autism...get the facts. 2019-02-20 AVAP Council Meeting Page 56 of 86 Resources for Healthcare Providers

Measles Information for Clinicians from the CDC Alaska Measles Testing Guidance (March 9, 2018) Measles Investigation Quicksheet (California Department of Public Health document) Alaska Section of Laboratories Test Directory (Measles test info on page 56) ASPHL-Fairbanks Lab Test Request Form Epidemiology Bulletins associated with Measles from the State of Alaska State of Alaska Immunization Program

Measles is a public health reportable condition in Alaska. Report suspect cases immediately to the Alaska Section of Epidemiology at 907-269-8000.

Measles Multimedia Resources from the CDC

Infectious Disease Program Resources

Epidemiology Procedure Manual - Measles Chapter

Archived Measles Public Health Alerts and Updates

AKPHAN: Measles Outbreak in Washington State — What Alaskans Should Know (January 29, 2019) AKPHAN: Measles Case in Cruise Ship Passenger — What Alaska Providers Should Know (August 14, 2018) Press Release: Measles case confirmed in Fairbanks (June 9, 2015) AKPHAN: Measles Confirmed in Fairbanks – What Alaska Providers Should Know (June 9, 2015) MMR Vaccine, Post-Exposure, and Isolation Recommendations for Fairbanks (June 12, 2015) June 2015 Measles Alert – Printable Poster AKPHAN Update: Measles Outbreak in Disneyland – What Alaska Providers Should Know (January 28, 2015) AKPHAN: Measles Outbreak in Disneyland – Possible Alaska Case (January 23, 2015) AKPHAN: Suspected Measles Case on Cruise Ship – Exposure to Alaskans Unlikely (September 12, 2014) AKPHAN: Measles – Situational Awareness (June 5, 2014)

Alaska Pioneer Homes Health Care Services Public Health Alaska Psychiatric Juvenile Justice Seniors & Disabilities Institute Office of Children's Services Contacts Accessibility Public Notices Staff Behavioral Health Services Substance Misuse and Webmaster Finance & Management Public Assistance Addiction Prevention Si State of Alaska myAlaska My Government Resident Business in Alaska Visiting Alaska State Employees State of Alaska © 2019 Webmaster

http://dhss.alaska.gov/dph/Epi/id/Pages/measles/default.aspx 2/5/2019 2019-02-20 AVAP Council Meeting Page 57 of 86

All Alaska Pediatric Partnership PO Box 230567 Anchorage, AK 99523

Senator Cathy Giessel Alaska State Senate

Dear Sen. Giessel:

I am writing in support of the reauthorization of Alaska’s Vaccine Assessment Program under Senate Bill 37.

The All Alaska Pediatric Partnership (AAPP) was an instrumental partner in the creation of VacTrAK, the Alaska Immunization Information Center. Until recently, AAPP also hosted Alaska’s immunization Outreach Coalition and actively engaged communities and Public Health clinics throughout the state in promotion of on-time immunizations through events and education. We continue to partner with Alaska’s Immunization Program at the Dept. of Health and Social Services to provide immunization outreach, especially in light of recent measles outbreaks in Alaska and Washington.

As you know, Alaska was a universal vaccine provider until 2010 when Federal funding was reduced and a cumbersome, expensive 2-tier system took its place. In 2015 Alaska successfully developed the AVAP (Alaska Vaccine Assessment Program), a consortium of public and private funding that once again provides universal vaccine access to Alaska’s children. The program has been incredibly successful in providing efficiency in procurement and distribution while simultaneously offering significant financial savings.

Reauthorization of this important legislation is key to continued success in Alaska continuing to be a universal vaccine provider. We have made great strides in increasing our rates of immunization, having the infrastructure in place to support efficient distribution, storage and tracking is crucial to our continued efforts to increase our rates.

Sincerely,

Tamar Ben-Yosef

Executive Director All Alaska Pediatric Partnership [email protected]

All Alaska Pediatric Partnership | Tax I.D. 47-342-8822 | PO Box 230567, Anchorage, AK 99523 | 907-903-6770 http://a2p2.org

2019-02-20 AVAP Council Meeting Page 58 of 86

February 12, 2019

Senator Natasha von Imhof, Co-Chair, Senate Finance Committee Senator Bert Stedman, Co-Chair, Senate Finance Committee Alaska State Capitol Juneau, AK 99801

Re: Senate Bill 37-Renewal of Vaccine Assessment Program

Dear Senators von Imhof and Stedman:

KidsVax® (KV) administers the Alaska Vaccine Assessment Program (AVAP) pursuant to a contract with the Department of Health and Social Services (DHSS). Mindful of that role, KV looks to statutes adopted by the AK Legislature and DHSS for policy guidance and does not advance policy positions. However, we are more than happy to provide any information which may be helpful as the Legislature considers AVAP’s reauthorization. KV was instrumental in all aspects of AVAP’s setup after legislation was passed five years ago. Similarly, KV was the founding administrator and I personally served in the initial Executive Director role for programs in the States of NH, WA, VT, and ME. KV also has assisted those states, together with CT, NM, and ID, in securing TRICARE’s participation in State Vaccine Program (SVP) funding.

A few salient points from AVAP’s history are the following:

1. AVAP’s Advisory Council, made up of a cross section of payers, providers, and state officials, unanimously supports its reauthorization. 2. AVAP has been exemplary in adopting financial best practices: a. All AVAP costs are covered by the assessments paid by those who benefit from cost savings achieved through this program. b. AVAP funds are collected through a dedicated lockbox, segregated, and timely accounted for with 24/7 view availability. c. AVAP has contracted with an AK-licensed CPA to perform an annual financial audit. d. AK submits its operating results for review by an independent CPA who annually calculates payer cost savings. 3. AVAP maintains an easily-accessible website and full financial transparency by posting minutes, audited financials, and assessment calculation worksheets. That website is available to the public, as well as State policy makers, and incorporates full search functionality. 4. Operationally, AVAP has enjoyed strong operating results: a. Annual operating costs have fallen materially each year from its formation. For the most recent audit period, they amounted to less than 7% of revenues. b. AVAP has fully funded its targeted cash reserve needed to maintain DHSS’s qualification to access the cost-beneficial national CDC vaccine purchase contract. 5. AVAP was able to absorb vaccine cost increases for the upcoming 2019 operating year and still reduce assessments. It contemplates that its assessment increase rate in the near term should remain below the annual vaccine manufacturer cost increases in the CDC contract.

KV will to do its best to provide any background data helpful to your committee or to other legislators as they consider this important legislation. Feel free to call or write at any time.

Very truly yours,

Fred L. Potter, Managing Member FLP/tmm

2019-02-20 AVAP Council Meeting Page 59 of 86 2019-02-20 AVAP Council Meeting Page 60 of 86

ALASKA VACCINE ASSESSMENT PROGRAM Statement of Net Assets December 31, 2018 [A] [B] [C] ASSETS

1 Cash 2 Held by the State of Alaska $ 14,695,419.67 3 Held by KidsVax, LLC 25,345.29 4 Total Cash $ 14,720,764.96

5 Assessments receivable 6 Payers 8,566.08 7 Providers (606.80) 8 Total Assessments Receivable 7,959.28

9 Total Assets $ 14,728,724.24

LIABILITIES AND NET ASSETS

10 LIABILITIES 11 Accounts payable 12 Vaccines $ 292,982.91 13 KidsVax, LLC 28,296.16 14 Alaska Department of Health 101,495.20 15 Total Accounts Payable $ 422,774.27

16 Assessments collected in excess of vaccine funding and administrative activities 8,544,372.29

17 Total Liabilities 8,967,146.56

18 NET ASSETS

19 Net assets - unrestricted - 20 Net assets - temporarily restricted 5,761,577.68

21 Total Net Assets 5,761,577.68

22 Total Liabilities and Net Assets $ 14,728,724.24

Unaudited - For Management Purposes Only 2/13/2019 Prepared by KidsVax, LLC 1 2019-02-20 AVAP Council Meeting Page 61 of 86

ALASKA VACCINE ASSESSMENT PROGRAM Statement of Activities For the Year Ended December 31, 2018

[A] [B] [C] [D] Temporarily - Unrestricted Restricted Total 1 Assessments 2 Payer assessments - children $ 9,133,616.49 $ - $ 9,133,616.49 3 Payer assessments - adults 2,667,515.88 - 2,667,515.88 4 Provider assessments 338,511.36 - 338,511.36 12,139,643.73 - 12,139,643.73

5 Transfer of administrative fee to Temporaly Restricted (293,392.66) 293,392.66 - 6 TRICARE 1,500,000.00 1,500,000.00 7 Interest income 19,848.41 19,848.41 8 Total Revenue 11,866,099.48 1,793,392.66 13,659,492.14

9 Program expenses 10 Vaccines 7,208,889.01 - 7,208,889.01 11 Equipment 111,183.00 - 111,183.00 12 Servicing agent 275,776.96 - 275,776.96 13 Total Program Expenses 7,595,848.97 - 7,595,848.97

14 Administrative costs 16,162.10 16,162.10 15 Authorized DOH expenditures 101,495.20 101,495.20

16 Total Expenses 7,612,011.07 101,495.20 7,713,506.27

17 Change in Net Activity 4,254,088.41 1,691,897.46 $ 5,945,985.87

Assessments collected in excess of vaccine funding and 18 administrative activities, beginning of year 4,290,283.88

Assessments collected in excess of vaccine funding and 19 administrative activities, end of year $ 8,544,372.29

20 Temporarily Restricted Fund, beginning of year 4,069,680.22

21 Temporarily Restricted Fund, end of year $ 5,761,577.68

Unaudited - For Management Purposes Only 2/13/2019 Prepared by KidsVax,LLC 2 2019-02-20 AVAP Council Meeting Page 62 of 86

February 20, 2019 Executive Director Report

2019 AVAP Self-Reporting Assessment Collections For the Assessment For the Assessment Quarter, Due on Quarter, Due on 8/15/2018 11/15/2018 (Measuring months (Measuring months ending 6/30/2018) e ending 9/30/2018)

Child Monthly Average Covered Lives: 88,971 88,269 Adult Monthly Average Covered Lives: 253,196 250,824 Total Assessments: $2,966,557.49_ $2,942,046.47 Total Interest: $562.79 $.05 Total Payers Reporting: 144 144

I am pleased to report that, as anticipated, implementation of the 2019 reduced assessment has gone smoothly. Thankfully, TRICARE has just confirmed its acceptance of the incremental assessment you authorized KidsVax® (KV) to implement at the last meeting. This will result in an additional $71,000+ of collections from TRICARE for just the first quarter. Meanwhile, as you will see in the reports in the Council packet, TRICARE work marches forward with hope for a favorable conclusion later on this quarter.

This has been a season of substantial change in leadership for the State of Alaska. Thankfully DHSS has been blessed by an ever-increasingly effective immunization program administration led by Matt Bobo. Additionally, other strong leadership has been retained or recruited. All are supportive of AVAP’s reauthorization. The initial Senate hearing went well and as this Council packet is being finalized, the Senate Finance Committee Hearing has just completed its hearing.

I look forward to our work together next week. We appreciate the high level of participation which has been confirmed and fully understand, in light of the reduced meeting time frame and limited number of action items, that several of you will be participating via teleconference.

Thank you, each one, for your diligence and support for this important work.

Very truly yours,

Fred L. Potter, Esq. Executive Director, AVAP 2019-02-20 AVAP Council Meeting Page 63 of 86

February 13, 2019

TRICARE PROJECT SUMMARY MEMORANDUM ALASKA VACCINE ASSESSMENT PROGRAM

I. Background KidsVax® (KV) began work on collecting for TRICARE beneficiaries from the Defense Health Agency (DHA) even before AVAP was formed. First, KV secured acknowledgement by DHA’s administration of the medical benefits of State Vaccine Programs (SVPs). DHA health officials acknowledged that SVPs support important health policy initiatives advanced by TRICARE. Yet, TRICARE asserted that it had no ability to pay because it was a “creature of statute,” not a benefit plan, and that Congress did not afford it the needed flexibility. At the suggestion of some within DHA, KV supported numerous efforts to deploy demonstration and other statutory provisions, all of which failed to overcome TRICARE’s bureaucratic inertia.

Accordingly, the Washington Vaccine Association launched a two-fold approach of preparation for litigation and legislative Congressional initiatives. These efforts bore fruit and, effective the end of 2016, Congress expressly authorized TRICARE to pay. But TRICARE still did not. That statute was made mandatory at the end of 2017. Even then, however, DHA’s implementation work was sluggish. KV’s continued press resulted in first payments to AVAP on September 9, 2018.

II. Administrative Implementation TRICARE’s administrative focus turned to the “limitations” portion of the statute rather than its core purpose. KV sought, beginning early in 2018, after federal legislation made TRICARE payments mandatory, to get DHA to align its limitations with the congressional mandate. Thankfully, that work has resulted in numerous concessions increasing the caps imposed by TRICARE.

III. Arrearage At the same time, KV has pressed to secure TRICARE acknowledgment that the statutory mandate applied to the arrears for AVAP as well as go-forward amounts. Those arrearage negotiations also focused on improving the limitations language. At this point, TRICARE has acknowledged that it owes $2,532,060.14 for AVAP arrears. An advance of $1.5 million has been made against that amount leaving $1 million+ to be recovered. In negotiations last fall, TRICARE confirmed that AVAP would be allowed to make an incremental assessment. This will result in an incremental collection of over $71,000 in the current quarter.

Alaska benefitted as issues it shared with other SVPs were resolved over the last year. Additionally, Alaska providers believe that TRICARE’s assertion that over 70 percent of its beneficiaries are immunized on base is incorrect. KV has offered numerous alternatives which would resolve this Alaska-specific matter, but TRICARE continues to resist KV’s efforts on that front.

IV. Current Status Amount collected to date: Assessments: $588,981.65 Arrearage: $1.500,000.00 Amount acknowledged as remaining due: Assessments: $ 71,932.95 Arrearage: $1,032.060.14 Total TRICARE amounts committed to date: $3,192,174.71

V. Anticipated steps Senator Shaheen’s (NH) office now is championing the multistate effort. We believe they will request data on the arrearage calculation which will enable us to advance AVAP’s argument for a higher level of assessment. Additionally, we will ask about actual immunizations on base in the State of Alaska as part of this data request. That should enable us to confirm whether the provider sense of under reporting by TRICARE is correct. If so, that will provide the impetus for further negotiations as to Alaska methodologies, or, possibly, re-visitation of the DHA assessment caps applicable to Alaska.

After gathering this supplemental data, KV contemplates accepting an outstanding invitation from the Senate Armed Services Committee (SASC) for a follow-up staff meeting and, if necessary, a meeting with SASC involving TRICARE officials. KV presently seeks to complete these remaining steps in the first quarter of 2019. Meanwhile, AVAP will continue to receive regular quarterly assessments and the incremental amounts. Additionally, should AVAP determine to discontinue work on improving TRICARE methodologies, it will be able to receive the balance of $1,032,060.14 on the arrearage by simply filing the settlement agreement which has been offered by DHA for that purpose.

2019-02-20 AVAP Council Meeting Page 64 of 86

PAST DUE NOTICE January 25, 2019 Sent Via Certified Mail/Return Receipt Requested

Sharon Seelmeyer Patricia Duvall TRICARE Health Plan Division, Deputy Assistant PGBA, LLC Director Healthcare Operations 17 Technology Circle Defense Health Agency Columbia, SC 29203 601 Pennsylvania Avenue, NW, #600 Washington, DC 20004

To Whom It May Concern:

As the Defense Health Agency (DHA) has repeatedly acknowledged, the National Defense Authorization Act of FY17 (NDAA 17), Section 719, and the National Defense Authorization Act for Fiscal Year 2018 (NDAA FY18), Section 718 authorize and direct the Department of Defense to reimburse State Vaccine Programs (SVPs) according to the “amount assessed by the entity carrying out such program to purchase vaccines provided to covered beneficiaries through such program.” NDAA FY17 Section 71(a)(2)(B) limits the amount that DHA may reimburse those entities, as follows:

“The amount…may not exceed the amount that the Department would reimburse an entity under the TRICARE program for providing vaccines to the number of covered beneficiaries who were involved in the applicable State vaccination program.”

The Alaska Vaccine Assessment Program (AVAP) believes that further adjustments are needed to the DHA methodology for computing limitations to comply with federal law and that adjustments will result in payment of additional funds to AVAP. DHA has declined to continue evaluation of those requested changes. Nonetheless, DHA has consistently acknowledged that it owes not less than an additional $1,032,060.14 to AVAP. A substantial portion of this unpaid arrearage is months, if not years, past due. Accordingly, AVAP formally advises DHA that the acknowledged $1,032,060.14 is past due and must be remitted immediately in accordance with the mandates of federal and state law. Additionally, AVAP reserves the right to notify DHA of additional sums due once AVAP gathers the data necessary to make such calculations.

Sincerely,

Fred L. Potter cc: Bryan T. Wheeler, Deputy Counsel, Defense Health Agency

2019-02-20 AVAP Council Meeting Page 65 of 86 2019-02-20 AVAP Council Meeting Page 66 of 86 2019-02-20 AVAP Council Meeting Page 67 of 86

Fred Potter

From: Fred Potter Sent: Tuesday, February 12, 2019 6:20 AM To: Seelmeyer, Sharon L CIV DHA HEALTHCARE OPS (US) Cc: Wheeler, Bryan T CIV DHA DGC FC (US); Mantooth, Mark C CIV DHA OGC (USA) Subject: FW: Billing for Vaccine Assessment Due February 15, 2019 Attachments: 2019-02-13 Summary and page Extracts for AK, VT & NH of TRICARE limitations.pdf

Importance: High

Sharon –

We received the email copied below from your administrator serving beneficiaries in the State of Alaska. Similar communications have been received by SVPs from administrators for the States of Vermont and New Hampshire. The copied email indicates that DHA has instructed its contractors to limit monthly assessments to $10.51 for child and $0.73 for adults as they process February 2019 assessment payments.

In contrast, the table below summarizes the presently‐effective computed limitations supplied to us by DHA last year.

Numbers in the above table are taken from the Kennell memos which were offered by DHA last year and became the predicates for the respective state settlements. I’ve attached the respective state memo pages for reference, highlighting the numbers which I understand from those memos to be applicable at the current time. Looking over these memos I’m wondering if the Vermont $2.72 is just a typo & the intended number is $2.27. Hence, actual DHA reductions imposed this month expose another methodological problem in that there appears to be no adjustment for the different adult vaccine formularies among states.

So, all of DHA’s 2019 contractor limits appear to be a throwback to last year’s limits and have now been applied to assessments due in 2019. Further, for New Hampshire, the agreed utilization bump‐up of TRICARE’s limitation cap, which was the subject of our hard work together last fall, has not been operationalized. Hence the predicates for each of the respective settlements to date has been undermined by actual implementation steps inconsistent with the bases for those settlements.

In light of the above, kindly advise:

1. Will DHA promptly bring forward its operational instructions so that: 1 2019-02-20 AVAP Council Meeting Page 68 of 86 a. The amounts paid in February 2019 are based upon the numbers given to the respective states by DHA as it solicited their acceptance of arrearage settlements just weeks ago?

b. Future years’ assessment limits and operational instructions by DHA to its contractors will conform with the presentations made by DHA to the states in the respective most recent Kennell memos?

2. Will DHA voluntarily supply the detailed data supporting its limitations caps for the three years 2016, 2017 & 2018 (see note a. below)?

3. Will DHA consider the simplified LIMITATIONS approach repeatedly offered by KidsVax® to avoid the evident lack of transparency and operational costs & error vulnerability of its current LIMITATIONS approach (see note b. below)?

Thankfully, our work last year narrowed the remaining implementation steps meaningfully. I had hoped to be able to finalize our initial work on this project this month. However, given the operational problems which came to light in the last two weeks, I want to allow time for DHA’s response to these questions before completing our updated multistate report.

Since I will be making an in‐person report to officials in the State of Alaska next week, I would appreciate having the benefit of your latest thinking on each of the above this week. Please call or write any time at your convenience. Also, if it is helpful for DHA’s deliberations to have a bit more time to respond, kindly advise. If I do not hear from you by the end of this week, I will proceed on the understanding that DHA’s response is “no” to each of the above and proceed accordingly.

Thanks again for your work last year. I trust that 2019 will be a good year for you and your team. Best wishes to you.

– Fred

Note a: This data must be readily available since it presumably was used to compute past DHA limitations and now actually has been deployed to limit agreed incremental assessments for TRICARE. No PHI need be involved in that data delivery. KidsVax is willing (and would prefer) to receive the data on a de‐identified basis and will agree to the restrictions applied by the DHA to the detailed data which was delivered to enable review of calculations applied to reach the WVA settlement. As you know, that data exchange was helpful to us in reaching a point where KidsVax® could recommend the various WVA settlements. I’m hopeful review of that data similarly could narrow or eliminate additional concerns about DHA’s implementation practices. This data goes to the calculation of the numerator for reference numbers for each non‐SVP state. We also would need the data for calculation of the denominator for each non‐SVP state for which data was used in the Kennell calculations (i.e., the number of “reliants” under TRICARE’s methodology). That, of course, is a much smaller data set & should be easy to deliver.

Note b: We continue to believe that TRICARE’s current “actual claims payment average” based LIMITATIONS system is not authorized by Congress’s “would reimburse” statutory language. To date DHA has preemptively dismissed KV’s recommendations for systems based upon publicly‐available data. Any objections raised to date by TRICARE could be resolved with minimal effort (and certainly much less effort which appears to lie behind its current complicated, costly, and error‐prone LIMITATIONS system). Further, the current system by definition cannot respond timely to vaccine practice innovation. This is particularly problematic for SVPs which fund adult vaccines since adults have dramatically lower immunization rates for federally‐recommended vaccines than do children. One of the objectives of state health departments with adult immunization programs is to improve those rates and capture the long‐term health benefits (and overall medical and societal cost savings) which follow.

2 2019-02-20 AVAP Council Meeting Page 69 of 86 Fred L. Potter • Managing Member

125 North State Street • Concord, NH 03302‐1885 cell 603.491.2389 | direct ph & fax 1.855.556.4101 main ph 1.855.KidsVax (543.7829) | main fax 1.855.KidsFax (543.7329) email [email protected]

From: Susan Armstrong Sent: Wednesday, February 6, 2019 10:39 AM To: Heather A. Veen Cc: Claire Roberge ; Fred Potter ; Sean R. Hershelman ; '[email protected]' Subject: RE: Billing for Vaccine Assessment Due February 15, 2019

Hi Ms. Veen,

Thank you for the quick response. Please update your records for the following DHA Point of Contact. Ms. Seelmeyer indicated she did not receive the January 28, 2019 letter likely because the address is incorrect. Ms. Seelmeyer provided the following address:

Sharon Seelmeyer Medical Benefits & Reimbursement TRICARE Health Plan Division, Deputy Assistant Director Healthcare Operations Defense Health Agency 16401 East Centretech Parkway Aurora, CO 80011

In addition, Ms. Seelmeyer provided the following in regards to the revised invoice amount:

“The updated rates from Mr. Potter's letter today ($10.85 child, $0.76 adult) are greater than the TRICARE cap amounts. The cap for children is $126.11 (annual cap) divided by 12= $10.51 rounded. The cap for adults is $8.80 (annual cap) divided by 12= $0.73 rounded.

Per policy, you are to pay the lesser of the SVP assessment amount or the TRICARE cap. The spreadsheet on the website shows this as $19,072 for adults, and $228,196 for children for a total of $247,268. Now that I have the actual updated assessment amount, I'll update the website to match the new AVAP assessment, but that won't change the reimbursement since it'll be the TRICARE cap. “

HNFS/PGBA will submit a voucher for payment of the difference between the revised amount ($247,268.85) and the previously paid amount ($175,335.87) which equals ($71,932.98).

3 2019-02-20 AVAP Council Meeting Page 70 of 86 Please continue to cc the following individuals on all correspondence related to TRICARE reimbursement to Alaska State Vaccine Program:

[email protected] [email protected] [email protected]

Thanks, Suzy

Susan L Armstrong Sr. Business Systems Analyst - Claims Administration Health Net Federal Services | 8733 Hwy 17 Bypass South, Surfside Beach, SC 29575 Phone: (843) 650-6100 EXT 17872 [email protected] | www.TRICARE-West.com

From: Heather A. Veen [mailto:[email protected]] Sent: Tuesday, February 5, 2019 3:57 PM To: Susan Armstrong Cc: Claire Roberge ; Fred Potter ; Sean R. Hershelman ; [email protected] Subject: RE: Billing for Vaccine Assessment Due February 15, 2019

EXTERNAL EMAIL: Please be cautious before you click on links, open attachments, or provide data.

Hello Suzy,

Attached is the letter requested regarding the incremental assessment.

Should you have any questions, please do not hesitate to contact us.

Thank you,

Heather Veen Sr. Executive Assistant, Paralegal

125 North State Street • Concord, NH 03301 ph 1.855.KidsVax (543.7829) direct 1.855.556.4103 cell 707.685.2328 | fax 1.855.KidsFax (543.7329) email [email protected]

From: Susan Armstrong Sent: Monday, February 4, 2019 5:18 PM To: Heather A. Veen Cc: Claire Roberge ; Fred Potter Subject: Billing for Vaccine Assessment Due February 15, 2019

Hi, 4 2019-02-20 AVAP Council Meeting Page 71 of 86

We are in receipt of the updated invoice for the amount due February 15, 2019. Please resubmit the notice concerning the incremental assessment applicable for TRICARE beneficiaries referenced in your attached letter re: Billing for Vaccine Assessment Due February 15, 2019.

We are required to compare the AK Monthly SVP Assessment amount for Children to the DHA Cap for Children and the AK Monthly amount for Adults to the DHA Cap for Adults in our worksheet prior to creating a voucher for submission to DHA. Our worksheet is a record of both the Alaska Assessment amount and the DHA Cap Amount to validate we are in compliance with DHA policy to pay the lesser amount.

I have also included the DHA Estimated Covered Lives and DHA Cap amount spreadsheet we used to create the previous invoice for your reference.

Please cc: [email protected] and [email protected] in addition to [email protected] regarding Alaska State Vaccine Assessments.

Thank you for your attention to this matter. Suzy

CONFIDENTIALITY NOTICE: This communication contains information intended for the use of the individuals to whom it is addressed and may contain information that is privileged, confidential or exempt from other disclosure under applicable law. If you are not the intended recipient, you are notified that any disclosure, printing, copying, distribution or use of the contents is prohibited. If you have received this in error, please notify the sender immediately by telephone or by returning it by return mail and then permanently delete the communication from your system. Thank you. CONFIDENTIALITY NOTICE: This communication contains information intended for the use of the individuals to whom it is addressed and may contain information that is privileged, confidential or exempt from other disclosure under applicable law. If you are not the intended recipient, you are notified that any disclosure, printing, copying, distribution or use of the contents is prohibited. If you have received this in error, please notify the sender immediately by telephone or by returning it by return mail and then permanently delete the communication from your system. Thank you.

5 2019-02-20 AVAP Council Meeting Page 72 of 86

TRICARE Limitations Data

Alaska: child adult

From 12/19/2018 Kennell Memo period: July 2018 -- Sept 2018 32.56 2.27 pp. 14 & 15. monthly: 10.85 0.76

Vermont:

From 10/19/2018 Kennell Memo period: July 2018 -- Sept 2018 32.56 2.72 pp. 13 & 14. monthly: 10.85 0.91

New Hampshire: From 11/29/2018 Kennell Memo period: July 2018 -- Sept 2018 36.69 p.12. monthly: 12.23

2019 TRICARE monthly limitations calculations 2/12/2019, 5:55 AM 2019-02-20 AVAP Council Meeting Page 73 of 86

Table 7

·Alaslca Child Expected DHA Payments by Quarter

Alaska - Child Estimated TRJCARE Per Inflation Estimated Quarterly Quarter!~ capita Adjusted Payment (Lesser of Inflatio n Payment using Quarterly capped TRICAREPer Adjusted TRICARE capped inflation Alaska TRJCARE SVP- Payme nt using Payme nt captia cap Payment Amount x Adjusted DHA Payment Due Quarterly TRICARE Po pulatio n Covered SVP Assessment TRICARE capped Amount for capped Amt Data Population or SVP Amountx cap for each Pe riod for Assessment Date Assessme nt Time Period Population Rate Paymentlime Period Quarte r per Qua.rter Source Population) period Oct-Dec 2014 2/15/20l5 $20.55 Oct-Dec 2014 6,904 $141.877 July 2014-Jun 2015 $26.41 S27.81 SVP $141.877 $191,991 Jan 2015-March 2015 5/15/2015 $20.55 Jan 2015-March 2015 7,024 $144,343 July 2014-Jun 2015 $26.41 $27.81 SVP $144,343 $195,321' April 2015-June 2015 8/15/2015 $20.55 April 2015-June 2015 7,063 $145,145 July 2014-Jun 2015 $26.41 S27.81 SVP $145,145 $196,413 July 2015-Sept2015 11/15/2015 $20.55 July 2015-Sept 2015 7,274 $149,481 July 2015-Jun 2016 '$27.75 $29.22 SVP $149,481 $212,527 Oct 2015-Dec 2015 2/15/2016 $20.31 Oct 2015-Dec 2015 7,166 $145,541 July 2015-Jun 2016 $27.75 $29.22 SVP $145,541 $209,371 Jan 2016-March 2016 S/15/2016 $20.31 Jan 2016-Ma.rch 2016 7,165 $145,521 July 2015-Jun 2016 $27.75 $29. .22 SVP $145,521 $209,34. Apri I 2016-J une 2016 8/15/2016 $20.31 April 2016-June 2016 7,141 $145,034 July 2015-Jun 2016 $27.75 $29.22 SVP $145,034 S208,64l July 2016-Sept 2016 11/15/2016 $20.31 July 2016-Sept 2016 7,180 $145,826 July 2016-Jun 2017 '$29.83 $31.41 SVP $145,826 $225, 51., Oct 2016-Dec2016 2/15/2017 $25.86 Oct 2016-Dec 2016 7,273 $188,080 July 2016-Jun 2017 $29.83 $31.41 SVP $188,080 $228,433 Jan 2017-March 2017 5/15/2017 $25.86 Jan 2017-March 2017 7,224 $186,813 July 2016-Jun 2017 $29.83 $31.41 SVP $186,813 $226,89

Note: This table calculates the total arrearage amount for Alaska. The SVP assessment total amounts for the April - June period do not represent what was paid by the contractor. See Table 9 for actual paid amounts.

1'4 (0 2019-02-20 AVAP Council Meeting Page 74 of 86

Table 8

Alaska Adulf\Expected DHA Payments by Quarter

Alaska - Adult

C Inflation Estimated Quarterly Estimated Estimated TRICAREAK Adjusted Payment (Lesser of Quarterly TRICARE Quarterly Adu lt Per- TRICAREAK Inflation Adjusted Paymen1 Population Count Payment using Capita Adult Per- TRICARE Per Capita Usini Alaska Quarterly for Quarter SVP assessme nt TRICARE Capped Capped Capita Capped Cap Payment Amountx Adjusted DHA Payment Due Assessment TRICARE Population (Average of the rate for each Payment Time Amount for Amount for Data Populatio n or SVP Cap for each Period for Assessment Date (Monthly x 3) Time Period Three Months) period Period Quarter Quarter Source Amountx Population) period Oct-Dec 2014 2/15/2015 $2.94 Oct-Dec 2014 8,248 $24, 249 July2014- June 2015 $1.79 $1.88 OHA $15,545 $15,545 Jan 2015-Mardi 2015 S/15/2015 $2.94 Jan 2015-March 2015 8,239 $24, 223 July 2014-June 2015 $1.79 $1.88 OHA $15,528 $15,528 April 2015-June 2015 8/15/2015 $2.94 April 2015--June 2015 8,102 $23,820 July 2014 - June 2015 $1.79 $1.88 OHA $15,270 $15,270 July 2015-Sept 2015 11/15/2015 $2.94 July 2015-Sept 2015 8,539 $25,105 July 2015 - June 2016 '$1.64 $1.73 OHA $14,764 $14,764 Oct 2015-Dec 2015 2/15/2016 $2.28 Oct 2015-0ec 2015 8,445 $19,255 July 2015 - June 2016 $1.64 $1.73 OHA $14,602 $14,602 Jan 2016-Mardi 2016 S/15/2016 $2.28 Jan 2016-March 2016 8,333 $1&,999 July 2015 - June 2016 $1.64 $1.73 OHA $14,408 $14,408 April 2016-June 2016 8/15/2016 $2.28 April 2016-June 2016 8,319 $18,967 July 2015 - June 2016 $1.64 $1.73 OHA $14,384 $14,384 July 2016-Sept 2016 11/15/2016 $2.28 July 2016-Se pt 2016 8,532 $19, 453 July 2016- June 2017 $1.90 $2.00 OHA $17,066 $17,0GE Oct 2016-Dec 2016 2/15/ 2017 $1.80 Oct 2016-Dec 2016 8,614 $15,505 July 2016- June 2017 $1.90 $2.00 SVP $15,505 $17,23( Jan 2017-March 2017 5/15/2017 $1.80 Jan 2017-March 2017 8,501 $15,302 July 2016- June 2017 $1.90 $2.00 SVP $15,302 $17,004 April 2017-June 2017 8/15/2017 $1.80 April 2017-June 2017 8,S62 $15,412 July 2016- June 2017 $1.90 $2.00 SVP $15,412 $17,W July 2017-Sept 2017 11/15/ 2017 $1.80 July 2017-Sept 2017 8,661 $15,590 July 2017 - June 2018 $2.0!l $2.20 SVP $15,590 $19,061 Oct 2017 - Dec 2017 2/15/ 2018 $1.80 Oct 2017-0ec2017 8,593 $15,467 July 2017 - June 2018 $2.0!l $2.20 SVP $15,467 $18,911 Jan 2018- II/larch 2018 5/15/2018 $2.64 Jan 2018 - March 2018 8,672 $22,894 July 2017 - June 2018 $2.0!l $2.20 OHA $19,085 $19,085 April 2018-June 2018 8/15/2018 $2.64 April 2018-June 2018 8,716 $23,010 July 2017 - June 2018 $2.0!l $2.20 DHA $19,175 $19,1~ fuly 2018-Sept 2018 11/15/ 2018 $2.64 July 2018 - Sept 2018 8,628 $22.778 Adjuste d 7/17-6/18 $2.16 $2.27 DHA $19,586 $19,58! Total $320,028 $256,689 $268,744

Note: This table calculates the total arrearage amount for Alaska. The SVP assessment total amounts for the April-June period do not represent what was paid by the contractor. See Table 9 for actual paid amounts.

j 5 0 2019-02-20 AVAP Council Meeting Page 75 of 86

Table 7

DHA Payments for Children in Vermont, by Quarter

Vermont - Child

TRICAREPer Inflation Estimated Quarterly Estimated Capita Adjusted TRICARE Payment(lesserof Inflation Quarterly Quarterly Capped Per Capita Adjusted TRICARE Per Capita Payment using VT Quarterly TRICARE SVP- Payment using Payment Capped Payment Capped Payment Amount x inflation Adjusted Assessment TRICARE Population Covered SVP Assessment TRICARE Capped TIme Amount for Amount for CapData PopulationorSVPAmountx DHACapforeach Period for Asse.ssment Payment Due Date (Monthlv x 3) nme Period Pooulation Rate Period Quarter Quarter Source Pooulation) oeriod Jan 2014-March 2014 5/ 15/2014 $74.94 Jan 2014-March 2014 1,937 $145,159 July 2013 - June 2014 $24.60 $25.91 DHA $50,183 $50,183 April 2014-June 2014 8/15/2014 $37.47 April 2014-June 2014 1,966 $73,666 July 2013-June 2014 $24.60 $25.91 DHA $50,934 $50,934 July 2014-Sept 2014 ll/15/2014 $37.47 July 2014-Sept 2014 1,975 $74,003 July 2014 - June 2015 $26.41 $27.81 DHA $54,922 $54,922 Oct 2014-0ec 2014 2/15/2015 $37.47 Oct 2014-Dec 2014 1,900 $71,193 July 2014-June 2015 $26.41 $27.81 DHA $52,836 $52,836 Jan 2015-March 2015 5/15/2015 $34.83 Jan 2015-March 2015 1,928 $67,152 July 2014-June 2015 $26.41 $27.81 DHA $53,615 $53,615 April 2015-June 2015 8/15/2015 $34.83 April 2015-June 2015 1,981 $68,998 July 2014-June 2015 $26.41 $27.81 DHA $55,089 $55,009 July 2015-Sept 2015 ll/15/2015 $34.83 July 2015-Sept 2015 2,048 $71,332 July 2015-June 2016 S27.75 $29.22 DHA $59,837 $59,837 Oct 2015-De C 2015 $34.83 2/15/2016 Oct 2015-0ec 2015 2,022 $70,426 July 2015-June 2016 $27.75 $29.22 DHA $59,077 S59,on Jan 2016-March 2016 5/15/ 2016 $3219 Jan 2016-March 2016 1,998 $64,316 July 2015-June 2016 $27.75 $29.22 DHA $58,376 $58,376 April 201~June 2016 8/15/2016 $3219 April 20l~June 2016 2,029 $65,314 July 2015-June 2016 $27.75 $29.22 DHA $59,282 $59,282 July 201~Sept 2016 ll/15/2016 $3219 July 2016-Sept 2016 2,071 $66,665 July 2016-June 2017 $29.83 $31-41 DHA $65,047 $65,047 Oct 201~Dec 2016 2/15/2017 $3219 Oct 2016-Dec2016 2,106 $67, 792 July 2016-June 2017 $29.83 $31-41 DHA $66,146 $66,146 Jan 2017-March 2017 5/15/2017 $35.85 Jan 2017-March 2017 2,161 sn,4n July 2016-June 2017 $29.83 $31-41 DHA $67,873 $67,873 April 2017 June 2017 8/15/2017 $35.85 April 2017 June 2017 2,155 sn,m July 2016-June 2017 $29.83 $31-41 OHA $67,685 $67,685 July 2017-Sept 2017 ll/15/2017 $35.85 July2017-Sept 2017 2,179 $78,117 July 2017 -June 2018 $29.94 $31-53 DHA $68,697 $68,697 Oct 2017-0ec 2017 2/15/2018 $35.85 Oct 2017-Dec 2017 1.m $63,562 July 2017-June 2018 $29.94 $31-53 DHA $55,897 $55,897 Jan 2018-March 2018 5/15/2018 $24.45 Jan 2018- March 2018 1,802 $44,059 July 2017 - June 2018 $29.94 $31-53 SVP $44,059 $56,811 April 2018--June 2018 8/15/2018 $0.03 April 2018-June 2018 1,n6 $53 July 2017 -June 2018 $29.94 $31.53 SVP $53 $55,992 July 2018-Sept 2018 U/15/2018 $0.03 July 2018- Sept 2018 1,785 $54 Adjusted 7/17-•6/18 $30.92 $3256 SVP $54 $58,117 $1,246,590 $989,662 $1,,116,417

Note: This table calculates the total arrearage amount for Vermont. The SVP assessment total amounts for the April - June period do not represent what was paid by the contractor. See Table 9 for actual paid amounts.

Table 8

DHA Payments for Adults in Vermont, by Quarter

Vermont - Adult Inflation Estimated Quarterly TRICARE Estimated Adjusted Payment (Lesser of Estimated Population Quarterly TRICAREPer TRICAREPer TRICARE Per Capita Quart.e r!\ Count for Payment Capita Capita Capped Payment Paymen1 Qua rte r usingSVP Capped Capped Amount x Using (Average of assessment Payment Payment Cap Population or SVP Adjusted DH.Q Payment Due VT Quarterly TRICARE Population the Three rate for each TRICARE Capped Amount for Amount for Data Payment Amount x Cap for each Pe riod for Assessment Date Assessment Time Period Months) period Time Period Quarter Quarter Source Population) period Jan 2014-March 2014 5/15/2014 $4.74 Jan 2014-March 2014 4,496 $21,311 July 2013-June 2014 $1.72 $1.81 OHA $8,128 $8,128 April 2014-June 2014 8/15/2!J14 $2.37 April 2014-June 2014 4,508 $10,684 July 2013-June 2014 $1.72 $1.81 OHA $8,150 $8,150 July 2014-Sept 2014 11/15/2014 $2.37 July 2014-Sept 2014 4,S45 $10,m July 2014-June 2015 $2.01 $2.12 OHA $9,626 $9,626 Oct 2014-Dec 2014 2/1S/20l5 $2.37 Oct 2014-0ec 2014 4,561 $10,810 July 2014-June 2015 $2.01 $2.12 OHA $9,659 $9,659 Jan 2015-March 2015 5/15/20l5 $2.52 Jan 2015-March 2015 4,587 $11,559 July 2014 • June 2015 $2.01 $2.12 OHA $9,714 $9,714 April 2015-June 2015 8/15/2015 $2.52 April 2015-June 2015 4,585 $11,5S4 July 2014-June 2015 $2.01 $2.12 OHA $9,710 $9,710 July 2015-Sept 2015 11/15/2015 $2.52 July 2015-Sept 2015 4,575 $11,529 July 2015-June 2016 $2.08 $2.19 OHA $10,013 $10,013 Oct 2015-Dec 2015 2/15/2016 $2.52 Oct 2015-0e c 2015 4,592 $11,572 July 2015-June 2016 $2.08 $2.19 OHA $10,051 $10,051 Jan 2016-March 2016 5/15/'2016 $1.74 Jan 2016-March 2016 4,.589 $7,985 July 2015-June 2016 $2.08 $2.19 SVP $7,985 $10,0

14 @) 2019-02-20 AVAP Council Meeting Page 77 of 86

Table 4 - New Hampshire Child Expected DHA Payments by Quarter

New Hampshire Estimated Quarterly Inflation Adjusted Payment {lesser of Estimated Quarterly Inflation TRI CARE Per Capita Inflation Adjusted Payment usini New Hampshire TRJCARE TRICARE Per Adjusted Capped Amt per TRI CARE Capped Inflation and Quarterly SVP- Quarterly Payment Capita Capped TRICAREPer Quarter ADJUSTED Cap Payment Amount x Immunization Assessment TRJCARE Population Covered usingSVP TRICARE Capped Payment Amount for Capita Capped for Immunization Data Population or SVP Adjusted DHA Cap fo1 Period for Assessment (Monthly x 3) Time Period Populatio n Assessment Rate Time Period Quarter Amt per Quarter Rates (127%) Source Amountx Population) e ach period

July 2010- Se.pt 2010 $66.00 July 2010-Sept 2010 4,640 $252.981 July 2010-June 2011 $2L71 $2286 $25.76 OHA $87,626 $98,75<1 Oct 2010-Dec 2010 $66.00 Oct 2010-Dec 2010 4,653 $307,098 July 2010 - June 2011 $2L71 $2286 $25.76 DHA $106,371 $119,88( Jan 2011-March 2011 $66.00 Jan 2011-March 2011 4,632 $305,712 July 2010 - June 2011 $2L71 $22.86 $25.76 DHA $105,890 $119,3l9 April 2011-June 2011 $66.00 April 2011-June 2011 4,598 $303,,468 July 2010 - June 2011 $2L71 $22.86 $25.76 OHA $105,113 $118,463 July 2011-Sept 2011 $66.69 July 2011-Sept 2011 4,449 $296,704 July 2011- June 2012 $23.12 $24.35 $27.44 DHA $100,313 $122,068 Oct 2011-Dec2011 $66.69 Oct 2011-Dec 2011 4,390 $292,769 Jul'y 2011-June 2012 $23.12 $24.3,S $27.44 OHA $106,876 Sll0,449 Jan 2012-Mardl 2012 $66.69 Jan 2012-March 2012 4,363 $290,968 July 2011-June 2012 $23.12 $24.35 $27.44 OHA $106,219 $119,709 April 2012-June 2012 $66.69 April 2012-June 2012 4,026 $268,494 July 2011 - June 2012 $23.12 $24.3,S $27.44 OHA $98,014 $110,46 July 2012-Sept 2012 $79.80 July 2012-Sept 2012 3,972 $316,966 July 2012 - June 2013 $23.54 $24.79 $27.94 OHA $98,456 $110,960 Oct 2012-Dec2012 $79.80 Oct 2012-0ec 2012 3,918 $312.656 July 2012 - June 2013 $23.54 $24.79 $27.94 OHA $97,118 $109,452 Jan 2013-Mardl 2013 $79.!ll Jan 2013-March 2013 3,901 $311.300 July 2012-June 2013 $23.54 $24.79 $27.94 OHA $96,697 $108,977 April 2013-June 2013 $79.80 April 2013-June 2013 3,926 $313,295 July 2012 - June 2013 $23.54 $24.79 $27.94 OHA $97,316 $109,675 July 2013-Sept 2013 $3L83 July 2013-Sept 2013 3,907 $124,360 July 2013 - June 2014 $24,60 $25.90 $29.19 OHA $101,206 $114,059 Oct 2013-0ec 2013 $31.83 Oct 2013-0ec2013 3,950 $125,729 July 2013-June 2014 $24.60 $25.90 $29.19 OHA $102,320 $115,315 Jan 2014-March 2014 $31.83 Jan 2014-March 2014 3,957 $125,951 July 2013 - June 2014 $24,60 $25.90 $29.19 OHA $102.501 $115,519 April 2014-June 2014 $31.83 April 2014-June 2014 3,.977 $126,588 July 2013-June 2014 $24.60 $25.90 $29.19 OHA $103,019 $116,103 July 2014-Se.pt 2014 $38.88 July 2014-Se.pt 2014 3,964 $154,120 July 2014-June 2015 $26.41 $27.81 $3L34 OHA $110,238 $124,238 Oct 2014-Dec2014 $38.88 Oct 2014-0ec2014 4,097 $159,291 July 2014-June 2015 $26.41 $27.81 $31-34 OHA $113,936 $128,406 Jan 2015-March 2015 $0.42 Jan 2015-March 2015 4,096 $1,720 July 2014 -June 2015 $26.41 $27.81 $31.34 SVP $1,720 $128,375 April 2015-June 2015 $0.42 April 2015-June 2015 4,ID3 $1,725 July 2014 -June 2015 $26.41 $27.81 $3L34 SVP $1,725 $128,751 July 2015-Sept 2015 $0.42 July 2015-Se.pt 2015 4,147 $1,742 July 2015 -June 2016 $27.75 $29.22 $32.93 SVP $1,742 $136,561; Oct 2015-0ec 2015 $0.42 Oct 2015-0ec 2015 4,236 $1,779 July 2015 -June 2016 $27.75 $29.22 $32.93 SVP $1,779 $139,499 Jan 2016-March 2016 $29.. 85 Jan 2016-March 2016 4,278 $127,698 July 2015 -June 2016 $27.75 $29.22 $32.93 SVP $125,006 $140,882 April 2016-June 2016 $29.85 April 2016-June 2016 4,303 $128,445 July 2015 -June 2016 $27.75 $29.22 $32.93 SVP $125,737 $141,705 July 2016-Se.pt 2016 $29.85 July 2016-Sept 2016 4,265 $127,310 July 2016-June 2017 $29.83 $3L41 $35.40 SVP $127,310 $150,982 Oct 2016-Dec 2016 $29.85 Oct 2016-0ec2016 4,271 $127,489 July 2016-June 2017 $29.83 $3,L41 $3,5.40 SVP $127,489 $151,194 Jan 2017-March 2017 $30.90 Jan 2017-March 2017 4,354 $134,539 July 2016-June 2017 $29.83 $3L41 $35.40 SVP $134,539 $154,132 April 2017-June 2017 $30.90 April 2017-June 2017 4,367 $134,940 July 2016-June 2017 $29.83 $3L41 $35.40 SVP $134,940 $154,593 July 2017-Se.pt 2017 $30.90 July 2017-Sept 2017 4,428 $136,825 July 2017 - June 2018 $29.94 $3L53 $35.53 SVP $136,825 $157,33( Oct 2017 - Dec 2017 $30.90 Oct 2017 - Dec 2017 2.917 $90,135 July 2017 -June 2018 $29.94 $3L53 $35.53 SVP $90,135 $103,64' Jan 2018-March 2018 $20.10 Jan 2018- March 2018 2.914 $58,571 July 2017 - June 2018 $29.94 $31.53 $35.53 SVP $58,5n $103,53; April 2018-June 2018 $20.10 April 2018-June 2018 2.969 $59,677 July 2017 - June 2018 $29.94 $3LS3 $35.53 SVP $59,677 $1ll5,49: July 2018-Se.pt2018 $20.10 July 2018 • Sept 2018 3,016 $60,622 Adjusted 7/17-6/18 $30.92 $32.56 $36.69 SVP $60,622 $ll0,66l $5,581,668 $3,035,049 $4,089,179

Note: The JuJy-Sept 2010 Ass.essment psiod is adjusted by 76/92 to r-eflect thitt lRJCARE-is payfngfor vaccinations ordered and p,ai d for on or after July 17th thatv.-ereadministered on or after December 23, 2010. Hote: 1he SVP ass.essmenttota-1 amounts. shown here for the April• Sepm:mber 2018 period do not represent what was acb.Jally paid by the<:o·ntracro,. See Table 9 for actual paid amounts.

12 ® 2019-02-20 AVAP Council Meeting Page 78 of 86

Alaska Vaccine Council Proposed Form of Votes February 20, 2019

The following are suggested forms of votes only. They are intended to be an aid to facilitate work by individual members. All Council policy and the final form of votes is exclusively the province of the Council acting collectively as the Alaska Vaccine Council.

Item under Agenda Section 2: VOTED: To approve the September 20, 2018 Council Meeting Minutes as submitted. [To approve the September 20, 2018 Council Meeting Minutes subject to the changes suggested at this meeting.]

2019-02-20 AVAP Council Meeting Page 79 of 86

Meeting Schedule – 2019

February 2019 In-Person Council Meeting Wednesday, February 20, 2019 TBD 9:30 11:00 a.m. May 2019 Council Meeting Thursday, May 23, 2019 Teleconference 9:30 a.m.

September 2019 In-Person Council Meeting Thursday, September 19, 2019 TBD 9:30 a.m.

2019-02-20 AVAP Council Meeting Page 80 of 86

Meeting Schedule – 2019

January 2019 Quarterly Finance Report Due Monday, January 14, 2019

February 2019 Covered Lives Report/ Friday, February 15, 2019 Quarterly Assessment In-Person Council Meeting Wednesday, February 20, 2019 BP Energy Center 9:30 11:00 a.m. April 2019 Quarterly Finance Report Due Monday, April 15, 2019

May 2019 Covered Lives Report/ Wednesday, May 15, 2019

Quarterly Assessment Council Meeting Thursday, May 23, 2019 Teleconference 9:30 a.m.

July 2019 Annual Financial Report Monday, July 1, 2019

Quarterly Finance Report Due Monday, July 15, 2019

August 2019 Covered Lives Report/ Thursday, August 15, 2019 Quarterly Assessment September 2019 In-Person Council Meeting Thursday, September 19, 2019 BP Energy Center 9:30 a.m.

October 2019 Quarterly Finance Report Due Tuesday, October 15, 2019

November 2019 Covered Lives Report/ Friday, November 15, 2019 Quarterly Assessment

2019-02-20 AVAP Council Meeting Page 81 of 86

AVAP Contact Directory As of 02/13/19

Council Members

DHSS Chief Medical Officer or Designee:

Joe McLaughlin, MD Phone: 907.269.8000 State Epidemiologist and Chief Fax: 907.562.7802 DHSS, Division of Public Health [email protected] PO Box 240249 Anchorage, AK 99524-0249

Director of Division of Insurance or Designee:

Sarah Bailey, AIE Phone: 907.465.4608 Supervisor, Fax: 907.465.3422 Life / Health Filings & Market Conduct [email protected] Alaska Division of Insurance 333 Willoughby Ave., 9th Fl. Juneau, AK 99801-1770

Physician Representatives:

Jodyne Butto, MD, FAAP Phone: 907.562.2423 Ext. 518 Anchorage Pediatric Group Fax: 907.563.1170 3340 Providence Drive [email protected] Building A, Suite 500 Anchorage, Alaska 99508

Rosalyn Singleton, MD, MPH Phone: (907) 563-2662 Pediatrician [email protected] Alaska Native Medical Center 4055 Tudor Centre Dr Anchorage, AK 99508

2019 Contact Directory 1 of 5

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Payer Representatives:

Mike Patton Phone: 425.918.6162 Director of Large Group Underwriting Cell: 425.260.1615 Premera [email protected] 7001 220th St, SW, Building 3 Mountlake Terrace, WA 98043

Lydia Bartholomew, MD Phone: 206.701.8047 Senior Director, Pacific NW Cell: 206.972.1137 Medical Health Services [email protected] Aetna One Union Square 600 University, Suite 920 Seattle WA 98101

Payer Representative – Plan Administrator:

Fred Brown Phone: 907.474.2446 Executive Director [email protected] Health Care Cost Management Corp. of Alaska 3000 A Street, Suite 300 Anchorage, AK 99503

Payer Representative – Tribal/Public Coverage:

Kara King, PharmD, MPH Phone: 907.729.2161 Alaska Native Tribal Health Consortium [email protected] 4000 Ambassador Drive Anchorage, AK 99508

2019 Contact Directory 2 of 5

2019-02-20 AVAP Council Meeting Page 83 of 86

Non-Voting Contributors Department of Health and Social Services

Lily Lou, MD Phone: 907.269.6680 Chief Medical Officer Fax: 907.269.2048 DHSS, Division of Public Health [email protected] 3601 C Street, Suite 756 Anchorage, AK 99503

Jill Lewis Phone: 907.465.8617 Deputy Director - Juneau Fax: 907.465.4632 DHSS, Division of Public Health [email protected] 350 Main Street, Ste 214 Juneau, Alaska 99811

Matthew Bobo, MPH Phone: 907.269.8015 Deputy Program Manager [email protected] Alaska Immunization Program Section of Epidemiology DHSS, Division of Public Health

Alicia Wieber Phone: 907.341.2214 Vaccine Depot Manager [email protected] Alaska Immunization Program Section of Epidemiology

KidsVax®

AVAP Support Staff

Fred L. Potter Phone: 855.556.4101 Managing Member Cell: 603.491.2389 PO Box 1885 [email protected] Concord, NH 03302-1885

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Claire Roberge Phone: 855.556.4102 Controller [email protected] PO Box 1885 Concord, NH 03302-1885

Heather Veen Phone: 855.556.4103 Sr. Executive Assistant, Paralegal Cell: 707.685.2328 PO Box 1885 [email protected] Concord, NH 03302-1885

Norm Roberge, CPA Phone: 603.496.7907 Assessment Monitoring and Internal Control [email protected] PO Box 1885 Concord, NH 03302-1885

Peter Smith, CPA Phone: 703.598.9975 Financial Analyst [email protected] 7856 Rysdale St. Niagara Falls, Ontario, Canada L2H 1G4

2019 Contact Directory 4 of 5

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Council Governance Roles & Committees

Council Members

Chair: Joe McLaughlin, MD Designee Voting Members: Sarah Bailey, AIE Designee Jodyne Butto, MD Rosalyn Singleton, MD Lydia Bartholomew, MD Derek Blomquist Fred Brown Kara King Mike Patton

• A quorum consists of at least five (5) Council Members

2019 Contact Directory 5 of 5

Map to BP Energy Center 2019-02-20 AVAP Council Meeting Page 86 of 86 900 E. Benson Blvd., Anchorage, AK (907) 743-4270

Directions: If northbound on New Seward Hwy., turn right into BP's southwest entrance. Turn right at the first stop sign into the BP Energy Center parking lot. Follow footpath through woods to building entrance. If eastbound on Benson Blvd., turn right into BP's main entrance. Turn right and follow access road to 4-way stop. Continue through intersection into the BP Energy Center parking lot.