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Agenda 09/13/2016 R Item #16E 8
16.E.8 09/13/2016 EXECUTIVE SUMMARY Recommendation to award joint RFP# 16-0036, Pharmacy Benefit Management Services to Envision Pharmaceutical Services, Inc., amending the existing agreement for a two year term effective January 1,2017,a savings of$2,945,116 over the existing Agreement. OBJECTIVE: To provide Pharmacy Benefit Management services to the Collier County Group Health Insurance Plan. CONSIDERATION: The Board of Commissioners through the Risk Management Division administers a partially self-funded group health insurance plan (the "Plan") for its employees and their covered dependents. A significant component of the Plan provides coverage for prescription medications through a Pharmacy Benefit Management program or "PBM". A PBM leverages large numbers of covered lives to negotiate favorable pricing terms from manufacturers and retail distributors for the Plans they service. The Board currently utilizes Envision to provide PBM services. The District School Board also contracts with Envision, and both Agreements terminate on December 31,2016. Therefore, the County and the District Schools agreed to pursue a joint Request for Proposals (RFP) process to attract the most favorable terms from interested vendors. The NCH Healthcare System also participated in the process. The RFP document was approved by County Procurement staff and released through the District Schools Purchasing Division. Staff from each entity served as the selection committee for their respective organization. Willis Towers Watson,the Benefits and Actuarial Consulting firm for the County, and the District Schools prepared the RFP and performed the actuarial analysis of the proposals. The RFP was released on April 14, 2016. A total of eleven firms submitted proposals. Willis Towers Watson reviewed the financial and operational terms of each proposal and performed an actuarial analysis for recommendation to the selection committee. The committee met on June 10,2016 to review the proposals and develop a potential short listing of firms to interview, if needed. Seven of the firms were eliminated because they were either 1) non responsive to requested per pill pricing infoiuiation; 2) pricing terms were not competitive; or 3) had a prior history of unacceptable performance. Finally, the committee evaluated the remaining four proposals to measure the impact of formulary disruption on members. Formulary disruption refers to the percentage of members who would be required to change medications if a new vendor were selected. Upon final review, the consensus of the selection committee was to recommend Envision for approval. On September 24, 2013 (Agenda Item #11G) the Board approved a two year Agreement with Envision effective January 1, 2014 and ending December 31, 2016. The Agreement contains a one year automatic renewal provision effective January 1 each year unless a 90 days notice of intent not to renew is exercised. The automatic renewal provision was exercised one time. Given the recommendation to award RFP# 16-0036 to Envision, the parties have agreed to an amendment of the existing Agreement that will incorporate an initial two-year teiin with fixed rates that will be effective on January 1, 2017 through December 31, 2018. The amendment contains an option to renew for two additional one (1) year terms. There is no automatic renewal provision. Packet Pg. 1903 1 6.E.8 09/13/2016 FISCAL IMPACT: It is estimated that the new rates will result in total savings of$2,945,116 to the Board's Health Insurance Program over a two year period when compared to the current rates. Funds are budgeted within Fund 517, Group Health and Life, Insurance Claims for this purpose. Estimated expenditures for pharmacy benefits in calendar year 2017 are $5,104,595 after rebates. GROWTH MANAGEMENT IMPACT: There is no growth management impact associated with this item. LEGAL CONSIDERATIONS: This item has been approved as to form and legality and requires majority vote for approval. - CMG RECOMMENDATION: That the Board awards joint RFP# 16-0036, Pharmacy Benefit Management Services to Envision and approves and authorizes the Chairman to execute the Amendment for an additional term including revised rates effective January 1,2017; after review and approval by the County Attorney's Office. Prepared by: Jeff Walker,CPCU,ARM,Division Director, Risk Management ATTACHMENT(S) 1. CCHCC-Govt Rx vendor Analysis 2016 06 09 (PDF) 2.Willis Towers Watson CCG Analysis of Responses and Recommendations 8-9-16 Final (PDF) 3. [Linked]Pharmacy Benefit Management RFP CCPS (PDF) 4.Amendment -approved by CAO (PDF) 5.2014 Pharmacy Benefit Mgmt Services Agreement (PDF) Packet Pg. 1904 16.E.8 09/13/2016 COLLIER COUNTY Board of County Commissioners Item Number: 16.E.8 Item Summary: Recommendation to award joint RFP# 16-0036, Pharmacy Benefit Management Services to Envision Pharmaceutical Services, Inc., amending the existing agreement for a two year term effective January 1,2017,a savings of$2,945,116 over the existing Agreement. Meeting Date: 09/13/2016 Prepared by: Title: Division Director-Risk Management—Risk Management Name: Jeff Walker 08/16/2016 1:35 PM Submitted by: Title: Division Director-Risk Management—Risk Management Name: Jeff Walker 08/16/2016 1:35 PM Approved By: Review: Administrative Services Department Pat Pochopin Level 1 Division Reviewer Completed 08/16/2016 1:37 PM Procurement Services Lissett DeLaRosa Level 1 Purchasing Gatekeeper Completed 08/16/2016 1:53 PM Procurement Services Sandra Herrera Level 1 Purchasing Reviewer 1-4 Completed 08/16/2016 2:04 PM Procurement Services Allison Kearns Level 1 Purchasing Reviewer 1-4 Completed 08/16/2016 2:11 PM Procurement Services Rhonda Burns Level 1 Purchasing Reviewer 1-4 Completed 08/16/2016 4:32 PM County Attorney's Office Colleen Greene Level 2 Attorney Review Completed 08/16/2016 4:58 PM Administrative Services Department Len Price Level 2 Division Administrator Review Completed 08/16/2016 5:53 PM Office of Management and Budget Valerie Fleming Level 3 OMB Gatekeeper Review Completed 08/17/2016 8:36 AM County Attorney's Office Jeffrey A.Klatzkow Level 3 County Attorney's Office Review Completed 08/17/2016 9:41 AM Office of Management and Budget Laura Wells Level 3 OMB 1st Reviewer 1-4 Completed 08/18/2016 9:10 AM County Manager's Office Nick Casalanguida Level 4 County Manager Review Completed 08/28/2016 10:26 AM Board of County Commissioners MaryJo Brock Meeting Pending 09/13/2016 9:00 AM Packet Pg. 1905 ;gauss Aoeuaaeyd `9£00-94 #ddi�l p.aeM' : 1094) 60 90 9102 slsAleuy Jopuen xa 1A00-30H30 :luauayoel;y co co o ui . co 0- V)m as o. 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C Z o 00 T to N > L U O > T `� L C C V O N CC '-' C L `V) V >� U ON +-I 'In d N •� O- O '6 .� O C O rD '� c C U C U 0) _ C CO C 4- co Q d N � N Q O (0 O1 v > C E D- 0 0- O C c m' WSW v 2 � C Q. en m C7 (n U 03 m N a y a) o v 'Q E 'Q °1 Uo 0 oN Q p I- E Z . + Z O U O O I6.E.B.b Collier County Health Care Consortium August 9,2016 Report on Request for Proposal for Managed Pharmacy Services Analysis Collier County Government Background ctr Prior to 2014,the Collier County Government(CCG), Collier County Public Schools (CCPS) and NCH a Health Care all utilized Express Scripts (ESI)to provide pharmacy benefit management services (PBM). CO M The Collier County Sherriff's office utilized EnvisionRx. o c.o There had been significant ongoing customer service issues with ESI that had not been appropriatelya. remedied and as a result,the CCG, CCPS and NCH initiated into a group RFP process lead by the CCPS purchasing department and supported by Willis Towers Watson. As a result of that process, on January 1st 2014, EnvisionRx was contracted to provide pharmacy benefit Q management(PBM) services to the Collier County Government and Collier County Public Schools. Prime Therapeutics was contracted to provide pharmacy benefit management(PBM)services to NCH at the co same time. The Collier County Sherriff's office was already under contract with EnvisionRx. is ii The original agreements were for a two-year period that would have ended on December 31, 2015. The co reasoning for a two year versus a three year agreement is that the pharmacy benefit landscape and d discount structures have been changing significantly over the past few years. Willis Towers Watson has co observed that contract terms longer than two years place the client at a disadvantage since they may not receive contractual recognition of the improving terms. The initial agreements with EnvisionRx and Prime Therapeutics did allow for a market check at the conclusion of the first two years. a a) E A market check was completed in 2015 and both Envision RX and Prime Therapeutics provided terms making it beneficial for these organizations to extend the agreement under revised terms for an additional year. The EnvisionRx agreement with the Collier County Sheriff's Office (CCSO) does not expire until the end of 2017. ccs Since the commencement of the agreements with EnvisionRx and Prime Therapeutics Scripts,there have not been significant customer service issues and the financial performance has been consistent Q. with expectations. However, EnvisionRx was recently acquired by Rite-Aid,which is in turn being acquired by Walgreens. Further,there continues to be significant changes in the PBM marketplace in terms of continued mergers and acquisitions as well as new entrance to the marketplace. N To make sure the current vendors represent the best possible choice for the CCG, CCPS and NCH, in April these organizations decided to release a joint RFP through the District School Board's Purchasing Department to evaluate alternative PBM's for a January 1, 2017 program commencement date. U Together,the three employers represent approximately 16,000 covered lives. Working together is more efficient and a joint bid enables the leveraging the size these organizations to attract favorable pricing and terms. L a> However,the RFP indicated that each group retains the right to select the vendor they determine will E°— best meet their needs.Willis Towers Watson,the actuarial and benefits consultant for these entities prepared an RFP document with the input from each organization. The RFP was then publically posted by the CCPS Purchasing Department and an e-mail notification provided to major vendors,which the employers collectively believed might be interested in evaluating a relationship. a> Proposals were received from the following eleven vendors: WillisTowersWatson 1.1'1'1.1 Page 1 Packet Pg. 1910 I6.E.B.b Collier County Health Care Consortium August 9,2016 Report on Request for Proposal for Managed Pharmacy Services Analysis Collier County Government U asE L 1. Magellan = n. 2. EnvisionRx 3. Navitusco 0 4. CitizensRx co 5. Optum n. 6. RxBenefits u" tx 7. Prime 17. ti 8. ESI Q 9. Maxor 10. Benecard coo 11. CVS Caremark Wsc Executive Summary co r Taking the opportunity to market the program as a group provided measurable benefit. It was apparent co that all respondents provided aggressive terms with an expectation of obtaining the business or in the c case of the incumbents, concern over losing all the business to another vendor. a :c To aid in reaching a determination as to whether a change was warranted Willis Towers Watson a) analyzed the financial terms quoted, per pill pricing and assessed the written responses to see if there E E was a material difference in the value propositions the proposing organizations offered which would o have warranted further consideration. These findings were discussed with the selection committee ofCe each organization individually and as a group. It was the unanimous opinion of the organizations that a c change was not warranted. y m N This recommendation was based on the following: o a.N N 1. The analysis of the financial terms and per pill pricing did not suggest a material benefit would e: accrue to any of the three organizations by making a change either individually or as a group. 8 2. None of the other organizations quoting were able to outline a service and management >, proposal that was materially different from the incumbents that might have warranted further `6 c consideration. ¢ 3. Changing PBMs does have an opportunity cost as it requires a significant investment of staff, cvj time to coordinate the change and communicated to employees. o 40 4. Any change to another PBM would have resulted in significant disruption to employees and cc dependents using certain medications due to differences in the formularies each organization L has adopted. 0 0 F The initial terms quoted by ESI and CVS suggested there may have been savings by moving to these v, organizations. The expected savings for the CCG was$500,000 over the two year term of the agreement. However, after the initial assessment and analysis of additional per pill pricing and formulary disruption, it was determined this savings would not likely be realized. 0 E U as - a 4. WillisTowers Watson 1.1'111.1 Page 2 Packet Pg. 1911 16.E.8.b Collier County Health Care Consortium August 9,2016 Report on Request for Proposal for Managed Pharmacy Services Analysis Collier County Government A After the initial financial assessments Willis Towers Watson was asked to approach both EnvisionRx and Prime Therapeutics and request best and final offers in light of the terms offered by ESI and CVS c Caremark. a The revised terms offered an improvement over the original terms quoted and a significant improvement over the current contract terms. The financial benefit to CCG is summarized in table 2 0 below: n. Table 2-Expected Costs($000) for 2017-2018 combined 4? itu '`? 2017-2018 Current Envision Envision Rates Govt Govt Administrative Fees $ 197,870 $ 209,149 $ 209,149 0 co Dispensing fee $ 162,134 $ 102,716 $ 98,047 76 Ingredient Cost Brand $ 7,072,909 $ 6,856,676 $ 6,840,837 Il. Generic $ 2,992,531 $ 2,580,777 $ 2,569,829 0 Specialty $ 4,352,464 $ 4,259,316 $ 4,244,731 Compound $ 86,932 $ 86,932 $ 86,932 co Total Costs $14,864,839 $14,095,566 $14,049,524 Brand Rebates S 316,960 _ 1Ea,'76S 1,897,766 0 Specialty Rebates 5 26,554 5 '.313 5 617,313 " Implementation Credit 5 S 4,228 5 4,228 Net Vendor Costs $14,521,375 $11,576,258 $11,530,217 -Member Copays $ 1,367,069 $ 1,367,069 $ 1,367,069 E Net Plan Costs $13,154,306 $10,209,190 $10,163,148 The table above shows that the CCG will see a two year benefit of$3.0 million over the current terms and achieved a $19,000 improvement via the best and final quote provided by EnvisionRx. It's °', important to keep in mind that these represent improvements in the terms on a gross basis and can not necessarily be construed as a reduction in cost since the analysis looks at the total costs and does not adjust for trend, utilization or employee cost share. 0 N Request for Proposal Process The CCG, CCPS and NCH asked Willis Towers Watson to develop a request for proposal (RFP) document and assist in the evaluation of responses. The RFP document was developed and finalized after several conference calls and in-depth discussion. U 0 N The distribution of the RFPs and receipt was overseen and conducted by the Purchasing Department atcc the CCPS. A copy of the RFP is attached as Appendix B. to L Q� Vendors were free to participate in the RFP process through a public competitive bid process. Eleven vendors were included in the RFP's and responses were received from all eleven. cn 1. Magellan 2. EnvisionRx a> 3. Navitus ..c- 4. 4. CitizensRx Q WillisTowers Watson 16111111•1 Page 3 Packet Pg. 1912 16.E.8.b Collier County Health Care Consortium August 9,2016 Report on Request for Proposal for Managed Pharmacy Services Analysis Collier County Government to 5. Optum 6. RxBenefits 7. Prime M 8. ESI 9. Maxor f° 10.Benecard a u_ 11.CVS Caremark In June,Willis Towers Watson conducted a preliminary analysis of the financial terms offered in each of the responses. •• ao Evaluation Approach "Fa Since there were not significant concerns over the level of service provided by either Envision Rx or Prime Therapeutics,the initial analysis focused on the financial terms.This analysis was completed to determine whether there was a significant financial benefit which would warrant serious consideration a, and interviewing of other firms. a0 a, Willis Towers Watson also evaluated the qualitative aspects of the response to assess whether any one respondent offered a compelling value proposition that was materially different from the incumbents. c E Willis Towers Watson performed a detailed financial analysis of the following areas affecting the o ultimate cost of a pharmacy benefit program: 1. Total expected cost based on all facets of the program,quoted discounts, rebates and administrative fees N a) 2. Contract language o C2. 3. Per pill pricing of the top 50 generic and brand medications. Willis Towers Watson obtained detailed claim file records for each of the three employers from EnvisionRx and Prime Therapeutics, including number of prescriptions,AWP,and ingredient cost for N, brand, generic, and specialty drugs, retail and mail order, and the amounts paid. The AWP and the utilization rates were trended forward for the two year term proposed in the RFP. v Each firm quoted terms that were then applied to the AWP and Rx counts on a gross level for the two year term of the agreement. , Based on current enrollment and the actual experience data, prescription drug plan ingredient costs and cn number of prescriptions for the respective members were projected forward through 2018 assuming no plan design changes, a 0%(zero) annual trend for brand use, 6%trend for specialty use and 1%trend for 60 overall use; and an 8%annual increase in the ingredient cost of brand, 12%for specialty, and 3%for generic medications. The cost and number of prescriptions was trended separately. This approach is more representative of E total drug trend and provides a better determination of ultimate cost. A two year time frame was utilized in the financial analysis since that is the period of time vendors were asked to guarantee terms. WillisTowersWatson 1.1'1'1.1 Page4 Packet Pg. 1913 16.E.8.b Collier County Health Care Consortium August 9,2016 Report on Request for Proposal for Managed Pharmacy Services Analysis Collier County Government U E: For the comparison,the quoted administration fees, dispensing fees, ingredient cost, and rebates were applied to each member's projected prescriptions, number of employees, and AWP to develop the total a costs. M 9 co Based on vendor's contract language,we made adjustment to the quoted discounts that vendors submitted. If a vendor did not include single source generics(SSG) in their generic discount guarantees, a u. that gives them an advantage of 1-2%on brands and 3-8%on generics. For firms that do not include SSG in their generic guarantees we adjusted their brand discount up 1.5%and their quoted generic discount up by 6%. The initial quotations received from ESI and CVS offered terms that suggested an improvement over the terms offered by EnvisionRx and Prime Therapeutics. The savings potential depending on the organization ranged from a low of$80,000 for NCH to almost$500,000 for the CCG. The table below summarizes the expected two year costs for 2017 and 2018 for the top 5 financial responses. ii CCG tcCPS Group NCH 2 NCH Group 00 � `� e * Kip vrn r tax r to ,, � � Pace.. . �� h, .� �Pr1cef _ x�,.v MPPCInri< Prime Therapeutics $10,727,381 n/a $14,064,520 n/a $6,622,087 n/a .173 EnvisioRX $10,209,190 $ 10,190,455 $12,687,788 $ 12,932,330 $7,129,747 $ 6,798,031 c CVS Caremark $ 9,737,010 n/a $12,471,200 n/a $6,535,754 n/a a) Navitus $11,531,983 $ 11,315,912 $15,481,660 $ 15,029,411 $7,618,362 $ 7,496,493 E Optum $10,929,351 $ 10,591,667 $14,168,353 $ 13,721,417 $7,279,429 $ 6,968,697 ESI $ 9,587,269 $ 9,698,254 $13,537,585 $ 12,547,984 $6,649,946 $ 6,612,321 Q: ct N The details of the analysis of financial terms for all respondents for the CCG are included in Appendix A. o_ The preliminary financial analysis suggested the CCG could save$500,000 by moving administration of the program to ESI or CVS Caremark. However, making a purchasing decision based on quoted discounts alone can be misleading. Contract y, language can have a significant impact and how discounts are calculated and hence the apparent size of the discounts. Although the Willis Towers Watson analysis process attempts to adjust most of these factors there are still small nuances which can affect discounts that are difficult to adjust for in the analysis. To address this potential risk, Willis Towers Watson uses a secondary analysis using per pill pricing. To determine whether the price difference suggested by the traditional financial analysis outlined above is likely to produce a savings is to evaluate the contracted per pill pricing terms as of a specific point in time.To accomplish this Willis Towers Watson provided each vendor with a file containing the specific NDC's for the top 50 generic and brand name drugs and asked that each vendor provide the pricing as of v, a specific consistent point in time. The results of this analysis are shown in the table below. E: r w .-. WillisTowersWatson 1.1'1'1.1 PageS Packet Pg. 1914 16.E.8.b Collier County Health Care Consortium August 9,2016 Report on Request for Proposal for Managed Pharmacy Services Analysis Collier County Government >' o ccs PBM ,,CCPS y t NCH ; t, r ` ? 4. CCG, `' E .._� Retail Mail Retail . ,-,. =Mair t Retail.' Mail Benecard other other other d Citizens 957,672 891,474 ' 3,546,941 3,398,424 3,657,011 3,503,443 co CVS Caremark 854,416 798,900 3,523,706 3,418,473 3,679,280 3,562,826 0 Envision 859,152 787,654 3,590,327 3,452,514 3,675,322 3,532,361 Express Scripts n/a n/a n/a 4t Magellan n/a n/a n/a LL Maxor n/a n/a 1.' n/a Navitus 834,966 794,850 ' 3,592,379 3,512,526 ` 3,625,005 3,543,972 72 OptumRx n/a I n/an/a Prime Therapeutics 845,109 814,458 3,464,277 n/a s'' 3,54 ,097 n/a Q Rx Benefits n/a n/a i n/a C- 0 oa v This analysis demonstrates that the more aggressive discounts quoted by CVS Caremark are more a function of how they calculate discounts versus superior pricing with pharmacies that would be pass- c through to the CCG. ESI would not provide per pill pricing. ca T Willis Towers Watson also conducted an assessment of the formulary disruption that would occur in co making a change. Formularies are created so PBMs are able to drive market share to a specific c manufacturer of a brand-name medication. For example there are several brand-name medications that o w are utilized to treat hyperlipidemia. By providing more favorable plan design structures to a certain c medication the PBM is able to negotiate rebates which benefit the plan sponsor in this case the CCPS. E However,this disruption brings with it the risk that employees won't change and pay the higher E copayment as well as the risk that more expensive medications may be included on the proposing as 0 a) opposed to incumbent PBM's formulary. ce 13 c The table below shows the results of this analysis. 0 a> N c CCHCC - Formulary Disruption a ', , Govt __`,��.� ' Schools , '!NCH , ' N Rx Members Rx Members Rx Members Ex w. Envision* n/a n/a 2,161 877 0 N to s >, Prime 5,004 1,335 6,421 1,877 1,944 746 G Q Expressscripts 2,171 921 2,759 1,428 1,811 723 U U Rx-Number of prescriptions negatively impacted by formulary change. c 0 Members-number of unique members impacted. 4 ra *Envision,as the incumbent,did not provide a formulary disruption for CCG or schools. u7 L The evaluation team of each organization individually and collectively considered these factors.As noted in the executive summary above,the determination was that there would be little if in fact any benefit at all to changing to a different PBM effective January 1 of 2017. 0 As a result it is in the best interest of the CCG to accept the best and final offer terms proposed by c EnvisionRX and contract with them for the two-year period beginning January 1, 2017 with an option to w E renew for an additional two years with an appropriate market check in 2018. -c U co Q WillisTowersWatson 1e1°1°111 Page 6 Packet Pg. 1915 16.E.8.b Collier County Health Care Consortium August 9,2016 Report on Request for Proposal for Managed Pharmacy Services Analysis Collier County Government A Evaluation Team `a Throughout this report, reference is made to the "group" evaluation of responses and analysis prepared by Willis Towers Watson. The group included the following representatives of the member organizations of the CCHCC who participated in reviewing the results and making the recommendation outlined in this report. `o o. Collier County Government co• Jeff Walker • Sonja Sweet co Collier County Public Schools • Ian Dean • Jane Knoble Manalich o • Marie Irwin 0o • Cynthia Battle NCH Healthcare cc V • Renee Thigpen E • Lori Darrah • Theresa Hansen a ct Willis Towers Watson provided technical guidance and financial analysis and assisted the group in writing this report and recommendation. The following individuals from Willis Towers Watson assisted N in this process: 0 • Douglas J. Ley, Senior Vice President/Director, National Actuarial Practice,Willis Towers Watson Employee Benefits cn • John Pauly,Vice President and Actuary, National Actuarial Practice,Willis Towers Watson Employee >, Benefits fs • Susan Cugno, Account Executive,Willis Towers Watson Employee Benefits co U • Mary Caligiuri, Senior Client Manager,Willis Towers Watson Employee Benefits • Chris Woertz,Senior Financial Analyst,Willis Towers Watson Employee Benefits ca u, 0 0 �-- E s a— Q WillisTowersWatson li11'1'1.1 Page 7 Packet Pg. 1916 I6.E.8.d Amendment# 1 to"Pharmacy Benefit Management Services Agreement" tn This Amendment, dated , 2016 to the referenced Agreement shall be by and between the a' parties to the original Agreement, dated January 1,2014,Envision Pharmaceutical Services, Inc., an Ohio Corporation, (to be referred to as "Envision") and Collier County Board of Commissioners, a political subdivision of the State of Florida(to be referred to as"Plan Sponsor"). Statement of Understanding 'N RE: "Pharmacy Benefit Management Services Agreement" w The parties hereby agree to amend the Agreement as provided below: ;' Change # 1: Exhibit 1 Drug Pricing and Fees is replaced in its entirety with the attached "Update to in Exhibit 1"effective January 1, 2017. E Change#2: Subsection 6.1 Term, is hereby replaced in its entirety with the following: a, co 6.1. Term: The term of this Agreement shall commence on January 1, 2017 and shall remain in full force 2 and effect for an initial term of two(2)years("Initial Term")unless earlier terminated as provided herein. Upon the expiration of the Initial Term,this Agreement may be renewed for two additional (1) one year terms, subject to the mutual approval by the parties, in writing, at least ninety (90) days prior to the commencement of each renewal term. If either party hereto does not notify the other in writing according to the renewal notice provision,the Agreement will terminate at the end of the current term. All other terms and conditions of the agreement shall remain in force. n IN WITNESS WHEREOF, the parties have each, respectively, by an authorized person or agent, have o executed this Amendment on the date(s)indicated below. co Accepted , 2016 u. Dwight E. Brock, Clerk BOARD OF COUNTY COMMISSIONERS 2 OF COLLIER COUNTY,FLORIDA BY: By: 03 ,Deputy Clerk Donna Fiala, Chairman 0 First Witness: Envision Pharmaceutical Services,Inc. By: -0 By: o L _ o. Print Name Q Ca Second Witness: Print Name and Title a) .proved as to Form and Legality: By: • E Print Name L.J: sistant County Attorney 0 E co [16-PRC-03130/1277286/1] Language deleted has been struck through. New language has been underlined. Cel.) Packet Pg. 1917 16.E.8.d ENVAliONR, ecce wrzv ALtlit.. 0 ON tet_ 0 a c R Collier County Board of Commissioners ct CC PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT o_ N y Update to Exhibit 1 w 0 w Effective January 1, 2017 0 The rates and terms set forth below replace the same rates and terms of any prior Exhibit 1 as of the cn effective date above (i.e. the changes set forth herein are not retroactive). a E co Drug Price(B) Dispensing Drug Price(C) Dispensing ct For Contract Year (Annual Average Fee(D) (Annual Average Fee(D) i 2017 Effective Rate (Annual Effective Rate (Annual Guarantee) Average Guarantee) Average c Guarantee) Guarantee) m AWP minus 17% AWP minus 80% E (Non-legend Drugs (Non-legend Drugs E 30 Days' Supply at a AWP minus AWP minusoa Retail Pharmacy 16.75%) $1.15 16.75%) $1.15 0 (Specialty Drugs: (Specialty Drugs: o AWP minus AWP minus to 16.50%) 16.50%) a U. AWP minus 22% AWP minus 82% -D (Non-legend Drugs (Non-legend Drugs co 90 Days' Supply at a AWP minus 22%) N/A AWP minus 22%) N/A a Retail Pharmacy (Specialty Drugs: (Specialty Drugs: c AWP minus AWP minus 00 16.50%) 16.50%) 0 Q AWP minus 24% AWP minus 83% o Mail Order Pharmacy (Non-legend Drugs (Non-legend Drugs (at Orchard AWP minus 24%) N A AWP minus 24%) N/A Pharmaceutical (Specialty Drugs: (Specialty Drugs: Q Services) AWP minus AWP minus o' 16.75%) 16.75%) c a) Specialty Pharmacy E (at Orchard (Pass-Through of Contract Rate with Dispensing Pharmacy) c 0 E e c w E s as w Clenr iy. 3enesicial. Packet Pg. 1918 16.E.8.d urac ENVMONR, uerac 1101c0 a) c } ca u) Pharmaceutical cc Services) c 0 Drug Price(B) Dispensing Drug Price(C) Dispensing (Annual Average Fee(D) (Annual Average Fee(D) w For Contract Year Effective Rate (Annual Effective Rate (Annual 0 2018 Guarantee) Average Guarantee) Average a Guarantee) Guarantee) U .. m AWP minus u) AWP minus 17% 80.25% a (Non-legend Drugs E (Non-legend Drugs G) m30 Days' Supply at a AW6P75%)s $1.15 AWP minus $1.15 0 Retail Pharmacy (Specialty Drugs: 16.75%) AWP minus (Specialty Drugs: AWP minus c 16.50%) 16.50%) m 0 AWP minus 22% AWP minus 82% E (Non-legend Drugs (Non-legend Drugsas 90 Days' Supply at a AWP minus 22%) N/A AWP minus 22%) N/A a. Retail Pharmacy (Specialty Drugs: (Specialty Drugs: M AWP minus AWP minus o 16.50%) 16.50%) `r° AWP minus 24% AWP minus 83% C Mail Order Pharmacy (Non-legend Drugs (Non-legend Drugs T. (at Orchard AWP minus 24%) N/A AWP minus 24%) C6 N A Pharmaceutical (Specialty Drugs: (Specialty Drugs: Q Services) AWP minus AWP minus o 16.75%) 16.75%) 03 Specialty Pharmacy (at Orchard 0 Pharmaceutical (Pass-Through of Contract Rate with Dispensing Pharmacy) sa Services) 0 L (A) Calculated price using the applicable negotiated contract rate (i.e.AWP or MAC rate, or U&C Price) aa. for the designated Network. The AWP discounts shown in the table above are Annual Average Effective `ts Rates using current Medi-Span published values. If the calculated price is lower than the allowable c amount under any state Medicaid "Favored Nations" rule, Envision shall pass-through, and Plan E Sponsor shall pay,the Medicaid allowable amount. c E c 0 E 0 C6 Q Cicari.,,,,. Beneficial. Packet Pg. 1919 16.E.8.d EN Vifi urac urac; f.CCPSVIIS ..0101. rnk. vi.., a...._e.... as (B)Annual Average Effective Rate for Brand Drugs is calculated using the actual price paid by Envision (before deducting earned Manufacturer Derived Revenue) to Participating Pharmacies in the designated Network, plus any Cost Share, (the Ingredient Cost) for all Brand Drug Claims (including g Claims paid at the U&C Price) during a Contract Year, excluding (i) Compound Drugs; (ii) drugs dispensed at a Specialty Pharmacy; (iii) Claims from non-Participating Pharmacies,LTC pharmacies,or government owned or operated pharmacies (e.g. Veterans Administration); (iv) Claims paid at o government required amounts (e.g. Medicaid); (v) 340B Claims; (vi) non-Prescription Drugs; and (vii) cn m Claims from Plan Sponsor's owned pharmacies,if any. (C)Annual Average Effective Rate for Generic Drugs is calculated using actual price paid by Envision to cn Participating Pharmacies in the designated Network, plus any Cost Share, (the Ingredient Cost) for all Generic Drug Claims (including Claims paid at the U&C Price) during a Contract Year, excluding (i) °7 Compound Drugs; (ii) drugs dispensed at a Specialty Pharmacy; (iii) Claims from non-Participating a, as Pharmacies, LTC pharmacies, or government owned or operated pharmacies (e.g. Veterans Administration); (iv) Claims paid at government required amounts (e.g. Medicaid); (v) 340B Claims; 2 (vi) non-Prescription Drugs; and(vii) Claims from Plan Sponsor's owned pharmacies,if any. w (D)Annual Average Dispensing Fee is the average per Claim fee for all Claims by Envision to Participating Pharmacies in the designated Network(including Claims paid at the U&C Price) during a m Contract Year,excluding(i) Compound Drugs; (ii) drugs dispensed at a Specialty Pharmacy; (iii) Claims from non-Participating Pharmacies, LTC pharmacies,or government owned or operated pharmacies (e.g.Veterans Administration); (iv) Claims paid at government required amounts (e.g. co Medicaid); (v) non-Prescription Drugs; and (vi) Claims from Plan Sponsor's owned pharmacies, if any. °- cc M Annual Average Earned Manufacturer Derived Revenue Guarantee(E),(F),(c),(H) tO For Contract Year 2017: n • For 30 Day Supply of Brand Drugs at a Retail Pharmacy- $66.63 per paid Brand Drug Claim • For 90 Day Supply of Brand Drugs at a Retail Pharmacy-$141.15 per paid Brand Drug Claim • For 90 Day Supply Brand Drugs at the Mail Order Pharmacy- $202.59 per paid Brand Paid Claim. • For a Specialty Drug at a Retail Pharmacy: $846.08 per paid Brand Drug Claim • For a Specialty Drug at the Specialty Pharmacy: $662.25per paid Brand Drug Claim o For Contract Year 2018: U • For 30 Day Supply of Brand Drugs at a Retail Pharmacy- $71.74 per paid Brand Drug Claim • For 90 Day Supply of Brand Drugs at a Retail Pharmacy- $154.37 per paid Brand Drug Claim • For 90 Day Supply Brand Drugs at the Mail Order Pharmacy- $219.53 per paid Brand Paid 2 Claim • For a Specialty Drug at a Retail Pharmacy: $973.66 per paid Brand Drug Claim • For a Specialty Drug at the Specialty Pharmacy: $745.03 paid Brand Drug Claim (E) Earned Manufacturer Derived Revenue guarantees are stated as annual average amounts per c Contract Year. °' E 67 tirA 4 %� � Bene€ieia[. Packet Pg. 1920 16.E.8.d EN usac urac .«.. 0.00 U 040lFl. (F)Guarantees require Plan Sponsor to maintain a Benefit Plan that has a tier structure with a minimum $20 differential in Cost Share between preferred Brand Drugs and non-preferred Brand Drugs. (G)340B Claims,Claims paid entirely by Covered Individuals,and Claims processed from Plan Sponsor's (,) owned pharmacies,if any,shall be excluded from the calculation of the guarantees above. (H)Guarantees require Plan Sponsor to utilize current Envision Select Formulary Administrative Fee (Payable to Envision; not including fees payable to Plan Sponsor's TPAs, v consultants, or brokers,if any) cn For Contract Year 2017 &2018: $1.85 per Claim a E a) Fees for Additional Services and Miscellaneous Expenses 1. Replacement by Envision of lost or stolen ID $1.00 per card plus $0.15 per packet and 2 Cards cost of postage 2. Manual Claims Processing (including DMRs) $1.50 per Claim processed m 3. Claim Adjustment Checks (charged to Plan Sponsor for reimbursements made to Covered Individuals for Claim adjustments requested a by Plan Sponsor.) $8.50 per check 4. Manually create or update the Eligibility File $1.00 per Covered Individual data entry 9 5. Ad Hoc Computer or Report Programming $150.00 per hour nom. 6. Clinical Prior Authorizations (Initial Coverage Determinations) $35.00 per authorization 7. Drug Therapy Care Gap Management $0.55 per Member,per month 0 8. Medication Adherence and Persistency (up to 00 three disease states) $0.55 per Member,per month o 9. Additional User to Access RxBirt (beyond 1 U user) $1,200.00 per user .0 10.Custom Formulary Management The greater of$0.20 per Member per o month (PMPM) or$2,000.00 per month C a> C C) E C U Cie„rE '. Beneficial. Packet Pg. 1921 16.E.8.e MEMORANDUM • rs: Date: October 29, 2013 To: Jeff Walker, Director cs) Risk Management Department From: Martha Vergara, Deputy Clerk Minutes & Records Department Re: Pharmacy Benefit Management Services Agreement a. e,) c) Attached for your records is one (1) original copy of the resolution referenced above, (Item #11G) adopted by the Board of County Commissioners on Tuesday, u. September 24, 2013. The Minutes and Record's Department has held the original document for the Official Record of the Board. co - If you have any questions, please contact me 252-7240. '5 CD Thank you. 6" Attachment c) cc) , E a. 0 N C C., Packet Pg. 1922 16.E.8.e 0 PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT This Pharmacy Benefit Management Services Agreement (hereinafter this "Agreement") is a' entered into by and between Envision Pharmaceutical Services, Inc., an Ohio Corporation (hereinafter "Envision"), and Collier County Board of Commissioners, a Florida county government (hereinafter "Plan Sponsor"). This Agreement is effective January 1m, 2014 (hereinafter the"Effective Date"). BACKGROUND Envision is a URAC accredited Pharmacy Benefit Management (PBM) company providing comprehensive pharmacy benefit management services nationwide to various employers,unions, and Plan Sponsors that establish and fund health benefit plans covering outpatient prescription medications. Plan Sponsor has established one or more health benefit plans providing coverage a. for prescription medications to covered individuals and desires to engage Envision to provide pharmacy benefit management services in accordance with the terms and conditions of this 9 Agreement. a. NOW, THEREFORE, in consideration of the mutual promises and agreements herein contained, Plan Sponsor and Envision hereby agree as follows: 1. DEFINITIONS a co 1.1 "Administrative Fee"means the amount that Envision charges Plan Sponsor for included services under this Agreement as set forth in Exhibit 1. 1.2 "Annual Average Effective Rate" means, for the category of drugs being reviewed, the result calculated by the following formula: (IC/AWP)-1,where IC("Ingredient Cost")is the sum CD `rn of all amounts paid by Plan Sponsor for the ingredient cost of the Covered Drugs dispensed during the calendar year, and AWP is the sum of the Average Wholesale Price amounts associated with the same Covered Drugs. CL) (n 1.3 "Average Wholesale Price" or "AWP" shall mean the average wholesale price of a Covered Drug indicated on the most current pricing file provided to Envision by Medi-Span®(or a) other applicable industry standard reference on which pricing hereunder is based) for the actual drug dispensed using the 11 digit National Drug Code(NDC)number provided by the dispensing c pharmacy. Envision uses a single source for determining AWP and updates the AWP source file m at least once weekly. 1.4 "Benefit Plan" means the group Plan Sponsor, insurance plan, prescription drug plan, or other benefit plan established and funded by Plan Sponsor that covers the cost of Covered Drugs dispensed to Covered Individuals. cv 1.5 `Benefit Specification Form" or"Benefit Specification Change Form"means the forms, as modified from time to time, that are completed by Plan Sponsor that specify the terms and provisions of the Benefit Plan and the configuration of System edits, such as which Prescription \PBMSA(frm062413) ©Envision Pharmaceutical Services,Inc. Page 1 of 35 5 ) Packet Pg. 1923 16.E.8.e 0 N Drugs are covered by Plan Sponsor, any limitations or exclusions, the Benefit Plan's tier structure and Cost Share requirements, and any conditions associated with the specific services to be rendered by Envision under this Agreement (i.e. Clinical Prior Authorizations, Drug Therapy Management, etc.). 1.6 "Brand Drug" means a Prescription Drug where the Medi-Span multisource ("MONY") code attached to the 11 digit NDC for such drug indicates an "N" (a single-source brand name drug product available from one pharmaceutical manufacturer and is not available as a generic), »� an"M"(a branded drug product that is co-branded and not considered generic, nor is it available as a generic, and is generally considered a single-source drug product despite multiple m pharmaceutical manufacturers), or an "0" (an original branded drug product available from one or more pharmaceutical manufacturers as a generic). A drug is classified as a Brand Drug at the Point-of-Sale based on the MONY code assigned by Medi-Span and shall not be reclassified for any purposes hereunder. o- 1.7 "Claim" means an invoice or transaction (electronic or paper) for a Covered Drug c dispensed to a Covered Individual that has been submitted to Envision by the dispensing pharmacy or a Covered Individual (including transactions where the Covered Individual paid. 100% of the cost). A"340B Claim"is a Claim which has been processed under Section 340B of u_ the Public Health Service Act. 1.8 "Claims Adjudication System" or "System" means Envision's on-line computerized claims processing system. ao 1.9 "Compound Drug" means a medication that requires compounding by a pharmacist because it is not available from a pharmaceutical manufacturer in the prescribed form or strength. Compound Drugs consist of two or more solid, semi-solid or liquid ingredients,at least one of which is a Prescription Drug. 1.10 "Contract Year" means the complete twelve month period commencing on the Effective a) j Date and each consecutive complete twelve month period thereafter that this Agreement remains in effect. a) 1.11 "Cost Share" means the amount of money that a Covered Individual must pay to the Participating Pharmacy to obtain a Covered Drug in accordance with the terms of the Benefit 2 47. Plan. The Cost Share may be a fixed amount(co-payment) or a percentage of the drug cost(co- insurance), or a deductible that must be satisfied before drugs are covered under the Benefit Plan. m >, 1.12 "Covered Drug" means a Prescription Drug or other permitted drug (OTC), medical supplies (e.g. diabetic testing strips), or a medical device (e.g. blood glucose monitoring device) which is dispensed to a Covered Individual and meets the requirements for coverage under the Benefit Plan as communicated to Envision by Plan Sponsor. �r O 1.13 "Covered Individual" or "Member" means each individual (including the Eligible Employee and each of his or her dependents) who has been identified by Plan Sponsor on the E Eligibility File as being eligible to receive Covered Drugs. 1PBMSA(frm062413) ©Envision Pharmaceutical Services,Inc. Page 2 of 35 ( Packet Pg. 1924 16.E.8.e 2 N U } L 1.14 "Eligibility File" means that electronic communication supplied to Envision by PlanGI Sponsor (or Plan Sponsor's agent) which identifies the Covered Individuals covered under Plan c Sponsor's Benefit Plan, along with other eligibility information necessary for Envision to E provide PBM Services hereunder. Plan Sponsor acknowledges that eligibility begins on the first day the Covered Individual is reported by Plan Sponsor (or its designee) to be effective and tztz continues through the last day the Covered Individual appears on the Eligibility File. a) 1.15 "Eligible Employee" means an active employee or a retiree of Plan Sponsor covered under Plan Sponsor's funded Benefit Plan. For purposes of calculating the Administrative Fee, m the Per Employee, per month (PEPM) amount stated in Exhibit 1 includes the Eligible > Employee's/retiree's eligible dependents. If,however,a dependent is also an Eligible Employee of Plan Sponsor, such dependent shall be deemed to be an Eligible Employee for purposes of s calculating the total Administrative Fee. a. 6 M 1.16 "Formulary" means an index of Prescription Drugs, which have been compiled by o Envision and reviewed by Envision's Pharmacy & Therapeutics Committee for safety and 0 efficacy (using evidence-based evaluation criteria), that is used, in conjunction with the Benefit a Plan,as a guide in the selection of Covered Drugs. The Formulary may be modified by Envision c from time to time as new medications and/or new clinical information become available. a 1.17 "Generic Drug" means a Prescription Drug where the Medi-Span multisource code Q attached to the 11 digit NDC for such drug indicates a "Y" (a generic drug product available c from one or more pharmaceutical manufacturers). A drug is classified as a Generic Drug at the 0 Point-of-Sale based on the MONY code assigned by Medi-Span and shall not be reclassified for C any purposes hereunder. E m 1.18 "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as rn amended. Q 1.19 "Mail Order Pharmacy"means the Mail Order Pharmacy specified in Exhibit 1. a) 1.20 "Manufacturer Derived Revenue" means rebates, discounts, administrative fees, and any other revenue earned by Plan Sponsor for Claims which comply with the utilization and benefit rn design requirements of pharmaceutical manufacturer contracts with Envision and otherwise meet 2 the terms and conditions hereunder. c a) 1.21 "MAC List"means a proprietary list of Prescription Drugs for which Envision establishes ma a maximum price ("MAC Price") payable to the dispensing pharmacy. Envision maintains one 0 commercial MAC List per Participating Pharmacy which is used to both determine the E negotiated price payable to the dispensing pharmacy and the price charged to Plan Sponsor. Plan ii Sponsor will be charged the exact negotiated amount payable by Envision to the dispensing a. pharmacy without any markup or spread. Envision updates the MAC List from time-to-time as o Np Prescription Drugs come on the market or come off the market, or as their availability changes c due to market circumstances. .. U k U'BMSA(frmO62413) ©Envision Pharmaceutical Services,Inc. Page 3 of 35 '3' i Packet Pg. 1925 16.E.8.e 0 N a) 1.22 "Participating Pharmacy" means a pharmacy (including the designated Mail Order or Specialty Pharmacy) that has entered into a negotiated pricing agreement with Envision toco dispense Covered Drugs to Covered Individuals. 'E a) E 1.23 "Plan Sponsor" means the entity (identified above as Plan Sponsor) which (i) has a, established and underwrites the Benefit Plan on behalf of its Covered Individuals; (ii) has c c determined the rules by which the Benefit Plan is to be administered; and (iii) is financially ca responsible for the payment of Administrative Fees, Fees for Additional Services and ; Miscellaneous Expenses (as set forth in Exhibit 1), and Covered Drugs dispensed to Covered a Individuals hereunder. m u 1.24 "Point-of-Sale" means the location and time that a Covered Drug is dispensed to a E Covered Individual, and the corresponding Claim is submitted by the dispensing pharmacy for ..as .. adjudication by the Claims Adjudication System. a. a M 1.25 "Prescriber" means a licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), o Doctor of Podiatry (D.P.M.), Doctor of Dentistry (D.D.S.), or other licensed health practitioner t with independent prescribing authority in the state in which the dispensing pharmacy is located. a u w 1.26 "Prescription Drug"means a substance intended for use in the diagnosis, cure,mitigation, I' treatment, or prevention of disease which is dispensed by a duly licensed pharmacy and required ea by federal law to be dispensed only upon the authorization of a Prescriber. For purposes of this Agreement, over-the-counter medications, medical supplies, and medical devices are not Prescription Drugs,whether or not ordered by a Prescriber. 00 �. 1.27 "Retail Pharmacy" means a state licensed retail community pharmacy that dispenses a prescription medications at its physical location. A Retail Pharmacy does not include a pharmacy that dispenses medications to patients primarily through mail, nursing home L pharmacies, long-term care facility pharmacies, hospital pharmacies, or clinics, unless such pharmacy is a Participating Pharmacy listed by Envision as a Retail Pharmacy. aa) U 1.28 "Specialty Drug" means a high-cost (i.e. costs more than $600.00 per month or per fill) a) !'` biotech, injectable, infused, oral, or inhaled Prescription Drug that may require special storage, o handling, or is available only through limited distribution channels, and/or requires close a, monitoring of the patient's drug therapy (including a few products, such as intrauterine devices E [IUDs]). Specialty Drugs are identified on the Envision Specialty Drug List, as modified from a time to time. c °' m 1.29 "Specialty Pharmacy" means a non-Retail Pharmacy that primarily dispenses Specialtyta Drugs and performs special ordering,handling and/or patient intervention services. ca o. 1.30 "Usual and Customary Price" or "U&C Price" means the retail amount the pharmacy charges its cash paying customers for the drug dispensed, as reported to Envision by the N dispensing pharmacy. c E r 44. 1PBMSA{frm062413) Cl)Envision Pharmaceutical Services,Inc. Page 4 of 35 �7 rPacket Pg. 1926 16.E.8.e I 0 U) a) U 2. STANDARD PBM SERVICES •L c Envision shall perfauu the following pharmacy benefit management services ("PBM Services"). E. Unless otherwise noted, the PBM Services specified below are included in the Administrative E Fee. mC Ca C ez 2.1 Welcome Kit: If requested by Plan Sponsor,Envision shall provide an initial "Welcome 2 Kit"which may include, at Plan Sponsor's option, (i) a welcome letter;(ii)plastic identification card("ID Card"),up to two per family; (iii) a pocket Formulary; and (iv)mail order brochure, as specified in the Benefit Specification Form. The standard Welcome Kits will be mailed to Plan co Sponsor or, at its option, directly to Covered Individuals. For any materials mailed directly to cc Covered Individuals, Plan Sponsor shall reimburse Envision for its cost of postage. Additional ID Cards or replacement ID Cards (i.e. for lost or stolen ID Cards) will be provided at a cost as specified in Exhibit 1. If Plan Sponsor desires to re-design and/or re-issue ID Cards, or for a. special graphic requests, additional charges may apply. o 2.2 Claims Processing: During the term of this Agreement, Envision shall accept, process, co and adjudicate Claims for Covered Drugs (i) submitted electronically by Participating Pharmacies; (ii) submitted by Covered Individuals as Direct Member Reimbursements (DMRs, Et as defined below); or (iii) received from third parties, such as Medicaid, for reimbursement by -a Plan Sponsor. Claims shall be checked for eligibility, benefit design, Cost Share requirements, and exclusions to determine which Claims are successfully processed, pended for prior Q authorization, or rejected for ineligibility or other factors in accordance with Plan Sponsor's o specifications as set forth in Plan Sponsor's Benefit Specification Form (incorporated herein by 0 this reference). For Claims that must be processed manually or require special handling, c including, without limitation, (i) DMRs or (ii) Claims received from third parties, such as c Medicaid, for reimbursement by Plan Sponsor for ineligible payments, Plan Sponsor will be a) charged a Manual Claims Processing fee as set forth in Exhibit 1. After termination of this a� Agreement, received for dates of service on or before the effective Q 1 re Envision shall process Claims re date of termination for a period of ninety(90)days ("Run-Out Period"), subject to the following. 0 Plan Sponsor shall deposit and maintain, with Envision, an amount equal to the last Claims invoice prior to termination. At the end of the Run-Out Period, the balance of the deposit shall in be promptly refunded to Plan Sponsor and,thereafter, any Claims received by Envision shall be rejected. c) 2 2.2.1 Direct Member Reimbursement(DMR): Envision shall provide,via its website, a t form for use by Covered Individuals to obtain reimbursement for amounts paid out-of-pocket m (other than Cost Share)for Covered Drugs (e.g. Covered Drugs dispensed at a non-Participating v Pharmacy) ("DMR Form"). Envision shall accept, process, and adjudicate DMR Claims within ten (10) business days of receipt of the DMR form,but shall not be liable to reimburse a Covered E L Individual until Plan Sponsor provides funds for such purpose. a 2.2.2 Claims Adjudication System Edits: Plan Sponsor's Benefit Plan may contain 0 y, additional rules which determine the way in which Claims are to be adjudicated. These rules t may include coverage limitations or exclusions, application of clinical intervention (e.g. step a> therapy, drug therapy management), application of dispensed as written (DAW) codes (e.g. to E Q \PBMSA(frm062413) U Envision Pharmaceutical Services,Inc. Page 5 of 35 ! C' Packet Pg. 1927 16.E.8.e 0 determine what portion of a Claim is payable by Plan Sponsor and what portion is payable by 2 Members), and administrative overrides to authorize the dispensing of Covered Drugs in certain circumstances (e.g. requests for lost or stolen drugs, vacation supplies, certain package sizes, N dosage changes, invalid days' supply). For this purpose, Envision shall program edits into the a Claims Adjudication System which are applied to Claims during the adjudication process as specified in the Benefit Specification Form. The Claims Adjudication System will provide the dispensing pharmacy with the appropriate messaging to advise the pharmacy of the applicable: a limitation,program,rule, or override. �. w m r Envision shall also program edits into the Claims Adjudication System which are applied to Claims during the adjudication process to identify the following drug utilization conditions: duplicate prescriptions; over-utilization/refill too soon; under-utilization; drug interactions; E pediatric warnings; geriatric warnings; acute/maintenance dosing; therapeutic duplication; drug inferred health state; drugs exceeding maximum dose; and drugs below minimum daily dosage, a as specified in the Benefit Specification Form. The Claims Adjudication System will provide the dispensing pharmacy with the appropriate messaging to advise the pharmacy of drug utilization issues. cc 2.3 Clinical Services re 2.3.1 Clinical Prior Authorizations (Initial Coverage Determinations): If Plan Sponsor 3 has elected to receive Clinical Prior Authorization services from Envision, for those Covered �t Drugs and circumstances specified by Plan Sponsor in the Benefit Specification Form, Envision shall contact the prescriber and verify that the requested drug is appropriate for the diagnosis in the judgment of the prescriber. Plan Sponsor will be charged for Clinical Prior Authorizations as specified in Exhibit 1. If additional internal appeals (redeterminations) and/or the services of an Independent Review Organization are to be provided under this Agreement, such services shall be included in an attached Coverage Determination and Appeals Process Addendum. 2.3.2 Drug Therapy Management (DTM) Programs: Envision offers clinical programs such as Drug Therapy Care Gap Management and Medication Adherence and Persistency. If clinical programs are to be provided under this Agreement, such services and any additional charges shall be set forth in an attached Clinical Services Addendum. cn E 2.4 Pharmacy Network: Envision shall arrange for the dispensing of Covered Drugs to Covered Individuals pursuant to contracts with one or more networks of Participating Pharmacies (referred to herein as a"Network"). The Network designated for Plan Sponsor to be used by Covered Individuals hereunder shall be named in Exhibit 1 and specified in the Benefit °0 Specification Form. Plan Sponsor acknowledges that the pharmacies participating in a Networkca may change from time to time, including the designated Mail Order Pharmacy and/or Specialty Pharmacy provider. The list of Participating Pharmacies is constantly updated to reflect any { changes in the Network, including pharmacy addresses and telephone numbers, and is accessible via Envision's website. Plan Sponsor acknowledges that(i) orders exceeding a thirty day supply o are not available at all Retail Pharmacies; (ii) Covered Drugs shall not be dispensed to Covered Individuals without a prescription order by a Prescriber; and (iii) the availability of drugs are a subject to market conditions and that Envision cannot, and does not, assure the availability of \PBMSA(frm062413) E=nvision Pharmaceutical Services,Inc. Page 6 of 35 fib [ acket Pg. 1928 - 16.E.8.e 0 N 0 any drug from any Participating Pharmacy. L a> cn 2.5 Customer Service: Envision shall maintain and operate a customer service center with c toll-free customer service numbers and adequately staffed with trained personnel 24 hours a day, E 7 days a week, 365 days a year, for the use of Plan Sponsor, Covered Individuals, Prescribers, a�' and Participating Pharmacies. a ca 2 2.6 Records: Envision shall maintain such business records as may be required by applicable law or regulation, or as may be necessary to properly document the delivery of,and payment for, Covered Drugs and the provision of services by Envision under this Agreement. Plan Sponsor m agrees to reimburse Envision for any cost incurred from the transfer of files from or to any u ca vendor or pharmacy at any time during this Agreement and,upon request of Plan Sponsor,at the termination of this Agreement. t o. 2.7 Reports: Envision shall provide Plan Sponsor with access to a web-based report M generator through which Plan Sponsor may create and download a variety of standard and o customized reports. Envision shall provide training for a Plan Sponsor designated individual on c the capabilities of Envision's web-based reporting program. Plan Sponsor represents that thea. designated individual has received training and has knowledge of the HIPAA privacy and u security regulations. Any reports that are to be provided by Envision to Plan Sponsor without -a cost(other than those available from Envision's web-based reporting program) shall be mutually 3 determined prior to the configuration of Plan Sponsor's Benefit Plan in the Claims Adjudication Q System and shall be specified in the Benefit Specification Form. Plan Sponsor shall be charged a c fee for any other reports requested by Plan Sponsor. 00 Included in the web-based reports described above, or provided separately,Envision shall supply a Plan Sponsor with reports of retrospective reviews to determine the drug utilization patterns of ai Members e.g• high cost/high utilization of a particular drug class,therapeutic appropriateness of drug for a particular disease state). N N 2.8 Retiree Drug Subsidy(RDS)Reports: For Plan Sponsors which submit requests for drug > subsidies under the Medicare RDS program, Envision shall provide Plan Sponsor with quarterly in reports summarizing Claims paid by Plan Sponsor for Medicare Part D drugs dispensed tosg Covered Individuals who Plan Sponsor has identified on the appropriate form as Medicare a, eligible retirees. Plan Sponsor acknowledges that any estimated earned Manufacturer Derived 2 Revenue which has been passed-through to Plan Sponsor will have been deducted from the c Claim amounts reported. Unless otherwise specified herein or included under an addendum to m this Agreement,Envision shall not be responsible or liable to Plan Sponsor for any RDS services or subsidies. Any assistance requested by Plan Sponsor and/or provided by Envision shall be E solely consultative and shall not be deemed to be an acceptance by Envision of any responsibility L or liability for the completion or submission of any RDS application or request for subsidies n under Medicare Part D. d' o • 2.9 Business Associate Agreement: Envision shall execute a HIPAA Business Associate c Agreement, attached as Exhibit 2. E v .II Q \PBMSA(frm062413) ®Envision Pharmaceutical Services,Inc. Page 7 of 35 CR Packet Pg. 1929 16.E.8.e N 4i 2.10 Additional Services: Any services to be rendered under this Agreement which are not included in the Administrative Fee as specified in this Section 2 shall be itemized in the Exhibits cn and Addendums hereto along with any associated costs or charges. 2.11 Performance Guarantees: Envision shall provide PBM Services in accordance with the Performance Guarantees specified in Exhibit 3. Unless otherwise stated, targets will be measured on a Contract Year basis. The total amount of penalties payable by Envision in any Contract Year shall not exceed ten percent(10%) of Envision's Administrative Fee paid by Plan Sponsor during applicable Contract Year. Unless otherwise stated, payment of penalties will be c credited towards future Administrative Fees. Failure to meet Performance Guarantees shall not m be deemed to be a breach of this Agreement. E 3. PRICING AND PASS-THROUGH METHODOLOGY a 3.1 Pass-Through of Discounts and Dispensing Fees: Envision has negotiated discounted M drug prices and dispensing fees with Participating Pharmacies. Envision shall pass-through to Plan Sponsor one hundred percent(100%)of the negotiated discount for the drug dispensed(plus c any applicable dispensing fee) without any reclassification, mark-up or spread by Envision. The a amount invoiced to Plan Sponsor shall be the exact drug ingredient cost and applicable dispensing fee which is paid to the dispensing pharmacy,in accordance with the following: 3.1.1 For Ingredient Cost: Envision shall invoice Plan Sponsor the lower of: Q (a) The calculated negotiated amount payable to the Participating Pharmacy co based on the 11 digit NDC number of the drug dispensed;or (b) If included on the then current Envision MAC List,the MAC Price for the drug dispensed;or a) (c) The Participating Pharmacy's U&C Price (except for drugs dispensed by c 41( the Mail Order or Specialty Pharmacy);less any applicable earned Manufacturer Derived Revenue and/or any applicable Covered Individual Cost Share. 3.1.2 For Dispensing Fees: Envision shall invoice Plan Sponsor the actual dispensing a, fee amount payable to the Participating Pharmacy. 2 3.1.3 Drug Pricing and Dispensing Fees Guarantee: Within four months after the end of each Contract Year, Envision shall provide Plan Sponsor with a report showing the actual 0° Annual Average Effective Rates and Annual Average Dispensing Fees paid by Plan Sponsor for the Contract Year. If the amounts paid by PIan Sponsor during the Contract Year for all Claims in any category in Exhibit 1 with a specified rate (i.e. 30 Day Retail Brand Drug; 30 Day Retail i Brand Drug Dispensing Fee; 30 Day Retail Generic Drug; 30 Day Retail Generic Drug Dispensing Fee; 90 Day Retail Brand Drug; 90 Day Retail Generic Drug; 90 Day Mail Brand N Drug; 90 Day Mail Generic Drug) are less favorable than the Annual Average Effective Rates and Average Dispensing Fees stated in Exhibit 1, Envision shall credit Plan Sponsor with the a) difference for that category. Plan Sponsor understands and agrees that if, after the Effective Date of this Agreement, there is a substantial change in drug utilization patterns of Covered \PRMSA(frm062413) CO Envision Pharmaceutical Services,Inc. Page 8 of 35 Co) Packet Pg. 1930 1 16.E.8.e o w d Individuals, or Benefit Plan setup parameters such as copay, pharmacy participation, or rules governing the application of the Formulary, which adversely affect any guaranteed Annual in Average Effective Rate or Average Dispensing Fee, such guarantee shall be adjusted to account c for such changes. Envision shall demonstrate to Plan Sponsor the factors upon which any such E adjustment is based and the methodology used to make such adjustment. Nothing in this Section a 3.1.3 shall affect Envision's obligation to pass through to Plan Sponsor 100% of all negotiated c discounts and dispensing fees for Plan Sponsor's Claims. Envision shall not be liable to Plan Sponsor for guaranteed Annual Average Effective Rates or Annual Average Dispensing Fees if w (i) Plan Sponsor makes a change to the Benefit Plan which affects the utilization or distribution m of Covered Drugs; (ii) the specifications provided by Plan Sponsor on the initial Benefit m Specification Form are inconsistent with the specifications provided to Envision prior to the et execution of the initial Benefit Specification Form; or (iii) the utilization data provided by Plan Sponsor (or Plan Sponsor's agent) upon which the calculation of guarantees were based is Rs inaccurate. Plan Sponsor is urged to submit any proposed changes to the Benefit Plan to -c Envision before such changes become effective so that Envision may advise Plan Sponsor if any M changes will affect Drug Pricing or Dispensing Fees Guarantees. Plan Sponsor acknowledges o that it has no right of offset to withhold any payment due Envision under this Agreement for any to amounts owed Plan Sponsor for financial guarantees. a. 4 rx 3.2 Manufacturer Derived Revenue 3.2.1 Pass-Through of Manufacturer Derived Revenue: Envision has negotiated Q contracts with pharmaceutical manufacturers to obtain Manufacturer Derived Revenue for o eligible Prescription Drugs, and shall pass through to Plan Sponsor one hundred percent(100%) co of all earned Manufacturer Derived Revenue paid to Envision by contracted pharmaceutical c manufacturers for Plan Sponsor's eligible Claims that comply with the terms of this Agreement. Prescription Drugs eligible for Manufacturer Derived. Revenue are included in the Formulary as provided by Envision. Plan Sponsor acknowledges that its yield of earned Manufacturer Derived as Revenue is dependent on certain factors including, without limitation, the following: (i) the Q effect of terms and conditions of Plan Sponsor's Benefit Plan on the application of the Formulary; (ii) the structure of Plan Sponsor's Benefit Plan, including but not limited to Cost • Share requirements and coverage rules such as Prior Authorizations, Quantity Limits, and Step in Therapy (as defined in the Benefit Specification Form); and (iii) the drug utilization patterns of Covered Individuals. Plan Sponsor further acknowledges that Plan Sponsor's portion of market share rebates is based on(i)Plan Sponsor's ability to meet and earn market share rebate levels by , pharmaceutical manufacturer and (ii) the ratio of Plan Sponsor's CIaims for a particular rebated c drug to the total number of Claims for such drug for all Envision clients, as adjusted for the m effect of Plan Sponsor's Benefit Plan (e.g. tier structure and Cost Share differentials) on the overall yield of market share rebates. Claims paid entirely by Covered Individuals (e.g. a Claim E occurring while the Covered Individual has not yet met his or her deductible), 340B Claims, and E CZ Claims for which Envision has not been paid in full, are ineligible for Manufacturer Derived a Revenue, and no Manufacturer Derived Revenue shall be payable to Plan Sponsor for such r , Claims. o N 3.2.2 Pass-Through Methodology: Manufacturer Derived Revenue shall be advanced E to Plan Sponsor by adjusting the Claim for an eligible Prescription Drug by the estimated earned c fa d TBMSA(frm062413) 0 Envision Pharmaceutical Services,Inc. Page 9 of 35 C' (-) Packet Pg. 1931 16.E.8.e 0 N N Manufacturer Derived Revenue using Envision's patented Point-of-Sale Technology. Envision's Point-of-Sale Technology generates a Claim that will be invoiced to Plan Sponsor at the net price a) cn after applying credit for estimated earned Manufacturer Derived Revenue. (Plan Sponsor acknowledges that, unless otherwise indicated by Plan Sponsor on the Benefit Specification a) Form, if a Covered Individual pays a percentage of the drug cost (i.e. co-insurance) under the a Benefit Plan, a proportional amount of the Manufacturer Derived Revenue will be passed on to c the Covered Individual at the Point-of-Sale). ca 3.2.3 Sole Source: Plan Sponsor represents and warrants to Envision that, at no time t during or after the term of this Agreement, is Plan Sponsor receiving rebates and other revenues m from pharmaceutical manufacturers other than through Envision, either directly or indirectly (through a Group Purchasing Organization, drug wholesaler, or otherwise) for Claims processed ca by Envision under this Agreement. Plan Sponsor agrees that it shall not, at any time, submit r Claims which have been transmitted to Envision to another pharmacy benefit manager or carrier a for the collection of rebates and other revenues from pharmaceutical manufacturers or create a M situation which would cause a pharmaceutical manufacturer to decline payments to Envision. o Envision reserves the right to recover from Plan Sponsor, and Plan Sponsor shall refund to Envision, any Manufacturer Derived Revenue,including any related penalties and fees, advanced a to Plan Sponsor by Envision which is connected with any Claims for which Plan Sponsor LL received rebates and other revenues from pharmaceutical manufacturers from any other source or 7 for amounts advanced to Plan Sponsor by Envision which have been withheld by a 3 pharmaceutical manufacturer as a result of such Claims not meeting conditions for rebates, the Q ineligibility of Claims for Manufacturer Derived Revenue (i.e. 340B Claims), or breach of this G Agreement by Plan Sponsor. ao 3.2.4 Manufacturer Derived Revenue Guarantee: Nine months after the end of each c Contract Year, Envision shall provide Plan Sponsor with a report reconciling Manufacturer E Derived Revenue amounts advanced to Plan Sponsor and Manufacturer Derived Revenue a7 amounts earned by Plan Sponsor for eligible Claims (including market share based amounts) during the Contract Year. e U (a) If the Manufacturer Derived Revenue advanced to Plan Sponsor for the Contract Year is, overall, lower than the overall Manufacturer Derived Revenue earned by Plan in Sponsor for the Contract Year,Envision shall pay the difference to Plan Sponsor. E el (b) If the Manufacturer Derived Revenue earned by Plan Sponsor for the 2 al aver e earned = lower than the annu a Manufacturer Derived Revenue 4 Contract Year is, overall, guaranteed amounts specified in Exhibit 1,Envision shall pay the difference to Plan Sponsor. a co Notwithstanding anything herein to the contrary, Envision shall not be liable to Plan Sponsor for as guaranteed earned Manufacturer Derived Revenue if: (i) Plan Sponsor makes a change to the E i Benefit Plan which affects the application of the Formulary(e.g. tier differentials),the conditions 2 for rebates of pharmaceutical manufacturer contracts; or otherwise affects earned Manufacturer a• Derived Revenue yields; (ii) there is a substantial change in the drug utilization patterns of o Covered Individuals; (iii)the utilization data provided by Plan Sponsor(or Plan Sponsor's agent) ; i upon which the calculation of guarantees were based is inaccurate; (iv) there is a loss of rebates CI) due to pharmaceutical manufacturer drug patent expirations, manufacturer bankruptcy, or E removal of a drug from the market; (v)there are changes in pharmaceutical manufacturer rebate 1PBMSA(ftm0624I3) ©Envision Pharmaceutical Services,Inc. Page 10 of 35 CAO Packet Pg. 1932 _ 16.E.8.e 1 i 0 N d U contracting terms or policies; (vi)Plan Sponsor fails to meet and earn market share rebate levels; (vii) if Plan Sponsor has been excluded by a manufacturer; or (viii) there is any governmental N regulation, ruling, or guidance that impacts Envision's ability to maintain current earned 5 Manufacturer Derived Revenue yields. Plan Sponsor acknowledges that it has no right of offset to withhold any payment due Envision under this Agreement for any amounts owed Plan a Sponsor for financial guarantees. ra a 4. PLAN SPONSOR RESPONSIBILITIES L;,-- a) 4.1 Implementation: No later than thirty (30) days prior to the Effective Date, Plan Sponsor m shall provide Envision with an executed Benefit Specification Form and such data as reasonably necessary for Envision to set up the Claims Adjudication System and commence the provision of E PBM Services as of the Effective Date. Such data includes, without limitation, prior utilization reports, pharmacy transfer files, and eligibility. For the first month of the Agreement only, a. Envisionwill credit Plan Sponsor an implementation credit of$0.50 per Eligible Employee. 0 0 4.2 Eligibility Data: Plan Sponsor shall provide Envision (either directly or through an t authorized third party administrator)with an Eligibility File, at least monthly, in the HIPAA 834 a standard transaction code set format, or such other format as has been previously agreed to byre Envision. Plan Sponsor shall provide timely eligibility updates (for example, additions, -P terminations, change of address or personal information,etc.)to ensure accurate determination of 3 the eligibility status of Covered Individuals. Plan Sponsor acknowledges and agrees that (i) Envision provides such eligibility data to the Participating Pharmacies and understands that c Envision and Participating Pharmacies will act in reliance upon the accuracy of data received ao from Plan Sponsor; (ii) Envision will continue to rely on the information provided by Plan w Sponsor until Envision receives notice that such information has changed; and (iii) Envision shall not be liable to Plan Sponsor for any Claims or expense resulting from the provision by a Plan Sponsor (or its designee) of inaccurate, erroneous, or untimely information. In addition, if a) Envision must create or update eligibility by manually entering Covered Individual data, Plan ¢ Sponsor will be charged a data entry fee as specified in Exhibit 1. In lieu of the Eligibility File, Plan Sponsor may provide eligibility information by updating the Claims Adjudication System •L directly (except for the initial Eligibility File, which must be provided to Envision during the can) initial implementation), provided Plan Sponsor continues to meet Envision's conditions and specifications for direct eligibility updates. 4.3 Benefit Plan: Plan Sponsor shall provide Envision with complete information concerning c the Benefit Plan. Plan Sponsor understands and agrees that Envision shall rely on the terms and m provisions provided by Plan Sponsor on the Benefit Specification Form. The Benefit >, Specification Form may be changed from time to time by Plan Sponsor by providing Envision with a replacement Benefit Specification Form or a Benefit Specification Change Form; provided, however, that the form must be signed by Plan Sponsor to be effective and the form _c provided to Envision at least thirty (30) days before any such change shall be implemented. The most recent executed Benefit Specification Form shall supersede any prior dated form. Plan N Sponsor shall have sole authority to determine the terms of the Benefit Plan and the coverage of c benefits thereunder, however, Plan Sponsor understands and agrees that any change in the a Benefit Plan or System configuration (e.g. mandatory generic program, coverage of over-the- II 11 \PBMSA(frm062413) ©Envision Pharmaceutical Services,Inc. Page 11 of 35 (6-47) Packet Pg. 1933 16.E.8.e counter drugs or medications, source of Covered Drugs, use of Plan Sponsor Owned pharmacies, etc.) may affect yields in earned Manufacturer Derived Revenue and/or average drug pricing. a) Plan Sponsor agrees that Envision shall not be liable to Plan Sponsor for a reduction of such `n yields or increase in pricing which result from any such change, or for any failure of Envision to meet financial guarantees which are affected by such change. a) ct 4.4 Formulary: Plan Sponsor shall adopt and adhere to the Formulary provided by Envision. Any customization of the Formulary by Plan Sponsor or use by Plan Sponsor of an alternate Formulary must be approved, in writing, by Envision. Plan Sponsor acknowledges that adherence to the Formulary is necessary to maximize yields in earned Manufacturer Derived Revenue. Envision shall not be liable to Plan Sponsor for any reduction in yields of earned Manufacturer Derived Revenue, or for any failure of Envision to meet financial guaranteesca resulting from Plan Sponsor's failure to adhere to the Formulary or a change to the Benefit Plan r that affects the application of the Formulary. a 4.5 Payment: Plan Sponsor shall timely pay,or cause its designee to timely pay,Envision for c services rendered hereunder in accordance with Section 4 below and Exhibit 1. 4 4 4.6 Cooperation: Plan Sponsor shall promptly provide Envision with all information (both verbal and written) that is requested by Envision and reasonably necessary for Envision to -a complete its obligations hereunder. Any information required to be provided by Plan Sponsor in order for Envision to perform a function under this Agreement shall be deemed to be untimely if not received by Envision at least five (5) business days prior to its due date. Further, Plan Sponsor shall not obfuscate,delay, impede, or otherwise fail to cooperate with Envision. 5. TERMS OF PAYMENT a 5.1 Fees and Rates: Plan Sponsor hereby accepts the fees and rates specified in Exhibit 1 and acknowledges the drug pricing amounts and annual average earned Manufacturer Derived Revenue guarantees specified in Exhibit 1 are conditioned upon Plan Sponsor's adherence to �, f certain conditions under this Agreement. The actual annual average discounts and earned Manufacturer Derived Revenue will depend on Plan Sponsor's drug utilization and mix of Participating Pharmacies. E ; 5.2 Payments for Claims: Envision shall invoice Plan Sponsor twice each month for Claims incurred. Plan Sponsor shall pay Envision's invoices no later than 12:00 p.m. Eastern time on m the tenth (10th) calendar day from receipt of said invoices. Invoices shall be deemed to have CO been received by Plan Sponsor upon the earliest delivery of the invoice by mail, e-mail, fax, or courier. ca � I 5.3 Payment of Administrative Fee: Beginning with the first month under this Agreement, Envision shall provide Plan Sponsor with an invoice of Administrative Fees on or about the first day of each month. Administrative Fees are due within seven (7) calendar days of receipt of N Envision's invoice. The monthly Administrative Fee is calculated by multiplying the number of c Eligible Employees who are eligible to receive services hereunder at any time during the prior month (as reflected in the Claims Adjudication System) by the Administrative Fee amount set c a J 1PBMSA(frm062413) 0 Envision Pharmaceutical Services,Inc, Page 12 of 35 Packet Pg. 1934 16.E.8.e . 0 N forth in Exhibit 1 (except for the initial invoice which is based on Plan Sponsor's initial Eligibility File). cn 5.4 Fees for Additional Services and Miscellaneous Expenses: Plan Sponsor agrees to reimburse Envision for Additional Services and Miscellaneous Expenses (e.g. postage) specified a� in Exhibit 1 hereunder,within seven(7)calendar days of receipt of an invoice. ca ca 5.5 Retroactive Disenroliment or Termination: Retroactive termination or disenrollment of a group, Eligible Employee, or Covered Individual shall not release Plan Sponsor of its obligation to pay Claims incurred, at any time, on behalf of a Covered Individual or Administrative Fees m due to Envision for a Covered Individual during any period for which services were renderable hereunder based on the then current eligibility. Further, termination of coverage of prescription drugs or the entering into a policy of insurance that covers prescription drugs shall not constitute a permitted termination of this Agreement. Q 5.6 Taxes, Assessment or Fees: Any sales or use taxes for Covered Drugs sold to Covered o Individuals shall be charged, collected, and paid to state and local taxing authorities by the dispensing pharmacy. As part of the reimbursement for a Claim, Plan Sponsor shall reimburse a Envision for such taxes payable by the dispensing pharmacy. These sales or use taxes will be added to the overall amount of the Claim and invoiced to Plan Sponsor and/or Member, in P accordance with the Benefit Plan. Further, Plan Sponsor shall reimburse Envision for any assessments or related fees required to be paid under state or federal regulations for Plan Q Sponsor's Claims. ao 5.7 Financial Responsibility: Plan Sponsor shall be and remain responsible for the payment of all invoices for Administrative Fees, Additional Services, Miscellaneous Expenses, and Claims (along with any associated Cost Share not timely paid by Members, dispensing fees, and taxes). Plan Sponsor acknowledges that Envision will not pay pharmacies for Plan Sponsor's Claims, nor be obligated to pay pharmacies for Claims, unless and until adequate funds are received from Plan Sponsor. 5.7.1 Untimely Payments: If Plan Sponsor should fail to timely pay any amounts due c� Envision hereunder for any reason, including, but not limited to, insolvency, bankruptcy, termination of business, sale, or rebuff,Envision reserves the right to (i)suspend the provision of services; (ii) offset such amounts owed to Envision by any amounts owed by Envision to Plan Sponsor and/or (iii) collect from Plan Sponsor, in addition to such unpaid amounts, interest at a rate of 1.5% per month on the outstanding balance (or, if lower, the rate of interest permitted m under the law of Plan Sponsor's state of domicile). If Envision suspends the provision of services, Covered Individuals will be required to pay 100% of the drug cost and any dispensing fees (or the U&C Price, if lower) to receive Covered Drugs. In addition, as a condition of continuing to perform services under this Agreement, Envision may require Plan Sponsor to deposit with Envision additional amounts to ensure the timely payment of future invoices and/or discontinue advancing earned Manufacturer Derived Revenue to Plan Sponsor. Plan Sponsor N further agrees that Envision shall not be liable for any consequences resulting from the untimely payment of Participating Pharmacies due to the failure of Plan Sponsor to timely pay Envision as E required under this Agreement. Further, if Plan Sponsor should fail to pay any amounts due ca \PBMSA(frm062413) ©Envision Pharmaceutical Services,Inc. Page 13 of 35 Packet Pg. 1935 1 16.E.8.e 0 Envision hereunder for drugs dispensed to Covered Individuals, Envision reserves the right to pursue payment from such Covered Individuals to the extent permitted by law. 5.7.2 Financial Viability: Plan Sponsor acknowledges that Envision will periodically conduct a credit check of Plan Sponsor. If such credit check reasonably indicates that Plan a) Sponsor is not financially viable, Envision may require Plan Sponsor to deposit with Envision a reasonable amount to ensure the timely payment of future invoices. fa 5.8 Financial Audit by Plan Sponsor: Within twelve months after the end of each Contract c Year hereunder, Plan Sponsor, at its sole expense, may audit Envision's records of Claims adjudicated during the prior Contract Year. Envision shall make available to Plan Sponsor's auditor, any and all financial records containing Plan Sponsor's information and such other E records as reasonably necessary for auditor to confirm that the amounts paid by Plan Sponsor are the cost to Envision on the day the Covered Drug was dispensed. Plan Sponsor agrees to not use a as its auditors, any person or entity which, in the sole discretion of Envision, is a competitor of Envision, a pharmaceutical manufacturer representative, or any other person or entity which has c a conflict of interest with Envision. Plan Sponsor understands that Envision's contracts with pharmaceutical manufacturers, Participating Pharmacies, and other third parties may contain a non-disclosure provisions, and hereby agrees to comply with such non-disclosure provisions. Plan Sponsor's auditor shall execute a conflicts of interest disclosure and confidentiality 7 agreement with Envision prior to the audit. Audits shall only be made during normal business 3 hours following thirty (30) days written notice, be conducted without undue interference to Envision's business activity, and in accordance with reasonable audit practices. Plan Sponsor's auditor may inspect Envision's contracts with Participating Pharmacies and pharmaceutical oo manufacturers at Envision's offices only, and no copies of such contracts may be removed from ;, Envision's offices. Plan Sponsor agrees to disclose the findings and methodologies of a E completed audit, and provide Envision with a reasonable period of time to respond to such findings and methodologies, before a demand is made by Plan Sponsor for amounts it believes a) are due from Envision. th 5.9 Financial Audit by Envision: Envision may,at reasonable intervals,request Plan Sponsor u to provide records for Envision's inspection which provide support for the information contained cn in the Eligibility File. In addition, and if warranted, Envision may, at its own expense, inspect and audit, or cause to be inspected and audited, once annually,the books and records of Plan Sponsor directly relating to the existence and number of Covered Individuals. Audits shall only be made during normal business hours following thirty (30) days written notice, be conducted without undue interference to Plan Sponsor's business activity, and in accordance with reasonable audit practices. Envision agrees to execute a confidentiality agreement with Plan Sponsor prior to the audit. 6. TERM AND TERMINATION n. 6.1 Term: The term of this Agreement shall commence on the Effective Date and shall remain in full force and effect for an initial term of two (2)years ("Initial Term") unless earlier terminated as provided herein. Upon the expiration of the Initial Term, and each subsequent renewal term, this Agreement shall renew automatically for an additional term of one year; � c Q 1PBMSA(frm062413) ©Envision Pharmaceutical Services,Inc. Page 14 of 35 Packet Pg. 1936 16.E.8.e 0 N d unless, at least ninety (90) days prior to the end of such term, either party hereto notifies the other,in writing,that this Agreement will terminate at the end of the current term. CD a.. 6.2 Termination: This Agreement may be terminated as follows: a) E m 6.2.1 For Cause: By either party hereto in the event the other party breaches any of its ct material obligations hereunder;provided,however,that the defaulting party shall have thirty(30) days to correct such breach after written notice is given by such non-breaching party specifying the alleged breach; a) a) m 6.2.2 Insolvency: By either party hereto in the event the other party (i) is adjudicated insolvent, under state and/or federal regulation, or makes an assignment for the benefit of E creditors; (ii)files or has filed against it, or has an entry of an order for relief against it, in any ili voluntary or involuntary proceeding under any bankruptcy, insolvency, reorganization or a receivership law, or seeks relief as therein allowed, which filing or order shall not have been M vacated within sixty (60) calendar days from the entry thereof; (iii) has a receiver appointed for c all or a substantial portion of its property and such appointment shall not be discharged or vacated within sixty (60) calendar days of the date thereof; (iv)is subject to custody, attachment It or sequestration by a court of competent jurisdiction that has assumed of all or a significant u_ portion of its property; or (v)ceases to do business or otherwise terminates its business -� operations, is declared insolvent or seeks protection under any bankruptcy, receivership, trust R deed,creditors arrangement or similar proceeding; `_ 6.2.3 Failure to Pay: By Envision, in addition to any other remedy available to 0 Envision hereunder, in the event Plan Sponsor fails to pay Envision according to terms of this Agreement. ca) E a) 6.3 Notices: All notices required in this Section 6 shall be reasonably specific concerning the CD cause for termination and shall specify the effective date and time of termination. Q N o) 6.4 Effect of Termination: Termination of this Agreement for any reason shall not release any party hereto from obligations incurred under this Agreement prior to the date of termination. Except as otherwise agreed, in writing, no services shall be provided by Envision after the E effective date of termination. Envision reserves the right to suspend advancing earned a, Manufacturer Derived Revenue to Plan Sponsor upon Plan Sponsor's notification of termination. a 0) 7. CONFIDENTIAL INFORMATION a m 7.1 Confidentiality: Except as otherwise stated herein or required by law, neither party03 hereto shall disclose any information of, or concerning the other party which has either been E provided by one party to the other or obtained by a party in connection with this Agreement 2 (including this Agreement and the terms of this Agreement) or related to the services rendered �r under this Agreement, all of which information is deemed confidential information. All data, information, and knowledge supplied by a party hereto shall be used by the other party exclusively for the purposes of performing this Agreement. Upon termination of this c Agreement, each party shall return to the other party or destroy (if such destruction is certified) E U f0 B 1PBMSA(frm062413) ©Envision Pharmaceutical Services,Inc. Page 15 of 35 (-) Packet Pg. 1937 16.E.8.e 1 0 i N d all confidential information provided including, without limitation, all copies and electronic 0_ magnetic versions thereof. Notwithstanding any of the foregoing to the contrary, "confidential a) information"shall not include any information which was known by a party prior to receiving it N from the other party, or that becomes rightfully known to a party from a third party under no a obligation to maintain its confidentiality,or that becomes publicly known through no violation of CD this Agreement. co c i 7.2 Protected Health Information: Plan Sponsor will have access to Protected Health Information(PHI) (as defined by HIPAA) contained in reports provided by Envision or accessed a by Plan Sponsor via Envision's website. Plan Sponsor agrees, for itself and its employees, that m PHI shall not be used for any impermissible purpose, including, without limitation, the use of PHI for disciplinary or discriminatory purposes, and any user names and passwords assigned to E designated individuals shall not be shared with non-designated individuals. In addition, Plan Sponsor, for itself and its Covered Individuals, authorizes Envision to use and share PHI as a necessary to carry its obligations hereunder. M 0 0 8. INDEMNIFICATION v; 8.1 Limited Indemnification by Envision: Envision hereby agrees to indemnify, hold u harmless, and defend Plan Sponsor and its employees, officers, directors, trustees, shareholders, -a and agents from and against any and all liabilities, actions, claims, damages, costs, losses and 3 expenses (including without limitation, reasonable costs of investigation and attorneys' fees) ¢ caused by or arising out of(i)any act or omission by Envision in the performance of the services provided under this Agreement; or (ii) any breach of any representation, covenant, or other ao agreement of Envision contained in this Agreement. �, c a) 8.2 Limited Indemnification by Plan Sponsor: To the extent allowable by law, Plan Sponsor E hereby agrees to indemnify, hold harmless, and defend Envision and its employees, officers, a) directors, shareholders, affiliates and agents from and against any and all liabilities, actions, ¢ claims, damages, costs, losses and expenses (including without limitation, reasonable costs of iv investigation and attorneys' fees) caused by or arising out of(i)the provision by Plan Sponsor or •� its designee of untimely, incomplete, or erroneous information; or (ii) Plan Sponsor's failure to cn comply with state or federal law in the operation of its Benefit Plan. E 01 8.3 Limitation of Liability: Except for the indemnification obligations set forth above (i) each party's liability to the other hereunder will in no event exceed the actual proximate losses or damages caused by breach of this Agreement; and (ii)in no event will either party or any of their a respective affiliates, directors,employees or agents, be liable for any indirect, special, incidental, m consequential, exemplary or punitive damages, or any damages for lost profits relating to a as relationship with a third party, however caused or arising, whether or not they have been informed of the possibility of their occurrence. _c 8.4 Survival: This Section 8 shall survive the expiration or termination of this Agreement for o.N any reason. ..; c m • 9. RELATIONSHIP WITH CONTRACTED PHARMACIES s V f Q \PBMSA(n111062413) ©Envision Pharmaceutical Services, d Inc. Page 16 of 35 I I I Packet Pg. 1938 ... __ 16.E.8.e 0 J.. N a) Plan Sponsor acknowledges that Envision is neither an operator of pharmacies nor exercises cn control over the professional judgment used by any pharmacist when dispensing drugs or medical supplies to Covered Individuals. Nothing in this Agreement shall be construed to usurp the dispensing pharmacist's professional judgment with respect to the dispensing or refusal to a) dispense any drugs or medical supplies to Covered Individuals. Plan Sponsor agrees that it shall not hold Envision responsible, nor shall Envision be liable to Plan Sponsor or Covered Individuals, for any liability arising from the dispensing of drugs or medical supplies to Covered Individuals by any pharmacy. 10. GENERAL E 10.1 Standards of Performance: Envision shall perform its obligations under this Agreement with care, skill, prudence, and diligence, and in accordance with the standards of conduct applicable to a fiduciary. Envision shall disclose all administrative fees and drug costs charged M to Plan Sponsor, disclose all earned Manufacturer Derived Revenue collected by Envision for c Plan Sponsor's Claims, and permit Plan Sponsor to audit such fees, costs, and revenues, as set to forth in this Agreement. Envision shall also disclose to Plan Sponsor any activity, policy, or a practice that presents a conflict of interest with the performance of its obligations hereunder. Notwithstanding anything to the contrary, Plan Sponsor retains the sole responsibility for the -a terms and provisions of the Benefit Plan; its compliance with applicable law, including, without limitation, any federally mandated requirements; and the interpretation and determinations of coverage under the Benefit Plan. Unless otherwise agreed in writing,Plan Sponsor shall also be o responsible for the disclosing or reporting of information regarding the Benefit Plan or changes 0 in the Benefit Plan(e.g.,calculation of co-payments, deductibles; or creditable coverage) as may , be required by law to be disclosed to governmental agencies or Covered Individuals. a) 10.2 Independent Contractors: Envision and Plan Sponsor are independent contractors. Notwithstanding anything herein to the contrary, neither party hereto, nor any of its respective employees, shall be construed to be the employee, agent, or representative of the other for any reason, or liable for any acts of omission or commission on the part of the other. Plan Sponsor acknowledges that, notwithstanding anything herein to the contrary, Envision negotiates contracts with pharmacies,pharmaceutical manufacturers,and vendors on its own behalf and not - specifically or exclusively for Plan Sponsor. 10.3 Exclusivity: During the term of this Agreement, Envision shall be the sole provider of c PBM Services to Plan Sponsor, including, without limitation, the exclusive contractor of rebates m with pharmaceutical manufacturers for Plan Sponsor's Claims. U, 10.4 Assignment: Except as follows, this Agreement may not be assigned by either party hereto without the express written consent of the other party, which may not be unreasonably a. withheld. Envision may assign this Agreement to a commonly controlled subsidiary or affiliate company,or a controlling parent company. 4 0 E U 1P$MSA(frm062413) 0 Envision Pharmaceutical Services,Inc. Page 17 of 35 1J Packet Pg. 1939 16.E.8.e 10.5 Binding Effect: This Agreement and the exhibits and schedules attached hereto shall be binding upon and inure to the benefit of the respective parties hereto and their respectivecn c, successors and assigns. 10.6 Intellectual Property: Each party hereto reserves the right to and control of the use of their names, symbols, trademarks or service marks presently existing or hereafter established, c and no party may use any names, symbols, trademarks or service marks of any other party without the owner's written consent. 10.7 Waiver: Neither the failure nor any delay on the part of either party hereto to exercise m any right, power or privilege hereunder will operate as a waiver thereof, nor will any single or partial exercise of any such right, power or privilege preclude any other or further exercise thereof, or the exercise of any other right, power or privilege. In the event any party hereto 0 should waive any breach of any provision of this Agreement, it will not be deemed or construed ii as a waiver of any other breach of the same or different provision. 0 10.8 Severability: The invalidity or unenforceability of any term or provision of this Agreement shall in no way affect the validity or enforceability of any other term or provision. 10.9 Change in Law or Market Conditions: If any law,regulation,or market condition(e.g. an applicable industry standard reference on which pricing hereunder is based, changes the methodology for determining drug price in a way that materially changes the pricing or economics of this Agreement), either now existing or subsequently occurring, affects the ability of either party hereto to carry out any obligation hereunder (a "Material Change"), Envision and 0 Plan Sponsor shall renegotiate the affected terms of this Agreement, in good faith,to preserve,to the extent possible, the relative positions of the parties that existed prior to such Material Change. Either party may notify the other party of a Material Change. If a successful renegotiation is not achieved within thirty (30) days after notification of a Material Change, any failure of the affected party to meet its obligations hereunder due to the effect of such Material Change shall not be deemed to be a breach of this Agreement; however, if continuation of this Agreement without modification is in violation of any law or regulation, or makes it impracticable for the affected party to meet its obligations hereunder, either party may terminate in this Agreement with sixty(60)days prior written notice. 10.10 Headings: The section or paragraph headings contained in this Agreement are for 2 reference purposes only and shall not affect the meaning or interpretation of this Agreement. CO 10.11 Entire Agreement: This Agreement shall constitute the entire agreement between Envision and Plan Sponsor with respect to the subject matter herein and supersede any prior understanding or agreements of any kind preceding this Agreement with respect to such subject matter. Any modification or amendment to this Agreement,or additional obligation assumed by Envision or Plan Sponsor in connection with this Agreement, shall be binding only if evidenced �r in a writing signed by both parties hereto. No term or provision of this Agreement shall establish N r a precedent for any term or provision in any other agreement. 10.12 Acceptance of Offer: Notwithstanding anything herein to the contrary, this Agreement H Q 11'BMSA(frm062413) 0 Envision Pharmaceutical Services,Inc. Page 18 of 35 °VD Packet Pg. 1940 . 16.E.8.e 0 1 to shall not be binding upon the parties hereto unless and until this Agreement is signed and C.) executed by a duly authorized officer of each of the parties. The signing of this Agreement by cn Plan Sponsor constitutes an offer only until the same has been accepted by Envision. c a> E 10.13 Dispute Resolution a, to c 10.13.1 Mediation: Prior to the initiation of any action or proceeding permitted by this E Agreement to resolve disputes between the parties, the parties shall make a good faith effort to resolve any such disputes by negotiation. The negotiation shall be attended by representatives of c Envision with full decision-making authority and by Plan Sponsor's designated representative m who would make the presentation of any settlement reached during the negotiations to the Plan u Sponsor's Board of County Commissioners for approval. Failing resolution, and prior to the rg commencement of depositions in any litigation between the parties arising out of this Agreement, the parties shall attempt to resolve the dispute through Mediation before an agreed-upon Circuit a Court Mediator certified by the State of Florida. The mediation shall be attended by M representatives of Envision with full decision-making authority and by Plan Sponsor's a designated representative who would make the presentation of any settlement reached at to mediation to the Plan Sponsor's Board of County Commissioners for approval. Should either a party fail to submit to mediation as required hereunder, the other party may obtain a court order u requiring mediation under Florida Statutes,section 44.102. "E tz 10.14 Choice of Law and Forum: This Agreement shall be construed, interpreted, and governed according to the laws of the State of Florida, without regard to its conflicts of laws o rules,except to the extent such laws are preempted by applicable Federal Law.Any suit or action O brought by either party to this Agreement against the other party relating to or arising out of this Agreement must be brought in the appropriate federal or state courts in and for Collier County, E Florida,which courts have sole and exclusive jurisdiction on all such matters. a L 10.15 Force Majeure: Neither Envision nor Plan Sponsor will be deemed to have breached this d Agreement or be held liable for any failure or delay in the performance of all or any portion of its obligations under this Agreement if prevented from doing so by a cause or causes beyond its .L control. Without limiting the generality of the foregoing, such causes include acts of God or the in public enemy, fires, floods, storms, earthquakes, riots, strikes, boycotts, lock-outs, acts of g terrorism, acts of war, war-operations, restraints of government, power or communications line failure or other circumstances beyond such party's control, or by reason of the judgment, ruling or order of any court or agency of competent jurisdiction, or change of law or regulation (or 5 change in the interpretation thereof) subsequent to the execution of this Agreement. The party as m claiming force majeure must provide the other party with reasonable written notice. However,as soon as the cause preventing performance ceases, the party affected thereby shall fulfill its obligations as set forth under this Agreement. This Section 10.15 shall not be considered to be a r waiver of any continuing obligations under this Agreement, including, without limitation, the oma. r obligation to make payments. v ' cv 10.16 Fax Communications: Plan Sponsor agrees that Envision may communicate with Plan c Sponsor via fax, and by doing so, such fax is not a violation of the Telephone Consumer Cl) E Protection Act,47 U.S.C. §227. r 0 • t. Q \PBMSA(frm062413) ©Envision Pharmaceutical Services,Inc. Page 19 of 35 /1 Packet Pg. 1941 f 16.E.8.e a N a) U 10.17 Notices: All notices required under this Agreement shall be in writing, signed by the party giving notice and shall be deemed sufficiently given immediately after being delivered by hand, or by traceable overnight delivery service, or by registered or certified mail (return receipt requested), to the other party at the address set forth below or at such address as has been given CD a) by proper notice. ca 2 10.18 Representations: Plan Sponsor represents and warrants that(i)it is self-insured; (ii)the 47. entering into this Agreement for PBM Services is not in violation of any other agreement; (iii) has no undisclosed conflicts of interest; and(iv)it maintains,and shall continue to maintain m throughout the term of this Agreement, any and all licenses, governmental authority,or other authorization required to operate an entity of its type. Envision represents that there are no E organizational arrangements that could potentially create a conflict of interest that affects clinical or financial decisions. In addition,each signatory named below represents and warrants that he a or she (i)has read this Agreement, Exhibits,and other attachments, and fully understands and agrees to the content therein; (ii)has entered into this Agreement voluntarily; (iii)has not o transferred or assigned or otherwise conveyed in any manner or form any of the rights, obligations or claims which are the subject matter of this Agreement;and(iv)has the full power and authority to execute this Agreement. This Agreement is not binding unless executed by all signatories below. CC [SIGNATURE PAGE FOLLOWS] Q co m E a> a) rn U, m U_ L a) •E C) cts a) m C4 N \PBMSA(frm062413) ©Envision Pharmaceutical Services,Inc. Page 20 of 35 Packet Pg. 1942 A 16.E.8.e 0 N PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT SIGNATURE PAGE a, u) IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Agreement as of the Effective Date above. a) m ca For ENVT;: For PLAT ISS'ON,SOR: 1 ' I i a c By: CO BY: B�I.Katz,R.Ph.,President Georgia A.Hiller, Chairwoman'1.0'ktt3 et Envision Pharmaceutical Services,Inc. Collier County Board of Commissioners E a. Address: Address: Envision Pharmaceutical Services,Inc. Collier County Board of Commissioners g 2181 East Aurora Road 3299 Tamiami Trail East CD Twinsburg,OH 44087 Naples,FL 34112-4901 a PH: 330-405-8080 PH:239-252-8906LJ— FX: 330-405-8081 FX:239-252-8048 ce T..'E-MAIL:AliceToppe@colliergov.net '' FEIN: 59-6000558 Q B ''��� ATTEST: ' 03 r A. Y: Thom. S.W- sh Dwight E.Brock;Clerk.of Courts ; a Chief F •ancial 0.'.icer 4....1A.A.,,,,...SAliorAicits- - rEEnvision ' - aceutical Services,Inc. By: ' Dep Clea :' '� Q Attest as to uiairman s iv signature only. .2 rm • I d -gali • a it'', 9 /Oh El/3 m I S-ci 4/.4.,,....ei(______,, ''E' • Scott R.Teach a Deputy County Attorney m a 0 ca E L gs a. .4- 7::, N a) E .c 0 ca Q t \PBIMMSA(frm062413) 0 Envision Pharmaceutical Services,Inc. Page 21 of 35 Packet Pg. 1943 I 16.E.8.e 0 N EXHIBIT 1 DRUG PRICING AND FEES co D6,00.a 010;armacY Network = I Broad Network 03_ Drug Pricing and Dispensing Fees(A) 1 i Supply/Source BRAND GENERIC a) •Dru Price(B) ' Dis ensin Dru Price Dis •ensin CO For Contract Year g p g g. P g 2014 (Annual Average. '`Fee- - (Annual Average Fee(t a (based on 2 year Effective Rate (Annual. ' Effective Rate (Annual cts Guarantee) Average Guarantee) Avera e -c . Agreement) , . g a Guarantee) Guarantee). cfl minus 0 Retail Pharmacy AWP minus 15.15% $1.40 A 7W7P50% $150. 9 It Mail Order Pharmacy (at Orchard ce AWP minus 20.50% N/A AWP minus N/A j -a Pharmaceutical 77,75x/0 L Services) a Specialty Pharmacy(at Orchard (Pass-Through of Contract Rate with Dispensing Pharmacy) Pharmaceutical �, I = Services) cu Supply/Source BRAND GENERIC Drug Price(B) Dispensing Drug Price f C) Dispensing a For Contract Year (Annual Average Fee(') (Annual=Average Fee °; 2015 Effective Rate (Annual • Effective Rate ' (Annual L Guarantee) Average, Guarantee) Average cn Guarantee) Guarantee) E AWP minus 2 Retail Pharmacy AWP minus 15.25% $1.4077 ESQ/o $1.50 CD Mail Order Pharmacy m j(at Orchard AWP minus 20.50% N/A AWP minus N/A Pharmaceutical 78,00% E I Services) L os Specialty Pharmacy (at cr Orchard (Pass-Through of Contract Rate with Dispensing Pharmacy) N Pharmaceutical Services) _ E (A)Calculated price using the applicable negotiated contract rate(i.e.AWP or MAC rate, or U&C Price)for v \BAA-Plan Sponsor[Rev.08-08-2013] 22 Packet Pg. 1944 ii 1 • 16.E.8.e 0 N a) U the designated Network. The AWP discounts shown in the table above are Annual Average Effective Rates using current Medi-Span published values. If the calculated price is lower than the allowable amount under in any state Medicaid "Favored Nations"rule, Envision shall pass-through, and Plan Sponsor shall pay, the Medicaid allowable amount. °' (B) Annual Average Effective Rate for Brand Drugs is calculated using the actual price paid by Envision a, (before deducting earned Manufacturer Derived Revenue) to Participating Pharmacies in the designated c Network,plus any Cost Share,(the Ingredient Cost)for all Brand Drug Claims(including Claims paid at the 2 U&C Price) during a Contract Year, excluding (i) Compound Drugs; (ii) drugs dispensed at a Specialty Pharmacy; (iii) Claims from non-Participating Pharmacies, LTC pharmacies, or government owned or` operated pharmacies(e.g. Veterans Administration); (iv) Claims paid at government required amounts (e.g. m Medicaid); (v) 340B Claims; (vi) non-Prescription Drugs; and (vii) Claims from Plan Sponsor's owned pharmacies, if any. (C) Annual Average Effective Rate for Generic Drugs is calculated using actual price paid by Envision to Participating Pharmacies in the designated Network, plus any Cost Share, (the Ingredient Cost) for all a Generic Drug Claims (including Claims paid at the U&C Price) during a Contract Year, excluding (i) cry Compound Drugs; (ii) drugs dispensed at a Specialty Pharmacy; (iii) Claims from non-Participating Pharmacies,LTC pharmacies,or government owned or operated pharmacies(e.g.Veterans Administration); m (iv) Claims paid at government required amounts (e.g. Medicaid); (v) 340B Claims; (vi) non-Prescription Drugs;and(vii)Claims from Plan Sponsor's owned pharmacies,if any. a. (D)Annual Average Dispensing Fee is the average per Claim fee for all Claims by Envision to Participating Pharmacies in the designated Network(including Claims paid at the U&C Price)during a Contract Year, ca excluding(i)Compound Drugs;(ii)drugs dispensed at a Specialty Pharmacy; (iii)Claims from non- Participating Pharmacies,LTC pharmacies,or government owned or operated pharmacies(e.g.Veterans Administration);(iv)Claims paid at government required amounts(e.g.Medicaid);(v)non-Prescription Drugs;and(vi)Claims from Plan Sponsor's owned pharmacies,if any. ocs Annual Average Earned Manufacturer Derived Revenue Guarantee(E).(F)(G) For Contract Year 2014: 'es) • For Brand Drugs at a Retail Pharmacy-$12.85 per paid Brand Drug Claim • For Brand Drugs at the Mail Order Pharmacy- $34.95 per paid Brand Paid Claim a For Contract Year 2015: a) • For Brand Drugs at a Retail Pharmacy- $13.30 per paid Brand Drug Claim • For Brand Drugs at the Mail Order Pharmacy-$35.65 per paid Brand Paid Claim (E) Earned Manufacturer Derived Revenue guarantees are stated as annual average amounts per Contract Year. w (F)Guarantees require Plan Sponsor to maintain a Benefit Plan that has a tier structure with a minimum$20 m differential in Cost Share between preferred Brand Drugs and non-preferred Brand Drugs. a (G) 340B Claims, Claims paid entirely by Covered Individuals, and Claims processed from Plan Sponsor's owned pharmacies,if any,shall be excluded from the calculation of the guarantees above. Administrative,Fee (Payable to:Envision; not including fees payable to Plan Sponsor's TPAs, consultants,or brokers, if any) N For Contract Year 2014: $3.80 Per Employee,Per Month(PEPM) For Contract Year 2015: $3.90 PEPM E ca .ems \BAA-Plan Sponsor[Rev.08-08-20131 23 Packet Pg. 1945 16.E.8.e 0 N Fees for Additional,Services and Miscellaneous Expenses 1. Replacement by Envision of lost or stolen ID $1.00 per card plus$0.15 per packet andcn Cards cost of postage a ti E 2. Manual Claims Processing(including DMRs) $1.50 per Claim processed a� 3. Claim Adjustment Checks(charged to Plan Sponsor for reimbursements made to Covered Individuals for CIaim adjustments requested by Plan Sponsor.) $8.50 per check m 4. Manually create or update the Eligibility File $1.00 per Covered Individual data entry 5. Ad Hoc Computer or Report Programming $150.00 per hour a € a 6. Clinical Prior Authorizations(Initial Coverage Determinations) $8.00 per authorization 7. Drug Therapy Care Gap Management $0.55 per Member,per month (I) CL � E 8. Medication Adherence and Persistency(up to three disease states) $0.55 per Member,per month c Q 7 co U E a> a) 9 ''a^) vI Y E g a> a) V ca E ca a v 4.3 0 d E U r Q \BAA-Plan Sponsor[Rev.08-08-2013) 24 Packet Pg. 1946 16.E.8.e 0 a) C.) EXHIBIT 2 BUSINESS ASSOCIATE AGREEMENT in This BUSINESS ASSOCIATE AGREEMENT (the "Agreement") is effective the 151 day of E January, 2014 (the "Effective Date"), by and between Envision Pharmaceutical Services, Inc. a, ("Business Associate") and Collier County Government ("Plan Sponsor"), each referred to individually herein as a"Party"or collectively as the"Parties". RECITALS C1) CO A. Plan Sponsor sponsors a health benefit plan that provides coverage for prescription medications and supplies to covered members. Plan Sponsor has entered into a service agreement with Business Associate to provide certain administrative services to, or on behalf of,Plan Sponsor. n. B. In order for Business Associate to provide services to Plan Sponsor, Plan Sponsor may o disclose certain Protected Health Information ("PHI") (as defined in Article 1 of this Agreement) of Plan Sponsor's members to Business Associate and anticipates that a Business Associate will create, receive, maintain or transmit PHI on behalf of Plan u Sponsor. -� C. The Parties desire to protect the privacy and security of all PHI in compliance with the Health Insurance Portability and Accountability Act ("HIPAA"), as amended by the c Health Information Technology for Economic and Clinical Health Act of 2009 ("the HITECH Act"), and the regulations promulgated there under. The purpose of this Agreement is to ensure such compliance. D. This Agreement incorporates provisions 42 U.S.C. § 17931(a) and 42 U.S.C. § 17934(a) a� of the HITECH Act. �t a NOW, THEREFORE, the Parties, in consideration of the mutual agreements herein contained, and for other good and valuable consideration, the receipt and adequacy of which are hereby acknowledged,do hereby agree as follows: z Article 1: Definitions a For the purposes of this Agreement, the following defined terms shall have the following a definitions. Except as otherwise stated herein, the defined terms used in this Agreement shall as have the meanings given them under HIPAA and the regulations thereunder, including any amendments thereto. 1.1 "Breach" shall mean the acquisition, access, use, or disclosure of PHI in a manner not a permitted under Subpart E of 45 C.F.R. Part 164, which compromises the security or o privacy of the PHI. N c "Breach"excludes: E s 1I3AA-Plan Sponsor[Rev,08-08-2013] 25 Packet Pg. 1947 16.E.8.e 0 (1) Any unintentional acquisition, access, or use of PHI by an employee or a person acting under the authority of Business Associate, if such acquisition, access, or use was a made in good faith and within the scope of the authority, and does not result in further use or disclosure in a manner not permitted under Subpart E of 45 C.F.R. Part 164. (2) Any inadvertent disclosure of PHI by a person authorized to access PHI at Business cts Associate to another person authorized to access PHI at Business Associate, and the a information received as a result of the disclosure is not further used or disclosed in a manner not permitted under Subpart E of 45 C.F.R. Part 164. m (3) A disclosure of PHI in which Business Associate has a good faith belief that an unauthorized person to whom PHI is disclosed would not reasonably have been able toco retain the information, 1.2 "Designated Record Set"shall have the meaning prescribed to it in 45 C.F.R. § 164.501. M 1.3 "HHS"shall mean the U. S. Department of Health and Human Services. o 1.4 "HIPAA Standards" shall mean the standards for privacy and security of Individually a Identifiable Health Information found at 45 C.F.R.Parts 160 and 164. u 1.5 "Individual"shall have the same meaning as the term"individual"in 45 C.F.R. § 160.103 and shall include a person who qualifies as a personal representative in accordance with 45 C.F.R. § 164.502(g). C 1.6 "Individually Identifiable Health Information" shall have the meaning prescribed to it in 45 C.F.R. § 160.103. a) E 1.7 "Protected Health Information" shall have the meaning prescribed to it in 45 C.F.R. § a 160.103, limited to Individually Identifiable Health Information transmitted or a maintained in any form or medium that Business Associate creates or receives from or on behalf of Plan Sponsor. •L � 1.8 "Required by Law" shall have the same meaning as the term "required by law" in 45 co C.F.R. § 164.103. E 1.9 "Secretary"shall mean the Secretary of HHS or his or her designee. a 1.10 "Security Incident" shall mean the attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system. 0 1.11 "Unsecured PHI" shall mean PHI that is not rendered unusable, unreadable, or indecipherable to unauthorized persons through the use of technology or methodology n. specified by the Secretary in the guidance issued under section 13402(h)(2) of Public Law 111-5. Article 2: Business Associate Use and Disclosure of PHI y 4 1BAA-Plan Sponsor[Rev.08-08-20131 26 rQ Packet Pg. 1948 16.E.8.e o N 2.1 Purpose. As further described above under Recitals,Business Associate performs certain administrative services for Plan Sponsor. 2.2 Receipt and Use of PHI. Performance of administrative services by Business Associate requires that Business Associate receive and use PHI obtained from or on behalf of PIan Sponsor, or that Business Associate create, receive, maintain, or transmit PHI on behalf of Plan Sponsor. To perform these administrative services, Business Associate may use or disclose PHI provided such use or disclosure would not violate the HIPAA Standards if done by Plan Sponsor. However, Business Associate may use PHI internally to carry out its legal responsibilities and for its proper management, internal auditing, and m administration,and at the request of Plan Sponsor,to provide data aggregation services to Plan Sponsor as permitted by the HIPAA Standards. 2.3 Disclosure of PHI. Performance of administrative services by Business Associate may a require that Business Associate disclose PHI to agents or subcontractors of Business Associate. Business Associate may disclose PHI to third parties with which it contracts o to assist in providing administrative services, and to its agents to carry out Business Associate's legal responsibilities, for proper management, internal auditing, and administration, only if(a) Business Associate obtains reasonable assurances from such u third parties or agents that the PHI will be held by them confidentially and used or further disclosed only as Required by Law or for the purpose for which it was disclosed to them, (b) such third parties or agents agree to implement reasonable and appropriate safeguards to protect the confidentiality, integrity, and availability of PHI, and (c) such third parties or agents agree to notify Business Associate of any instance of which they are aware thatco the confidentiality of the information has been breached or that a Security Incident has occurred. Notwithstanding the foregoing, Business Associate will be permitted to exchange PHI freely with any Business Associates of the Plan Sponsor with which the Plan Sponsor has executed a Business Associate Agreement/Addendum. 2.4 Satisfactory Assurances. Plan Sponsor may not transfer or transmit PHI to Business C Associate or permit Business Associate to create, receive, or transmit PHI on behalf of Plan Sponsor without satisfactory assurances from Business Associate that it will appropriately safeguard the information. E Article 3: Duties of Business Associate 3.1 Limitations on Use of PHI. Business Associate shall not use PHI except as permitted or required by this Agreement or as Required by Law. Business Associate shall only use m PHI in a manner that is consistent with the HIPAA Standards. U (6 3.2 Limitations on Disclosure of PHI. Business Associate shall not disclose PHI except as permitted or required by this Agreement or as Required by Law. Business Associate ii shall only disclose PHI in a manner that is consistent with the HIPAA Standards. . 3.3 Minimum Necessary. Business Associate shall request, use and disclose the minimum amount of PHI necessary to accomplish the purpose of the request, use or disclosure, in m accordance with 42 U.S.C. § 17935(b). E \BAA-Plan Sponsor[Rev.08-08-20131 27 Q I Packet Pg. 1949 16.E.8.e 0 cn 4 a) 3.4 Safeguarding PHI. Business Associate shall use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164, to prevent the use or disclosure of PHI other than as cn provided for by this Agreement. Business Associate shall comply with the provisions of 45 C.F.R. §§ 164.308, 164.310, 164.312 and 164.316 in the same manner that such E provisions apply to Plan Sponsor, and implement administrative, physical, and technical a) cts safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the PHI that it creates, receives, maintains, or transmits on behalf of Plan Sponsor as required by the HIPAA Standards. 3.5 Third Party Agreements. Business Associate may need to enter into agreements with m third parties, including agents or subcontractors, in order to satisfy its obligations to Plan Sponsor. In accordance with 45 C.F.R. § 164.502(e)(1)(ii) and 164.308(b)(2), should E third parties, agents, or subcontractors create, receive, maintain, or transmit PHI on 2 behalf of Business Associate,Business Associate shall require such third parties or agents o_ to agree,in writing,to (a)be bound by the same restrictions,conditions,and requirements that apply to Business Associate with respect to such information, and (b) implement o reasonable and appropriate administrative, technical and physical safeguards to protect CO PHI and the confidentiality, integrity and availability of PHI. Notwithstanding the foregoing, Business Associate will be permitted to exchange PHI freely with any Business Associates of the Plan Sponsor with which the Plan Sponsor has executed a Business Associate Agreement/Addendum. 3.6 Reporting of Security Incidents. Business Associate shall identify and respond to Plan Sponsor any suspected or known Security Incidents, mitigate, to the extent practicable, ao harmful effects of Security Incidents that are known to Business Associate,and document Security Incidents and their outcomes. 3.7 Reporting of Unauthorized Uses and Disclosures. If Business Associate becomes aware that Unsecured PHI has been, or is reasonably believed to have been accessed, acquired, used, or disclosed as a result of a Breach by Business Associate, its employees, officers, cr, or other agents, except as provided in 45 C.F.R. § 164.412, Business Associate shall notify Plan Sponsor of the Breach, in writing, without unreasonable delay, and no later than thirty (30) calendar days after discovering the Breach. Business Associate is _ deemed to have discovered the Breach on the first day Business Associate knows about E the Breach,or by exercising reasonable diligence, would have been known to any person, other than the person committing the Breach, who is an employee, officer, or other agent of Business Associate. m 3.8 Content of Notification. To the extent possible, Business Associate's notice to Plan '' Sponsor shall include the identification of each Individual whose Unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, used, or disclosed as during the Breach. a. At the time of notification or soon thereafter as information becomes available,Business Associate shall provide the following information to Plan Sponsor: c (a) A brief description of what occurred, including the date of the Breach and the date of discovery of the Breach,if known; \BAA-Plan Sponsor[Rev.08-08-2013] 28 � Packet Pg. 1950 16.E.8.e 0 N (b) A description of the types of Unsecured PHI involved in the Breach; (c) Steps Individuals should take to protect themselves from potential harm resulting from the Breach; a) (d) A brief description of what Business Associate is doing to investigate the Breach, to mitigate harm to Individuals,and to protect against any further Breaches; and (e) Contact procedures for Individuals to ask questions or learn additional m information, including a toll-free telephone number, an e-mail address,website or m postal address. 3.9 Burden of Proof. Business Associate shall have the burden of demonstrating that it made all notifications to Plan Sponsor, including evidence showing the necessity of any delay, or that the use or disclosure did not constitute a Breach. 3.10 Mitigation of Disclosure of PHI. Business Associate agrees to mitigate, to the extent 9 practicable,any harmful effect that is known to Business Associate of a use or disclosure of PHI by Business Associate in violation of the requirements of this Agreement. a. 3.11 Access to PHI. Within ten(10)business days of Plan Sponsor's written request,Business Associate shall provide Plan Sponsor or an Individual who is the subject of the PHI with access to PHI in Business Associate's possession, if Business Associate's information Q consists of a Designated Record Set in order for Plan Sponsor to comply with 45 C.F.R. § 164.524. ao 3.12 Availability of PHI for Amendment. The Parties acknowledge that the HIPAA Standards permit an Individual who is the subject of PHI to request certain amendments of his or her records. Within ten (10) business days of Plan Sponsor's written request, Business a Associate shall make PHI contained in a Designated Record Set in Business Associate's possession available for amendment and shall incorporate any amendments in accordance with 45 C.F.R. § 164.526. 2 3.13 Accounting of Disclosures. Business Associate agrees to document disclosures of PHI, N and to make available, within ten (10) business days of Plan Sponsor's written request, information to Plan Sponsor concerning Business Associate's disclosure of PHI for which Plan Sponsor needs to provide an Individual with an accounting of disclosures as required by 45 C.F.R. § 164.528. Should an accounting of the PHI of a particular Individual be requested more than once in any twelve (12) month period, Business m Associate may charge Plan Sponsor a reasonable,cost-based fee. 3.14 Compliance with Subpart E of 45 C.F.R. Part 164. To the extent Business Associate carries out Plan Sponsor's obligations under Subpart E of 45 C.F.R. Part 164, Business a Associate shall comply with the requirements of Subpart E that apply to Plan Sponsor in the performance of such obligations. N 3.15 Availability of Books and Records. For purposes of determining compliance of Plan a> Sponsor with the HIPAA Standards, Business Associate agrees to make available to the cai a \BAA-Plan Sponsor[Rev.03-08-2013) 29 9 I n Packet Pg. 1951 16.E.8.e 0 U) Secretary its internal policies and procedures, books and records relating to the use and disclosure of PHI received from, or created or received by Business Associate on behalf in of,Plan Sponsor. 3.16 Treatment of PHI at Termination. With respect to PHI received from Plan Sponsor, or created, maintained, or received by Business Associate on behalf of Plan Sponsor, upon termination of this Agreement for any reason, Business Associate, shall: _ a� m (a) Retain only that PHI which is necessary for Business Associate to continue its �• proper management and administration or to carry out its legal responsibilities; co (b) Return to Plan Sponsor or, if agreed to by Plan Sponsor, destroy the PHI that is a. not retained by the Business Associate under(a)above; M (c) Continue to use appropriate safeguards and comply with Subpart C of 45 CFR �b Part 164 to prevent use or disclosure of the PHI, other than as provided for in this Agreement, for as long as Business Associate retains the PHI; u_ (d) Not use or disclose the PHI retained by Business Associate other than for the purposes for which such PHI was retained and subject to the same conditions set out at in Section 2.2 and Section 2.3 which applied prior to termination; and c (e) Return to Plan Sponsor or, if agreed to by Plan Sponsor, destroy the PHI retained by Business Associate when it is no longer needed by Business Associate for itsCD proper management and administration or to carry out its legal responsibilities. L Article 4: Duties of Plan Sponsor Q N 4.1 Limitations in Notice of Privacy Practices. Plan Sponsor shall notify Business Associate of any limitations in the notice of privacy practices of Plan Sponsor under 45 C.F.R. § 164.520, to the extent that such limitation may affect Business Associate's use or `n disclosure of PHI. E 2 4.2 Changes in Permission. Plan Sponsor shall notify Business Associate of any changes in, or revocation of; the permission by an Individual to use or disclose his or her PHI, to the c extent that such changes may affect Business Associate's use or disclosure of PHI. m 4.3 Restriction on Use or Disclosure of PHI. Plan Sponsor shall notify Business Associate of any restriction on the use or disclosure of PHI that Plan Sponsor has agreed to or is required to abide by under 45 C.F.R. § 164.522, to the extent that such restriction may a affect Business Associate's use or disclosure of PHI. 0 C4 Article 5: Term and Termination a) 5.1 Term. The term of this Agreement shall be effective as of the Effective Date stated above, and shall terminate on the date Business Associate discontinues the provision of \BAA-Plan Sponsor[Rev,08-08-2013} q 30 Packet Pg. 1952 ■ 16.E.8.e 0 N d U services to or on behalf of Plan Sponsor, or on the date Plan Sponsor terminates for cause as authorized in Section 5.2,whichever is sooner. in w c 5.2 Termination for Cause. Business Associate authorizes termination of this Agreement by E Plan Sponsor,if Plan Sponsor reasonably determines that Business Associate has violated a material term of the Agreement and Business Associate has not cured the breach or ended the violation within the time specified by Plan Sponsor or ten (10) business days, whichever is greater. Plan Sponsor shall provide Business Associate notice of such breach or violation, in writing, with sufficient specificity as to reasonably permit Business Associate to cure such breach or violation. Plan Sponsor understands that, upon m termination of this Agreement,Business Associate will no longer be authorized to create, v receive,or transmit PHI on behalf of PIan Sponsor,except as otherwise provided herein. E L 5.3 Survival of Certain Rights and Obligations. The respective rights and obligations of ii Business Associate under Section 3.16 of this Agreement shall survive the termination of M this Agreement. Article 6: Miscellaneous a. LL 6.1 Regulatory References. A reference in this Agreement to a section in the HIPAA Standards means the section as in effect or as amended. 6.2 Amendment. The Parties to this Agreement agree to take such action as is necessary to amend this Agreement from time to time as is necessary to comply with the requirements c of the HIPAA Standards and any other applicable law. 6.3 Prior Business Associate Agreements or Addenda. This Agreement shall supersede any prior Business Associate Agreement or Business Associate Agreement Addenda. c, 6.4 Interpretation. Any ambiguity in this Agreement shall be interpreted to permit Q compliance with the HIPAA Standards. CD6.5 HIPAA. Business Associate will comply with all requirements under HIPAA that apply to business associates. E IN WITNESS WHEREOF, the Parties have, by their duly authorized representatives, executed this Agreement to be effective as of the date first above written. PLAN SPONSOR: BUS + S A.:SOC1ATE: ca By. s...,, _� /4"-IBy: 44, 4111k1a. 37- e{ - : ESS Print Nhme and Title Print Name and Title �} C` "� d� Q 1BAA-Plan Sponsor fRev.08-08-2013] 31 Packet Pg. 1953 e I16.E.8.e 0 cn0 o EXHIBIT 3 .; PERFORMANCE GUARANTEES cin c t �' � �-' te'7 bite.; °_mAt' G��r-4_ kPe 'i Sok �,, ' jl p 3 .. ;i, ( ,,•:1411, ,i4 E M1 _ va -� -^y i :rG12t3 33 4E `Ssr' � aT - E" 3. ,1 ,d',,,,;E t� 41.1 ( ,_ 5. ilii xtitat i;, �, q,1: .'1-----14----7-::111.17g.. =S '3 .r .11:N �'�;n C ,,.r 3 '4F"i.:31.74:r.T H'il{r,„k',," � zs�,'�..r: rp .._._.^',Ali.. ,... • ,,"j A' y�' G r.7-4-4C -11 xi yr .„. fC s .I.tr:. r. ,c?..Ii'sari..t.'�"-y {,4 g 100%of MDR received from pharmaceutical m Manufacturer Derived o manufacturers ispassed ` Revenue(MDR) 100%Pass-through $10,000.00 m through to Plan Sponsor,in accordance with the ci • Agreement. f6 1= L I00%of network discounts .`e and dispensing fees are a Network Discountso passed through to Planco- Network Dispensing Fees 100%Pass-through $10,000.00 c Sponsor upon the effective G date of any negotiated co change. E yS , F Fe �[.'f„t`n+ EL 01 r t�r a 1 iV a i e s ji -.511r11'i t 1V 1 ^r,k,., u. i' tr.....i•k,:. r n s, ,::,i."� a., 11 ""I ::3 :.�,'..�t ;s, li,11 :.,:�` `„.l.. '4 1-;- } 1 �4 .'` ce i ,s srE. dZe..;liar SC h3,xT�"E�,-c1 ,r� . ...t9- �'�M.l��� .i'���1�4'�E�A�,c"+J x3 �,�: � f f Calculated as the amount of o time the Claims Adjudication R System Availability 99.5/0 $10,000.00 System is available to Q - process Claims. IC as the time co- Calculated T commencing immediately •cu after receipt of the last m • System Response time <4 seconds character of a transaction E submitted by a pharmacy $10,000.00 a°'i until the first character of the a, response is sent to the Q pharmacy. Should adjudication of a > r Claim be delayed due to a• a) malfunction of Envision's t Adjudication Delay One(1)business day System,Envision shall E $2,500.00 per occurrence co correct the malfunction and 2 inform the affected Covered Y Individual within one(I) m 1 day ,"`;0,',. ' ic.,c.. l i .-354.-74,g v`.—,is-.a'i {u Y gi3 3'1 IS*,at Gz, L ai V i a-- u -4 I 3 u'i 3 w 5 ` fit s 2�q s- m '{ tetarl' nd ad llaimS Pxapes n o i 4t i i �a.-..1. ,,,, a:b mc.:,r, 1u.s.;,yra � .Cl... ,?. .� .r t.. i,t,,itil X11[ � i r. is 1 t �,l..a r..-.+rs:� Rii,,,;.;7.�39...:,x•.�.3;,��d.T i�?I_ i V Based on PBM's internalE quality review. Calculated as as is Percent of all claims paid >99.98%Retail all claims audited and found n. $10,000.00 i with no errors >99.98%Mail to be without error of any v form,divided by all claimsCD N audited. "" n.+ t a-r-^i.�"�, t. '--A ,� cr-�F..,-a %x, z "Y'4' 'x :;�°'F'T' a WC. v -c-- s al i" s C :, l stonier.Sir rc� e, k ted er vn l a = u �a w E i r' ,i s;a+T -.,.?x 9 ,,„y.,.z*u ,, - S � 1 g:..5 .,,c r�zi .x., r .+ ,u... r- U P U 1BAA-Plan Sponsor[Rev.08-08-2013] 32 i Packet Pg. 1954 16.E.8.e 1 1 0 U) 4 n4eaz aas.- c f Cty`�L ann 1 4�' �4l3 fi yi,fe ,frK9 3nvr ➢Y .u, e'/1H.'g. icf^�s�x �n r, )X' .. I Lz GES I , l',11,1 � >L�z� ,.4i 3'i°t N 3-� I� , ... �4 a 4's 44,t1,Ylit �,t.b.,,.--,. a .... ,$110?1,, � y r The amount of time that N elapses between when a call c is received into the customer E service queue and the time as Percent of calls that will be 95%answered in an average the phone is answered by a as answered within 30 seconds of 30 seconds or less Customer Service $10,000.00 2 Representative(CSR). .._. m Measurement and target a� determination will be based m on an annual average. ci ca Percentage of calls that are not answered by a CSR _c (caller hangs up before call is a answered). Calculated as the C° M number of calls that are not o 0 Percent of calls abandoned <5% answered divided by the $10,000.00 cc number of calls received. at a Measurement and target cL determination will be based "E on an annual average. cc } 3 .p}j, t-=- g pFY� -.11 "�� €fA s5i { - s in S s b, tilt• �"�' tmom- dLruk - ,Iy'3�..d0 'i , 'r l' < gripe ee ed,terC e t ' F til w x Y. � . wr ..... — i a,fs ,:;.i1Er.^ _`=-�k. i .i.3,1'-,-1:4441,,,,-..-`"- . ,r`.,-'i-. __- '' i4}i(ii.".._a,4f4. 4µ,sr �� r Percentage of all calls made c to Envision that were - resolved by initial CSR. E. Percent of calls with Calculated as the total calls a) resolution at end of first call to Envision minus total E m (i.e.no further inquiry by >90% number of unresolved calls caller required to obtain divided by the total number $10'000.00 Q requested information or of calls received. co 3. action) m U Measurement and target •L determination will be based a) to on an annual average. E Percent of written inquiries Response time for all written responded to by paper within inquiries will be based on the 10 business days or 99% number of business days $10 000.00 m subtracting the date received c responded to electronically (I)at Envision from the date the to within 2 business days �, response was sent. m 1 Based on network pharmacy E access within 10 miles for as i Pharmacy Network Access >95% Plan Sponsor's Covered $10,000.00 ii Individuals. `1 _ ;,..:.,;,40-.,_,..11,:*,,,.,�,aa� c u „,,...,---,, ,,„:,4!:tiit -1,.111,),,'=,.711;,...., ii �,4 i L: Sili :1414,V;�.,�. s . 1s t 7 ...k,9. �5 C7 A rgem feu ” v<<3r ilto �N,i m rdt dsmiry' ,. ki 1U 0,:4 ,1 CSI s^�..rz. xie -,.� _ .;N..� "�m.. .—�f�_.�.`_".... 1,.,t _ ..�``�` x�.�� . ..� '� - idl-r�,-::±# -v�.x�3! r_�� .;4�'`i .-,, � ++ C Initial client inquiries will be a) Account Management Two(2)business days acknowledged and responded $10,000.00 Responsiveness v to within two business days. t w. d ?7 1BAA-Plan Sponsor[Rev.08-08-20131 33 Packet Pg. 1955 16.E.8.e i o 6a'4`C� �f iYg IWp 1..,. n > i � zf.g as'i 3.i3 ..1 4,' ,4� is r 7 �� ,�t I s iii V' •-- 9 3 -- 1 U 1Xt ,G �.,:SR+-— ve � ��31� 3 i r� � -�� T z r n�car� nt•`!>± r�'kF �. ( r a 3 x ,,,,,,,,,,,v,,,,,,,,,,„,-,,,,„„---74‘ i1s3i i n—. t""s' 012�i{}.ter" z, Ia .y 4t�'f i„' ,5,: 3lti?� e0,,,,L : lital' lli`'� F i1e! { rur ai S.,.'* y tC ELcn N :„, .,,, TFI - tlTI,VI ii ...t f'- p k J d n i'M { (4. 1,. i1 1 7; �Z {i +.F�S'...'prof r—J..f'i''p f.i S1v....ii_i.f ..7 ,1,] .`?'ft ,, ,sY"1 -tt-amm *1 ., Y'tax ! G 1i ,,.may , l Eligibility information a) submitted to Envision will m become effective within 2 at business days followingthe caas Enrollment Processing Two(2)business days y $10,000.00 `� date of receipt. Assumes complete and accurate ; information is sent to m IEnvision. 1 M A tAGL`S�'n } lj t�R'�ia �_' T"'__9k� f 'yy +', ��5,.. Y.Y, i�'1 S Y P,iri3 .) o,,,,iS l� ,‘,.:=4,,,,,,,,v0.4.):: >, i.ix.:..,,a3., s-,r a L il,zie,-'',M;, tlu 'Sw 4r.t t ti ry�-'�ar. EIK :3n, MAS r sr:” % 3L__,c� .,�.vi� •It 13§s_._. 13 4`_c; , Program Implementation December 20th,2013 Date of implementation $10,000.00 E t Distribution of ID Cards December 20th,2013 Date of distribution $10,000.00 a r sxi3.F4':AIt's�e,,t�3i3:T pst 1d1� 7 '° tsSt 3ti urxr�FV ,, a.:it.: <r,s #' '� SJ "c`t i .tri cif �� i , sC,��.-...'"°it1 t 1ita:`us. .,yrs i�- 1_ l��'�11 4u3 i tEt1...-7- . e,)j ._- ?� _ l l: ri C,,,i7;- TiCk ,_.. ;3.�7 K _ ..,— .,phi! , Mi j,,i aF� o Acceptable monthly claims By the 15th of the close of co data extracts provided to each month for prior month $10 000.00 Verisk and other firms that a ct the School Board may as agreed upon in the final designate contract cc C ll�t°I�}� c V ��3 f �S�.;fv�tirt is t!1!Izs `#iie ",°�� �'iF�!r ifi j ':------`4% -t"7- .. ..iN IrnJ 1�1 �� '4..4L'..; c,[4 .,...4 '..7"' ip- ;;,i`�V'�.._. lfr^3 4 gf117 i,'1 i 13n? sf't,..- ^4 ;. i` — 1. : �{§1" -1"� r=- a ..z�,.•to '—�,„�.... = --�,, 'l3 1 < �1 Si --�-7as'�"'� R y`�'Mtge ,. For the applicable Pharmacy Channel,If Actual GDR— Guaranteed GDR<0,Then �- • Generic efficiency rates for Retail 75.50% the(GDR X(Total claims— entire contract period Mail 72.25% Total Generic Claims)) X $10,000.00 CD E (Avg Brand Plan Paid a) Amount-Avg Generic Plan °.' p Paid Amount) Q ;R i D `i 1 1 i11 ' ., t k iiii1,�,31 ,,4N itt .e°1 e ',,rill �.1 It,ova f .141 .�,. h� r7SY. >1a ce. m.11 �i 1.5?-?.,, 7 H'i iutn., isa'3,oie-c-Zv' 7b a 9F 'T7 .... LY",,.._ , t �,.�-a its., l i •a'� cc) Quarterly and annual reports will be delivered,in hard co Quarterly and year end copy,to CCHCC within 30 E reports delivery time frame business days of the close of $10,000.00 the quarter and contract year, 2 respectively. ._ a as ° wit iiit''tx--'3 l lis .ti't s: } fi y, T ,•s• K y C X e �i(7 i p: 1 i 3W 1a� :i 1 ':'tr'i ,at ¢ v 1 }3ow l oc ,4d....,—„.... t5�t `f , ....„, — w ..��� .v.„. S'3 , t T.. ,ro7r� 9 l�"�-'a i.r m �.�, �-^� .. .t,._ S .. �:�.�txt�t i3�Ets�' ..�aY.,�.;�.:..�..;�'.8°` e i�i..'-:.x tc ..>;., More than 95%of all o prescriptions requiring no E E intervention will be cc h i processed within two(2) n. Turnaround Time business days. $10,000.00 V” 0 z More than 98%of �`+ F prescriptions requiring administrative or clinical °' intervention will process - V 1BAA-Plan Sponsor[Rev.08-08-2013] (7., 34 I Packet Pg. 1956 ti f 16.E.8.e 0 a) .< �tr. _1 �:r� F$, ,y E i y 9 - 'k'F u ii�#.e'—'' i} aaa.. h�aI( $ itr " i s.�...--�-. �, _Fs�, !s -.i+ti.. .. > ,-. an- within five(5)business days. Turnaround time will be E measured by time and date stamp and will be defined as the time the prescription is received in the facility to the time it ships. 51_riSt aC�''A riilx} � fit ! 9l i.rNriS :Threat II }YuWa@ k CO ..1.1?0 Envision shall accept, process,and adjudicate DMR Claims within ten(10) m business days of receipt of Turnaround Time Ten(10)business days the DMR form,but shall not $2,500.00 per occurrence be liable to reimburse a `' Covered Individual until Plan c Sponsor provides funds for such purpose. n� -aa�'' y° 6 s' ,��- {�4�'�.4}- n hx-'�kkyYtr +�{ {a. !}tY�3�,k}�+;_,,, i tts 4 t t - LL AY out t'8 QA b S IY Rlj 1 uj jtS 'C�tSS y �£ SkAllit ali$�i 4x. „r .^ j .y t� � lot'.F1�ti ,.e...,_s.. -.;:.,.tF-.._... Claims for compound drug 3 Claims from participating compounding pharmacies that are delayed due to an act Ten(10)business days or or omission of Envision shall o Turnaround Time $2,500.00 per occurrence earlier be electronically adjudicated at the compounding m pharmacy within ten(10) E business days,or processed as a DMR as set forth herein. aux- p. 1 � i :s t ...r �l� .9, ..:;3 y'.. �,,,r, . f 3 � Tt_ C ,''c1�.3 F cls' q m U If a Covered Individual does .> not receive a Specialty Drug m that was previously shipped by the Specialty Pharmacy E Emergency Fill Twenty four(24)hours for any reason shall receive $2,500.00 per occurrence that Specialty Drug within twenty four(24)hours of m authorization from Plan w Sponsor. DO U fc *Exclusions from GDR calculation include products such as OTC's,Vaccines,Compounds,Specialty drugs,DAW's(0,3,4,56,9) and branded generics for purposes of marketing. cts 0- r 0 aC-. a) o cc 1BAA-Plant Sponsor[Rev.08-08-20131 35 Packet Pg. 1957 -..