Agenda 09/24/2013 Item #11G 9/24/2013 11 .G.
EXECUTIVE SUMMARY
Recommendation to approve the award of Pharmacy Benefit Management Services to
Envision Rx, authorize the Chairwoman to sign the attached agreement, and terminate
the current agreement with Express Scripts effective January 1, 2014.
OBJECTIVE: To provide Pharmacy Benefit Management services to the Collier County Group Health
Insurance Plan.
CONSIDERATION: The Board of Commissioners through the Risk Management Department
administers a partially self-funded group health program (the Plan) for its employees and their covered
dependents. A significant component of the Plan provides coverage for prescription medications. The
Plan currently utilizes Express Scripts, Inc. to provide pharmacy benefit management (PBM) services.
These services include the provision of a retail pharmacy network for acute and chronic medications
and a mail order pharmacy network for chronic medications. The use of a PBM enables the county to
purchase medications at rates which are significantly below average wholesale rates. The current
agreement with Express Scripts will expire on December 31, 2015.
Since the commencement of the current agreement with Express Scripts, there have been significant
customer service issues that have not been appropriately remedied. These issues primarily involve the
delivery of specialty medications in a timely manner; the refund of overpayments by members; and
software failures that delayed the receipt of medications by members.
In April, 2013, Collier County Government and the District School Board of Collier County decided to
release a joint RFP through the District School Board's purchasing department to evaluate PBM's in
anticipation of a January 1, 2014 program commencement date. The NCH Healthcare System also
asked to participate in the RFP process. All three employers utilize Express Scripts and have
experienced similar service issues. Together, the three groups represent approximately 18,000 covered
lives and a joint bid would enable the leveraging of group size to attract favorable pricing and terms.
However, each group retained the right to select a different vendor. Willis, Inc., the actuarial and
benefits consultant for all three employers prepared an RFP document which was released in May,
2013.
The RFP was requested by seven vendors. Proposals were received from six vendors. The selection
committee consisted of members from the Board of Commissioners, the District Schools and NCH.
Willis provided an initial financial analysis and the committee performed a review of proposals in order
to create a shortlist of three vendors for finalist interviews. The companies selected were Catamaran,
Envision Rx, and NC Caremark. The selection committee then prepared a set of weighted interview
questions that were distributed to the finalists. Interviews were completed on August 8th and each group
ranked their final selection according to criteria established by the group. The final committee ranking of
both the District Schools and the Board of Commissioners is as follows.
1. Envision Rx
2. Catamaran
3. NC Caremark
NCH chose to delay the selection of a PBM vendor due to broader changes being considered within the
organization.
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By utilizing this cooperative process with local agencies, the County will see a reduction of $328,875 in
the cost of these services. Staff is recommending per the Board's Purchasing Policy (XIV) the use of
this cooperative competitive solicitation and the resultant contract. The commencement date of the
agreement is January 1, 2014. Program implementation will begin upon approval by the Board.
FISCAL IMPACT: In calendar year 2014, the expenditure for pharmacy services under the Express
Scripts agreement is projected to be $5,758,684. Projected pharmacy expenditures through Envision
Rx for the same period are projected to be $5,429,809. Changing the program from Express Scripts to
Envision Rx will result in a projected reduction in program cost of$328,875. The agreement is for a two
year period. Sufficient funds are budgeted within Fund 517, Group Health and Life, for this purpose.
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 approves the award of Pharmacy Benefit Management
Services to Envision Rx, authorizes the Chairwoman to sign the attached agreement, and terminates
the current agreement with Express Script effective January 1, 2014.
PREPARED BY: Jeff Walker, CPCU, ARM, Director, Risk Management
Attachments:
• Solicitation Document
• Rankings
• Contract
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COLLIER COUNTY
Board of County Commissioners
Item Number: 11.11.G.
Item Summary: Recommendation to approve the award of Pharmacy Benefit
Management Services to Envision Rx, authorize the Chairwoman to sign the attached
agreement, and terminate the current agreement with Express Scripts effective January 1,
2014. (Jeff Walker, Administrative Services Risk Management Director)
Meeting Date: 9/24/2013
Prepared By
Name: WalkerJeff
Title: Director-Risk Management,Risk Management
8/23/2013 2:38:37 PM
Submitted by
Title: Director-Risk Management,Risk Management
Name: WalkerJeff
8/23/2013 2:38:39 PM
Approved By
Name: MarkiewiczJoanne
Title: Manager-Purchasing Acquisition,Purchasing&Gene
Date: 9/3/2013 8:26:19 PM
Name: pochopinpat
Title: Administrative Assistant,Facilities Management
Date: 9/4/2013 3:01:59 PM
Name: WardKelsey
Title: Manager-Contracts Administration,Purchasing&Ge
Date: 9/6/2013 9:43:52 AM
Name:NorthrupAdam
Title: Procurement Strategist, Purchasing
Date: 9/9/2013 10:20:10 AM
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Name: GreeneColleen
Title: Assistant County Attorney,County Attorney
Date: 9/13/2013 10:59:05 AM
Name: PriceLen
Title: Administrator, Administrative Services
Date: 9/13/2013 1:13:16 PM
Name: KlatzkowJeff
Title: County Attorney
Date: 9/13/2013 1:46:20 PM
Name: PryorCheryl
Title: Management/Budget Analyst, Senior,Office of Manag
Date: 9/15/2013 1:29:17 PM
Name: OchsLeo
Title: County Manager
Date: 9/17/2013 3:15:56 PM
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PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT
This Pharmacy Benefit Management Services Agreement (hereinafter this "Agreement") is
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 1`t, 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
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
Agreement.
NOW, THEREFORE, in consideration of the mutual promises and agreements herein contained,
Plan Sponsor and Envision hereby agree as follows:
1. DEFINITIONS
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
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.
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
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
pharmacy. Envision uses a single source for determining AWP and updates the AWP source file
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.
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
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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
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.
1.7 "Claim" means an invoice or transaction (electronic or paper) for a Covered Drug
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
the Public Health Service Act.
1.8 "Claims Adjudication System" or "System" means Envision's on-line computerized
claims processing system.
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
Date and each consecutive complete twelve month period thereafter that this Agreement remains
in effect.
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
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.
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.
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
Eligibility File as being eligible to receive Covered Drugs.
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1.14 "Eligibility File" means that electronic communication supplied to Envision by Plan
Sponsor (or Plan Sponsor's agent) which identifies the Covered Individuals covered under Plan
Sponsor's Benefit Plan, along with other eligibility information necessary for Envision to
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
continues through the last day the Covered Individual appears on the Eligibility File.
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,
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
calculating the total Administrative Fee.
1.16 "Formulary" means an index of Prescription Drugs, which have been compiled by
Envision and reviewed by Envision's Pharmacy & Therapeutics Committee for safety and
efficacy (using evidence-based evaluation criteria), that is used, in conjunction with the Benefit
Plan,as a guide in the selection of Covered Drugs. The Formulary may be modified by Envision
from time to time as new medications and/or new clinical information become available.
1.17 "Generic Drug" means a Prescription Drug where the Medi-Span multisource code
attached to the 11 digit NDC for such drug indicates a "Y" (a generic drug product available
from one or more pharmaceutical manufacturers). A drug is classified as a Generic Drug at the
Point-of-Sale based on the MONY code assigned by Medi-Span and shall not be reclassified for
any purposes hereunder.
1.18 "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as
amended.
1.19 "Mail Order Pharmacy"means the Mail Order Pharmacy specified in Exhibit 1.
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
design requirements of pharmaceutical manufacturer contracts with Envision and otherwise meet
the terms and conditions hereunder.
1.21 "MAC List"means a proprietary list of Prescription Drugs for which Envision establishes
a maximum price ("MAC Price") payable to the dispensing pharmacy. Envision maintains one
commercial MAC List per Participating Pharmacy which is used to both determine the
negotiated price payable to the dispensing pharmacy and the price charged to Plan Sponsor. Plan
Sponsor will be charged the exact negotiated amount payable by Envision to the dispensing
pharmacy without any markup or spread. Envision updates the MAC List from time-to-time as
Prescription Drugs come on the market or come off the market, or as their availability changes
due to market circumstances.
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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 to
dispense Covered Drugs to Covered Individuals.
1.23 "Plan Sponsor" means the entity (identified above as Plan Sponsor) which (i) has
established and underwrites the Benefit Plan on behalf of its Covered Individuals; (ii) has
determined the rules by which the Benefit Plan is to be administered; and (iii) is financially
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
Individuals hereunder.
1.24 "Point-of-Sale" means the location and time that a Covered Drug is dispensed to a
Covered Individual, and the corresponding Claim is submitted by the dispensing pharmacy for
adjudication by the Claims Adjudication System.
1.25 "Prescriber" means a licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.),
Doctor of Podiatry (D.P.M.), Doctor of Dentistry (D.D.S.), or other licensed health practitioner
with independent prescribing authority in the state in which the dispensing pharmacy is located.
1.26 "Prescription Drug"means a substance intended for use in the diagnosis,cure,mitigation,
treatment, or prevention of disease which is dispensed by a duly licensed pharmacy and required
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.
1.27 "Retail Pharmacy" means a state licensed retail community pharmacy that dispenses
prescription medications at its physical location. A Retail Pharmacy does not include a
pharmacy that dispenses medications to patients primarily through mail, nursing home
pharmacies, long-term care facility pharmacies, hospital pharmacies, or clinics, unless such
pharmacy is a Participating Pharmacy listed by Envision as a Retail Pharmacy.
1.28 "Specialty Drug" means a high-cost (i.e. costs more than $600.00 per month or per fill)
biotech, injectable, infused, oral, or inhaled Prescription Drug that may require special storage,
handling, or is available only through limited distribution channels, and/or requires close
monitoring of the patient's drug therapy (including a few products, such as intrauterine devices
[IUDs]). Specialty Drugs are identified on the Envision Specialty Drug List, as modified from
time to time.
1.29 "Specialty Pharmacy" means a non-Retail Pharmacy that primarily dispenses Specialty
Drugs and performs special ordering,handling and/or patient intervention services.
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
dispensing pharmacy.
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2. STANDARD PBM SERVICES
Envision shall perform the following pharmacy benefit management services ("PBM Services").
Unless otherwise noted, the PBM Services specified below are included in the Administrative
Fee.
2.1 Welcome Kit: If requested by Plan Sponsor, Envision shall provide an initial"Welcome
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
Sponsor or, at its option, directly to Covered Individuals. For any materials mailed directly to
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
special graphic requests,additional charges may apply.
2.2 Claims Processing: During the term of this Agreement, Envision shall accept, process,
and adjudicate Claims for Covered Drugs (i) submitted electronically by Participating
Pharmacies; (ii) submitted by Covered Individuals as Direct Member Reimbursements (DMRs,
as defined below); or (iii) received from third parties, such as Medicaid, for reimbursement by
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
authorization, or rejected for ineligibility or other factors in accordance with Plan Sponsor's
specifications as set forth in Plan Sponsor's Benefit Specification Form (incorporated herein by
this reference). For Claims that must be processed manually or require special handling,
including, without limitation, (i) DMRs or (ii) Claims received from third parties, such as
Medicaid, for reimbursement by Plan Sponsor for ineligible payments, Plan Sponsor will be
charged a Manual Claims Processing fee as set forth in Exhibit 1. After termination of this
Agreement,Envision shall process Claims received for dates of service on or before the effective
date of termination for a period of ninety(90)days ("Run-Out Period"), subject to the following.
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
be promptly refunded to Plan Sponsor and, thereafter, any Claims received by Envision shall be
rejected.
2.2.1 Direct Member Reimbursement(DMR): Envision shall provide,via its website, a
form for use by Covered Individuals to obtain reimbursement for amounts paid out-of-pocket
(other than Cost Share) for Covered Drugs (e.g. Covered Drugs dispensed at a non-Participating
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
Individual until Plan Sponsor provides funds for such purpose.
2.2.2 Claims Adjudication System Edits: Plan Sponsor's Benefit Plan may contain
additional rules which determine the way in which Claims are to be adjudicated. These rules
may include coverage limitations or exclusions, application of clinical intervention (e.g. step
therapy, drug therapy management), application of dispensed as written (DAW) codes (e.g. to
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determine what portion of a Claim is payable by Plan Sponsor and what portion is payable by
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,
dosage changes, invalid days' supply). For this purpose, Envision shall program edits into the
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
limitation,program,rule, or override.
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;
pediatric warnings; geriatric warnings; acute/maintenance dosing; therapeutic duplication; drug
inferred health state; drugs exceeding maximum dose; and drugs below minimum daily dosage,
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.
2.3 Clinical Services
2.3.1 Clinical Prior Authorizations (Initial Coverage Determinations): If Plan Sponsor
has elected to receive Clinical Prior Authorization services from Envision, for those Covered
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.
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
Specification Form. Plan Sponsor acknowledges that the pharmacies participating in a Network
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
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
subject to market conditions and that Envision cannot, and does not, assure the availability of
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any drug from any Participating Pharmacy.
2.5 Customer Service: Envision shall maintain and operate a customer service center with
toll-free customer service numbers and adequately staffed with trained personnel 24 hours a day,
7 days a week, 365 days a year, for the use of Plan Sponsor, Covered Individuals, Prescribers,
and Participating Pharmacies.
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
agrees to reimburse Envision for any cost incurred from the transfer of files from or to any
vendor or pharmacy at any time during this Agreement and,upon request of Plan Sponsor, at the
termination of this Agreement.
2.7 Reports: Envision shall provide Plan Sponsor with access to a web-based report
generator through which Plan Sponsor may create and download a variety of standard and
customized reports. Envision shall provide training for a Plan Sponsor designated individual on
the capabilities of Envision's web-based reporting program. Plan Sponsor represents that the
designated individual has received training and has knowledge of the HIPAA privacy and
security regulations. Any reports that are to be provided by Envision to Plan Sponsor without
cost (other than those available from Envision's web-based reporting program) shall be mutually
determined prior to the configuration of Plan Sponsor's Benefit Plan in the Claims Adjudication
System and shall be specified in the Benefit Specification Form. Plan Sponsor shall be charged a
fee for any other reports requested by Plan Sponsor.
Included in the web-based reports described above, or provided separately, Envision shall supply
Plan Sponsor with reports of retrospective reviews to determine the drug utilization patterns of
Members (e.g. high cost/high utilization of a particular drug class,therapeutic appropriateness of
drug for a particular disease state).
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
reports summarizing Claims paid by Plan Sponsor for Medicare Part D drugs dispensed to
Covered Individuals who Plan Sponsor has identified on the appropriate form as Medicare
eligible retirees. Plan Sponsor acknowledges that any estimated earned Manufacturer Derived
Revenue which has been passed-through to Plan Sponsor will have been deducted from the
Claim amounts reported. Unless otherwise specified herein or included under an addendum to
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
solely consultative and shall not be deemed to be an acceptance by Envision of any responsibility
or liability for the completion or submission of any RDS application or request for subsidies
under Medicare Part D.
2.9 Business Associate Agreement: Envision shall execute a HIPAA Business Associate
Agreement, attached as Exhibit 2,
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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
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
credited towards future Administrative Fees. Failure to meet Performance Guarantees shall not
be deemed to be a breach of this Agreement.
3. PRICING AND PASS-THROUGH METHODOLOGY
3.1 Pass-Through of Discounts and Dispensing Fees: Envision has negotiated discounted
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
any applicable dispensing fee) without any reclassification, mark-up or spread by Envision. The
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:
(a) The calculated negotiated amount payable to the Participating Pharmacy
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
(c) The Participating Pharmacy's U&C Price (except for drugs dispensed by
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
fee amount payable to the Participating Pharmacy.
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
Annual Average Effective Rates and Annual Average Dispensing Fees paid by Plan Sponsor for
the Contract Year. If the amounts paid by Plan 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
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
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
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
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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
Average Effective Rate or Average Dispensing Fee, such guarantee shall be adjusted to account
for such changes. Envision shall demonstrate to Plan Sponsor the factors upon which any such
adjustment is based and the methodology used to make such adjustment. Nothing in this Section
3.1.3 shall affect Envision's obligation to pass through to Plan Sponsor 100% of all negotiated
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
(i) Plan Sponsor makes a change to the Benefit Plan which affects the utilization or distribution
of Covered Drugs; (ii) the specifications provided by Plan Sponsor on the initial Benefit
Specification Form are inconsistent with the specifications provided to Envision prior to the
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
inaccurate. Plan Sponsor is urged to submit any proposed changes to the Benefit Plan to
Envision before such changes become effective so that Envision may advise Plan Sponsor if any
changes will affect Drug Pricing or Dispensing Fees Guarantees. Plan Sponsor acknowledges
that it has no right of offset to withhold any payment due Envision under this Agreement for any
amounts owed Plan Sponsor for financial guarantees.
3.2 Manufacturer Derived Revenue
3.2.1 Pass-Through of Manufacturer Derived Revenue: Envision has negotiated
contracts with pharmaceutical manufacturers to obtain Manufacturer Derived Revenue for
eligible Prescription Drugs, and shall pass through to Plan Sponsor one hundred percent(100%)
of all earned Manufacturer Derived Revenue paid to Envision by contracted pharmaceutical
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
provided by Envision. Plan Sponsor acknowledges that its yield of earned Manufacturer Derived
Revenue is dependent on certain factors including, without limitation, the following: (i) the
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
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 Claims for a particular rebated
drug to the total number of Claims for such drug for all Envision clients, as adjusted for the
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
occurring while the Covered Individual has not yet met his or her deductible), 340B Claims, and
Claims for which Envision has not been paid in full, are ineligible for Manufacturer Derived
Revenue, and no Manufacturer Derived Revenue shall be payable to Plan Sponsor for such
Claims.
3.2.2 Pass-Through Methodology: Manufacturer Derived Revenue shall be advanced
to Plan Sponsor by adjusting the Claim for an eligible Prescription Drug by the estimated earned
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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
after applying credit for estimated earned Manufacturer Derived Revenue. (Plan Sponsor
acknowledges that, unless otherwise indicated by Plan Sponsor on the Benefit Specification
Form, if a Covered Individual pays a percentage of the drug cost (i.e. co-insurance) under the
Benefit Plan, a proportional amount of the Manufacturer Derived Revenue will be passed on to
the Covered Individual at the Point-of-Sale).
3.2.3 Sole Source: Plan Sponsor represents and warrants to Envision that, at no time
during or after the term of this Agreement, is Plan Sponsor receiving rebates and other revenues
from pharmaceutical manufacturers other than through Envision, either directly or indirectly
(through a Group Purchasing Organization, drug wholesaler, or otherwise) for Claims processed
by Envision under this Agreement. Plan Sponsor agrees that it shall not, at any time, submit
Claims which have been transmitted to Envision to another pharmacy benefit manager or carrier
for the collection of rebates and other revenues from pharmaceutical manufacturers or create a
situation which would cause a pharmaceutical manufacturer to decline payments to Envision.
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
to Plan Sponsor by Envision which is connected with any Claims for which Plan Sponsor
received rebates and other revenues from pharmaceutical manufacturers from any other source or
for amounts advanced to Plan Sponsor by Envision which have been withheld by a
pharmaceutical manufacturer as a result of such Claims not meeting conditions for rebates, the
ineligibility of Claims for Manufacturer Derived Revenue (i.e. 340B Claims), or breach of this
Agreement by Plan Sponsor.
3.2.4 Manufacturer Derived Revenue Guarantee: Nine months after the end of each
Contract Year, Envision shall provide Plan Sponsor with a report reconciling Manufacturer
Derived Revenue amounts advanced to Plan Sponsor and Manufacturer Derived Revenue
amounts earned by Plan Sponsor for eligible Claims (including market share based amounts)
during the Contract Year.
(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
Sponsor for the Contract Year,Envision shall pay the difference to Plan Sponsor.
(b) If the Manufacturer Derived Revenue earned by Plan Sponsor for the
Contract Year is, overall, lower than the annual average earned Manufacturer Derived Revenue
guaranteed amounts specified in Exhibit 1,Envision shall pay the difference to Plan Sponsor.
Notwithstanding anything herein to the contrary,Envision shall not be liable to Plan Sponsor for
guaranteed earned Manufacturer Derived Revenue if: (i) Plan Sponsor makes a change to the
Benefit Plan which affects the application of the Formulary(e.g. tier differentials),the conditions
for rebates of pharmaceutical manufacturer contracts; or otherwise affects earned Manufacturer
Derived Revenue yields; (ii) there is a substantial change in the drug utilization patterns of
Covered Individuals; (iii)the utilization data provided by Plan Sponsor(or Plan Sponsor's agent)
upon which the calculation of guarantees were based is inaccurate; (iv)there is a loss of rebates
due to pharmaceutical manufacturer drug patent expirations, manufacturer bankruptcy, or
removal of a drug from the market; (v) there are changes in pharmaceutical manufacturer rebate
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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
regulation, ruling, or guidance that impacts Envision's ability to maintain current earned
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
Sponsor for financial guarantees.
4. PLAN SPONSOR RESPONSIBILITIES
4.1 Implementation: No later than thirty (30)days prior to the Effective Date, Plan Sponsor
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
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,
Envision will credit Plan Sponsor an implementation credit of$0.50 per Eligible Employee.
4.2 Eligibility Data: Plan Sponsor shall provide Envision (either directly or through an
authorized third party administrator) with an Eligibility File, at least monthly, in the HIPAA 834
standard transaction code set format, or such other format as has been previously agreed to by
Envision. Plan Sponsor shall provide timely eligibility updates (for example, additions,
terminations, change of address or personal information, etc.)to ensure accurate determination of
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
Envision and Participating Pharmacies will act in reliance upon the accuracy of data received
from Plan Sponsor; (ii) Envision will continue to rely on the information provided by Plan
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
Plan Sponsor (or its designee) of inaccurate, erroneous, or untimely information. In addition, if
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
directly (except for the initial Eligibility File, which must be provided to Envision during the
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
the Benefit Plan. Plan Sponsor understands and agrees that Envision shall rely on the terms and
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
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
Sponsor shall have sole authority to determine the terms of the Benefit Plan and the coverage of
benefits thereunder, however, Plan Sponsor understands and agrees that any change in the
Benefit Plan or System configuration (e.g. mandatory generic program, coverage of over-the-
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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.
Plan Sponsor agrees that Envision shall not be liable to Plan Sponsor for a reduction of such
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.
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 guarantees
resulting from Plan Sponsor's failure to adhere to the Formulary or a change to the Benefit Plan
that affects the application of the Formulary.
4.5 Payment: Plan Sponsor shall timely pay, or cause its designee to timely pay,Envision for
services rendered hereunder in accordance with Section 4 below and Exhibit 1.
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
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
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
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.
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
the tenth (10th) calendar day from receipt of said invoices. Invoices shall be deemed to have
been received by Plan Sponsor upon the earliest delivery of the invoice by mail, e-mail, fax, or
courier.
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
Envision's invoice. The monthly Administrative Fee is calculated by multiplying the number of
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
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forth in Exhibit 1 (except for the initial invoice which is based on Plan Sponsor's initial
Eligibility File).
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
in Exhibit 1 hereunder,within seven(7)calendar days of receipt of an invoice.
5.5 Retroactive Disenrollment 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
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.
5.6 Taxes, Assessment or Fees: Any sales or use taxes for Covered Drugs sold to Covered
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
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
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
Sponsor's Claims.
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
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
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
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
required under this Agreement. Further, if Plan Sponsor should fail to pay any amounts due
II
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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
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.
5.8 Financial Audit by Plan Sponsor: Within twelve months after the end of each Contract
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
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
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
a conflict of interest with Envision. Plan Sponsor understands that Envision's contracts with
pharmaceutical manufacturers, Participating Pharmacies, and other third parties may contain
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
agreement with Envision prior to the audit. Audits shall only be made during normal business
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
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
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
are due from Envision.
5.9 Financial Audit by Envision: Envision may, at reasonable intervals,request Plan Sponsor
to provide records for Envision's inspection which provide support for the information contained
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
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;
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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.
6.2 Termination: This Agreement may be terminated as follows:
6.2.1 For Cause: By either party hereto in the event the other party breaches any of its
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;
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
creditors; (ii)files or has filed against it, or has an entry of an order for relief against it, in any
voluntary or involuntary proceeding under any bankruptcy, insolvency, reorganization or
receivership law, or seeks relief as therein allowed, which filing or order shall not have been
vacated within sixty (60) calendar days from the entry thereof; (iii) has a receiver appointed for
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
or sequestration by a court of competent jurisdiction that has assumed of all or a significant
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
deed,creditors arrangement or similar proceeding;
6.2.3 Failure to Pay: By Envision, in addition to any other remedy available to
Envision hereunder, in the event Plan Sponsor fails to pay Envision according to terms of this
Agreement.
6.3 Notices: All notices required in this Section 6 shall be reasonably specific concerning the
cause for termination and shall specify the effective date and time of termination.
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
effective date of termination. Envision reserves the right to suspend advancing earned
Manufacturer Derived Revenue to Plan Sponsor upon Plan Sponsor's notification of termination.
7. CONFIDENTIAL INFORMATION
7.1 Confidentiality: Except as otherwise stated herein or required by law, neither party
hereto shall disclose any information of, or concerning the other party which has either been
provided by one party to the other or obtained by a party in connection with this Agreement
(including this Agreement and the terms of this Agreement) or related to the services rendered
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
Agreement, each party shall return to the other party or destroy (if such destruction is certified)
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all confidential information provided including, without limitation, all copies and electronic
magnetic versions thereof. Notwithstanding any of the foregoing to the contrary, "confidential
information" shall not include any information which was known by a party prior to receiving it
from the other party, or that becomes rightfully known to a party from a third party under no
obligation to maintain its confidentiality, or that becomes publicly known through no violation of
this Agreement.
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
by Plan Sponsor via Envision's website. Plan Sponsor agrees, for itself and its employees, that
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
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
necessary to carry its obligations hereunder.
8. INDEMNIFICATION
8.1 Limited Indemnification by Envision: Envision hereby agrees to indemnify, hold
harmless, and defend Plan Sponsor and its employees, officers, directors, trustees, shareholders,
and agents from and against any and all liabilities, actions, claims, damages, costs, losses and
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
agreement of Envision contained in this Agreement.
8.2 Limited Indemnification by Plan Sponsor: To the extent allowable by law, Plan Sponsor
hereby agrees to indemnify, hold harmless, and defend Envision and its employees, officers,
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
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
comply with state or federal law in the operation of its Benefit Plan.
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
respective affiliates, directors, employees or agents, be liable for any indirect, special, incidental,
consequential, exemplary or punitive damages, or any damages for lost profits relating to a
relationship with a third party, however caused or arising, whether or not they have been
informed of the possibility of their occurrence.
8.4 Survival: This Section 8 shall survive the expiration or termination of this Agreement for
any reason.
9. RELATIONSHIP WITH CON!lZACTED PHARMACIES
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Plan Sponsor acknowledges that Envision is neither an operator of pharmacies nor exercises
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
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
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
to Plan Sponsor, disclose all earned Manufacturer Derived Revenue collected by Envision for
Plan Sponsor's Claims, and permit Plan Sponsor to audit such fees, costs, and revenues, as set
forth in this Agreement. Envision shall also disclose to Plan Sponsor any activity, policy, or
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
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
responsible for the disclosing or reporting of information regarding the Benefit Plan or changes
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.
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
PBM Services to Plan Sponsor, including, without limitation, the exclusive contractor of rebates
with pharmaceutical manufacturers for Plan Sponsor's Claims.
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
withheld. Envision may assign this Agreement to a commonly controlled subsidiary or affiliate
company,or a controlling parent company.
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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 respective
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,
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
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
should waive any breach of any provision of this Agreement, it will not be deemed or construed
as a waiver of any other breach of the same or different provision.
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
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
this Agreement with sixty(60)days prior written notice.
10.10 Headings: The section or paragraph headings contained in this Agreement are for
reference purposes only and shall not affect the meaning or interpretation of this Agreement.
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
in a writing signed by both parties hereto. No term or provision of this Agreement shall establish
a precedent for any term or provision in any other agreement.
10.12 Acceptance of Offer: Notwithstanding anything herein to the contrary, this Agreement
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shall not be binding upon the parties hereto unless and until this Agreement is signed and
executed by a duly authorized officer of each of the parties. The signing of this Agreement by
Plan Sponsor constitutes an offer only until the same has been accepted by Envision.
10.13 Dispute Resolution
10.13.1 Mediation: Prior to the initiation of any action or proceeding permitted by this
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
Envision with full decision-making authority and by Plan Sponsor's designated representative
who would make the presentation of any settlement reached during the negotiations to the Plan
Sponsor's Board of County Commissioners for approval. Failing resolution, and prior to the
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
Court Mediator certified by the State of Florida. The mediation shall be attended by
representatives of Envision with full decision-making authority and by Plan Sponsor's
designated representative who would make the presentation of any settlement reached at
mediation to the Plan Sponsor's Board of County Commissioners for approval. Should either
party fail to submit to mediation as required hereunder, the other party may obtain a court order
requiring mediation under Florida Statutes, section 44.102.
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
rules,except to the extent such laws are preempted by applicable Federal Law. Any suit or action
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,
Florida, which courts have sole and exclusive jurisdiction on all such matters.
10.15 Force Majeure: Neither Envision nor Plan Sponsor will be deemed to have breached this
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
control. Without limiting the generality of the foregoing, such causes include acts of God or the
public enemy, fires, floods, storms, earthquakes, riots, strikes, boycotts, lock-outs, acts of
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
change in the interpretation thereof) subsequent to the execution of this Agreement. The party
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
waiver of any continuing obligations under this Agreement, including, without limitation, the
obligation to make payments.
10.16 Fax Communications: Plan Sponsor agrees that Envision may communicate with Plan
Sponsor via fax, and by doing so, such fax is not a violation of the Telephone Consumer
Protection Act, 47 U.S.C. §227.
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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
by proper notice.
10.18 Representations: Plan Sponsor represents and warrants that(i)it is self-insured; (ii)the
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
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
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
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
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.
[SIGNATURE PAGE FOLLOWS]
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PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT
SIGNATURE PAGE
IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Agreement as of the
Effective Date above.
For ENVISION: For PLAN SPONSOR:
By: By:
B 47 I. Katz,R.Ph.,President Georgia A. Hiller, Chairwoman
Envision Pharmaceutical Services,Inc. Collier County Board of Commissioners
Address: Address:
Envision Pharmaceutical Services, Inc. Collier County Board of Commissioners
2181 East Aurora Road 3299 Tamiami Trail East
Twinsburg,OH 44087 Naples,FL 34112-4901
PH: 330-405-8080 PH:239-252-8906
FX: 330-405-8081 FX:239-252-8048
E-MAIL:AliceToppe @colliergov.net
FEIN: 59-6000558
B 4 A'1TEST:
Thom. r. W- sh Dwight E.Brock, Clerk of Courts
Chief F ancial • cer
Envision ' s aceutical Services,Inc. By:
Deputy Clerk
Approved as to form and legality:
By: S 71/- e,(.,„c_
Scott R. Teach
Deputy County Attorney
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EXHIBIT 1
DRUG PRICING AND FEES
&wu
s>tgnnt @� harma�y
Broad Network
Drug Pricing-and Dispensing Fees(A)
Supply/Source BRAND GENERIC
•
For Contract Year Drug Price(B) Dispensing Drug Price(c) Dispensing
2014 (Annual Average. Fee(D) (Annual Average . Fee(D)
(based on 2 year Effective Rate: (Annual Effective.Rate (Annual
Guarantee) .Average.; .Guarantee) Average
Agreement) Guarantee) ,Guarantee)
Retail Pharmacy AWP minus 15.15% $1.40 AWP minus $1.50
77.50/0
Mail Order Pharmacy
(at Orchard AWP minus 20.50% N/A AWP minus N/A
Pharmaceutical 77.75%
Services)
Specialty Pharmacy(at
Orchard (Pass-Through of Contract Rate with Dispensing Pharmacy)
Pharmaceutical
Services)
Supply/Source BRAND GENERIC
Drug Price(B) Dispensing Drug Price( ) Dispensing
For Contract Year (Annual Average Fee(D) (Annual Average Fee(D)
2015 Effective Rate . (Annual .Effective Rate (Annual
Guarantee) Average Guarantee) Average
Guarantee)` Guarantee)
Retail Pharmacy AWP minus 15.25% $1.40 AWP minus $1.50
77.75%
Mail Order Pharmacy
(at Orchard AWP minus 20.50% N/A AWP minus N/A
Pharmaceutical 78.00%
Services)
Specialty Pharmacy(at
Orchard (Pass-Through of Contract Rate with Dispensing Pharmacy)
Pharmaceutical
Services)
(A)Calculated price using the applicable negotiated contract rate(i.e. AWP or MAC rate, or U&C Price)for
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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
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
(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 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 government required amounts (e.g.
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
Generic Drug Claims (including 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 government required amounts (e.g. Medicaid); (v) 340B Claims; (vi) non-Prescription
Drugs; and(vii)Claims from Plan Sponsor's owned pharmacies,if any.
(n)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,
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.
Annual Average Earned Manufacturer Derived Revenue Guarantee(E).(F)'(G)
For Contract Year 2014:
• 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
For Contract Year 2015:
• 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.
(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.
(6) 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)
For Contract Year 2014: $3.80 Per Employee,Per Month (PEPM)
For Contract Year 2015: $3.90 PEPM
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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
Cards cost of postage
2. Manual Claims Processing(including DMRs) $1.50 per Claim processed
3. Claim Adjustment Checks(charged to Plan
Sponsor for reimbursements made to Covered
Individuals for Claim adjustments requested by
Plan Sponsor.) $8.50 per check
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
6. Clinical Prior Authorizations(Initial Coverage
Determinations) $8.00 per authorization
7. Drug Therapy Care Gap Management $0.55 per Member,per month
8. Medication Adherence and Persistency(up to
three disease states) $0.55 per Member,per month
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EXHIBIT 2
BUSINESS ASSOCIATE AGREEMENT
This BUSINESS ASSOCIATE AGREEMENT (the "Agreement") is effective the 18r day of
January, 2014 (the "Effective Date"), by and between Envision Pharmaceutical Services, Inc.
("Business Associate") and Collier County Government ("Plan Sponsor"), each referred to
individually herein as a"Party"or collectively as the"Parties".
RECITALS
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.
B. In order for Business Associate to provide services to Plan Sponsor, Plan Sponsor may
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
Business Associate will create, receive, maintain or transmit PHI on behalf of Plan
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
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)
of the HITECH Act.
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:
Article 1: Definitions
For the purposes of this Agreement, the following defined terms shall have the following
definitions. Except as otherwise stated herein, the defined terms used in this Agreement shall
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
permitted under Subpart E of 45 C.F.R. Part 164, which compromises the security or
privacy of the PHI.
"Breach"excludes:
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(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
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
Associate to another person authorized to access PHI at Business Associate, and the
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.
(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 to
retain the information.
1.2 "Designated Record Set"shall have the meaning prescribed to it in 45 C.F.R. § 164.501.
1.3 "HHS"shall mean the U. S. Department of Health and Human Services.
1.4 "HIPAA Standards" shall mean the standards for privacy and security of Individually
Identifiable Health Information found at 45 C.F.R. Parts 160 and 164.
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).
1.6 "Individually Identifiable Health Information" shall have the meaning prescribed to it in
45 C.F.R. § 160.103.
1.7 "Protected Health Information" shall have the meaning prescribed to it in 45 C.F.R. §
160.103, limited to Individually Identifiable Health Information transmitted or
maintained in any form or medium that Business Associate creates or receives from or on
behalf of Plan Sponsor.
1.8 "Required by Law" shall have the same meaning as the term "required by law" in 45
C.F.R. § 164.103.
1.9 "Secretary"shall mean the Secretary of HHS or his or her designee.
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.
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
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
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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 Plan
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
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
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
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
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 that
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
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.
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
PHI in a manner that is consistent with the HIPAA Standards.
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
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
accordance with 42 U.S.C. § 17935(b).
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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
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
provisions apply to Plan Sponsor, and implement administrative, physical, and technical
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
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
third parties, agents, or subcontractors create, receive, maintain, or transmit PHI on
behalf of Business Associate,Business Associate shall require such third parties or agents
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
reasonable and appropriate administrative, technical and physical safeguards to protect
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,
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,
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
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.
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
during the Breach.
At the time of notification or soon thereafter as information becomes available, Business
Associate shall provide the following information to Plan Sponsor:
(a) A brief description of what occurred, including the date of the Breach and the date
of discovery of the Breach,if known;
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(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;
(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
information, including a toll-free telephone number, an e-mail address, website or
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
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.
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
consists of a Designated Record Set in order for Plan Sponsor to comply with 45 C.F.R. §
164.524.
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
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.
3.13 Accounting of Disclosures. Business Associate agrees to document disclosures of PHI,
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
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
Associate shall comply with the requirements of Subpart E that apply to Plan Sponsor in
the performance of such obligations.
3.15 Availability of Books and Records. For purposes of determining compliance of Plan
Sponsor with the HIPAA Standards, Business Associate agrees to make available to the
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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
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) Retain only that PHI which is necessary for Business Associate to continue its
proper management and administration or to carry out its legal responsibilities;
(b) Return to Plan Sponsor or, if agreed to by Plan Sponsor, destroy the PHI that is
not retained by the Business Associate under(a)above;
(c) Continue to use appropriate safeguards and comply with Subpart C of 45 CFR
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;
(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
(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 its
proper management and administration or to carry out its legal responsibilities.
Article 4:Duties of Plan Sponsor
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
disclosure of PHI.
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
extent that such changes may affect Business Associate's use or disclosure of PHI.
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
affect Business Associate's use or disclosure of PHI.
Article 5: Term and Termination
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 � o
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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.
5.2 Termination for Cause. Business Associate authorizes termination of this Agreement by
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
termination of this Agreement, Business Associate will no longer be authorized to create,
receive,or transmit PHI on behalf of Plan Sponsor, except as otherwise provided herein.
5.3 Survival of Certain Rights and Obligations. The respective rights and obligations of
Business Associate under Section 3.16 of this Agreement shall survive the termination of
this Agreement.
Article 6: Miscellaneous
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
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.
6.4 Interpretation. Any ambiguity in this Agreement shall be interpreted to permit
compliance with the HIPAA Standards.
6.5 HIPAA. Business Associate will comply with all requirements under HIPAA that apply
to business associates.
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 r S A'SOCIATE:
By: By: : ,AI,
6:-O• L,
Print Name and Title Print Name and Title
(.1)
\BAA-Plan Sponsor[Rev.08-08-2013]
31
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EXHIBIT 3
PERFORMANCE GUARANTEES
rl eexis V r�s§ r
L t �� �.��°'7 t: °Z,/,'9- 4-r as "-4T # ' P I /F w: F
'
tar: �n.Vi:...."E�3� ..
100%of MDR received from
pharmaceutical
Manufacturer Derived o manufacturers is passed
Revenue(MDR) Pass-through $10,000.00
100%
through to PIan Sponsor,in
accordance with the
Agreement.
100%of network discounts
and dispensing fees are
Network Discounts 100% passed through to Plan
Network Dispensing Fees 100%Pass-through $10,000.00
Sponsor upon the effective
date of any negotiated
change.
r
s ."rs e � ` vs uxu'-
Calculated as the amount of
System Availability 99.5% time the Claims Adjudication $10,000.00
System is available to
process Claims.
Calculated as the time
commencing immediately
after receipt of the last
System Response time <4 seconds character of a transaction
submitted by a pharmacy $10,000.00
until the first character of the
response is sent to the
pharmacy.
Should adjudication of a
Claim be delayed due to a
malfunction of Envision's
Adjudication Delay One(1)business day System,Envision shall $2 500.00 per occurrence
correct the malfunction and '
inform the affected Covered
Individual within one(1)
day.
. E .f 1�atttts rotes c
'�.° x>�� k "..,14 qq
.. t d. .. aa x
Based on PBM's internal
quality review. Calculated as
Percent of all claims paid >99.98%Retail all claims audited and found
with no errors >99.98%Mail to be without error of any $10,000.00
form,divided by all claims
audited.
da. 9S # .gip es a�w' ire : ��s. h 7� '" ^' •?' .�. '' p..�.,, "+ 4u,a ss a gi
d
U
1BAA-Plan Sponsor[Rev.08-08-2013] 32
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i �r ".--°tg' ki d Er,..rc:� s" �' -:.i .",•, +r°S'
t ..6. e. k N
a •.-s g� xr 3!'s . '+a 4.4
.._ _ ...w...„'s.`..a t'.,a �.p..aa,�. ,. �r....�. .� � -
The amount of time that
elapses between when a call
is received into the customer
service queue and the time
Percent of calls that will be 95%answered in an average the phone is answered by a
answered within 30 seconds of 30 seconds or less Customer Service $10,000.00
Representative(CSR).
Measurement and target
determination will be based
on an annual average.
Percentage of calls that are
not answered by a CSR
(caller hangs up before call is
answered). Calculated as the
number of calls that are not
Percent of calls abandoned <5% answered divided by the $10,000.00
number of calls received.
Measurement and target
determination will be based
on an annual average.
#z'.�k r;77 e t` r�; C� x;:n'r ° w v
Yat. '°° +zz a,s 'Ptp �"' a :`-"`" °`... ,. -r
9..a,....h �!saa' �".v.,.,, � o .-.4'�. 'am.�...._...—..m'C"?.'r. ._
Percentage of all calls made
to Envision that were
resolved by initial CSR.
Percent of calls with Calculated as the total calls
resolution at end of first call to Envision minus total
(i.e.no further inquiry by >90% number of unresolved calls
caller required to obtain divided by the total number $10,000.00
requested information or of calls received.
action)
Measurement and target
determination will be based
on an annual average.
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
responded to electronically subtracting the date received
within 2 business days at Envision from the date the
response was sent.
Based on network pharmacy
Pharmacy Network Access >95% access within, 10 miles for $10,000.00
Plan Sponsor's Covered
Individuals.
.4v '1,11,,""AC'
?M# . e111 N+ ae ° ', ij
..�£�' }� —�+
Account Management Initial client inquiries will be
Responsiveness Two(2)business days acknowledged and responded $10,000.00
to within two business days.
1BAA-Plan Sponsor[Rev.08-08-2013] 33
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9/24/2013 11 .G.'
f » i�F :Vi°i`` K C :,477;r ..„ ,z �" , a� i s3?. ,- *'�¢',x'p `'of.,k A'* , ;e:ar_x
�1.—''''''-g:: ,, 3. ,y, r - ,fit r ,, N irk a� Aid
MI w� a,. .L .�o _ �xv .v.,�, a_...:. �..�' �'= _w.a_.....,«3r"���'9t. ,ai.,.,m: _.� „.,'Y' .:'�b..,.'. °_.,�R' .'' .�.,
Eligibility information
submitted to Envision will
become effective within 2
Enrollment Processing Two(2)business days business days following the $10,000.00
date of receipt. Assumes
complete and accurate
information is sent to
Envision.
Sp' 4414....Yt ,pq {T'i:-r ,',,,,P,,,,-,75';;;-,,,,' .y`,-45,."' l''''.....1,; - '1P,-�i , o. @ - r
,w ° t`�.2 ._ fa ':a.. .�b a' (, a,‘...=6;e R_ �,#r#�ava !,0 . t, z.....=,
Program Implementation December 20th,2013 Date of implementation $10,000.00
Distribution of ID Cards y December 20th,2013 Date of distribution $10,000.00
i t'e 4 �'si' tr .;Y.�t W.1t...m ..m y 1. xi :'�P `��p s `!%P ,•cks, ":
...a° r.;�..,. ✓ tr.:sa�"tY.rYn,.: ,z .s.�.,.. �;*'bf ?" =. e- .°' :.�_e F qk ..s rp._ 1.,,. ,x 7ae._ a . 4'i4 fF .r.7 *' '
Acceptable monthly claims By the 15"' of the close of
data extracts provided to each month for prior month
Verisk and other firms that as agreed upon in the final $10,000.00
the School Board may
designate contract
_ 4 P' r . ��:� .mod �a� �Ma �"
.._.«.w=.:: x P _ F5�:. .r..,,. _.. s.. ».Wn r�s�.a� .-w...,.�`s. .�sr rYt m:�;�,;N
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
(Avg Brand Plan Paid
Amount-Avg Generic Plan
Paid Amount)
.+. Y . --.� � . `fix , " " r 5, /aam ,, -.gyp_ d Cg F»^ .0 str & r C" 4 0-- !R'±'7 J 'd G N . d ,y .� k a .
Quarterly and annual reports
will be delivered,in hard
Quarterly and year end copy,to CCHCC within 30 $10,000.00
reports delivery time frame business days of the close of
the quarter and contract year,
respectively.
4'-- aO 4 We3.ada h8' ey_g -a-¢ r .»pw x 3— "�x'N '3 i,.'5.«« ' - ! t.: - r,-;*47.0...Tr.
».x ...., .-x{ 1 .7' '
More than 95%reqof uirinall g no
intervention will b
processed
prescriptions within t we
(2)
Turnaround Time business days. $10,000.00
More than 98%of
prescriptions requiring
administrative or clinical
intervention will process
(71
\BAA-Plan Sponsor[Rev.08-08-2013] 34
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*rs t' ". r=• +'' a'._s-:_d,�a. t,� +r s a ��y e a« %'• �w ij s-S'
'd 'a'iauPae a �caar- rr?i--e. 4._, c*.,„ ,ew+;c,ae�,�a�:1Fffis .sn+":`'"'F '>k ,HY ; &d� ,�+� � 5 �mYr!�`trt:7+a,:
within five(5)business days.
Turnaround time will be
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.
, 4, 41,11lj4 „ r ' a `"'±' �., ,„mss- c:�i KT�.��
k �� 7 M f13 ib 411x 6y�k 4 �".2 pk. "4 O.,4b� i.2 vy o
Envision shall accept,
process,and adjudicate DMR
Claims within ten(10)
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
Sponsor provides funds for
such purpose.
a4 k t� R �..r.e*Rr.�z- *��;& i&&aLX'TI`.. e-
a � g ��`,�.ss ,r E 1 b* 14 , -� �' g4
., P4i ....-. �...sow.i...W.v...,...a«,.
Claims for compound drug
Claims from participating
compounding pharmacies
that are delayed due to an act
Turnaround Time Ten(10)business days or or omission of Envision shall $2,500.00 per occurrence
earlier be electronically adjudicated
at the compounding
pharmacy within ten(10)
business days,or processed
as a DMR as set forth herein.
(M `�'"` 7 '.-�m }mow' CSC �xu sr e'er r 'y »t. g:........ E,, }..
... ' _ . �' as ..U< a as v .. '..;.e u'ux � �4'•'•F'�t .Y �R t �'
If a Covered Individual does
not receive a Specialty Drug
that was previously shipped
by the Specialty Pharmacy
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
authorization from Plan
Sponsor.
*Exclusions from GDR calculation include products such as OTC's, Vaccines,Compounds,Specialty drugs,DAW's(0,3,4,5,6,9)
and branded generics for purposes of marketing,
\BAA-Plan Sponsor[Rev.08-08-2013] 35
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Packet Page-715-
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RFP#156-6/13 Pharmacy Benefits Management Services/CCHCC
BACKGROUND
The Collier County Health Care Consortium (CCHCC) is comprised of the following major Collier County
employers:
• Collier County Government(CCG)
• Collier County Sheriffs Department(CCSO)
• District School Board of Collier County(DSBCC)
• NCH Healthcare System, Inc. (NCH)
This group is committed to better understand the factors that drive health care costs and partner with
local providers to develop collaborative efforts to address those factors.Through this partnership, the
CCHCC employers wish to foster the creation of a process and strategy to ensure efficient delivery of
health care that is appropriate, provides optimal patient outcomes, and supports prudent expenditures of
financial resources.The CCHCC employers have approximately 11,100 employees covered under
various medical plan options that include pharmacy benefits. When spouses and children are included
with employees,the total number of covered lives is in excess of 22,100.
Provider network access, population management support, utilization review, case and disease
management processes are provided through a partnership agreement with Community Health Partners
(CHP).
Since 2002, members of the CCHCC have collectively utilized the services of Express Scripts to manage
their pharmacy benefit programs. By using a single pharmacy benefit manager(PBM), the CCHCC
employers achieve the following goals:
• Minimize administrative costs;
• Maximize rebates in a thoughtful way recognizing that bigger rebates are not necessarily in
the best interest of plan sponsors as large rebates stem from the use of more expensive
medications;
• Utilize a consistent formulary;
• Create consistent administrative processes and functions;
• Utilize consistent cost management processes (i.e. step therapy, generic substitution,
therapeutic MAC's concurrent drug utilization management, etc.);
• Provide access to online interactive detailed reporting functions for Willis, CHP and other
parties that may be designated;
• Provide access to prior authorization approval processes to CHP, members of the CCHCC
and other parties as may be designated in the future;
• Allow regular electronic exchanges of eligibility information between the CCHCC members,
their third party administrators and Community Health Partners;
• Partner with the CCHCC employers, CHP and Willis in the creation of innovative, custom
processes designed to slow the upward trend in pharmacy costs; and
Packet Page-716-
9/24/2013 11 .G.
• Conduct educational programs for local physicians concerning pharmacy cost issues and
special programs designed to improve the financial efficiency of the CCHCC employer'
pharmacy programs.
Of interest to the CCHCC employers and its provider partners are quality service, administrative flexibility,
real time reporting, good relationships with pharmacies, administrative efficiency and transparency.
Approximately every three years, the CCHCC conducts a comprehensive marketing process to ensure
that the incumbent vendors'financial terms and service are competitive. Upon completion of the
marketing process in 2011,the CCG, DSBCC and NCH entered into a three year agreement with ESI to
continue to provide services. At this time, the CCSO selected EnvisionRX.
Due to ongoing service issues, the CCG, DSBCC and NCH have decided to investigate other PBM
arrangements. The CCSO will remain with EnvisionRX.
As a result, further references in this Request For Proposal document to the CCHCC
refer to individually and collectively to the Collier County Government (CCG), District
School Board of Collier County (DSBCC) and NCH Healthcare System. Inc. (NCH) only.
since the Collier County Sheriff's Office (CCSO) is not participating in this process.
..ter.,
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RFP#156-6/13, Pharmacy Benefits Management Services
1.0 PURPOSE
The purpose of this Request for Proposal (RFP) is to solicit competitive sealed proposals for
Pharmacy Benefits Management Services for the use of Collier County Health Care Consortium
(CCHCC).
The Sheriff's Office has been very happy with the services that they are receiving so they will
not be participating in this RFP process.
The remaining CCHCC employers are seeking terms from Pharmacy Benefit Managers (PBMs) to
administer their existing pharmacy programs. They also wish to explore the potential use of Group
Purchasing (GPO)pricing alternatives.
The medical program is not to be included as part of this RFP.
EMPLOYER BACKGROUND:
Name and Address of Headquarters:
Collier County Government
3311 Tamiami Trail East
Naples FL 34112-4901
District School Board of Collier County
5775 Osceola Trail
Naples FL 34109
NCH Healthcare System, Inc.
350 7th Street
Naples FL 34012
Nature of Business: Healthcare, Municipal Government and Education
Carrier/Administrator History: The retail prescription drug program has been administered by
Express Scripts (ESI)for the last 10 years.
2.0 SCOPE OF SERVICES
Over the last several years the pharmacy benefits landscape has changed. The industry is
consolidating while at the same time new PBMs are entering the market place. Of principal concern
to CCHCC is:
• the AWP lawsuit exposed issues concerning base pricing upon which discounts are applied,
• the increased focus on the way that PBM discounts are measured and guaranteed,
• factors impacting larger rebates,
• the fact that large retailers are now selling select generic drugs for a flat cost of$2.00 or $4.00
per script,
• the pros and cons of greater transparency pass through of 100% of rebates versus traditional
pricing approaches where rebates are guaranteed, and
• analysis of the potential benefits of accessing GPO or own use pricing via mail order or a limited
retail network.
Of continued interest to CCHCC is the movement toward greater"transparency" and the ability to:
REVISED 2-22-13 KR Page 3 of 48
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RFP#156-6/13, Pharmacy Benefits Management Services
• gain a full understanding of contract terms and how they affect quoted discounts,
• assess how performance guarantees are developed/measured,
• obtain more transparent disclosure of reimbursement rates,
• understand how rebates are negotiated, and
• understand how rebates and other manufacturer incentives are passed or not passed back to
clients.
Further, as more medications become available through multiple sources and as patents expire,
there are tremendous opportunities to manage costs within a class as well as the potential to
increase plan costs short term as more block-buster drugs become available as generics. The same
can be said for generic medications within the same therapeutic class.
Given the evolving landscape, CCHCC is interested in assessing the prospective PBM's ability to
work in collaboration with CCHCC as an employer group, its employees and CHP to deliver cost
effective pharmacy programs and financing.
Interested firms shall address the following key objectives in their response:
• Minimize administrative costs and thoughtfully maximize rebates (recognizing that larger
rebates are a result of more expensive medications that may not provide superior outcomes).
CCHCC is seeking the full pass through of rebates with a guaranteed minimum rebate as well
as full pass through pricing as an option. Quoted rebate guarantees should be based on all
drugs not just those for which rebates are obtained;
• Bend or eliminate trend in future years by striving for the lowest ultimate cost by delivering a
transparent innovative program that optimizes both the cost savings and clinical outcomes to
CCHCC as well as its covered employees and dependents;
• Address the cost spiral in specialty medications from a use and unit cost perspective;
• Deliver a stable formulary which carefully balances rebates and lowest net cost and is updated
as appropriate with sufficient notice of changes to CCHCC, employees, and employed and
affiliated providers;
• Explore accessing GPO pricing via mail order or a limited retail network or both;
• Provide monthly claims extracts as required by CCHCC's Benefits Consultant (currently
WillisMed Verisk data reporting system) if needed and ensure a fully integrated data reporting
system that is compatible with the systems and process utilized by CCHCC, their TPA, CHP
and Benefits Consultant (currently Willis), to enhance understanding of claims utilization and
disease management;
• Demonstrate the ability to provide at least the current level of cost management processes (i.e.
ability to administer a therapeutic MAC for PPIs, step therapy, generic substitution, concurrent
drug utilization management, over the counter(OTC) programs, etc.);
• Provide a structured program to assist CCHCC and CHP in addressing potential abuse or
diversion of narcotic medications such as oxycodone;
• Demonstrate the ability to implement new innovative programs to address opportunities that are
uncovered through the ongoing analysis of both medical and pharmacy claims (for example, the
ability to administer a therapeutic MAC for specific classes of medications such as proton pump
inhibitors (PPIs)and non-sedating antihistamines);
• Provide quarterly reporting regarding key cost drivers, effectiveness of cost management
programs and overall financial performance. Firms must also be willing to make changes in
these reports to address the needs of CCHCC on an ongoing basis;
REVISED 2-22-13 KR Page 4 of 48
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RFP#156-6/13, Pharmacy Benefits Management Services
• Provide specific communication support to reinforce current programs as well as new ones that
may be implemented in the future;
• Provide a seamless retail and mail order process that is user friendly to both employees and
physicians. Please note that CCHCC has evaluated and will not pursue a mandatory mail
order platform. They would like to explore the use of GPO pricing for selection
medications,where a separate class of trade makes economic sense for the CCHCC.
• Provide a robust quarterly reporting process that assesses the cost performance of the plan,
offers insights concerning principal cost drivers,suggestions to address and mitigate those cost
drivers as well as compare the performance of the CCHCC plans to your book of business and
other public entity employers;
• Work with the selected Third Party claims administrator(s)and other entities that may be
involved with the administration of the health plan to provide daily electronic exchanges of
eligibility information and claims on a regular basis (weekly exchanges).
To meet its key requirements, CCHCC is seeking a two-year agreement with the selected vendor
effective January 1, 2014. Terms should include the option to renew for two additional one year
terms (see page 6 under award term). The main financial and strategic objectives to be attained
are;
• Manage Specialty spend and trends;
• Employees and their dependents should perceive administration as better than the current
program;
• The trend in prescription drug costs should decrease;
• Work and provide guidance to CCHCC and its consultants to minimize plan cost and optimize
plan member access to GPO pricing to select medications;
• Build and expand the collaborative approach to working in partnership with all stakeholders to
better manage pharmacy costs while improving patient outcome;
• Work to develop methods to control costs as drugs become available generically or over-the-
counter and others remain on patent and be willing to stand up to the drug manufactures and
resist the"siren" call of larger rebates;
• Demonstrate processes to identify either individuals or pharmacies that are abusing the
program;
• Work closely with CHP to coordinate delivery of special programs, access to the PBMs system
for overrides on clinical programs and educate local providers.
• Provide access to detailed information to integrate pharmacy data with medical claims data,
and
• Be willing to work with participants and physicians to encourage acceptance of and compliance
with cost management processes.
The successful firm must agree to allow CCHCC or its designee the right to audit the financial and
non-financial records of the prescription drug administrator and its agents as they relate to the
administration of their programs whenever deemed appropriate. Such audits may be performed by
CCHCC personnel or selected outside auditors.
CLAIMS RECORD RETENTION/TRANSFER
The claims administrator will be required to maintain all pertinent claim records for seven (7) years
from the date of each claim payment.
REVISED 2-22-13 KR Page 5 of 48
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RFP#156-6/13, Pharmacy Benefits Management Services
In the event of termination, the prescription drug administrator must agree to transfer to CCHCC (or
another party as designated by CCHCC) within thirty (30) days notification, all required data and
records necessary to administer the plans. This data would include, but not be limited to, the
following:
• List of covered employees and dependents,
• Preauthorization information for specific medicines,
• Records or hard copy of claims transaction data as designated by CCHCC,
• Current mail order prescriptions.
No fees may be charged to provide data less than two(2)years old.
Upon selection of a new vendor, it is expected that contracts, necessary administrative forms,
administrative manual, employee communications, prior authorization transfer data and other
materials will be prepared as quickly as reasonably possible. The chosen administrator will be
expected to bear the cost of installation of appropriate administrative systems, contract preparation,
billing, network enhancements, related administrative manuals, enrollment forms and
communication with employees and providers in a timely manner.
WILLIS REMUNERATION AND REMUNERATION TO OTHER PARTIES
To ensure a level playing field for all prospective vendors, all proposals should be quoted NET of
commissions or fees payable to Willis or any other third party. In addition, if so directed by
the CCHCC, collect and remit commissions to any party that they might individually
designate. Any such commissions would be added to your quoted fees. Further, if in your
agreement with other parties or PBMs require you to pay fees or commissions to parties other than
Willis, those amounts must be disclosed as a separate line item and clearly stated as such in your
response. Please delete all commissions or payments from your quoted core administrative fees
and note them as a separate line item.
VERISK DATA REQUIREMENTS
Through a master agreement with Willis, CCHCC will have access to a medical and pharmacy claim
data aggregator known as Verisk. This is an Internet-based data analysis tool that enables CCHCC
and Willis to identify potential high-cost claims and areas of high utilization through the use of data-
driven, fact-based research, and develop targeted intervention programs.
The system consolidates claim information at the diagnosis and procedure code levels and delivers
a series of online interactive reports via a secure web application. Vendors must agree to provide
data at their expense on a monthly basis in the format provided (see Attachment Q for format).
3.0 SPECIAL TERMS & CONDITIONS
3.01 AWARD TERM
CCHCC's goal is to promote partnership relationships within the policies and procedures of public
procurement. Pursuant toward that end, the successful vendor(s) shall be awarded a contract for an
initial two (2)year term with up to two (2)additional one (1)year renewal periods.
The award term recommendation will be that which is determined to be in the best interest of
CCHCC. The renewal option shall be exercised only if all original contract terms, conditions and
prices remain the same. All renewals will be contingent upon mutual written agreement and, when
applicable, approval of CCHCC.
REVISED 2-22-13 KR Page 6 of 48
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RFP#156-6/13, Pharmacy Benefits Management Services
3.02 RFP CLOSING DATE
Proposals must be received by no later than 2:00 p.m., local time, on 7/23/13. Proposals received
after this time will not be considered
3.03 DELIVERY OF PROPOSALS
All proposals shall be sealed and delivered or mailed to (faxes/e-mails will not be accepted):
District School Board of Collier County
Purchasing Department
5775 Osceola Trail
Naples, FL 34109
Mark package(s) "RFP#156-6/13 Pharmacy Benefits Management Services/CCHCC"
An electronic copy should also be emailed to John Pauly at Willis: john.pauly @willis.com
3.04 PUBLIC RFP OPENING
A. Only the names of the firms submitting proposals will be read aloud at the RFP opening. The
proposals will be available for inspection during normal business hours in the Office of
Purchasing until such time as the agency provides notice of a decision or intended decision
or 30 days after proposal opening date; whichever is earlier, by appointment.
B. A complete recap of proposals will be available after the committee makes a
recommendation. A copy of the completed proposal recap will be available at
www.Demandstar.com within ten (10)days of the committees' recommendation.
C. Individuals covered by the Americans with Disabilities Act of 1990 in need of
accommodations to attend public RFP openings or meetings should contact the District
School Board of Collier County's Office of Purchasing at least five (5) days prior to the RFP
opening date.
3.05 PROPOSAL FORM
A. See Submittal Requirements for complete details.
**It is not necessary to return every page of this document with the Proposal; return
only the pages that require signatures or information.
B. Each respondent shall submit nine (9)complete sets of the Proposal Submittals:
• One (1) hard copy marked "ORIGINAL"with fee structures in a sealed envelope
• Eight(8) hard copies marked "COPY"
• Two (2) COMPLETE electronic copies on CD's, in PDF format (Excel
spreadsheets shall not be recorded in PDF). Note solicitation number and name
of company on the disk.
If a Non-disclosure Agreement is signed and confidential materials are submitted,
such confidential materials shall not be included on the master CD. Confidential
materials shall be segregated on a separate CD, plainly labeled "Confidential
Materials."
C. Terms and conditions differing from those in this RFP may be cause for disqualification of
the proposal.
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3.06 QUESTIONS CONCERNING RFP
A. Questions concerning any portion of this RFP shall be directed in writing or by e-mail to the
Buyer named herein, who shall be the official point of contact for this RFP. Questions should
be submitted at least seven (7) days before the closing date.
B. Mark cover page or envelope(s) "Questions on RFP, Pharmacy Benefits Management
Services"
Submit questions to:
Nancy Sirko, Director of Purchasing
Telephone: 239-377-0047
Fax: 239-377-0074
E-mail: sirkona(a?collierschools.com
Responses will be provided in an addendum and posted on www.Demandstar.com.
3.07 CLARIFICATION AND ADDENDA
A. It is incumbent upon each respondent to carefully examine all specifications, terms, and
conditions contained herein. Any inquiries, suggestions, or requests concerning
interpretation, clarification or additional information shall be made in writing, (facsimile
transmissions acceptable, 239-377-0074 through the Buyer named herein. The CCG,
DSBCC and NCH (CCHCC) will not be responsible for any oral representation(s) given by
any employee, representative or others. The issuance of a written addendum is the only
official method by which interpretation, clarification or additional information can be given.
B. If it becomes necessary to revise or amend any part of this RFP, notice may be obtained by
accessing our web site. Respondents in their proposal must acknowledge receipt of
amendments. Each respondent should ensure that they have received all addenda and
amendments to this RFP before submitting their proposal. Please check the web site
at http://www.Demandstar.com for any addenda. CCHCC will not mail/fax/email addenda
to prospective respondents.
3.08 AWARD
CCHCC reserves the right to award the contract to the respondent(s)that CCHCC deems to offer the
best overall proposal(s). CCHCC is therefore not bound to accept a proposal on the basis of lowest
price. In addition, CCHCC at its sole discretion, reserves the right to cancel this RFP, to reject any
and all proposals, to waive any and all informalities and/or irregularities, or to re-advertise with either
the identical or revised specifications, if it is deemed to be in the best interest of CCHCC to do so.
CCHCC also reserves the right to make multiple awards, based on experience and qualifications if it
is deemed to be in CCHCC's best interest. CCHCC reserves the right to further negotiate any
proposal, including price, with the highest rated respondent. If an agreement cannot be reached with
the highest rated respondent, CCHCC reserves the right to negotiate and recommend award to the
next highest respondent or subsequent respondents until an agreement is reached. Further, each
member can make its independent decision to contract or not contract with the proposer.
3.09 ASSIGNMENT
The Respondent shall not sell, assign or transfer any of its rights, duties or obligations under the
Contract, or under any purchase order issued pursuant to the Contract, without the prior written
consent of CCHCC. In the event of any assignment, the Respondent remains secondarily liable for
the performance of the Contract, unless CCHCC expressly waives such secondary liability. CCHCC
may assign the Contract with prior written notice to Respondent of its intent to do so. For the purpose
of this Contract, "assignment" means any voluntary, involuntary, direct or indirect assignment, sale,
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or other transfer by Respondent or its owner(s), of any interest in this Agreement, more than ten
percent (10%) of the ownership interest in Respondent, or one of a series of transfers that in the
aggregate constitute the transfer of more than ten percent (10%) of the ownership interest in
Respondent. The term includes, without limitation: (1) transfer of ownership of capital stock or any
partnership interest; (2) merger, consolidation, or issuance of additional securities representing more
than ten percent (10%) of the ownership interest in Respondent; (3) sale of common stock of
Respondent pursuant to a private placement or registered public offering, which transfers more than
ten percent(10%)of the ownership interest in Respondent; (4)transfer of any interest in Respondent
in a divorce proceeding or otherwise by operation of law; or (5) transfer of more than ten percent
(10%) of the ownership interest in Respondent in the event of the death of an owner, by will,
declaration of or transfer in trust, or under the laws of intestate succession.
3.10 DISCLOSURE OF PROPOSAL CONTENT
A. All material submitted becomes the property of the CCHCC and may be returned only at the
CCHCC's option. The CCHCC has the right to use any or all ideas presented in any reply to
this Bid. Selection or rejection of any Bid Submittal does not affect this right.
B. The DSBCC and the CCG are governed by the Public Record Law.
RETURN THIS FORM ONLY IF CONFIDENTIAL MATERIALS ARE BEING INCLUDED IN
THE SUBMITTAL. PLEASE READ THE SECTION IN THE RFP DOCUMENT TO
DETERMINE IF THIS APPLIES. THE CONFIDENTIAL MATERIALS WILL ONLY BE
HANDED OUT TO THE SELECTION COMMITTEE ON THE DAY OF THE EVALUATION,
THEREFORE, THE EVALUATION OF THIS MATERIAL WILL BE LIMITED TO THAT
TIME ONLY.
3.11 RESPONDENT'S RESPONSIBILITY
A respondent, by submitting a proposal, represents that:
A. The respondent understands the RFP in its entirety and that the proposal is made in
accordance therewith, and;
B. The respondent possesses the capabilities, resources, and personnel necessary to provide
efficient and successful service to the CCHCC, and;
C. Before submitting a proposal, each respondent shall make all investigations and
examinations necessary to ascertain site and/or local conditions and requirements affecting
the full performance of the contract and to verify any representations made by the CCHCC,
upon which the respondent will rely. If the respondent receives an award because of its
proposal submission, failure to have made such investigations and examinations will in no
way relieve the respondent from its obligations to comply in every detail with all provisions
and requirements of the contract, nor will a plea of ignorance of such conditions and
requirements be accepted as a basis for any claim by the respondent for additional
compensation or relief,and;
D. The respondent will be held responsible for any and all discrepancies, errors, etc. in
discounts or rebates which are discovered during the contract term or up to and including
five (5)fiscal years following the CCHCC annual audit, including five (5)years thereafter.
3.12 CONFLICT OF INTEREST FORM
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All respondents shall complete and have notarized the attached disclosure form of any potential
conflict of interest that the respondent may have due to ownership, other clients, contracts, or
interest associated with this project.
3.13 MINOR IRREGULARITIES
CCHCC reserves the right to waive minor irregularities in proposals, providing such action is in the
best interest of CCHCC. Minor irregularities are defined as those that have no adverse effect on
CCHCC's best interests, and will not affect the outcome of the selection process by giving the
respondent an advantage or benefit not enjoyed by other respondents.
3.14 INSURANCE REQUIREMENTS
The Contractor will provide before commencement of work, and attach to this agreement, a
certificate(s) evidencing such insurance coverage to the extent listed in 1 to 5 below. CCHCC
reserves the right to be named as an additional insured or to reject such coverage and terminate this
agreement if coverage is determined to be inadequate or insufficient. The Contractor will carry and
maintain as a minimum the following coverage from insurance carriers that maintain a rating of"A" or
better and a financial size category of "VII" or higher according to the A. M. Best Company. Such
certificates must contain a provision for notification to the Board thirty (30) days in advance of any
material change in coverage or cancellation. This is applicable for the procurement and delivery of
products, goods, or services furnished to or for the CCHCC and the District School Board of Collier
County and any of its ancillary schools, departments or organizations.
1. General Liability Insurance:
Negligence including Bodily Injury: Per Claim $1,000,000
Including Bodily Injury: Per Occurrence $2,000,000
Property Damage: Each Accident $1,000,000
2. Product Liability or Completed Operations Insurance:
Negligence Including Bodily Injury: Per Claim $ 500,000
Negligence Including Bodily Injury: Per Occurrence $1,000,000
3. Automobile Liability:
Negligence Including Bodily Injury: Per Claim $ 500,000
Negligence Including Bodily Injury: Per Occurrence $1,000,000
Property Damage: Each Occurrence $ 500,000
4. Workers' Compensation/Employer's Liability:
W.C. Limit Required Statutory Limits
E.L. Each Accident $1,000,000
E.L. Disease—Each Employee $1,000,000
E.L. Disease—Policy Limit $1,000,000
Workers' Compensation Exemption forms will not be accepted. All entities or individuals are
required to purchase a Workers' Compensation insurance policy.
5. Professional Liability Insurance(E&O, D&O etc.):
For services, goods or projects that will exceed $1,000,000 in values over a year.
Each Claim: $3,000,000
Per Occurrence: $3,000,000
For services, goods or projects that will not exceed $1,000,000 in values over a year.
Each Claim: $ 250,000
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Per Occurrence: $ 500,000
6. Network Security and Privacy coverage
Each Claim: $5,000,000
Per Occurrence: $5,000,000
The respondent shall either cover any subcontractors on its policy or require the subcontractor to
obtain coverage to meet these requirements and file appropriate forms with CCHCC.
3.15 DEVIATIONS
All proposals must clearly and with specific detail, note all deviations to the exact requirements
imposed upon the respondent by the Specifications. Such deviations must be stated upon the
Proposal Form otherwise CCHCC will consider the subject proposals as being made in strict
compliance with said Specifications to respondents;the respondent being held therefore accountable
and responsible. Respondents are hereby advised that CCHCC will only consider proposals that
meet the exact requirements imposed by the Specifications; except, however, said proposals may
not be subject to such rejection where, at the sole discretion of CCHCC, the stated deviation is
considered to be equal or better than the imposed requirement and where said deviation does not
destroy the competitive character of the RFP process by affecting the amount of the proposal such
that an advantage or benefit is gained to the detriment of the other respondents.
3.16 WAIVER OF CLAIMS
Once this contract expires, or final payment has been requested and made, the awarded respondent
shall have no more than thirty (30) calendar days to present or file any claims against CCHCC
concerning this contract. After that period, CCHCC will consider the respondent to have waived any
right to claims against CCHCC concerning this agreement.
3.17 TERMINATION/CANCELLATION OF CONTRACT
CCHCC reserves the right to cancel the contract without cause with a minimum thirty (30) days
written notice.
Termination or cancellation of the contract will not relieve the respondent of any obligations for any
deliverables entered into prior to the termination of the contract(i.e., reports, statements of accounts,
etc., required and not received).
Termination or cancellation of the contract will not relieve the respondent of any obligations or
liabilities resulting from any acts committed by the respondent prior to the termination of the contract.
The Respondent may cancel the resulting contract with one hundred twenty (120) days written
notice to the Director of Purchasing. Failure to provide proper notice to CCHCC may result in the
respondent being barred from future business with CCHCC.
3.18 TERMINATION FOR DEFAULT
CCHCC's Contract Administrator shall notify, in writing, the respondent of deficiencies or default in
the performance of its duties under the Contract. Three separate documented instances of
deficiency or failure to perform in accordance with the specifications contained herein shall constitute
cause for termination for default, unless specifically specified to the contrary elsewhere within this
solicitation. It shall be at CCHCC's discretion whether to exercise the right to terminate.
Respondent shall not be found in default for events arising due to acts of God.
3.19 TERMINATION FOR CCHCC'S CONVENIENCE
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The performance of work under this contract may be terminated in accordance with this clause in
whole, or from the time in part, whenever CCHCC representative shall determine that such
termination is in the best interest of CCHCC. Any such termination shall be effected by the delivery
to the respondent of a Notice of Termination specifying the extent to which performance of work
under the contract is terminated, and the date upon which such termination becomes effective. Upon
such termination for convenience, respondent shall be entitled to payment, in accordance with the
payment provisions, for services rendered up to the termination date and CCHCC shall have no
other obligations to respondent. Respondent shall be obligated to continue performance of contract
services, in accordance with this contract, until the termination date and shall have no further
obligation to perform services after the termination date.
3.20 VENDOR PERFORMANCE
CCHCC project personnel shall monitor Contractor performance.A 'Report of Unsatisfactory Product
or Service' form (Attachment B) shall be utilized to document unsatisfactory performance during the
term of this contract. The report may become an important part of the Contractor's history. The report
and process will assist the Purchasing Department to determine whether there is a continuing
pattern of problems which may need to be addressed through termination of contract and/or
suspension of Contractor from future bidding.
3.21 COLLUSION
The CCHCC reserves the right to disqualify bids upon evidence of collusion with intent to defraud, or
other illegal practices to include circumventing or manipulating the bid process in a manner that
conflicts with applicable law, upon the part of the Bidder(s), Bidder's employees or agents, the
CCHCC's Professional Consultant(s), or Consultant's agents, or any CCHCC employee(s)who may,
or may not, be involved in the development of bid specifications and/or firm bid schedules. Multiple
bids from an individual, partnership, corporation, association (formal or informal) or firm under the
same or different names shall not be considered. Reasonable grounds for believing that a Bidder has
interest in multiple proposals for the same work shall be cause for rejection of all proposals in which
such Bidder is believed to have an interest in. Any and/or all proposals shall be rejected if there is
any reason to believe that collusion exists among one or more of the Bidders, the CCHCC's
Professional Consultant(s) or CCHCC's employees. Contractors involved in developing a bid
specification or Contractors with knowledge of bid specifications prior to a bid advertisement shall be
disqualified from participating in the applicable bid process.
3.22 INCURRED EXPENSES
This RFP does not commit CCHCC to award a contract nor shall CCHCC be responsible for any cost
or expense which may be incurred by the respondent in preparing and submitting the proposal called
for in this RFP, or any cost or expense incurred by the respondent prior to the execution of a contract
agreement.
3.23 POST-PROPOSAL DISCUSSIONS WITH RESPONDENTS
It is CCHCC's intent to award a contract(s) to the respondent(s) deemed most advantageous to
CCHCC in accordance with the evaluation criteria specified elsewhere in this RFP. CCHCC reserves
the right however, to conduct post-closing discussions with any respondent who has a realistic
possibility of contract award including, but, not limited to: request for additional information,
competitive negotiations and best and final offers.
3.24 PRESENTATIONS BY RESPONDENTS
A. CCHCC, at its sole discretion, may ask individual respondents to make oral presentations,
informal telephone interviews and/or demonstrations without charge to CCHCC.
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B. CCHCC reserves the right to require any respondent to demonstrate to the satisfaction of
CCHCC that the respondent has the fiscal and managerial abilities to properly furnish the
services proposed and required to fulfill the contract. The demonstration must satisfy
CCHCC and CCHCC shall be the sole judge of compliance.
C. Respondents are cautioned not to assume that presentations will be required and should
include all pertinent and required information in their original proposal package.
3.25 MINIMUM SPECIFICATIONS
The specifications listed in the Scope of Service are the minimum required performance
specifications for this RFP. They are not intended to limit competition nor specify any particular
respondent but to ensure that CCHCC receives quality services.
3.26 COMPLIANCE WITH LAWS AND REGULATIONS
The respondent shall be responsible to know and to apply all applicable federal and state laws, all
local laws, ordinances, rules, regulations, and all orders and decrees of bodies or tribunals having
jurisdiction or authority which in any manner affect the work, or which in any way affect the conduct
of the work. Respondent shall always observe and comply with all such laws, ordinances, rules,
regulations, orders and decrees. Respondent shall protect and indemnify CCHCC and all its officers,
agents, servants, or employees against any claim or liability arising from or based on the violation of
any such law, ordinance, rule, regulation, order, or decree caused or committed by respondent, its
representatives, subcontractors, subconsultants, professional associates, agents, servants or
employees. Additionally, respondent shall obtain and maintain at its own expense all licenses and
permits to conduct business pursuant to this contract from the Federal Government, State of Florida,
Collier County or municipalities when legally required and maintain same in full force and effect
during the term of the contract.
3.27 RECORDS & RIGHT TO AUDIT
The respondent shall maintain such financial records and other records as may be prescribed by
CCHCC or by applicable federal and state laws, rules and regulations. The respondent shall retain
these records for a period of five (5) years after final payment, or until they are audited by CCHCC,
whichever event occurs first. These records shall be made available during the term of the contract
and the subsequent three year period for examination, transcription and audit by CCHCC, its
designees or other entities authorized by law.
3.28 CHANGES IN SCOPE OF WORK/SERVICE
A. CCHCC may order changes in the work consisting of additions, deletions, or other revisions
within the general scope of the contract. No claims may be made by the respondent that the
scope of the project or of the respondent's services have been changed, requiring changes
to the amount of compensation to the respondent or other adjustments to the contract,
unless such changes or adjustments have been made by written amendment to the contract
signed by CCHCC Representative, School Board's Director of Purchasing, and the
respondent.
B. If the respondent believes that any particular work is not within the scope of services of the
contract, is a material change or will otherwise require more compensation to the
respondent, the respondent must immediately notify CCHCC's Representative in writing of
this belief. If CCHCC's Representative believes that the particular work is within the scope of
the contract as written, the respondent will be ordered to and shall continue with the work as
changed and at the cost stated for the work within the scope. The respondent must assert its
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right to an adjustment under this clause within thirty (30) days from the date of receipt of the
written order.
C. CCHCC reserves the right to negotiate with the awarded respondent(s) without completing
the competitive RFP process for materials, products, and/or services similar in nature to
those specified within this RFP for which requirements were not known when the RFP was
released.
3.29 MODIFICATIONS DUE TO PUBLIC WELFARE OR CHANGE IN LAW
CCHCC shall have the power to make changes in the contract as the result of changes in law and/or
rules of CCHCC to impose new rules and regulations on the respondent under the contract relative
to the scope and methods of providing services as shall from time-to-time be necessary and
desirable for the public welfare. CCHCC shall give the respondent notice of any proposed change
and an opportunity to be heard concerning those matters. The scope and method of providing
services as referenced herein shall also be liberally construed to include, but is not limited to the
manner, procedures, operations and obligations, financial or otherwise, of the respondent. In the
event any future change in Federal, State or County law or rules of CCHCC materially alters the
obligations of the respondent, or the benefits to CCHCC, then the contract shall be amended
consistent therewith. Should these amendments materially alter the obligations of the respondent,
then the respondent or CCHCC shall be entitled to an adjustment in the rates and charges
established under the contract. Nothing contained in the contract shall require any party to perform
any act or function contrary to law. CCHCC and respondent agree to enter into good faith
negotiations regarding modifications to the contract which may be required in order to implement
changes in the interest of the public welfare or due to change in law. When such modifications are
made to the contract, CCHCC and the respondent shall negotiate in good faith, a reasonable and
appropriate adjustment for any changes in services or other obligations required of the respondent
directly and demonstrably due to any modification in the contract under this clause.
3.30 RIGHT TO REQUIRE PERFORMANCE
A. The failure of CCHCC at any time to require performance by the respondent of any provision
hereof shall in no way affect the right of CCHCC thereafter to enforce same, nor shall waiver
by CCHCC of any breach of any provision hereof be taken or held to be a waiver of any
succeeding breach of such provision or as a waiver of any provision itself.
B. In the event of failure of the respondent to deliver services in accordance with the contract
terms and conditions, CCHCC, after due written notice, may procure the services from other
sources and hold the respondent responsible for any resulting additional purchase and
administrative costs. This remedy shall be in addition to any other remedies that CCHCC
may have.
3.31 FORCE MAJEURE
CCHCC and the respondent will exercise every reasonable effort to meet their respective obligations
as outlined in this RFP and the ensuing contract, but shall not be liable for delays resulting from force
majeure or other causes beyond their reasonable control, including, but not limited to, compliance
with any Government law or regulation, acts of God, acts or omissions of the other party,
Government acts or omissions, fires, strikes, national disasters, wars, riots, transportation problems
and/or any other cause whatsoever beyond the reasonable control of the parties. Any such cause
will extend the performance of the delayed obligation to the extent of the delay so incurred.
3.32 RESPONDENT'S PERSONNEL
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The respondent shall be responsible for ensuring that its employees, agents and subcontractors
comply with all applicable laws and regulations and meet all federal, state and local requirements
related to their employment and position.
The respondent certifies that it does not and will not during the performance of the contract employ
illegal alien workers or otherwise violate the provisions of the federal Immigration Reform and
Control Act of 1986, as amended.
During the performance of the contract, the respondent agrees to the following:
The respondent shall not discriminate against any employee or applicant for employment because of
race, religion, color, sex, age, handicap or national origin, except when such condition is a bona fide
occupational qualification reasonably necessary for the normal operations of the respondent. The
respondent agrees to post in conspicuous places, visible to employees and applicants for
employment, notices setting forth the provisions of this nondiscrimination clause.
The respondent, in all solicitations or advertisements for employees placed by or on behalf of the
respondent, shall state that such respondent is an Equal Opportunity Employer.
Notices, advertisements and solicitations placed in accordance with federal law, rule or regulation
shall be deemed sufficient for the purpose of meeting the requirements of this section.
The respondent shall include the provisions of the foregoing paragraphs above in every subcontract
or purchase order so that the provisions will be binding upon each respondent.
The respondent and any subcontractor shall pay all employees working on this contract not less than
minimum wage specified in the Fair Labor Standards Act(29 CFR 510-794)as amended.
Any information concerning CCHCC, its products, services, personnel, policies or any other aspect
of its business learned by the respondent or personnel furnished by the respondent in the course of
providing services pursuant to the Agreement, shall be held in confidence and shall not be disclosed
by the respondent or any employee or agents of the respondent or personnel furnished by the
respondent, without the prior written consent of CCHCC.
3.33 CLAIM NOTICE
The respondent shall immediately report in writing to CCHCC's designated representative or agent
any incident that might reasonably be expected to result in any claim under any of the coverage
mentioned herein. The respondent agrees to cooperate with CCHCC in promptly releasing
reasonable information periodically as to the disposition of any claims, including a resume of claims
experience relating to all respondent operations at CCHCC project site.
3.34 CONTRACT/RESPONDENT RELATIONSHIP
The CCHCC reserves the right to award one or more contracts to provide the required services as
deemed to be in the best interest of CCHCC.
Any awarded respondent shall provide the services required herein strictly under a contractual
relationship with CCHCC and is not, nor shall be, construed to be an agent or employee of CCHCC.
As an independent respondent the awarded respondent shall pay any and all applicable taxes
required by law; shall comply with all pertinent Federal, State and local statutes including, but not
limited to, the Fair Labor Standards Act, The Americans with Disabilities Act, the Federal Civil Rights
Act and any and all relevant employment laws. The respondent shall be responsible for all income
tax, FICA, and any other withholdings from its employees or sub-respondent's wages or salaries.
Benefits for same shall be the responsibility of the respondent including, but not limited to, health and
life insurance, mandatory social security, retirement, liability/risk coverage, and worker's and
unemployment compensation.
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The independent respondent shall hire, compensate, supervise, and terminate members of its work
force; shall direct and control the manner in which work is performed including conditions under
which individuals will be assigned duties, how individuals will report and the hours individuals will
perform.
The independent respondent shall not be provided special space, facilities or equipment by CCHCC
to perform any of the duties required by the contract nor shall CCHCC pay for any business, travel,
or training expenses or any other contract performance expenses not specifically set forth in the
specifications.
Prior to commencing work, the successful respondent will be required to sign a written contract
incorporating the specifications and terms of the Request for Proposal and the response thereto. Any
contract awarded as a result of this RFP shall begin on or about January 1, 2014 and continue
through December 31, 2015 with the ability to renew two additional one-year terms.
The independent respondent shall not be exclusively bound to CCHCC and may provide
professional services to other private and public entities as long as it is not in direct conflict and does
not provide a conflict of interest with the services to be performed for CCHCC.
3.35 PROPOSAL ACCEPTANCE/REJECTION
CCHCC reserves the right to accept or reject any or all proposals received as a result of this RFP, or
to negotiate separately with competing respondents, and to waive any informalities, defects, or
irregularities in any proposal, or to accept that proposal or proposals, which in the judgment of the
proper officials, is in the best interest of CCHCC.
3.36 FUNDING OUT/TERMINATION/CANCELLATION
A. Florida Laws prohibit School Boards from creating obligations in anticipation of budgeted
revenues from one fiscal year to another without year-to-year extension provisions in the
agreements.
B. It is necessary that fiscal funding out provisions be included in all proposals in which the
terms are for periods longer than one (1)year.
C. Therefore, the following funding out provisions is an integral part of this proposal and must
be agreed to by all respondents:
CCHCC may, during the contract period, terminate or discontinue the services covered in
this proposal at the end of CCHCC's then current fiscal year upon ninety (90) days prior
written notice to the successful respondent.
Such written notice will state:
a. That the lack of appropriated funds is the reason for termination, and
b. "This written notification will thereafter release CCHCC of all further
obligations in any way related to the services covered herein."
c. The Funding Out statement must be included as part of any agreement. No
agreement will be considered that does not include this provision for
"funding out."
3.37 POSTING OF RFP CONDITIONS/SPECIFICATIONS
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This RFP will be posted on www.Demandstar.com for review by interested parties.
3.38 NOTICE OF PROPOSAL PROTEST BONDING REQUIREMENT
Any person who files an action protesting a decision or intended decision pertaining to this proposal
pursuant to FS 120.57(3)(b), shall post with the Purchasing Department at the time of filing the
formal written protest, a bond payable to the CCHCC in an amount equal to 1 percent (1%) of the
total estimated contract value, but not less than $500 nor more than $5,000, which bond shall be
conditioned upon the payment of all costs which may be adjudged against the protester in the
administrative hearing in which the action is brought and in any subsequent appellate court
proceeding. See 3.67 Protests.
3.39 EXAMINATION OF DOCUMENTS
Document files may be examined, during normal working hours, 30 days after proposals have been
opened.
3.40 TOBACCO FREE
The CCHCC is tobacco free. Tobacco and tobacco products are prohibited on any of the CCHCC
properties.
3.41 TAXES
CCHCC is exempt from Federal and State Tax for Tangible Personal Property. A copy of the
District's Tax Exempt Certificate is available upon request. Firms or Respondents doing business
with the CCHCC shall not be exempted from paying sales tax to their suppliers for materials to fulfill
contractual obligations with the District, nor shall any Vendor/Respondent be authorized to use the
District's Tax Exemption Number in securing such materials.
3.42 LIQUIDATED DAMAGES
In case of failure on the part of the successful respondent to complete the work within the time(s)
specified in the Contract, or within such additional times) as may be granted by formal action of the
CCHCC or failure to prosecute the work, or any separable part thereof, with such diligence as will
ensure its completion within the time(s) specified by the Owners representative, and which the
CCHCC will suffer damage, the amount of which is difficult, if not impossible to ascertain. Therefore,
the Firm shall pay to the CCHCC, as liquidated damages, the amount expended by the District to
provide the goods or services; in no way shall costs for liquidated damages be construed as a
penalty on the Respondent.
3.43 ADVERTISING
The successful respondent shall not publicly disseminate any information concerning the Contract
without prior written approval from the CCHCC, including, but not limited to mentioning the Contract
in a press release or other promotional material, identifying the District, Individual Departments,
District Personnel, as a reference, or otherwise linking the Customer's name and either a description
of the Contract or the name of the District, its departments, or employees, in any material published,
either in print or electronically, to any entity that is not a party to the Contract, except potential or
actual authorized subcontractors, distributors, dealers, resellers, or service representatives.
3.44 SECURITY AND CONFIDENTIALITY
The successful respondent shall comply fully with all security procedures of the District in
performance of the Contract. The successful respondent or its agents, distributors, resellers,
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subcontractors, officers or employees in the course of performing Contract work, including, but not
limited to, security procedures, business operations information, or commercial proprietary
information in the possession of the District. The successful respondent shall not be required to keep
confidential information or material that is publicly available through no fault of the successful
respondent, material that the successful respondent developed independently without relying on the
District's confidential information or material that is otherwise obtainable under State law as a public
record. To insure confidentiality, the successful respondent shall take appropriate steps as to its
personnel, agents and subcontractors. The warranties of this paragraph shall survive the Contract.
3.45 SUSPENSION OF WORK
CCHCC's Authorized Representative may in its sole discretion suspend any or all activities under the
Contract, at any time, when in the best interest of CCHCC to do so. CCHCC's Authorized
Representative shall provide the successful respondent written notice outlining the particulars of
suspension, including the length of time the contract shall be suspended (i.e.: 90 days). Examples of
the reason for suspension include, but are not limited to; budgetary constraints, declaration of
emergency or other such circumstances. After receiving a suspension notice, the successful
respondent shall comply with the notice and shall not accept any purchase orders during the
specified time of suspension. Within ninety days, or any longer period agreed to by the successful
respondent, CCHCC's Authorized Representative shall either (1) issue a notice authorizing
resumption of work, at which time activity shall resume, or (2)terminate the Contract. Suspension of
work shall not entitle the Vendor/Respondent to any additional compensation.
3.46 INSTALLATION
Where installation is required, the successful bidder shall deliver, set in place, install, make ready to
run, and test (test to be accomplished in the presence of an authorized representative of the
CCHCC). The bidder shall provide a qualified person, at no extra cost, to assure performance of the gook,
item and to make the initial start-up and achieve the successful testing. Upon completion of the
successful testing of the item, the authorized representative of CCHCC shall accept it. All
miscellaneous installation materials shall be included in the Total Turnkey price. The miscellaneous
installation materials include the following: conduit, wire, fiber, connectors, fittings, boxes, etc. All
materials used in the installation shall be of good quality and shall be free of defects that would
diminish the appearance of the product or render it structurally or operationally unsound. Installation
includes the furnishing of any equipment, rigging, and materials required to install or replace the
product in the proper location. Successful bidder shall protect the site from damage and shall repair
damages or injury caused during the installation by the successful bidder or its employees or agents.
If any alternation is required to the Building to achieve installation, the successful bidder shall
promptly restore the structure or site to its original condition. Successful bidder shall perform
installation work so as to cause the least inconvenience and interference with CCHCC and with
proper consideration of others on site. Upon completion of the installation, the location and
surrounding area of work shall be left clean and in a neat and unobstructed condition, with everything
in satisfactory repair and order.
3.47 LITERATURE
Upon request, the Respondent shall furnish literature reasonably related to the Services offered, for
example, user manuals, price schedules, catalogs, descriptive brochures, etc.
3.48 INSPECTION AND ACCEPTANCE
CCHCC's Project Manager will accept each Deliverable when it meets the requirements of this
Contract and the relevant project noted on the Purchase Order. Inspection may include validation of
information or software through the use of automated tools and/or testing of the Deliverables, as A
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specified in the projects proposal. The scope and nature of this testing should be negotiated prior to
the Purchase Order and should be sufficiently comprehensive to ensure the completeness, quality
and adequacy of all Deliverables.
3.49 TERMS &CONDITIONS
The terms and conditions contained in this section shall apply to all Purchase Orders issued under
this contract unless the CCHCC specifically details other terms on the Purchase Order. The School
District and the Respondent should take care to ensure that project specific changes to these terms
are as explicit as possible. All inconsistencies will be resolved in the best interests of the School
District.
3.50 KEY PERSONNEL
Respondent's Key Personnel (if any) shall be identified on the projects proposal/quote, and may
include employees, agents, subcontractors or other personnel of the Respondent. The Respondent
agrees that in the event it becomes necessary for the Respondent to change Key Personnel while
performing Services under the purchase order, substitution of Key Personnel shall take place only
upon Customer's prior written consent. Failure to notify Customer prior to the change of Key
Personnel, or a substantial change in Key Personnel as determined by the Customer, may be
sufficient cause for Termination.
3.51 WARRANTY
Respondent warrants the Services furnished under the Contract shall be free of defective material
and workmanship, and shall otherwise perform in accordance with required performance criteria, for
a period of one (1)year from the date of acceptance.
Equipment provided must include the Manufacturer's warranty, the successful Respondent shall fully
guarantee all items furnished hereunder against defect in material and workmanship for the
Manufacturer's normal period of time from date of acceptance by CCHCC. Should any defect in
material or workmanship appear, excepting ordinary wear and tear, during the warranty period, the
successful Respondent shall repair or replace same at no cost to CCHCC immediately upon written
notice from CCHCC. All warranty paperwork shall be included with deliverables prior to acceptance
by CCHCC.
3.52 WARRANTY OF AUTHORITY/SERVICE AGREEMENT
Each person signing the Contract warrants that he or she is duly authorized to do so and to bind the
respective party to the Contract.
3.53 LITIGATION
Respondents shall submit details of all litigation, arbitration or other claims, whether pending or
resolved in the last five years, with the exception of immaterial claims which are defined herein as
claims with a possible value of less than $25,000.00 or which have been resolved for less than
$25,000.00. Notwithstanding the foregoing, all litigation, arbitration or other claims, of any amount,
asserted by or against a state, city, county, town, school district, political subdivision of a state,
special district or any other governmental entity shall be disclosed. Please indicate for each case the
year, name of parties, case of litigation, matter in dispute, disputed amount and whether the award
was for or against the Respondent.
3.54 PROHIBITION AGAINST CONTRACTING WITH SCRUTINIZED COMPANIES
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A person or affiliate who has been placed on the convicted vendor list following a conviction for a
public entity crime may not submit a bid, proposal, or reply on a contract to provide any goods or
services to a public entity; may not submit a bid, proposal, or reply on a contract with a public entity
for the construction or repair of a public building or public work; may not submit bids, proposals, or
replies on leases of real property to a public entity; may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant under a contract with any public entity; and may not
transact business with any public entity in excess of the threshold amount provided in s. 287.017 for
CATEGORY TWO for a period of 36 months following the date of being placed on the convicted
vendor list.
3.55 PROTESTS
A bidder who wishes to file a bid protest, must file such notice and follow procedures prescribed by
F.S. 120.57(3), for resolution. The notice must be filed with the Purchasing Department.
Any person who files an action protesting a decision or intended decision pertaining to a bid pursuant
to F.S. 120.57(3)(b), shall post at the time of filing the formal written protest, a bond payable to the
Board in an amount equal to$25,000 or two percent(2%)of the lowest accepted bid, whichever is
greater, for projects valued over$500,000 and five percent(5%)of the lowest accepted bid for all
other projects. The bond shall be conditioned upon the payment of all costs which may be adjudged
against the protester in the administrative hearing in which the action is brought and in any
subsequent appellate court proceeding. If, after completion of the administrative hearing process and
any appellate court proceedings,the District prevails, it shall recover all costs and charges, which
shall be included in the final order or judgment, including charges made by the Division of
Administrative Hearings, but excluding attorney's fees. If the protester prevails, s/he shall recover
from the District all costs and charges which shall be included in the final order of judgment,
excluding attorney's fees.
Failure to file a notice of intent to protest, or failure to file a formal written protest within the time
prescribed in section F.S. 120.57(3), shall constitute a waiver of proceedings under F.S. Chapter
120.
4.0 EVALUATION CRITERIA
Willis is assisting the members of the CCHCC with several areas related to this RFP process. For
example, Willis has assisted the members in developing this RFP, as well as identifying critical
selection criteria. A final recommendation and selection will be made via the following process.
The members of the CCHCC have identified a project selection team. The project selection team is
made up of representatives appointed from each member organization. This team, with the technical
support and guidance of Willis will be responsible for providing the necessary evaluations of potential
vendors responding to this RFP. The analysis and selection will adhere to the following steps:
1. Each member of the evaluation team will review and score the written responses to the RFP
according to a predetermined scoring tool.
2. Willis will perform an evaluation of the financial terms and provide a summarization of the
qualitative aspects of the RFP.
3. Willis will tabulate scores to the written responses to the RFP.
4. The financial terms of your response will be evaluated by a process where the lowest vendor
overall financially will receive the highest possible score. Scores for the remaining vendors will
be determined utilizing the following formula:
Score= (number responding x [lowest cost]/vendor cost)
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5. Based on a composite evaluation of the financial terms and the project team's evaluation of the
written responses to this RFP, two or more finalists will be selected.
6. Finalists will be expected to travel to Naples, Florida to be interviewed. Additionally,
representatives of the CCHCC employers may want to tour the PBM operations. During these
tours, finalists will be subjected to a consistent set of predetermined questions. Each member of
the evaluation team will independently score response to these questions.
7. A final recommendation and selection will be based on the weighted scores of the evaluation
team with respect to the following:
Scores regarding written responses to the proposal
b Scores regarding financial response
g> Scores regarding finalist interviews
During the entire process, Willis will provide technical support, as well as objective tabulation of the
responses and assistance in drafting a collective recommendation for each entities board or decision
makers.
This RFP process and the terms you provide are to be based on the assumption that all of the entities
that make up the CCHCC contracting with your organization collectively for the contract term. Any and
all entities reserve the right independently or collectively to not contract with the respondent. If any
one entity elects not to participate, your proposal becomes null and void. The CCHCC employers
reserve the right to modify their final section process, to modify the factors for consideration and make
their selection in the manner they choose.
The weighting of the RFP Responses will be provided in a following addendum, but will likely include
the following:
Financial Terms
Written Response and References
Finalist Interviews
5.0 ATTACHMENTS
"A" RFP Date of Events
"B" Proposal Form and Statement of Compliance
"C" Drug Free Workplace Certification Form
"D" Certification Regarding Debarment, Suspension Ineligibility and Voluntary Exclusion
"E" Conflict of Interest
"F" Non-Disclosure Agreement for Confidential Materials
"G" Certification Statement Prohibition Against Contracting with Scrutinized Companies
"H" Statement of No Response
Questionnaire
"J" Plan Design
"K" Historical Utilization Data
"L" Pricing Data Per Pill Prices
"M" Financial Terms
"N" Financial Terms (continued)
"0" Contract Terms
"P" Formulary Comparison
"Q" Verisk Data File Layout
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ATTACHMENT A
RFP DATE OF EVENTS
Date Description
June 20, 2013 RFP Posted to Demandstar at www.Demandstar.com
To Be Determined Not Mandatory Pre-Proposal Meeting
To Be Determined Addenda released (if necessary)
Addenda addressing questions received prior to the question
Deadline will be sent to firms attending Pre-Proposal Meeting
July 23, 2013 Submittals Due at 2:00 pm
Deliver to: District School Board of Collier County
District School Board of Collier County
Purchasing Department
5775 Osceola Trail
Naples, FL 34109
Mark package(s)"RFP#13- Pharmacy Benefits Management Services"
An electronic copy should also be emailed to John Pauly at Willis:
iohn.pauly(a�willis.com
July 23—August 16 CCHCC Consultant Evaluation of Submittals
August 19—20 Selection Committee Evaluation of Submittals
To Be Determined Short Listed Firms Notified
To Be Determined Award Recommendation Posted
To Be Determined Schedule Board Presentation
To Be Determined Contract Development
To Be Determined Agenda Due Date
To Be Determined Board Approval of Contract(Tentative)
January 1, 2014 Program Effective Date
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ATTACHMENT B
PROPOSAL FORM AND STATEMENT OF COMPLIANCE
TO: CCHCC
Company
Per (Print name)
Signature
Address
City State ZIP
List local(Collier County)office address if applicable and provide supporting documentation
(Business Tax Receipt).
Telephone Fax
E-Mail Address:
Dunn&Bradstreet# Fed. I.D.#
Division of Corporations Registration Number:
END OF FORM
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ATTACHMENT C
DRUG FREE WORKPLACE
CERTIFICATION FORM
In accordance with Florida Statute 287.087, preference shall be given to businesses with drug-free
workplace programs. Whenever two or more proposals are equal with respect to price, quality and
service are received by the State or by any political subdivision for the procurement of commodities or
contractual services; a proposal received from a business that certifies that it has implemented a drug-
free workplace program shall be given preference in the award process. Established procedures for
processing tie proposals will be followed if none of the tied vendors have a drug-free workplace
program. In order to have a drug-free workplace program,a business shall:
1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in the workplace and specifying the actions
that will be taken against employees for violations of such
prohibition.
2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of
maintaining a drug-free workplace, any available drug counseling, rehabilitation, and employee
assistance programs and penalties that may be imposed upon employees for drug abuse violations.
3. Give each employee engaged in providing the commodities or contractual services that are under
contract a copy of the statement specified in subsection(1).
4. In the statement specified in subsection(1) notify employees that as a condition of working
on the commodities or contractual services that are under contract, the employee will abide by the
terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo-
contendere to, any violation of chapter 893 or of any controlled substance law of the United States or
any state, for a violation occurring in the workplace no later than five (5)days after such conviction.
5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or
rehabilitation program if such is available in the employee's community, by any employee who is so
convicted.
6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this
section.
As the person authorized to sign the statement, I certify that this firm complies fully with the above
requirements.
Vendor's Signature
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ATTACHMENT D
CERTIFICATION REGARDING DEBARMENT, SUSPENSION
INELIGIBILITY AND VOLUNTARY EXCLUSION—LOWER TIER COVERED TRANSACTIONS
This certification is required by the regulations implementing Executive Order 12549, Debarment and
Suspension, 7 CFR Part 3017, Section 3017.510 Participants responsibilities. The regulations were
published as Part IV of the January 30, 1989, Federal Register(pages 4722-4733).
***** BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS ON NEXT PAGE*****
(1) The prospective lower tier participant certifies, by submission of this proposal, that neither it nor
its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this transaction by any Federal department of agency.
(2) Where the prospective lower tier participant is unable to certify to any of the statements in this
certification,such prospective participant shall attached an explanation to this proposal.
Organization Name RFP Name& Number
Names and Titles of Authorized Representative(s)
Signature(s) Date
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ATTACHMENT D CONTINUED
INSTRUCTIONS FOR DEBARMENT CERTIFICATION
1. By signing and submitting this form, the prospective lower tier participant is providing the certification set out
herein in accordance with these instructions.
2. The certification in this clause is a material representation of fact upon which reliance was placed when this
transaction was entered into. If it is later determined that the prospective lower tier participant knowingly
rendered an erroneous certification, in addition to other remedies available to the Federal Government, the
department of agency with which this transaction originated may pursue available remedies, including
suspension and/or debarment.
3. The prospective lower tier participant shall provide immediate written notice to the person to whom this
proposal is submitted if at any time the prospective lower tier participant learns that its certification was
erroneous when submitted or has become erroneous by reason of changed circumstances.
4. The terms "covered transaction", "debarred", "suspended", "ineligible", "lower tier covered transaction", "
participant", "person", "primary covered transaction", "principal", "proposal", "voluntarily exclude", as used in
this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive
Order 12549. You may contact the person to which this proposal is submitted for assistance in obtaining a copy
of these regulations.
5. The prospective lower tier participant agrees by submitting this form that, should the proposed covered
transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who
is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction,
unless authorized by the department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this form that it will include this clause titled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion — Lower Tier Covered
Transactions", without modification in all lower tier covered transactions and in all solicitations for lower tier
covered transactions.
7. A participant in a covered transaction may rely upon a certification of a perspective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the eligibility of its principals. Each participant may, but is not required to, check
the Non-procurement List.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order
to render in good faith the certification required by this clause. The knowledge and information of a participant is
not required to exceed that which is normally possessed by a prudent person in the ordinary course of business
dealings.
9. Except for transactions authorized under paragraph 5 of these instructions, if a participant in a covered
transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred,
ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to
the Federal Government, the department or agency with which this transaction may pursue available remedies,
including suspension and/or debarment.
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ATTACHMENT E
CONFLICT OF INTEREST
I hereby certify that
1. I (printed name) am the
(title)
and the duly authorized representative of the firm of (Firm Name)
whose address is
, and that I possess the legal authority to make this
affidavit on behalf of myself and the firm for which I am acting; and,
2. Except as listed below, no employee, officer, or agent of the firm have any conflicts of interest, real or apparent, due
to ownership,other clients, contracts, or interests associated with this project;and,
3. The business nor any authorized representative or significant stakeholder of the business has been determined
by judicial or administrative board action to be in noncompliance with or in violation of any provision/contract of the School
Board of Collier County, nor has any outstanding past due debt to the School Board of Collier County, Florida;and
4. The School Board of Collier County reserves the right to disqualify RFPs upon evidence of collusion with intent to
defraud, or other illegal practices to include circumventing or manipulating the RFP process as required by law, upon the part
of the Respondent(s), the District's Professional Consultant(s) or any District employee(s) who may, or may not, be involved
in developing RFP specifications and/or firm RFP schedules. Multiple RFPs from an individual, partnership, corporation,
association (formal or informal); firm under the same or different names shall not be considered. Reasonable
grounds for believing that a Respondent has interest in multiple proposals for the same work shall be cause for rejection of all
proposals in which such Respondent is believed to have an interest in. Any and/or all proposals shall be rejected if there is
any reason to believe that collusion exists among one or more of the Respondents, the District's Professional Consultant(s)
or District employees. Contractors involved in developing a RFP specification or Contractors with knowledge of RFP
specifications prior to the advertisement shall be disqualified from participating in the RFP process.
EXCEPTIONS (List)
Signature:
Printed Name:
Firm Name:
Date:
COUNTY OF STATE OF
Sworn to and subscribed before me this day of , 20 by
, who is personally known to me or who has produced
as identification.
NOTARY PUBLIC—STATE OF
Type or print name:
Commission No.:
Commission Expires (Seal)
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Notification Regarding Public Entity Crime and Discriminatory Vendor List Requirements and
Disqualification Provision
A. Pursuant to Florida Statutory requirements,potential Respondents are notified:
287.133(2)(a) A person or affiliate who has been placed on the convicted vendor list following a
conviction for a public entity crime may not submit a bid, proposal, or reply on a contract to provide any goods or
services to a public entity; may not submit a bid, proposal, or reply on a contract with a public entity for the
construction or repair of a public building or public work; may not submit bids, proposals, or replies on leases of
real property to a public entity; may not be awarded or perform work as a contractor, supplier, subcontractor, or
consultant under a contract with any public entity; and may not transact business with any public entity in excess
of the threshold amount provided in s. 287.017 for CATEGORY TWO for a period of 36 months following the
date of being placed on the convicted vendor list.
287.133(2)(b) A public entity may not accept any bid, proposal, or reply from, award any contract to, or
transact any business in excess of the threshold amount provided in s. 287.017 for CATEGORY TWO with any
person or affiliate on the convicted vendor list for a period of 36 months following the date that person or affiliate
was placed on the convicted vendor list unless that person or affiliate has been removed from the list pursuant to
paragraph (3)(f). A public entity that was transacting business with a person at the time of the commission of a
public entity crime resulting in that person being placed on the convicted vendor list may not accept any bid,
proposal, or reply from, award any contract to, or transact any business with any other person who is under the
same, or substantially the same, control as the person whose name appears on the convicted vendor list so long
as that person's name appears on the convicted vendor list.
287.134(2)(a) An entity or affiliate who has been placed on the discriminatory vendor list may
not submit a bid, proposal, or reply on a contract to provide any goods or services to a public entity; may not
submit a bid, proposal, or reply on a contract with a public entity for the construction or repair of a public building
or public work; may not submit bids, proposals, or replies on leases of real property to a public entity; may not
be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any
public entity; and may not transact business with any public entity.
287.134(2)(b) A public entity may not accept any bid, proposals, or replies from, award any
contract to, or transact any business with any entity or affiliate on the discriminatory vendor list for a period of 36
months following the date that entity or affiliate was placed on the discriminatory vendor list unless that entity or
affiliate has been removed from the list pursuant to paragraph (3)(f). A public entity that was transacting
business with an entity at the time of the discrimination resulting in that entity being placed on the discriminatory
vendor list may not accept any bid, proposal, or reply from, award any contract to, or transact any business with
any other entity who is under the same, or substantially the same, control as the entity whose name appears on
the discriminatory vendor list so long as that entity's name appears on the discriminatory vendor list.
B. By submitting a proposal, the Respondent represents and warrants that the submission of its proposal
does not violate Section 287.133, Florida Statutes, nor Section 287.134, Florida Statutes.
C. In addition to the foregoing, the Respondent represents and warrants that Respondent, Respondent's
subcontractors and Respondent's implementer, if any, is not under investigation for violation of such statutes.
D. Respondent should read carefully all provisions of 287.133 and 287.134, Florida Statutes.
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ATTACHMENT F
NON-DISCLOSURE AGREEMENT
For
CONFIDENTIAL MATERIALS
Reference#
NON-DISCLOSURE AGREEMENT For CONFIDENTIAL MATERIALS
Reference#
RETURN THIS FORM ONLY IF CONFIDENTIAL MATERIALS ARE BEING INCLUDED IN THE SUBMITTAL.
PLEASE READ THE SECTION IN THE BID DOCUMENT TO DETERMINE IF THIS APPLIES. THE
CONFIDENTIAL MATERIALS WILL ONLY BE HANDED OUT TO THE SELECTION COMMITTEE ON THE
DAY OF THE EVALUATION, THEREFORE, THE EVALUATION OF THIS MATERIAL WILL BE LIMITED TO
THAT TIME ONLY.
Respondent:
Address:
This Agreement is entered into as of the date of the last signature set forth below between the School Board of
Collier County, a political subdivision of the State of Florida (the "District"), and the above named Respondent
(hereinafter the "Respondent"). The School Board of Collier County and the Respondent are collectively
referred to as the"Parties"and may be referred to individually as a Party.
RECITALS
WHEREAS, the Respondent possesses certain confidential trade secret materials that it wishes to disclose to
the School Board of Collier County for the purpose of responding to a request for proposal or otherwise
conducting business with the School Board; and
WHEREAS, the School Board desires to review such materials in order to evaluate the District's interest in
negotiating and concluding an agreement for the purchase of certain products and services, or otherwise
conducting business with the Respondent.
NOW THEREFORE, in consideration of the mutual promises and premises contained herein, the receipt and
sufficiency of which are hereby acknowledged,the School Board and the Respondent agree as follows:
1. Confidential Materials. The Respondent warrants and represents to the School Board that the materials
described in the attached Exhibit A (the "Confidential Materials") constitute trade secrets as defined by Section
812.081(1)(c), Florida Statutes, or financial statements required by the School Board for projects as defined in
119.071(1)(c), Florida Statutes. Subject to the terms and conditions of this Agreement,the School Board agrees
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not to disclose such Confidential Materials to third parties, with the exception of its designated third party
consultant(s).
2. Additional Materials. During the course of the negotiations or the business relationship with the School
Board, the Respondent may disclose additional confidential or trade secret information to the District in which
case the restrictions and obligations on the use and disclosure of the Confidential Materials imposed by this
Agreement shall also apply to such additional information to the extent permitted by Florida law. Any such
additional confidential or trade secret information shall be duly marked and stamped "confidential" or "trade
secret" prior to delivery to the School Board, and shall be subject to this Agreement and Section 812.081(2),
Florida Statutes,only if written receipt is provided by the School Board acknowledging receipt of such materials.
3. Exclusions. For purposes of this Agreement, the term "Confidential Materials" does not include the
following:
(a) Information already known or independently developed by the School Board;
(b) Information in the public domain through no wrongful act of the School Board;
(c) Information received by the School Board from a third party who was legally free to disclose it;
(d) Information disclosed by the Respondent to a third party without restriction on disclosure;
(e) Information disclosed by requirement of law or judicial order, including without limitation Chapter
119 Florida Statutes; or
(f) Information that is disclosed with the prior written consent of the Respondent, but only to the extent permitted
by such consent.
4. Non Disclosure by Respondent. In the event that the School Board discloses confidential or trade
secret information to Respondent, the Respondent agrees to not disclose such information to any third party or
copy such information or use it for any purpose not explicitly set forth herein without the School Board's prior
written consent. Further, upon conclusion of discussions or business transactions between the School Board
and the Respondent, or at any time upon request of the School Board, Respondent agrees to return such
information(including any copies)to the School Board.
5. Duty of Care. Each Party agrees to treat the other Party's confidential or trade secret information with
the same degree of care, but not less than reasonable care, as the receiving Party normally takes to preserve
and protect its own similar confidential information and to inform its employees of the confidential nature of the
disclosing Party's information and of the requirement of nondisclosure. In the event either Party has actual
knowledge of a breach of the nondisclosure requirements set forth in this Agreement, the Party acquiring such
knowledge shall promptly inform the other Party and assist that Party in curing the disclosure, where possible,
and preventing future disclosures.
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6. Limitations of Florida Law. Respondent understands and agrees that its assertion that any item is
confidential or a trade secret does not, in and of itself, render such material exempt from the Florida Public
Records Law, Chapter 119 of the Florida Statutes, and that the School Board's ability to prevent disclosure of
confidential and trade secret information may be subject to determination by a Florida court that such materials
qualify for trade secret protection under Florida law. In the event a third party makes a public records request
for the Confidential Materials or other materials deemed by Respondent to be confidential or a trade secret, the
School Board may submit the materials to the court for inspection in camera as set forth in Section 119.07(1)(g)
Florida Statutes. Respondent further understands that the School Board may be required to disclose such
information if directed by a court of competent jurisdiction.
7. Indemnification by Respondent. In the event of any litigation instituted by a third party to compel the
School Board to disclose such materials, Respondent shall, at its sole cost and expense, provide assistance to
the School Board in defending the denial of the records request, and shall hold the School Board harmless from
any claim for statutory costs and attorneys fees arising from the School Board's refusal to disclose such
materials.
8. No Additional Obligations. This Agreement shall not be construed in any manner to be an obligation for
either Party to enter into any subsequent contract or agreement.
9. Sovereign Immunity. Nothing in this Agreement shall be deemed as a waiver of immunity or limits of •
liability of the School Board beyond any statutory limited waiver of immunity or limits of liability, which has been
or which may be adopted by the Florida Legislature, regardless of the nature of any claim which may arise,
including but not limited to a claim sounding in tort, equity or contract. In no event shall the School Board be
liable for any claim or claims for breach of contract, including without limitation the wrongful disclosure of
confidential or trade secret information for an amount which exceeds, individually and collectively, the then
current statutory limits of liability for tort claims. Nothing in this Agreement shall inure to the benefit of any third
party for the purpose of allowing any claim against the School Board, which would otherwise be barred under
the Doctrine of Sovereign Immunity or by operation of law.
10. Notice. Whenever either Party desires to give notice unto the other, it must be given by written notice,
sent by registered United States mail, with return receipt requested, addressed to the party for whom it is
intended, at the place last specified, and the place for giving of notice in compliance with the provisions of this
paragraph. For the present, the Respondent designates the address set forth above as its place for receiving
notice, and the School Board designates the following address for such notice:
The District School Board of Collier County
Purchasing Department
5775 Osceola Trail
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Naples, Florida 34109
11. Governing Law. This Agreement shall be governed by the laws of the State of Florida, and
venue for any action arising out of or relating to the subject matter of this Agreement shall be exclusively
in Collier County, Florida.
12. Respondent and the School Board hereby expressly waive any rights either may have to a trial
by jury of any civil litigation related to this Agreement for any litigation limited solely to the parties of this
Agreement.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by their
duly authorized officers the day and year as set forth below.
The School Board of Collier County, Florida
BY:
NAME: Nancy Sirko
TITLE: Director of Purchasing_
DATE:
Respondent :
BY:
NAME:
TITLE:
DATE:
ATTEST:
BY:
NAME:
TITLE:
DATE:
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ATTACHMENT G
CERTIFICATION STATEMENT
PROHIBITION AGAINST CONTRACTING WITH SCRUTINIZED COMPANIES
Not Applicable for this Solicitation
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ATTACHMENT H
STATEMENT OF NO RESPONSE
The District School Board of Collier County
Office of Purchasing
5775 Osceola Trail
Naples, FL 34109
Attn: Nancy Sirko, Director of Purchasing
RFP#13—Pharmacy Benefits Management Services
We,the undersigned, have decided not to bid for the following reasons.
We do not handle products/services in this classification
Opening date does not allow sufficient time to complete bid
Cannot supply at this time
Suitable but engaged in other work
Quantity too small
Cannot meet required delivery
Equivalent not presently available
Unable to meet specifications
Unable to meet insurance/bond requirements
Please remove our name from the vendor file for the commodity listed above
Please remove our name from the School Board's entire vendor files
Other reasons or remarks
We understand that if the"No Bid" letter is not returned by the bid due date, our name may be deleted
from the School Board of Collier County's vendor list for this commodity.
Company Name
Authorized Signature
Print Name of Authorized Person
Email Address for Authorized Person
Telephone Number
Fax Number
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ATTACHMENT I
QUESTIONNAIRE
A. Eligibility
Al. A full eligibility file will be sent to you weekly by CCHCC and their administrator. Please confirm
that you can upload files on a weekly basis. File layouts can be provided upon request.
A2. Can you accept faxes of employee terminations so that they can be promptly handled to minimize
program use by employees and dependents after coverage is terminated? Alternatively, will you
allow CCHCC online access to make these changes immediately? How will you reconcile
changes made on-line with files received from the medical plan administrator or insurer?
A3. As with any eligibility process there is the possibility for files to become out of sync. How do you
propose to address this?
A4. When would you need to receive the eligibility file in order to have identification cards distributed
by December 20, 2013 to each member?
A5. The design of the CCHCC health plans are such that a husband, wife and children may be
enrolled in separate plans with different pharmacy benefits. Is your system able to handle this? If
yes, please describe how identification cards are issued and how the system will process claims
correctly when members receive their medications.
B. Performance Guarantees and Contract Requirements
B1. Describe in detail all performance guarantees you are willing to include in the contract regarding
the implementation and ongoing service. Please be specific regarding penalties, incentives and
ways to monitor these performance guarantees.
The following are required guarantees in addition to the ones you suggest. Please confirm that
you agree to each, and indicate the penalty associated with a failure to meet the required
measures:
• Program implemented and ID cards distributed by December 20, 2013
• Acceptable monthly claims data extracts provided to Verisk and other firms that CCHCC may
designate by the 15`h of the close of each month for prior month.
• Generic efficiency rates for entire contract period (Generic Fill Rate GFR)
• The date by which quarterly and year end reports will be delivered
• Discount guarantees for the flowing areas:
1. Retail/Generic
2. Retail/Brand
3. Retail/Specialty
4. Mail/Generic
5. Mail/Brand
6. Mail/Specialty
• Mail order processing turnaround time
B2. If Generic Fill Rate (GFR) performance falls short of guarantees, will you credit the shortfall on a
dollar-for-dollar basis? How will the performance against the goal be calculated? Will you do a
separate calculation for retail and mail? If you miss the guarantee, how will you calculate what is
due to CCHCC?
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B3. Many times single source generic medications may not be classified as generic. Please fully
disclose the instances in which this may occur and how this is addressed in your reporting of
performance as compared to guarantees taking into account the requirements outlined above.
B4. Are you willing to offer a guarantee not to exceed average drug cost net of specialty medications
for 2014 and 2015? If yes, please include this with pricing proposal and outline how this would
work.
Listed below is a brief example of what CCHCC is interested in:
PBM is pleased to offer CCHCC the following guarantee.
PBM guarantees that CCHCC's contract year one (2014)pharmacy drug cost on a per member basis
will not exceed$xx.xx.
PBM guarantees that the CCHCC's contract year two (2015) pharmacy drug cost on a per member
basis will not exceed$xx.xx.
Details
• Provide details of how this will be settled
Conditions
• Provide any limitations associated with this guarantee.
B5. In addition to the required guarantees outlined above, please outline other guarantees you
believe are appropriate and the financial penalties you will associate with a failure to reach those
goals. Please note that each must stand alone and cannot be offset by exceeding the goals in
other areas.
B6. What steps do you take on an ongoing basis to minimize claims processing issues? If problems
are anticipated due to system upgrades or changes, do you notify clients of this in advance?
B7. How do you ensure you are prepared to assist clients in complying with past and emerging
requirements related to health care reform?
B8. What steps do you take to make sure you are ready to implement changes prior to the required
effective date?
C. Price and Utilization Management Processes
FOR EACH QUESTION, PLEASE DETAIL YOUR RESPONSE SEPARATELY FOR THE RETAIL
AND MAIL ORDER PROGRAMS WHERE PROCESSES MAY DIFFER.
C1. Please describe your ability to implement a proactive therapeutic alternative program. Under this
program, after the first prescription is filled, would you seek authorization from the prescribing
physician to dispense a therapeutically equivalent prescription drug on the formulary in place of a
more expensive non-formulary or formulary drug?
C2.Are you willing to implement a therapeutic MAC pricing? This pricing applies to the generic
copayment and limits to reimbursement after the copayment for all medications in a defined class
to a predetermined maximum allowable cost (MAC). If the member's cost is higher, they pay the
difference.
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For example, a program may apply to Proton Pump Inhibitors (PPIs). If the member wanted a
brand name equivalent medication such as Nexium, Protonix or Acifex, payment is limited to the
"MAC" amount for Omeprazole. For individuals meeting certain clinical criteria, CCHCC or its
designee would have access to your system to allow the patient to access Prevacid or Nexium at
the brand name copayment. Please describe whether your system would support this approach
and how you would see it working. This may be expanded to other classes of medications such
as non-sedating antihistamines in the future.
C3. Describe your approach to developing your Maximum Allowable Cost (MAC) program for
generics. How many drugs are on your MAC list? What is the effective discount that your MAC
pricing yields off of AWP assuming that single source generics are included? Do you bundle
generics with rebate negotiations for brand name drugs with manufacturers? How does this affect
you MAC pricing? In addition, please confirm the following for CCHCC under both the traditional
and pass through pricing approaches quoted:
• If the pharmacy bills less than the MAC price, is the client billed for the lesser or MAC or the
billed amount(U&C)?
• If the employee copayment is less than the MAC price, the actual cost is billed to the
employee and what amount, if any, is the employer billed?
C5. How often do you update your MAC list in response to the changes in manufacturer prices and
the number of firms dispensing a particular drug? How do you control repackaging to prevent a
manufacturer from creating its own AWP to circumvent MAC pricing?
C6. Do you enforce any MAC programs for name brand drugs based on a common purchase size
requirement?
C7. Please describe in detail how participating pharmacists are paid under your program. How do
your agreements differ from chain to chain compared to independents? What is the typical
contract term with each chain? Are the terms of the contract with major chains the same
nationally or does it differ by region?
C8. Please describe how each of the approaches you quote (traditional and pass though)will provide
verifiable transparency in fees, rebates and pricing. A report showing rebates for each quarter
does not necessarily mean transparency. How will you prove that the CCHCC is getting full pass
through of rebates? Address your position on about transparency; pass through and traditional
pricing approaches. Individual employers are seeking full pass through with a guaranteed floor
under the traditional pricing quotation. If you have not quoted a separate fee for administration,
how will you be compensated?
C9. Please carefully review the plan design data in Attachment J and the utilization data in
Attachment K.
Attachment L contains abridged files. Please provide your per pill pricing as of April 1, 2013 had
the terms you are quoting for January 1, 2014, been in force. In other words, apply your discount
terms to the current base price used as of April 1, 2013. The retail per pill costs should reflect a
weighted average of the current claims distribution between the major chains for your current
Florida book of business. Please indicate whether your pricing with these firms applies to the full
state of Florida or differs by region. For mail order, apply the proposed terms to your mail per pill
mail order pricing as of April 1, 2013.
Note: If you believe that a narrow network will provide better terms, please complete duplicate
Attachment 0 and Attachment P labeled narrow network and provide the details of that narrow
network in Collier County, FL as compared to your standard network.
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Is your pricing for other vendors such as Wal-Mart the same as for CVS and Walgreens or
different?
C10. Specialty medications is the fastest growing area of pharmacy spend for CCHCC. Please
describe your approach to addressing cost trends in this area for CCHCC as an employer and
Rx vendor.
D. Vendor Information
D1. Please confirm your organization's willingness to allow CCHCC the right to independently audit
your claims processing unit.
D2. Describe the history, organization and ownership of your company.
D3. Describe your malpractice and errors and omissions coverage for the mail order program. In
addition, provide a copy of the Certificate of Insurance for your Errors and Omissions coverage
and all stated insurance requirements.
E. Claims Processing, Cost Management Edits and Customer Service
E1. Describe the procedure network pharmacists follow to collect proper co-pays and process claims
in routine circumstances.
E2. Describe the options available to collect co-payments from members under the mail order
program when the co-payment is a percent of the cost.
E3. Please detail common program edits. For example, does the program have a computer system
linking, on a real time basis, the following edits?
a. "Too soon" refills
b. Duplicate prescriptions
c. Number of refills
d. Day's supply
e. Concomitant therapies
E4. Describe your drug utilization review procedures (DUR). Include a list of the criteria used in the
DUR evaluation. How do you act on problems uncovered through DUR?
E5. Please describe the procedures followed if there is a problem accessing the computer network
system. Discuss situations where pharmacists have been unable to access the system and the
steps you have taken to ensure such situations will not be repeated.
E6. How many times have pharmacists or network pharmacies been unable to access the system in
the last 12 months? How have you dealt with it?
E7. What are your customer service hours? Are pharmacists available during that time? Provide
information for both your retail and mail order services. Please provide information regarding the
information that is available to plan members through your member portal web site to help them
manage costs; understand the medications they are taking, etc.
E8. Describe your capabilities to administer coordination of benefits. What would you project the
savings to be?
E9. How do you monitor participant satisfaction with your services?
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E10. Will you make a representative available to support the CCHCC during employee meetings to
present the new program and change to your firm?
Ell. Provide samples of the communication materials you would mail to participants explaining the
new program.
E12. Please evaluate how well your pharmacy network covers the Collier County area and the U.S.
Are you missing any major chains in your broad network? Are you willing to pursue adding
pharmacies to your provider network if you are selected as the vendor? Please indicate how
successful you have been in upgrading your network for specific clients in the past. Do you
provide Internet access to your pharmacy directory?
E13. Describe your ability to provide claims history extracts to third party administrators and
utilization review firms so data can be mined and integrated data reporting provided.
E14. Describe how participants access the mail order pharmacy. Outline the documentation that
must be submitted, how prescriptions are filled and anticipated turnaround time, including
shipping. Can physicians phone prescriptions to your mail order facility?
E15. There have been documented cases of abuse and resale of narcotic medications. How will you
detect, act on and prevent such abuses? Keep in mind when responding that pharmacies
generally ignore soft edits and do not want to refuse to fill a prescription and hence indirectly
imply the patient is abusing a narcotic drug at point of sale.
F. Data Reporting and Access
F1. Please describe the systems you will utilize and show how you will provide online real time
access to utilization data for CCHCC, Willis and/or other designated entities to support analysis
and input to decision support. Can Willis and others, as designated by CCHCC, have direct
access to this system or will they need to work through an account manager? Lack of direct
access will not be viewed favorably.
F2. Please provide a sample of your standard quarterly utilization reports both on line and paper.
F3. CCHCC will require access to a vendor-provided reporting system to support monitoring
physician prescribing patterns, especially those that are employed or affiliated with this vendor
system. This must be on line and physician specific. Provide samples of the reports that can be
generated from the system.
F4. Please confirm that you will be able to accept outstanding pre-authorization orders from the
incumbent PBM to ensure continuation of care where applicable.
F5. Attachment Q contains details concerning the data extracts needed for Verisk. Please confirm
that you can provide the necessary data monthly to support the Verisk system. Do you currently
work with Verisk on any other clients today?Approximately how many?
F6. The CCHCC employers utilize a Allegiance Benefit Plan Administrators as their TPA.
Attachment R contains the data extract that you will need to send to Allegiance on a regular
basis. Please confirm you can provide this data on a regular schedule.
G. Additional Information
G1. In your response, please include the following information:
• Copies of your standard prepaid claim submission envelopes, brochures, announcement letter
and educational materials that will accompany identification cards.
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• A copy of your proposed contract.
• Your standard utilization and expense reports, plus a description of each report.
• Copies of your provider directories for the CCHCC for the network you propose to use and your
narrow network if quoted.
G2. Please confirm that you are able to administer the current plan designs outlined in Attachment
M. Assuming that a 20% differential is maintained between formulary and non-formulary
medications, are there any plan design changes CCHCC may make that would affect your
pricing? If so what are those?
G3. What is your source for post AWP settlement pricing? Why did you select that source? How
often is it updated?
G4. Please describe your approach to formulary development. Please see Attachment P which
outlines the current medications on Express Scripts. Please note if the medication is on your
formulary and if not what medication(s)is offered in that class that is on your formulary.
G6. What is your firm doing in the area of behavioral research and communications that focus on
therapy continuance, how people make decisions to change a course of therapy, view generic
medications, etc.?
G7. What additional member education services can you offer that help make people better
consumers and bend trend?
H. Group Purchasing Organizations (GPO) Pricing
Recently, CCHCC has become interested in the concept of "own use" or Group Purchasing
Organizations (GPO) to assist in managing the cost of its pharmacy program. CCHCC understands
that certain State organizations as varied as schools, colleges, State health departments, and other
related organizations are eligible to utilize an exemption to the Robinson-Patman Act to reduce
pharmacy expenditures for their employees, retirees, and their dependents. By participating in
purchasing cooperatives known as Group Purchasing Organizations, these organizations can save
material amounts on their pharmaceutical drug cost.
The ability to purchase for "own use" populations implies a significant and substantial savings
opportunity for GPO-qualified organizations, including state and local government institutions.
GPO agreements typically offer the greatest savings on high-cost brand name medications that are
used to treat chronic or recurring conditions. These items are oftentimes the greatest individual cost
drivers of an institution's pharmacy benefit. Since twenty percent of all medications generally drive a
significant portion of pharmacy costs, CCHCC wants to focus on these high cost items in exploring an
"own use" program to relieve ever-increasing pharmacy benefit costs.
To assist in assessing your capabilities in this area, please answer the following:
H1. Does your organization have experience with public bodies and hospital providers in
implementing such a program?
H2. What was the structure of the program, and how did it work?
H3. For individual employers would you recommend a mail only or mail and limited retail network for
GPO pricing?
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H4. Please see the Attachment P of the top 50 brand-name medications and complete that
Attachment P utilizing your assumptions if GPO pricing would apply to all these medications.
H5. Please complete a separate Attachment for own use pricing applied to these 50 medications.
H6. What do you believe is the overall savings potential to CCHCC if it were to implement such a
program?
H7. What is your overall opinion of these programs and whether you believe they would benefit
CCHCC?
H8. Please describe the typical approach you have utilized with a client to optimize the use of GPO
pricing for their medical plan and its employees.
I. Specialty Medications Management
11. Cost in this area is growing rapidly; why do you think this is happening?
12. What are your plans to assist CCHCC in addressing Specialty trends?
13. Provide detail on how you manage costs for medical specialty medications across diverse sites of
service for CCHCC (e.g., percentage of dollars hospital inpatient, outpatient, patient home, etc.)
14. Detail your efforts to manage drug trend on medical specialty and control costs at the drug level.
15. Provide a breakdown of medical specialty drug spend by condition and related costs for CCHCC.
16. How do you support Specialty patients/customers holistically?
17. How are you preparing for Biosimilars?
18. How are you thinking about innovation within Specialty Pharmacy plan design? How does
CCHCC design impact the Specialty Design?
19. Where else do you see specialty innovation on the medical benefit?
110.How are you planning to optimize pharmacogenomics/pharmacogenetics in your Specialty
strategy?
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ATTACHMENT J—PLAN DESIGN
(See Attached SPD)
ATTACHMENT K—HISTORICAL UTILIZATION DATA
(See File Attachments)
ATTACHMENT L—PRICING DATA PER PILL PRICES—REPRICE BOTH ATTACHMENTS(BY
COUNT AND BY COST)AS OF 3/1/2013
(See Attachments)
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ATTACHMENT M
FINANCIAL TERMS
(Complete separately and clearly label traditional/pass through/broad/narrow network options)
PBM Name and
Pricing
Approach:
2014 2015
Retail
Administrative fee per employee per month
Administrative fee per claim
Dispensing fee:
a. Brand legend
b. Generic legend
c. Compounded drugs
d. Non-legend
e. Specialty
Basis of claim payment to retail pharmacy
(% off AWP)*:
a. Brand medications (guaranteed discount)
b. Generic(guaranteed discount)
c. Compounded drugs (guaranteed discount)
d. Non-legend (guaranteed discount)
e. Specialty (guaranteed discount)
*If your claim payment to pharmacies is other than a percent off AWP, please describe your approach
and estimate what the expected savings off AWP will be.
Rebates 2014 2015
Minimum Guaranteed or Estimated Rebate for all Retail
Scripts
Implementation Credit
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ATTACHMENT N - CONTINUED
2014 2015
Other Fees- Please Specify*
*List each type of fee (e.g., ID cards, data reports,toll-free lines, concurrent drug utilization reviews, etc.)
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ATTACHMENT N -CONTINUED
PBM Name
and pricing
approach:
2014 2015
Mail Order
Administrative fee per employee per month
Administrative fee per claim
Dispensing fee
a. Brand legend
b. Generic legend
c. Compounded drugs
d. Non-legend
e. Specialty
Basis of claim payment to retail pharmacy
(% off AWP)
f. Brand medications (guaranteed discount)
g. Generic(guaranteed discount)
h. Compounded drugs (guaranteed discount)
Non-legend (guaranteed discount)
j. Specialty(guaranteed discount)
*If your claim payment to pharmacies is other than a percent off AWP, please describe your approach
and estimate what the expected savings off AWP will be.
Rebates 2014 2015
Minimum Guaranteed Rebate for all mail order Scripts
When completed you should have provided
pricing attachments labeled as follows:
1. Broad Network Guarantees
2. Broad Network Full Pass Through
3. Narrow Network Guarantees
4. Narrow Network Full Pass Through
5. GPO Pricing
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In addition, please address the following questions concerning the terms you have quoted:
1. Are discounts calculated on an aggregate minimum post-AWP Settlement basis? If not, what is
the basis?
2. Are zero-balance claims charged to the plan or plan member based on the actual cost charged
and submitted for payment NOT the contacted rate or valued at 100% discount? If you have a
different approach, detail how you handle such claims.
3. Are any medications excluded from calculations of guarantees? If any are excluded, please
outline which medications and under what circumstances these medications will be excluded.
4. Do composite discount guarantees exclude U&C, compound, and OTC claims from the
calculation? If not, which are included in the calculation?
5. Will composite discounts contain any shared savings elements? If so, what are they?
6. Do discounts in excess of guarantees accrue to the benefit of the CCHCC for all of your quoted
arrangements or just the ones with full pass through?
7. Do your composite brand and generic discount guarantees assume that single source generics or
originator medications are included in the generic category or brand for purposes of the
guarantees and calculation of such guarantees?
8. Please provide a detailed definition of what you consider to be single source generics within your
contact and for purposes of calculating guarantees.
NOTE: AS ALLUED TO IN THIS RFP, EACH EMPLOYER HAS THE RIGHT TO
INDIVIDUALLY ACCEPT OR REJECT YOUR PROPOSAL.
THE QUOTES YOU PROVIDE SHOULD BE BASED ON THE ASSUMPTION THAT
THE CCG, DSBCC AND NCH ALL ELECT YOUR FIRM. IF WOULD NOT BE THE
CASE, PLEASE OUTLINE WHAT ADJUSTMENTS WOULD BE MADE IN YOUR
QUOTE IF ONLY TWO OR ONE EMPLOYER ELECT TO CONTRACT WITH YOU.
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ATTACHMENT 0
CONTRACT TERMS
There is considerable variance in contract terms between PBMs that affect the terms quoted. Please note
how your proposed contract with CCHCC addresses each of these items. Further, please comment on
why your agreement is structured the way it is.
How do you define each of the following?
1. The "Adjudicated Dispensing Fee"
2. The "Adjudicated Ingredient Cost"
3. The"Average Wholesale Price" or"AWP"
4. A"Brand" claim
5. A"Covered Drug(s)"
6. A"Dispense As Written"or"DAW' claim
7. A"Generic" claim
8. The "Ingredient Cost" of a claim
9. "MAC" or"Maximum Allowable Cost"
10. A"Member's Copayment"
11. A"Paid" claim.
12. A claim's"Sales Tax"
13. "Usual and Customary" or"U&C"
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ATTACHMENT P
FORMULARY COMPARISON
Please provide 2 lists:
1) Drugs on your Formulary and not on ESI's
2) Drugs on ESI's Formulary and not on yours and what your proposed replacement is.
(Attachment will be provided in Addendum)
ATTACHMENT Q
VERISK DATA FILE LAYOUT
(See File Attachments)
REVISED 2-22-13 KR Page 48 of 48
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PURCHASING DEPARTMENT
Collier County Public Schools
July 5, 2013
Addendum#1
RFP#156-6/13 Pharmacy Benefits Management Services/CCHCC
Please be advised that as of this date, Friday,July 5, 2013, it has been determined that the dates that
the School Board and Consortium Members will be interviewing the Finalists selected for the Pharmacy
Benefits Management Services will be Wednesday, 8/7/13 and Thursday, 8/8/13. Please keep these
dates open in the event your firm is chosen.
This addendum shall modify and become part of the above referenced Request For Proposal (RFP). As it
forms an integral part of the RFP, it must be executed and returned with the bidder's response to the
RFP no later than 2:00 p.m., Friday,July 19, 2013. Failure to do so may be reason for disqualification of
the non-responding vendor.
Nancy Sirko
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Director of Purchasing
Signature/Date Print Name/Title
Firm
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PURCHASING DEPARTMENT
Collier County Public Schools
July 10, 2013
Addendum#2
RFP#156-6/13 Pharmacy Benefits Management Services/CCHCC
Please be advised that as of this date, Wednesday,July 10, 2013,the following questions have been
posed by several prospective bidders. All questions are listed and answered on Attachment A.
This addendum shall modify and become part of the above referenced Request For Proposal (RFP). As it
forms an integral part of the RFP, it must be executed and returned with the bidder's response to the
RFP no later than 2:00 p.m.,Tuesday,July 23, 2013. Failure to do so may be reason for disqualification
of the non-responding vendor.
Nancy Sirko
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Director of Purchasing
Signature/Date Print Name/Title
Firm
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Phone:.(239)3774)034 'FAX:(239)377-0974
www,cnllierschools,com
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Addendum #2
QUESTION 1: Do you have the attachments that were uploaded on Demand Star available in Word or
Excel format for us to respond to the questionnaire?
RESPONSE: PLEASE USE DOCUMENTS IN THE FORMATS PROVIDED.
QUESTION 2: Will we receive any detailed pharmacy data?Please reference the attached document as
an example of what we need.
RESPONSE: DETAILED PHARMACY DATA IS PROVIDED AS PART OF THIS ATTENDUM AS "ATTACHMENT S
—DETAILED CLAIMS DATA".
QUESTION 3: Attachment K: Financial Terms. Is a claims data file available in order to provide a
comprehensive financial analysis, including more accurate estimated rebates?
RESPONSE: DETAILED PHARMACY DATA IS PROVIDED AS PART OF THIS ATTENDUM AS "ATTACHMENT S
—DETAILED CLAIMS DATA".
QUESTION 4: RFP Page 7,3.05 Proposal Form: Each respondent shall submit nine(9) complete sets of
the Proposal Submittals:
One(1) hard copy marked "ORIGINAL"with fee structures in a sealed envelope
Eight(8) hard copies marked "COPY"
Two(2) COMPLETE electronic copies on CD's,in PDF format(Excel spreadsheets shall not be
recorded in PDF). Note solicitation number and name of company on the disk. If a Non-disclosure
agreement is signed and confidential materials are submitted,such confidential materials shall be
Item B.
A. We would like to confirm that all of the hard copies should include all material(even confidential
material).
RESPONSE: The original should include all material including confidential material. The 8 copies should
include all material with the exception of the confidential material.
B. We would also like to confirm that confidential material should not be included on the master CD
but should be included on the second CD.
RESPONSE: Confidential material should not be included on the second CD.
C. Finally, we would like to confirm that a third CD would contain just the confidential material(as
well as the signed NDA)as indicated in the instructions.
Aloft
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RESPONSE: That is correct.
QUESTION 5: RFP Page 10,3.14 Insurance Requirements: Such certificates must contain a provision
for notification to the Board thirty(30)days in advance of any material change in coverage or
cancellation. Will the Contractor's proposal be rejected if its insurance carrier will only endeavor to
provide notification to the Board thirty(30)days in advance of any material change in coverage or
cancellation?
RESPONSE: Yes
QUESTION 6: RFP Page 10,3.14 Insurance Requirements and 6. Network Security and Privacy
Coverage,Each claim:$5,000,000, Per Occurrence: $5,000,000. Will the Contractor's proposal be
rejected if it does not carry this type of policy?
RESPONSE: Yes
QUESTION 7: RFP Page 13,Records and Right to Audit 3.27: The respondent shall maintain such
financial records and other records as may be prescribed by CCHCC or by applicable federal and state
laws, rules and regulations.The respondent shall retain these records for a period of five(5)years
after final payment,or until they are audited by CCHCC,whichever event occurs first.These records
shall be made available during the term of the contract and the subsequent three year period for
examination,transcription and audit by CCHCC,its designees or other entities authorized by law.
Please confirm that records must be available:(a)during the term of the contract; (b)during the three-
year period subsequent to contract termination, which is also included in (c)the five years after final
payment or until an audit by CCHCC.
RESPONSE: That is correct.
QUESTION 8: RFP Page 37,C.9: Attachment L contains abridged files. Please provide your per pill
pricing as of April 1,2013 had the terms you are quoting for January 1,2014, been in force. In other
words,apply your discount terms to the current base price used as of April 1,2013.The retail per pill
costs should reflect a weighted average of the current claims distribution between the major chains
for your current Florida book of business. Please indicate whether your pricing with these firms
applies to the full state of Florida or differs by region. For mail order,apply the proposed terms to
your mail per pill mail order pricing as of April 1,2013. Attachment L requests per pill pricing as of
March 1, 2013, whereas the RFP requests per pill pricing as of April 1, 2013. Can CCHCC please confirm
which date should be used?
RESPONSE: PLEASE USE THE PER PILL PRICING AS OF APRIL 1, 2013.
QUESTION 9: RFP Page 37,C.9: Note: If you believe that a narrow network will provide better terms,
please complete duplicate Attachment 0 and Attachment P labeled narrow network and provide the
details of that narrow network in Collier County,FL as compared to your standard network. Can the
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attachment letters be confirmed? Attachment 0 currently requests definitions of contract terms and
Attachment P(to be provided via an addendum)currently requests a formulary comparison.
RESPONSE: PLEASE USE THE DATA FROM THE NEW"ATTACHMENT P—ESI FORMULARY LIST" PROVIDED
WITH THIS ADDENDUM. PLEASE BE SURE TO COMPLETE THE TWO FORMULARY COMPARISON LISTS AS
REQUESTED IN ATTACHMENT P OF THE ORIGINAL RFP. YOU ONLY NEED TO COMPLETE A SEPARATE
FORMULARY COMPARISON AND OTHER DOCUMENTS IF THERE ARE DIFFERENCES IN THE FORMULARY
OR CONTRACT PROVISIONS WITH YOUR NARROW VERSUS BROAD NETWORK.
QUESTION 10: RFP Page 39, F6: Attachment R contains the data extract that you will need to send to
Allegiance on a regular basis. Please confirm that you can provide this data on a regular schedule. Is
Attachment R pending release? It does not seem to be included with the rest of the proposal materials
currently available on the DemandStar website.
RESPONSE: YES. PLEASE SEE THE ATTACHED"ATTACHMENT R—TPA DATA EXTRACT"WHICH IS
PROVIDED WITH THIS ADDENDUM.
QUESTION 11: RFP Page 40,G4: Please describe your approach to formulary development. Please see
Attachment P which outlines the current medications on Express Scripts. Please note if the medication
is on your formulary and if not what medication(s) is offered in that class that is on your formulary.
Please confirm that Attachment P is pending release as of 7.3.13, when these questions were prepared.
Is there a target date for providing this attachment?
RESPONSE: PLEASE USE THE DATA FROM THE NEW"ATTACHMENT P—ESI FORMULARY LIST" PROVIDED
WITH THIS ADDENDUM. PLEASE BE SURE TO COMPLETE THE TWO FORMULARY COMPARISON LISTS AS
REQUESTED IN ATTACHMENT P OF THE ORIGINAL RFP. THEN, FOR THE MEDICATIONS NOT ON YOUR
FORMULARY, PLEASE NOTE WHAT MEDICATION(S) IS OFFERED IN THAT CLASS THAT IS ON YOUR
FORMULARY.
QUESTION 12: RFP Page 41, H.4: Please see the Attachment P of the top 50 brand-name
medications and complete that Attachment P utilizing your assumptions if GPO pricing would apply
to all these medications. Please confirm that the RFP is actually referring to Attachment L(Top 50 by
ING).
RESPONSE: CORRECT. THE TOP 50 BRAND-NAME MEDICATIONS IS ATTACHMENT"L". THIS QUESTION
IS RELATED TO GPO PRICING. IF YOU ARE GOING TO QUOTE GPO PRICING, PLEASE PROVIDE THE TOP 50
BRAND AND GENERIC FOR BOTH RETAIL AND MAIL ORDER WHICH WOULD REFLECT YOUR GPO PRICING
VERSUS THE STANDARD PRICING AVAILABLEUNDER YOUR RETAIL AND MAIL ORDER NETWORKS.
QUESTION 13: RFP Page 43-45,Attachments M and N: Financial Terms. Please confirm that
Attachment M includes Retail Financial Terms(p. 43-44)and Attachment N(p. 45)includes Mail
Financial Terms.
RESPONSE: CORRECT. "ATTACHMENT M" IS FOR RETAIL AND "ATTACMENT N" IS FOR MAIL ORDER.
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QUESTION 14: RFP Page 46, NOTE:As alluded to in this RFP,each employer has the right to
individually accept or reject your proposal. The quotes you provide should be based on the
assumption that the CCG, DSBCC,and NCH all elect your firm. If that would not be the case,please
outline what adjustments would be made in your quote if only two or one employer elects to contract
with you. Page 21 of the RFP states: "This RFP process and the terms you provide are to be based on the
assumption that all of the entities that make up the CCHCC contracting with your organization
collectively for the contract term. Any and all entities reserve the right independently or collectively to
not contract with the respondent. If any one entity elects not to participate, your proposal becomes null
and void." If adjustments are outlined to address a scenario in which only one or two entities elect to
contract with the bidder, would the proposal remain valid?
RESPONSE: PLEASE COMPLY WITH THE REQUEST ON PAGE 46. PLEASE PROVIDE PRICING FOR ALL OF
THE MEMBERS TOGETHER AS WELL AS EACH EMPLOYER INDIVIDUALLY AS WELL AS ANY COMBINATION
OF THE TWO EMPLOYERS.
QUESTION 15: The RFP states the total number of CCHCC covered lives is 22,100. Does this include the
Sheriff's Department?
RESPONSE: YES.
A. If yes,what is the total covered lives without the Sheriff's department since they are not in
scope for this RFP?
RESPONSE: PLEASE SEE ATTACHMENT K FOR A BREAKDOWN OF MEMBERSHIP BY EMPLOYER. EACH
EMPLOYER'S DATA IS ON A SEPARATE TAB.
QUESTION 16: Will vendors be receiving detailed claims data, inclusive of a group identifier in order to
assist in knowing which member belongs to which group and has which plan design?
RESPONSE: YES. DETAILED PHARMACY DATA IS PROVIDED AS PART OF THIS ATTENDUM AS
"ATTACHMENT S—DETAILED CLAIMS DATA".
QUESTION 17: What specialty arrangement does CCHCC currently have with their PBM? Open?
Exclusive?
RESPONSE: THE CURRENT ARRANGEMENT IS EXCLUSIVE WITH CURASCRIPT. MEMBERS AR ALLOWED
ONE (1) FILL AT RETAIL AND THEN THEY MUST FILL THROUGH CURASCRIPT.
QUESTION 18: RFP Page 40,G4. Please describe your approach to formulary development.Please see
Attachment P which outlines the current medications on Express Scripts.Please note if the medication
is on your formulary and if not what medication(s) is offered in that class that is on your formulary."
A. We do not have access to "Attachment P"—can you please provide?
RESPONSE: PLEASE USE THE DATA FROM THE NEW"ATTACHMENT P—ESI FORMULARY LIST" PROVIDED
WITH THIS ADDENDUM. PLEASE BE SURE TO COMPLETE THE TWO FORMULARY COMPARISON LISTS AS
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REQUESTED IN ATTACHMENT P OF THE ORIGINAL RFP. THEN, FOR THE MEDICATIONS NOT ON YOUR
FORMULARY, PLEASE NOTE WHAT MEDICATION(S) IS OFFERED IN THAT CLASS THAT IS ON YOUR
FORMULARY.
QUESTION 19: Availability of the most recent 12 months of prescription claims data for CCHCC. In
order to provide the best financial response to this RFP we would really like to have this important data.
Will this be released?
RESPONSE: DETAILED PHARMACY DATA IS PROVIDED AS PART OF THIS ATTENDUM AS "ATTACHMENT S
—DETAILED CLAIMS DATA".
QUESTION 20: In reviewing attachment K, can you please confirm that the column labeled"Avg Mbr
Count"represents the number of utilizers, and not the enrollees.
RESPONSE: CONFIRMED.
QUESTION 21: Please confirm that these numbers(in attachment K) do not include those of the
Sherriff's Office(CCSO), since they have elected not to participate.
RESPONSE: CONFIRMED. EACH EMPLOYER'S DATA IS ON A SEPARATE TAB.
QUESTION 22: On Attachment N, are bidders required to provide a quote for each (e.g. broad network,
narrow network)or is it the vendor's choice?
RESPONSE: VENDORS ARE NOT REQUIRED TO PROVIDE A QUOTE FOR EACH, BUT PRICING FOR EACH
WOULD BE PREFERRED.
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CCG, DSBCC and NCH
Finalist Interview Questions
August 8th, 2013
You have twenty(90)minutes to present your response to the following questions. The group may
have additional questions following your presentation over the following thirty(30)-minute period.
The group is familiar with you your organization and background so please keep introductions to a
minimum and focus on concise answers to the questions posed.
Topic 1—Responsiveness to Presentation;Ability, Capacity and Skill of Propose.
1. Knowing what you do about the CCG, DSBCC and NCH, what would be your objectives
(beyond the basics of implementation and claims processing) over the next two years? How
would you measure the results of your efforts?
Topic 2—Specialty Drug Experience
1. All respondents seem to have identical responses relative to specialty medication. Exclusive
home delivery, prior authorization,therapy management, appropriateness of therapy,
formularies, etc. have evolved and been put into play over the last three years. The story
sounds good but it isn't compelling with respect to controlling specialty cost. Realistically, do
you think anything can really be done to better control these escalating costs and if so,what
would that be?
Topic 3—Approach and Methodology
1. The employers all value the integration of pharmacy and medical claims data through their
TPAs. They will want to ensure the data is fully-integrated in order to better understand
utilization, disease management and total health of their population. Describe how you
would integrate your data with BCBSFL,Allegiance and CHP to support overall management
of the cost of their health plans. What is the process to set up the integration? What fees, if
any, apply to integrating the pharmacy data with our TPA's system?
2. NCH as a health system is moving towards the creation of an ACO with Blue Cross Blue Shield
of Florida.The public employers are very interested in this concept. How will you support
the employers' efforts in this area?
Topic 4-Implementation and Ongoing Service Strategy
1. Describe your implementation process in detail,and clarify the role of your team members
during that process.
2. Both member education and physician/provider education are extremely important to this
group. Describe your approach to addressing both, and describe the flexibility you have to
create custom education and communication materials and initiatives for both parties.
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Topic 5—GPO Pricing
1. CCHCC employers may consider GPO Pricing in the future. NCH as a health care provider is
very interested in leveraging own use pricing.The public employers also understand that
they have the opportunity to leverage GPO pricing. They're very interested in what the State
of Oregon and other public bodies have accomplished in this area. Please outline what
actual experience you've had with GPO pricing, how you would make it available,and what
the expected savings would be.
Topic 6—Lowest Cost Channel
1. The plan design of each individual employer utilizes coinsurance versus a fixed copayment
for medications. One of the reasons this was implemented was to get members more
engaged in shopping around for the lowest cost. This recognizes there is significant
difference in the cost of having an identical prescription filled at Walgreens versus Costco.
Please describe how you will support educating plan members about the difference in cost
between pharmacies and how using that information can benefit both the member and
employer.
2. Also please comment on mail order. The employers have all experienced significant issues
with mail order costs.This is especially true with respect to the cost of generic drugs through
mail order versus retail. This is why they will not adopt a mandatory mail order program.
Please address this issue within the context of driving people to the lowest channel of cost in
conjunction with a voluntary mail order program.
Topic 7—Value Based Plan Design and Wellness
1. All the employers have extremely robust population management processes in place.There
are significant incentives to employees to complete regular health screening processes to
identify the presence of chronic disease and participate in programs designed to address
them.The group is considering offering 100%coverage for certain generic medications
associated with the treatment of chronic disease. Have you had experience in supporting
this approach? If so,for what disease types have you seen this work, and how do you go
about administering such a program?
Topic 8—Support to CHP
1. Through Community Health Partners(CHP)the group has a close working relationship with
local providers.This relationship goes beyond simply negotiating discounts and attempts to
address quality practice and prescribing patterns. Further, CHP is responsible for many
pharmacy prior authorization programs such as overrides for the therapeutic MAC process
for PPIs. Please comment on how you will support CHP in its efforts to educate providers
regarding pharmacy cost, administer prior authorization programs and work in partnership
with the employers to mitigate pharmacy trends.
Topic 9—Fixing Problems
1. In spite of everyone's best efforts errors do occur. What is important to the employers is
how responsive the PBM is in fixing problems once they are brought to their attention. They
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have experienced too many cases where problems just aren't resolved promptly leaving the
member without their medication or reimbursement.This will not be tolerated, and the
employers want you to agree to and comment on the following service guarantees and the
penalties associated with them:
• The member cannot get a prescription filled due to an issue with your system. If the
employer authorizes payment,you will make arrangements to direct the member to the
original pharmacy or another nearby that will fill the prescription and collect only the
applicable copayment from the member. This must be resolved that day or a penalty of
$5,000 will apply for each occurrence.
• The member does not receive reimbursement on a timely basis on a member pay claim.
If the employer contacts you and authorizes payment to the member it will be made and
the check overnighted to the member within 48 hours. A penalty of$5000 will apply for
each occurrence when such check is not created and mailed to the member within 48
hours
• Compound medications do not process and result in delays in payment of these claims
when they are submitted by the member. Members have had continuing issues filling
compound medications at the following pharmacies:Clinical Compound Pharmacy,
Creative Scripts and Walgreens at the Vineyard. Are these pharmacies in your network?
Will you guarantee if there is a problem in processing a claim that you will either:
1. Arrange for the prescription be filled at point of sale for the appropriate
member co-pay or
2. If the member has to pay the pharmacy, process with the claim with client
authorization and provide member reimbursement within five days of
notification and receipt of authorization. A$5000 penalty per occurrence will
apply to claims not processed for payment and/or not received when authorized
within five days.
• Member did not receive a specialty medication. If contacted by the employer and
authorized,the member must receive overnight delivery within 24 hours. Penalty of
$5000 will occur for each occurrence for this time frames not met.
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Undisclosed spontaneous questions for group to ask:
The PBM industry is increasingly utilizing contract language to manipulate quoted discounts
and guarantees to provide the illusion of more attractive terms when in reality there is no
net improvement. This is an area of increasing frustration for the employers. How will your
organizations philosophy and agreement with them address this issue?
2. How will you proactively help CHP and the employers address abuse of narcotic
prescriptions?
3. The PBM industry gets rebates. We understand that there are other incentives from drug
manufacturers which are not classified as rebates. Please describe the magnitude of these
incentives to your organization, how they are used, and whether you would consider passing
them on to the clients?
4. Your financial proposal helped to place you as a finalist in our selection process. All vendors
claim to offer significant savings. If you were the incumbent, other PBMs would show
savings over your results.This has caused us distrust the industry. If you are awarded the
contract,what steps will you take and how will you prove that your program will be
competitive over the term of the agreement?
Willis
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