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Item C10County 4 4 BOARD OF COUNTY COMMISSIONERS of Monroe �, Mayor David Rice, District 4 1i Mayor Pro Tern Sylvia J. Murphy, District 5 The Fl®nda. Keys'=.�` Danny L. Kolhage, District 1 �y George Neugent, District 2 Heather Carruthers, District 3 County Commission Meeting December 13, 2017 Agenda Item Number: C.10 Agenda Item Summary #3644 REVISED BACKUP DAY OF MEETING: Inserted final executed agreement for each of the two (2) agreements replacing the draft agreements originally attached. BULK ITEM: Yes DEPARTMENT: Employee Services TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez -Gonzalez (305) 292-4448 n/a AGENDA ITEM WORDING: Approval of a three (3) year Pharmacy Benefit Management Services Agreement with Envision Pharmaceutical Services, LLC, and approval of a three (3) year Medicare Employer Group Administrative Services Only Agreement with supplemental wrap- around benefits (EGWP/WRAP ASO) with Envision Insurance Company. ITEM BACKGROUND: An RFP was done in early 2017 for Pharmacy Benefit Management (PBM) Services. A total of six (6) proposals were received. Gallagher Benefit Services prepared the Non -technical analysis of each proposal and Health Care Analytics prepared the Technical analysis of each proposal. The RFP's and the analyses received were provided to all Selection Committee Members. The Selection Committee Members met September 13, 2017 and the Envision -Broad Network/Select Formulary proposal was ranked #1 with Blue Cross Blue Shield of Florida (BCBSF)-Prime Therapeutics ranked #2. The Envision -Broad Network/Select Formulary proposal projects approximate savings of over $2.2 million dollars over this three-year period vis-a-vis the current program. Projected savings will come from lower administration fees and higher rebates passed through to Monroe County. One of the changes approved by the BOCC in July 2017 during its review of the plan was to change from a Retiree Drug Subsidy model to an Employer Group Waiver Program with supplemental wraparound benefits program (EGWP/WRAP). Both RDS and EGWP provide the County with reimbursements for claims that have been paid for Medicare -eligible retirees in the Plan. Under RDS, the County receives an annual reimbursement at the end of the plan year. Under EGWP, the County receives reimbursements monthly during the plan year. There is no difference in Plan benefits. As shown in the attached slide, this option was projected to save the County approximately $250K per year. Envision Insurance Company was the only vendor to offer an Administrative Services Only plan to run the Employer Group Waiver Program with a supplemental wraparound benefits program (EGWP/WRAP ASO) which was part of the RFP. This item requests that the MCBOCC approve three-year agreements with Envision Pharmaceutical Services, LLC to provide pharmacy benefit management services and Envision Insurance Company to provide the EGWP/WRAP ASO services. PREVIOUS RELEVANT BOCC ACTION: RFP done in early 2011 — Envision Pharmaceutical Services, LLC was the selected PBM and an agreement for three years (10/l/11 — 9/31/14) was approved by the MCBOCC. Amendment #1 to Envision agreement approved 10/1/14 extended the contract through 9/30/17 Amendment #2 to Envision agreement approved 1/1/17 extended the contract through 12/31/17. CONTRACT/AGREEMENT CHANGES: Three (3) year Pharmacy Benefit Management Services Agreement and Medicare Employer Group Agreement (EGWP/WRAP ASO). Expected savings with this renewed contract is approximately $2.2 million over three year period. STAFF RECOMMENDATION: Approval DOCUMENTATION: FINAL EXECUTED PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT (Updated 12 12 17) FINAL EXECUTED EGWP+WRAP ASO Agt (2018) (Updated 12 12 17) Option 15, EGWP explanation, Power Point presentation 6-20-2017 2011 ENVISION AGREEMENT AMENDMENT 1 ENVISION AMENDMENT 2 ENVISION FINANCIAL IMPACT: Effective Date: 1/1/18 Expiration Date: 12/31/21 Total Dollar Value of Contract: Estimated $9,648,165 dependent upon claims Total Cost to County: Estimated $9,648,165 dependent upon claims and fees paid by covered lives Current Year Portion: n/a Budgeted: Source of Funds: Primarily Ad Valorem CPI: Indirect Costs: Estimated Ongoing Costs Not Included in above dollar amounts: Revenue Producing: If yes, amount: Grant: County Match: Insurance Required: Additional Details: 12/13/17 502-08003 GROUP INS CLAIMS $3,740,165.00 rx claims 12/13/17 502-08002 GROUP INS OPERATIONS $74,000.00 adm fees and misc expenses Total: $3, 814,165.00 REVIEWED BY: Bryan Cook Completed Assistant County Administrator Christine Hurley 11/28/2017 9:01 AM Cynthia Hall Completed Budget and Finance Completed Maria Slavik Completed Kathy Peters Completed Board of County Commissioners Pending 11/27/2017 12:06 PM Completed 11/28/2017 10:23 AM 11/28/2017 11:14 AM 11/28/2017 12:00 PM 11/28/2017 12:26 PM 12/13/2017 9:00 AM This Pharmacy Benefit Management Services Agreement (hereinafter this "Agreement") is entered into by and between Envision Pharmaceutical Services, LLC, an Ohio Limited Liability Company (hereinafter "Envision"), and Monroe County Board of County Commissioners (hereinafter "Plan Sponsor"). This Agreement is effective January 1, 2018 (hereinafter the "Effective Date"). Envision is a URAC accredited Pharmacy Benefit Management (PBM) company providing 4-*niyr,*1wwiv* * Wrers, 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: 1.1 "Administrative Fee" means the amount that Envision charges Plan Sponsor for included services under this Agreement as set forth in Exhibit 1. 1.2 "Benefit Plan" means the Plan Sponsor's group 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. 1.3 "Benefit Specification Form" or "Benefit Specification Change For 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 is Prescription Drugs are covered by Plan Sponsor (including, for example Limited Distribution Drugs or Specialty Drugs), 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.). If there is any inconsistency between the terms of this Agreement and the Benefit Specification Form or any Benefit Specification Change Form submitted in connection with the services to be provided under this Agreement, then the provisions of the most recent signed Benefit Specification Form or Benefit Change Form shall control. A separate Benefit Specification form shall be provided by Plan Sponsor for each unique Benefit Plan, is Benefit Plan shall be identified by a unique group number. 1.4 "Brand Drug" means a Prescription Drug designated as a branded drug product by Medi- Span as indicated by the multisource (i.e. MONY) code attached to the I I digit NDC for such Monroe County CBMSA 092217 \PBMSA (firn I 2091M 101 Envision Phannaceutical Services, LLC Page 1 of 48 91.1rely., �01 9 =1 1.5 "Claim" means an invoice or transaction (electronic or paper) for a Covered Drug • to a Covered Individual that has been submitted to Envision by the dispensing • or a Covered hidividual (including transactions where the Covered Individual paid 100% of the cost). A "34013 Claim" is a Claim which has been processed under Section 340B of the Public Health Service Act. 1.6 "Claims Adjudication System" or "System" means Envision's on-line computerized claims processing system. 1.7 "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. 1.8 "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. 1.9 "Covered Drug" means a Prescription Drug or other permitted drug (OTC), medical supplies (e.g. diabetic testing strips), or a medical device (e.gs 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. 1.10 "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, 1.11 "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 PEM 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. 1.12 "Eligible Employee" means an active employee or a Retiree of Plan Sponsor covered under Plan Sponsor's funded Benefit Plan. For purposes of this Agreement, a Retiree is a retired individual who is covered, primarily, by Plan Sponsor and not Medicare Part D. 1.13 "Formulary" means an index of Prescription Drugs and supplies developed by Envision's pharmacy and therapeutics committee, which is hereby adopted by Plan Sponsor, and shall be used in conjunction with the Benefit Plan as a guide in the selection of Covered Drugs. The Prescription Drugs and supplies on the Formulary will be modified by Envision from time to time as a result of factors including, but not limited to, medical appropriateness, manufacturer arrangements and patent expirations. Additions and deletions to the Formulary are hereby Monroe County EBMSA 082217 \PBMSA (ftm 120916) 0, Envision Pharmaceutical Services, LLC Page 2 of 48 adopted by Plan Sponsor. u 4 In. t . 1I Ill 1.15 "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as amended. 1.16 "Limited Distribution Drugs" means Prescription Drugs that are distributed by manufacturers through a limited number of pharmacies and wholesalers which have been selected by the manufacturer based on approved participation criteria. For purposes of this Agreement, Limited Distribution Drugs are not considered Specialty Drugs. 1.17 "Mail Order Pharmacy" means Orchard Pharmaceutical Services, LLC d/b/a EnvisionPharmacies. 1.18 "Manufacturer Derived Revenue" means retrospective Formulary rebates, discounts, administrative fees, and other revenue payable by pharmaceutical manufacturers that are received by Envision pursuant to the terms of a forraulary rebate contract negotiated independently by Envision with a pharmaceutical manufacturer, and which is directly attributable to Claims that comply with the utilization and benefit design requirements of such il�wharmaceutical manufacturer rebate contracts and that otherwise meet the terms and conditions hereunder. 119 "MAC List" means a proprietary list of Prescription Drugs for which Envision establishes a maximum price ("MAC Price") payable to the dispensing pharmacy. Envision utilizes the same MAC List 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 amount paid by Envision to the dispensing pharmacy for the Claim 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. 1.20 "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 and participates in the Network selected by Plan Sponsor. 1.21 "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 an 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. 1.22 "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. Monroe County PBMSA 092217 \PBMSA (firsi 'D Envision Phannacoutical Services, LLC Page 3 of 48 I INNIIHJE� �gilwnlrm ilia N.:01 � � _g1121.71KTI� 111! If % 1.23 "Prescriber" means a licensed health practitioner with independent prescribing authority in the state in which the dispensing pharmacy is located. 1.24 "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. 1.25 "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. 126 "Specialty Drug" means a Prescription Drug that is typically a high -cost biotech, injectable, infused, oral, or inhaled Prescription Drug, and/or a Prescription Drug that requires special storage, handling, and/or requires close monitoring of the patient's drug therapy to ensure appropriate use and clinical outcome. For purposes of this Agreement, Specialty Drugs are not considered Limited Distribution Drugs. 1.27 "Specialty Pharmacy" means Orchard Pharmaceutical Services, LLC d/b/a EnvisionPharmacies. 1.28 "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. 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 Cardup to two per family; (iii) a pocket Formulary; and (iv) Mail Order Pharmacy 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 Proces�in: 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 Plan Sponsor's owned pharmacies or Plan Sponsor's contracted Monroe County PBMSA 082217 TBMSA (Son 120916) [c Envision Pharmaceutical Services, LLC Page 4 of 48 ptiarmacies, it any, knot incluctin7AITBI-77aims, unTiM 71777 Ill a seyaraw 340B Agreement); (iii) submitted by Covered Individuals as Direct Member Reimbursements (DMRs, as defined below), or (iv) 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 • Specification Form (incorporated herein by this reference). For Claims that must be processed manually or require special handling, including, without limitation, (i) DMRs, (ii) Claims received from third parties, such as Medicaid, for P1 n n, i im.-,- Plan S onsor will M I �11 6 Monroe County PBMSA 082217 \PBMSA (firin 120916) 1 Envision Pharmaceutical Services, LLC Page 5 of 48 duplicate prescriptions; over-utilization/refill too soon; under -utilization; drug interactions; pediatric warnings; geriatric warnings; acutellmaintenance 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 Wrugs and circumstances specified by Plan Sponsor in the Benefit Specification Form, Envision shall contact the prescriber and veri - that the retuested 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 a separate or 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 a separate or attached clinical programs exhibit. 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 (each referred to herein as a "Network"'). The Network designated for Plan Sponsor to be used by Covered Individuals hereunder shall be specified in the Benefit Specation Form. Plan Sponsor acknowledges that the Pharmacies participating in a Network may be changed from time to time by Envision, including the designated Mail Order Pharmacy and/or Specialty Pharmacy provider. Contact information for Participating Pharmacies is constantly updated to reflect any changes 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 any drug from any Participating Pharmacy. 2.4.1 Plan Sponsor Owned Phannacies. If Plan Sponsor desires to include one or more of its owned or affiliated pharmacies in the network of Pharmacies authorized to dispense Covered Drugs to Plan Sponsor's Covered Individuals, it shall indicate same on the Benefit Specification Form. If Plan Sponsor desires its pharmacy to be available to other Envision clients using one or more of Envision's Networks, such pharmacy shall enter into an Envision Participating Pharmacy Agreement (PPA). If the pharmacy will be for the use of Plan Sponsor's employees only, such pharmacy shall complete an Envision -supplied form indicating the amounts to be invoiced to Plan Sponsor for Claims processed. In either case, the pharmacy shall submit all Claims to Envision for processing. Unless indicated otherwise in the Benefit Monroe County PBMSA 082217 \PBMSA (firn I 2091M i�Envision Phannaceutical Services, LLC Page 6 of 4ti Specification Form, Envision shall invoice Plan Sponsor for Claims received from Plan Sponsor's owned pharmacy. If the pharmacy is a Participating Pharmacy, Claims shall be adjudicated at the Network rates included in the A. 2.5 Customer Service- Envision shall maintain and operate a customer service center with toll -free customer service numbers and adequately staffed 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. Upon termination of this Agreement, Envision agrees to provide only industry -standard transfer files to a subsequent pharmacy benefit manager at Plan Sponsor's written request. Plan Sponsor agrees to pay or reimburse Envision for any cost charged by a vendor or pharmacy related to the transfer of files from or to such vendor or pharmacy at any time during this Agreement or connected with 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 fora 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). 2.7.1 Access to Third Parties: If Plan Sponsor desires Envision to provide one or more third parties access to web -based or other reports, Plan Sponsor shall complete and submit an Envision provided authorization form. Plan Sponsor acknowledges that any reports to be provided to Plan Sponsor's authorized third parties which are not accessible via the web -based reports generator, shall be provided via a secure FTP server. 2.8 Retiree Drug Subsidy (RDS) Rpports: 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 Manufacturer Derived Revenue is has been passed -through to Plan Sponsor will have been deducted from the Claim Monroe County PBMSA 082217 \PBMSA (fim 120916) ft) Envision Pharmaceutical Services, LLC Page 7 of 48 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 kWedlity for the comyletion or submission of any RDS a lication or request for subsidies under Medicare Part D. 2.9 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. 2.10 Performance Guarantees: Envision shall provide PBM Services in accordance with the Performance Guarantees specified in Exhibit 2 and shall compensate the Plan Sponsor for failure to meet any of the Perforinance Guarantees as outlined in Exhibit 2. 3.1 Pass -Through of Discounts and Dispensing Fees: The amount invoiced to Plan Sponsor shall be the exact drug ingredient cost and applicable dispensing fee which is paid to thso dispensing Pharmacy when the Claim is adjudicated without any reclassification, mark up, or spread by Envision, in accordance with the following: (a) The calculated negotiated amount payable to the Participating Phannacy based on the I I digit NDC number of the drug dispensed; car (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 Pharmacy or Specialty Pharmacy); Less any applicable 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. W, I Pass -Through of Manufacturer Derived Revenue: Envision shall pass through to 1,*,Ian Sponsor one hundred percent (100%) of all Manufacturer Derived Revenue earned by PI'm Sponsor for eligible Claims. Prescription Drugs eligible for Manufacturer Derived Revenue are included in the Formulary provided by Envision. Plan Sponsor acknowledges that the Manufacturer Derived Revenue earned by Plan Sponsor 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 Monroe County PBMSA 082217 \PBMSA (f=120916) —��) Envision Pharmaceutical Services, LLC Page 8 of 48 ME= 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. No Manufacturer Derived Revenue shall be payable to Plan Sponsor for 340B Claims, Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy, Claims for which Envision has not been paid in full, and other Claims not eligible for Manufacturer Derived V evenue. 3.2.2 Pass -Through Method2logy: Manufacturer Derived Revenue shall be advanced to Plan Sponsor by adjusting the Claim for an eligible Prescription Drug by an estimated amount for applicable 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 a credit for estimated 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 costco- 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 re"iweJoisk *-Ih*r r*ven-,YjK frtr-q 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. 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 Adjudication System and commence the - revision of PBM Services as of the Effective Date. Such data includes, without limitation, prior utilization reports, pharmacy transfer files, and eligibility. Monroe County PBMSA 082217 \PBMSA (frm 120916) �) Envision Pharmaceutical Services, LLC Page 9 of 48 11! 4.2 Eligibility Data: Plan Sponsor shall provide Envision (either directly or through authorized third party administrator) with an Eligibility File, at least monthly, in the HIPAA 83 standard transaction code set format, or such other format as has been previously agreed to b] I Envision. Plan Sponsor shall provide timely eligibility updates (for example, addition terminations, chan, e of address or -personal information etc.� to ensure accurate deterrmination A INRYA W] Nil WOH I M 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 • t coverage of benefits thereunder, however, Plan Sponsor understands and agrees that any cha in the Benefit Plan or System configuration (e.g. mandatory generic program, coverage of ove the -counter drugs or medications, source of Covered Drugs, use of Plan Sponsor Own pharmacies, etc.) may affect yields in Manufacturer Derived Revenue and/or average d pricing. Plan Sponsor agrees that Envision shall not be liable to Plan Sponsor for any reducti of such yields or increase in pricing which result from any such change. Further, any change the Benefit Plan that affects a material term of this Agreement will require an amendment beret Plan Sponsor agrees to execute an amendment, at Envision's request, before implementing t change to the Benefit Plan. 4.4 Formulary: Plan Sponsor hereby adopts and shall adhere to the Formulary identified the Benefit Specification Form. Plan Sponsor acknowledges the formulary may be modified Envision from time to time. Any custornization of the Formulary by Plan Sponsor or use by PI Monroe County PBMSA 082217 \PBMSA (fim120916) Envision Pharmaceutical Services, LLC Page 10 of 4, Sponsor of an alternate Formulary must be approved, in writing, by Envision. Plan Sponsol acknowledges that adherence to the Formulary is necessary to maximize yields in Manufacturer Derived Revenue. Plan Sponsor agrees that Envision shall not be liable to Plan Sponsor for any reduction in yields of Manufacturer Derived Revenue or increase in drug pricing 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. 45 Payment: Plan Sponsor shall timely pay, or cause its designee to timely pay, Envision for services rendered hereunder in accordance with Section 5 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. • 5.2 PayMents for Claims- Envision shall invoice Plan Sponsor twice each month for Claims incurred. Plan Sponsor shall pay Envision's invoices in accordance with the Florida Local Goverm-nent Prompt Pay Act, Section 218.70, Florida Statutes. 5.3 PayMent of Administrative Fee: Plan Sponsor agrees that the Administrative Fee set forth in Exhibit I shall be added to the invoiced amount for each Invoiced Claim and shall be paid by Plan Sponsor in conjunction with the payment of Claims as set forth in Section 5.2. For purposes of this Section, an "Invoiced Claim" shall be a Claim payable by Plan Sponsor under this Agreement, but shall not include transactions for Claims which have been rejected under the specifications of the Benefit Plan, transactions for previously paid Claims which have been reversed (e.g. as a result of a reversal of a Claim by a Participating Pharmacy or by Envision as a result of an audit), or transactions for reprocessed Claims (e.g. to correct a previously paid Claim). 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 I hereunder in accordance with the Florida Local Government Prompt Payment Act. 5.5 Retroactive Disenrollment or Termination: Retroactive termination or disenrollment of a Covered Individual as 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 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. Monroe County PBMSA 082217 \PBMSA (fan 120916) �,O Envision Phannaceutical Services, LLC Page 11 of 48 MEM I � I I I I I I !III IIIII 111 1: 1 1 1/ii I I �1# 1 . 5.6 Financial Respoqgbility: Plan Sponsor shall be and remain responsible for the payme of all invoices for Administrative Fees, Additional Services, Miscellaneous Expenses, an Claims (along with any associated dispensing fees, taxes, assessments and fees, and Cost Sha not ultimately paid by Members). Plan Sponsor acknowledges that Envision will not pa pharmacies for Plan Sponsor's Claims, nor be obligated to pay pharmacies for Claims, unle and until adequate funds are received from Plan Sponsor. 5.6.1 Untimely Payments: If Plan Sponsor should fail to timely pay any amounts Envision hereunder for any reason, including, but not limited to, insolvency, bankruptc kIIirmhirAiwxwf Itimi end the provision] services; (ii) offset such amounts owed to Envision by any amounts owed by Envision to Pla 4 iii) 1] TA. PRITal As part of the finalization process, Envision shall be permitted to use as a credit against anj Monroe County PBMSA 082217 \PBMSA (frm 120916) QO Envision Pharmaceutical Services, LLC Page 12 of 48 amounts due to Plan Sponsor, the total amount of over performance achieved by Envision for any and all financial guarantees. Upon final settlement of audit, Envision shall remit any funds agreed to be due to Plan Sponsor within thirty (30) calendar days in the form of a credit memo to Plan Sponsor. The audit provisions hereunder shall survive the termination of this Agreement for twelve (12) months following the effective date of tennination. 5.8 Financial Audit by Envision: Envision may, at its sole expense and at reasonab intervals, request Plan Sponsor to provide records for Envision's inspection which provi supporting documentation for the information contained in the Eligibility File and the d provided by Plan Sponsor (or its designate) upon which the financial terms herein were base Plan Sponsor agrees to provide such supporting documentation to Envision within ten (I b ns usiness days of such request. In addition, and if warranted, Envision may, at its own expe al inspect and audit, or cause to be inspected and audited, once annually, the books and records i Plan Sponsor directly relating to the existence and number of Covered Individuals. Audits shal only be made during normal business hours following thirty (30) days written notice, I conducted without undue interference to Plan Sponsor's business activity, and in accordanc with reasonable audit practices. Envision agrees to execute a confidentiality agreement wi Plan Sponsor prior to the audit. 6. TERM AND TERMINATION 6°1 Term: The to of this Agreement shall commence on the Effective Date and shall remain in full force and effect for an initial term of three (3) years ("Initial Tenn") 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 to of one year-, 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. Upon request, Envision agrees to provide Plan Sponsor with estimated renewal pricing within one hundred eighty (18 0) days prior to the end of the Initial Term. 6.2 Termination: This Agreement may be terminated as follows- 62 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 Monroe County PBMSA 082217 TBMSA (fi-in120916) o'Envision, Phannaccutical Services, LLC Page 13 of 48 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. 6.2.4 Termination Without Cause- After the first Contract Year, Plan Sponsor may terminate this Agreement without cause, by notifying Envision, in writing, at least ninety (90) days prior to the effective date of termination. Envision may terminate this Agreement without cause, by notifying Plan Sponsor, in wrng, at least ninety (90) days prior to the effective da of the termination. 615 Market Check- Following initial eighteen (18) months of this Agreement (but not before), Plan Sponsor or its designee may provide Envision with a written firm proposal for pharmacy benefit management services offered by a third party PBM provider to Plan Sponsor which includes similar plan design, Formulary, clinical and trend programs, retail pharmacy, mail pharmacy, and specialty pharmacy mix and utzation, demographics and other relevant factors necessary to provide an appropriate comparison ("Plan Sponsor's Current Market Price"). Plan Sponsor's Current Market Price will be measured on the basis of a total, aggregate comparison of the pricing terms, and not on the basis of individual or best price points. Envision shall have a reasonable opportunity to evaluate Plan Sponsor's Current Market Price. If the proposal concludes that Plan Sponsor's Current Market Price would yield an annual three percent (3%) or more savings of "Net Plan Costs" (with Net Plan Costs defined as the sum of the cost of Covered Drugs, dispensing fees, and Claims Administrative Fees, less Rebates received by Plan Sponsor) under the Agreement, and Envision is unable or unwilling to offer new tenns X.4 vlu-aki )vwok-hin rj�rist�F percent (90%) of such offer, then Sponsor may terminate this Agreement upon ninety (90) days prior written notice to Envision. 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 releas(i 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 Manufacturer Derived Revenue to Plan Sponsor upon Plan Sponsor's notification of termination. In the even) that Plan Sponsor terminates this Agreement prior to completion of the Initial Tenn, Plan Sponsor shall refund any prorated amounts outstanding for any amount of money that Envision has funded to or on behalf of Plan Sponsor, including but not limited to allowances, credits and fees as set lb-th herein. Monroe County PBMSA 082217 \PBMSA (finnI20916) �0 Envision Phannaceritical Services, LLC Page 14 of 48 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) 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. T2 Protected Health Information: Plan Sponsor will have access to Protected Healt (n rt ZCc&aaJ by Plan Sponsor via Envision's website. Plan Sponsor agrees, for itself and its employees, A PHI shall not be used for any impermissible purpose, including, without limitation, the use PHI for disciplinary or discriminatory purposes, and any user names and passwords assigned designated individuals shall not be shared with non -designated individuals. In addition, PI Sponsor, for itself and its Covered Individuals, authorizes Envision to use and share PHI necessary to carry its obligations hereunder. Envision and Plan Sponsor shall execute a HIP Business Associate Agreement. I MIFUMONIRMODIRNM 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, damages, costs, losses and expenses (including without limitation, reasonable costs of investigation and attorneys' fees) incurred in connection with any and all third party claims which were caused by or arising out of (i) any negligent 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: Subject to and without waiving the provisions of Section 768.28, Florida Statutes, 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, damages, costs, losses and expenses (including without limitation, reasonable costs of investigation and attorneys' fees) incurred in connection with any and all third party claims which were 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 Liabilfty: Except in the case of fraud, the rights of the parties hereto for Monroe County PBMSA 082217 TBMSA (fim120916) h( 0 Envision Phannaceutical Services, LLC Page 15 of 48 ■ II 'I'll llorw islinsin will wor■ la lssrrr r indemnification relating to this Agreement or the transactions contemplated hereby shall be strictly limited to those contained in this Section 8, and such indemnification rights shall be the exclusive remedies of the parties with respect to any matter arising under or in connection with this Agreement. Notwithstanding 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, dental, 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. I 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 iriii.yiu"t -lic., for any liabilitpi arisin■3 from the dispensin_&DJ "ru-4s or medical supplies to Covered Individuals by any pharmacy. IO.GENE RAL 10.1 Acknowledgement: Plan Sponsor acknowledges and agrees that it retains the sole responsibility for the terms and conditions of its Benefit Plan; its compliance with applicable law, and that of its Benefit Plan, including, without limitation, the interpretation and applicability of any state or federally mandated requirements; and determinations of coverage under the Benefit Nan; and, shall not rely *n amy atvice +r rec-*&-A:rea4zti*As 6f Fnvisi*n vsz su4sOut(.- ftr obtaining its own independent accounting, tax, legal, or regulatory advice. 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. Monroe County PBMSA 082217 \PBMSA (firm 120916) �60 Envision Pharmaceutical Services, LLC Page 16 of 48 ME= lillilini 11 il-lollill 11111!11J! Jill, plillill 11 JJ I• 10.3 Exclusivity: During the to 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. 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 P 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. Monroe County PBMSA 082217 \PBMSA (ftm 120916) V Envision Pharmaceutical Services, LLC Page 17 of 48 services provided hereunder, or the fees or revenues generated by the items dispensed or services provided hereunder, or any other amounts Envision or one or more of its subsidiaries or affiliates may incur or be required to pay arising from or relating to Envision's or its subsidiaries' or affiliates' performance of services as a pham-iacy benefit manager, third party administrator, or otherwise in any jurisdiction, will be the sole responsibility of Plan Sponsor or the Member. If Envision is legally obligated to collect and remit, or to incur or pay, any such sales, use, excise, gross receipts or other similarly assessed and administered tax, surcharge, or fee in a particular urisdiction. such amount will be reflected on the a plicable invoice or subsequentl invoiced at H J Monroe County PBMSA 082217 \PBMSA (firtt120916) 0 Envision Pharmaceutical Services, LLC Page 18 of 48 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. 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 health plan; (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 is 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. 10.19 Third Party Administrator/Consultants/Brokers: Unless otherwise stated herein, no payments shall be made by Envision to any of Plan Sponsor's Third Party Administrators (TPA), consultants, brokers, or other third party to carry out any of Plan Sponsor's obligations under this Agreement or for any other reason. 11. FLORIDA REQUIRED CONTRACTUAL LANGUAGE 11.1 Florida State Law: Pursuant to Florida Statute (F. S.) 119.071, Envision agrees to the following provisions: 119.071 Envision and its subcontractors shall comply with all public records laws of the State of Florida, specifically to: Lal Keep and maintain public records that ordinarily and necessarily would be required by Monroe County in the performance of this Agreement; (1?1 Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law-, fc) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law-, tdj Meet all requirements for retaining public records and transfer, at no cost, to Monroe County all public records in possession of the Proposer upon termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements, All records stored electronically must be provided to Monroe County in a format that is compatible with the information technology systems of Monroe County; and Cel Upon completion of the contract, transfer, at no cost, to the County all public records in possession of the Contractor or keep and maintain public records that would be required by the County to perform the service. If the Contractor transfers all public records to the County upon completion of the contract, the Contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the Contractor keeps and maintains public records upon completion of the contract, the Contractor shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the County, upon request from the County's custodian of records, in a format thal is compatible with the information technology systems of the County. 12.0 Federal Contractual Provisions. Recognizing that a portion of the funds used to RU for the services covered by this agreement come from a federal award, as that term is defined in 2 CFR -part 200.38, the contractual -provisions contained in Exhibit 3, attached hereto, are made 12art of this agreement. To the extent that any of the federal contractual provisions are inconsistent with a provision in this agreement, the federal contractual provisions contained in Exhibit 3 shall control, Monroe County PBMSA 082217 TBMSA (firn120916) C Envision Pharmaceutical Services, LLC Page 20 of 48 TA7�7_tEN=T SIGNATURE PAGE IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Agreement as of the Effective Date above. For ENVISION: DocuSigned by; By: F� -3 By: F Matthew A. Gibbs, Pharm D. President, Commercial & Managed Markets Print Name & Title Address-, Address: Envision Pharmaceutical Services, LLC 2181 East Aurora Road Twinsburg, OH 44087 PH: 330-405-8080 PH: EX: 330-405-8081 EX: E-MAIL: FEIN: Monroe County PRMSA 082217 \PBMSA (frm120916) > Envision Pharmaceuticat Services, LLC Page 21 of 48 �1 ��� 23-:1121511F M! I � i i � i I i, 11 i 11 1881immam EXHIBIT I FEES AND FINANCIAL GUARANTEE] Administrative Fee (Payable to Envision; not including fees payable to Plan Sponsor's TPAs, consultants, or brokers, if any) For Contract Year 1: $1.00 Per Claim For Contract Year 2: $1.04 Per Claim For Contract Year 3: $1.08 Per Claim Fees for Additional Services and Miscellaneous Expenses 1. Manually create or update the Eligibility File $ 1. 00 per Covered Individual data entry 2. Replacement by Envision of lost or stolen ID $1.15 per card plus cost of postage Cards (individual), $2.00 per card (family) plus $0.15 per ID Card packet and cost of postage 3. Ad Hoc Reporting (for a one-time, standard report) No charge 4. Coverage Determinations (including Clinical Prior $35.00 per request Authorizations) 5. Manual Claims Processing (including DMRs) $1.50 per Claim processed Fees for Additional Optional Services and Miscellaneous Expenses 1. Custom Eligibility File layouts (accommodation or development) $1,000.00 per layout 2. Member Communications Cost of production and postage 3. Custoebsite Quoted upon request 4. Standard Online Reporting User Access Standard Online Reporting includes access for 3 active Plan Sponsor users and 1 consultant user. A licensing fee of $1,200.00 would apply for each additional user. 5. Development of Ad Hoc Non -Standard report $2,500 Development of a recurring, non-standard report quoted upon request 6. Incoming Data Transfer Files 1 $250.00 per industry -standard file (non -industry standard file formats will be quoted upon request) 7. Benefit Integrity Enhanced Services (as set forth I To be quoted upon request, and based upon Monroe County PBMSA 082217 \PBMSA (fian 120916) C' ) Envision Phannaceutical Services, LLC Page 22 of 48 in the Benefit Integrity Enhanced Services service area Addendum) 8. Submission of Medicare Part D subsidy $1.00 per Member, per month, minimum $2,000 per year 9. Customized Formulary $0.20 per Member, per month, minimum of $2,000 per month 10. Redetermination (Internal Appeals) $125 per request 11. External Appeals including services of an 100% pass -through of costs incurred Independent Review Organization (IRO) (ranging between $250 to $350 per appeal, average cost is approximately $300 per appeal) 12. e-Prescribing $0.30 per transaction, minimum of $250.00 per month 13. Claim Adjustment Checks (charged to Plan Sponsor for reimbursements made to Covered Individuals for Claim adjustments requested by Plan Sponsor.) $8.50 per check 14. Explanation of Benefits (EOB) production and distribution $ 1. 00 per EOB plus postage 15. Medicaid Subrogation Claim Adjudication $3.50 per Claim 16. Drug Therapy Care Gap Management $0.55 per Member, per month 17. Medication Adherence and Persistency (up to three disease states) $0.55 per Member, per month 18. Outgoing Data Transfer Files (Claims History, Prior Authorization Files, Open Refill Files (Mail and Specialty), Accumulator Files (deductible, out-of-pocket, etc.), and/or related participant data $5,000 for any or all of the identified files (i.e. patient addresses, etc.) reports 19. ControlTrackRx Retail Pharmacy Audit Program 80% of recoveries passed to Plan Sponsor 20. ControlTrakRx On -site Plan Sponsor -requested $1,500 per onsite audit, plus 80% of pharmacy audit recoveries passed to Plan Sponsor Drug Pricing and Dispensing Fees (A) Supply/Source BRAND GENERIC For Contract Year 1 Drug Price (B)(C) Average Dispensing (c) Drug Price (11)(C) Average Dispensing (c) (based on 3 year (Annual Fee (Annual Fee Agreement) Effective Rate (Annual Effective Rate (Annual Guarantee) verage Guarantee) Average Monroe County MBMSA 082217 \PBMSA orm 120916) C) Envision Phannaceutical Services, LLC Page 23 of 48 Guarantee) Guarantee) Retail Pharmacy (30 AWP minus 17.00% $1.00 AWP minus $1.00 Days' Supply) 80.00% Retail Pharmacy (84 Days' Supply or AWP minus 22.00% N./A AWP minus N/A greater) (non -Mail 84.00% Order) Mail Order Pharmacy AWP minus (45 Days' Supply or AWP minus 17.00% N/A N/A 80.00% less) Mail Order Pharmacy AWP minus (46 Days' Supply or AWP minus 23.00% N/A. N/A 85.00% greater) 1 1 Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) Supply/Source BRAND GENERIC Drug Price CRXQ Dispensing Drug Price (BPQ Dispensing For Contract Year 2 (Annual Average Fee (C) (Annual Average Fee (C) (based on 3 year Effective Rate (Annual Effective Rate (Annual Agreement) Guarantee) Average Guarantee) Average Guarantee) Guarantee) Retail Pharmacy (30 AWP minus 17.00% $1.00 AWP minus $1.00 Days' Supply) 80.25% Retail Pharmacy (84 Days' Supply or AWP minus 22.00% N/A AWP minus N/A greater) (non -Mail 84.00% Order) ') Mail Order Pharmacy AWP minus (45 Days' Supply or AWP minus 17.00% N:!A 80.25% N/A less) Mail Order Pharmacy AWP minus (46 Days' Supply or AWP minus 23.00% N/A 85.00% N/A. greater) I I Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) Supply/Source BRAND GENERIC For Contract Year 3 Drug Price (0)(c) Dispensing Drug Price (B)CC) Dispensing (based on 3 year (Annual Average Fee (c) (Annual Average Fee (c) Agreement) Effective Rate (Annual Effective Rate (Annual Guarantee) Average Guarantee) Average Monroe County PBMSA 082217 \PBMSA (fnnl209l6) 40, Envision Pharmaceutical Services, LLC Page 24 of 48 Guarantee) Guarantee) Retail Pharmacy (30 AWP minus 17.00% $1.00 AWP minus $1.00 Days' Supply) 80.50% Retail Pharmacy (84 Days' Supply or AWP minus 22.00% N/A AWP minus N/A greater) (non -Mail 84.00% Order) (') Mail Order Pharmacy AWP minus (45 Days' Supply or AWP minus 17.00% N./A 80.50% N/A less) Mail Order Pharmacy AWP minus (46 Days' Supply or AWP minus 23.00% N/A 85.00% N/A greater) Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) (A) For purposes of this Agreement the "Average Wholesale Price" or "AVvT" means the average wholesale price of a Covered Drug indicated on the most current pricing file provided to Envision by Medi-Sang (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 AWE and updates the AWP source file at least once weekly. (B) For purposes of this Agreement, the "Annual Average Effective Rate" means, for the category of drugs being reviewed, the result calculated by the following formula: 1. (IC/AWP)-1, where IC (the "Ingredient Cost") is the sum of all amounts paid by Plan Sponsor for the ingredient costs of the Covered Drugs paid to Participating Pharmacies in the designated Network during the Contract Year, before deducting applicable Manufacturer Derived Revenue; and 2. AWP is the sum of the Average Wholesale Price amounts associated with the same Covered Drugs during the Contract Year. 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. (c) The Annual Average Effective Rate and Annual Average Dispensing Fee is calculated using actual price paid by Envision to Participating Pharmacies in the designated Network, plus any Cost Share, (the Ingredient Cost) for all Claims for the applicable category above (including Claims paid at the U&C Price) during a Contract Year, excluding (i) compound drugs-, (ii) Limited Distribution Drugs; (iii) drugs dispensed at a Specialty Phanyracy; (iv) Claims from non -Participating Pharmacies, LTC pharmacies, home infusion or government owned or operated pharmacies (e.g. Veterans Administration); (v) Claims paid at government required amounts (e.g. Medicaid); (vi) 340B Claims; (vii) vaccines-, (viii) non -Prescription Drugs (including OTC); (ix) drugs in limited supply; (a) Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy; (xi) manually processed Claims-, (xii) coordination of benefits Claims; and (xiii) Medicaid subrogation Claims. J)' 84 Days' supply or greater at retail pharmacy guarantees apply only if Plan Sponsor's Benefit Plan includes a 90 days' supply at retail benefit for the entire Contract Year. Annual Average Effective Rate and Annual Average Dispensing Fee Guarantee Plan Sponsor acknowledges that the Annual Average Effective Rates and Annual Average Dispensing Fees Monroe County PBMSA 082217 \PBMSA (ftro 120916) Envision Phannaceutical Services, LLC Page 25 of 48 ■ in this Exhibit I are conditioned upon Plan Sponsor's adherence to certain conditions under this Aareement and that the actual Annual Avera e Effective Rates and Annual Average isl2ensi WORK ■ Lo or more laloi■ for each drug type or category individually. If the amounts paid by Plan Sponsor for all Claims during the Contract Year are less favorable, in the aggregate and after application of any additional offsets allowed under this Agreement, than the combined Annual Average Effective Rates and Annual Average Dispensing Fees stated in Exhibit 1, Envision shall credit Plan Sponsor with the difference as set forth below. Envision shall not be liable to Plan Sponsor for shortfalls in guaranteed Annual Average Effective Rates or Annual Average Dispensing Fees if (i) Plan Sponsor makes a change to the Benefit Plan at any time (regardless of whether or not such change is required by law); (ii) the configuration of System edits is modified by ■ Sponsor; (iii) Plan Sponsor ■ not adhere to the Formulary; (iv) the utilization data provided by ■ Sponsor (or Plan Sponsor's agent) upon which the calculation of guarantees were based is inaccurate, incomplete; (v) there is a change +/- 20% in drug utilization patterns of Covered Individuals; or (vi) Plan Sponsor terminates before completion of the applicable, full Contract Year. In addition, Plan Sponsor agrees that Envision's liability to Plan Sponsor for shortfalls in financial guarantees, in the aggregate, for any Contract Year shall be limited to amounts paid ■ Plan Sponsor to Envision for Administrative Fees during the applicable Contract Year, and ■ Sponsor has no right of offset to withhold any payment due Envision under this Agreement for any amounts ■ Sponsor believes are owed by Envision for financial guarantees. I Annual Average Manufacturer Derived Revenue Guaranteeh),"' (G),(H) I For Contract Year 1: • For 30 day supply of Brand Drugs at a Retail Pharmacy - $96.92 per paid Brand Drug Claim • For 84 days' supply of Brand Drugs at a Retail Pharmacy- $263.26 per paid Brand Drug Claim • For up to 45 days' supply of Brand Drugs at the all Order Pharmacy- $96.92 per paid Brand Drug Claim • For 46+ days' supply of Brand Drugs at the Mail Order Pharmacy- $407.53 per paid Brand Drug Claim • For Specialty Brand Drugs - $468.54 per paid Specialty Brand Drug Claim For Contract Year 2: • For 30 day supply of Brand Drugs at a Retail Pharmacy - $100.59 per paid Brand Drug Claim • For 84 days' supply of Brand Drugs at a Retail Pharmacy- $285.20 per paid Brand Drug Claim • For up to 45 days' supply of Brand Drugs at the Mail Order Pharmacy- $100.59 per paid Brand Drug Claim • For 46+ days' supply of Brand Drugs at the Mail Order Pharmacy- $463 , 16 per paid Brand Drug Claim • For Specialty Brand Drugs - $550.41 per paid Specialty Brand Drug Claim For Contract Year 3: • For 30 day supply of Brand Drugs at a Retail Pharmacy - $111.39 per paid Brand Drug Claim • For 84 days' supply of Brand Drugs at a Retail Pharmacy- $315.88 per paid Brand Drug Claim • For up to 45 days' supply of Brand Drugs at the Mail Order Pharmacy- $111.39 per paid Brand Drug Claim • For 46+ days' supply of Brand Drugs at the Mail Order Pharmacy- $579.94 per paid Brand Drug Claim Monroe County PBMSA 082217 \PBMSA (firn 120916) (0 Envision Pharmaceutical Services, LLC Page 26 of 48 e con I ions Tor reoates or praiarinacel (ix) if Plan Sponsor has been excluded by a manufacturer; (x) there is any governmental regulation, ruling, or guidance that impacts Envision's ability to maintain current Manufacturer Derived Revenue yields; or, (xi) Plan Sponsor terminates before completion of the applicable, Contract Year. Plan Sponsor agrees that': Envision's liability to Plan Sponsor for shortfalls in financial guarantees, in the aggregate, for any Contract Year shall be limited to amounts paid by Plan Sponsor to Envision for Administrative Fees during the applicable Contract Year, and Plan Sponsor has no right of offset to withhold any payment due Envision under this Agreement for any amounts Plan Sponsor believes are owed by Envision for financial guarantees. Envision reserves the right to modify the pricing if the actual enrollment on the program decreases by 20% or more from total enrollment on the effective date of this agreement. Monroe County PBMSA 082217 TBMSA (frm 120916) �'O Envision Phannaceutical Services, LLC Page 27 of 48 EXHIBIT 2 Envision shall provide PBM Services in accordance with the Performance Guarantees specified in this Exhibit. So long as both parties have executed the Agreement, Envision shall provide Plan Sponsor with a Performance Guarantee report within ninety (90) days after the end of each Contract Year. The total amount of penalties payable by Envision in any Contract Year shall not exceed ten Year for on -going Performance Guarantees with no more than 20% to be allocated towards one performance area. If not allocated, the total amount at risk shall be evenly distributed across the proposed Performance Guarantees. Failure to meet Performance Guarantees shall not be deemed to be a breach of this Agreement. Unless otherwise noted in this Exhibit, Performance Guarantees shall be measured annually on a client specific basis. Milli■ ot the Fertormance (Juarantees notect in this hxmbit and flan �iponsor desires to assess then Plan Sponsor will provide Envision, within forty-five (45) days of receipt, with written notice to assess a penalty. Amy penalties assessed against Envision pursuant to this Agreement will be credited against future billings to Plan Sponsor in accordance with the execution of this Agreement and Envision's standard procedures. In the event that any failure by Envision to meet any Performance Guarantee is due to a force majeure as defined in this Agreement, failure by Plan Sponsor to perform its obligations under this Agreement, or actions or inactions of Plan Sponsor that adversely impact Envision's ability to maintain the Performance Guarantee(s), Envision will be excused from compliance with such Performance Guarantee(s) until such circumstances have been resolved and any existiq�� backlogs or other related effects have been eliminated. The following performance guarantees shall apply through 9/30/2020, for services that have been fully delegated to Envision. Envision Performance Guarantees PG# Performance Performance Standard Category Account Management Account Envision guarantees an average account Management management satisfaction rate of 3 or Satisfaction higher per Contract Year, on Envision's standard Account Management survey with a scale of 1 to 5 (5 being the highest). Plan Sponsor employees, who have routine day to day interactions with Envision's account management team, shall promptly complete and return all surveys. UEM= Up to 20% of total amount at risk. Monroe County PBMSA 082217 TBMSA (frin120916) 'd Envision Phannaceutical Services, LLC Page 28 of 48 Envision Performance Guarantees PG# Performance Performance Standard Measurement Category Period 2 Standard Benefit Envision guarantees that it shall modify Annually Modification standard changes to existing benefits Turnaround within thirty (30) calendar days or less from the date that Envision receives the signed Benefit Change or from Plan Sponsor. Plan sponsor understands that urgent and custom requests are excluded from the measurement of this performance guarantee. Help Desk 3 Average Speed Envision shall answer calls to the Annually 4 ID of Answer - member service telephone line Member Service administered by Envision within an average of thirty (30) seconds per Contract Year, measured on a book of business basis. Call Center Envision shall make available a toll free Abandonment member help desk telephone line. The Rate Abandonment Rate of the member help desk telephone line will be five percent (5%) or less per Contract Year, measured on a book of business basis. Blocked Call 1 % or less of calls to nvision's member Rate help desk call centers will receive a busy signal each Contract Year, measured on a book of business basis. "Blocked Call Rate" means the W number of incomplete member telephone calls to member help desk call centers each Contract Year which were never received due to the caller receiving a busy signal, divided by (ii) the total number of member telephone calls presented to member help desk call centers during such Contract Year. Annually Up to 20% of total amount at risk. Annually Up to 20% of total amount at risk. Monroe County PBMSA 082217 \PBMSA (ftinI20916) (7' Envision Pharmaceutical Services, LLC Page 29 of 48 PG4 Performanffl Category 6 Dispensing Accuracy Envision Performance Guarantees Performance Standard Measurement Annual Penalty Period Mail Order Pharmacy Dispensing Accuracy Rate for each Contract Year will be 99.993% or 0,usiN sured on a book of b ness ir WM "Dispensing Accuracy Rate" means (i) the number of all mail and specialty pharmacy prescriptions dispensed by Envision, less the number of those prescriptions which are reported to Envision and verified by Envision as having been dispensed with the incorrect drug, strength, or form, divided by (fl) the number of all mail and specialty pharmacy prescriptions dispensed by Envision. 7 Mail Turnaround Envision shall dispense "Clean Mail Time — Clean Service Orders" within an average of two Orders (2) business days per Contract Year, provided Envision Pharmacies has dispensed a minimum of one thousand (1,000) total mail service orders in such Contract Year. "Clean Mail Service Order"means mail service orders received by Envision Pharmacies that are in stock and which do not require physician or patient contact or other non-standard procedures prior to dispensing by Envision Pharmacies. Annually Up to 20% of total amount at risk. I Monroe County PBMSA 082217 \PBMSA (firrn120916) 0 Envision Phannaccutical Services, LLC Page 30 of 48 Envision Performance Guarantees PG# Performance Performance Standard Measurement Annual Penalty Category Period 8 Mail Turnaround Envision shall dispense intervention mail Annually Up to 20% of Time — service orders within an average of five total amount at Intervention (5) business as per Contract Year, risk. Orders provided Envision Pharmacies has dispensed a minimum of one thousand (1,000) total mail service orders in such Contract Year. "Intervention Mail Service Order" means mail service orders received by Envision Pharmacies that are not in stock and which do require physician or patient contact or other non-standard procedures prior to dispensing by Envision Pharmacies. Retail Pharmacy 9 Online Claims Except for scheduled maintenance Annually Up to 20% of Processing periods, Envision's claims adjudication total amount at System system will be available at least ninety risk. Availability nine percent (99%) of the time, measured on a book of business basis, 10 Online Claims Ninety-eight percent (98%) or more of Annually Up to 20% of Processing online transactions will be processed total amount at System within four (4) seconds based on an risk. Response annual average, measured on a book of business basis. Other Services 11 Eligibility Load Envision guarantees 99.98% of usable Annually $250 per file, Turnaround eligibility files received before 7:00 AM subject to a Eastern Time on any business day will maximum be accurately loaded and active in the penalty of 20% on-line claims adjudication system within of at risk amount two (2) business days of Envision's per Contract receipt. Year. 12 Standard Envision's standard financial reporting Annually $500 per file, Financial package will be made available online subject to a Reporting within 30 days following the end of the maximum Package quarter. penalty of 20% Turnaround of at risk amount per Contract Year. Monroe County PBMSA082217 \PBMSA(fiTn 120916) �E) Envision Pharmaceutical Services, LLC Page 31 ■,. 48 yJnJffMAJ. EV:161MMUNII11FOUR 10 11111111 4111101111 =1 11111 1111111, 1 1 1 , ........... ... 1­11111111 Concurrent Drug Utilization Review ("DUR") Program — point of sale system checks to identify contraindicated drugs and drug strengths not recommended Envision's Concurrent DUR Program provides electronic clinical monitoring of prescription drugs at the point -of -sale claims system edits. It is designed to encourage cost-effective, high quality drug therapies by notifying pharmacists of potential drug therapy complications at the point -of -sale before prescriptions are dispensed. The DUR Program is intended to be used by the pharmacist as a screening tool to detect outlying prescription drug utilization patterns, but not substitute for professional judgment. All claims submitted through the Envision Concurrent DUR Program are entered into the patient's active drug profile, thus allowing the system to evaluate prescription claims prior to the initiation of drug therapy. The patient's profile is accessed regardless of the participating pharmacy the patient may choose. Drug Utilization Review Listed below are the eleven major Concurrent DUR modules that Envision utilizes during the processing of prescription drug claims. All of the clinical modules use National Council of Prescription Drug Plans ("NCPDP") standard conflict codes: • Duplicate Therapy (drugs from the same therapeutic class) • Drug -Drug Interaction (combinations of drugs with potential for severe adverse effects) • Low Dose Alert (drug doses that fail to meet the suggested minimum daily dose) • High Dose Alert (drug doses that exceed the suggested maximum daily dose) • Excessive Utilization ("Too Soon Refill" Monitoring which monitors refill claims sent before a defined percentage of the previous fill is used) • Geriatric Precautions (drugs inappropriate for patients over the age of 60) • Pediatric Precautions (drugs inappropriate for pediatrics based on the patient's tender age) • Drug Duplication (drugs containing the same ingredients) • Drug -Gender Precaution (drugs not indicated for a specific gender) • Drug -Disease Precaution (drugs inappropriate) • Under -Utilization (Late Refill Monitoring which is a refill for a chronic maintenance drug requested at an interval longer than directed by the prescriber) Each DUR warning is accompanied by the appropriate NCPDP DUR conflict code and message. The message received will be in a format designed by the pharmacy software vendor. Additionally, most pharmacy software may also have editing capability, but may be limited to prescriptions filled at that store or chain. Monroe County PBMSA 082217 \PBMSA (f=120916) 10 Envision Phannaceutical Services, LLC Page 32 of 48 12AII !'I I I' I! I I 1! 1 11 fl %fi ....................... Envision's Medication Therapy Management/Drug Therapy Management Program is designed to achieve appropriate therapeutic outcomes for targeted patients through improved medication use. This includes the involvement of patients, caregivers, care providers, pharmacists, physicians, educators, and care coordinators. The Program is consistent with evidence based -guidelines, including guidance from the Centers for Medicare and Medicaid Services ("CMS"). Prospective candidates for the DTM/MTM Program are those patients who have multiple chronic conditions, are taking multiple medications, and will most likely incur high annual drug costs. In addition, specific patients that fall outside of the previously mentioned identification criteria may be identified as eligible for DTM/MTM intervention due to significant therapy care gaps. The MTM/DTM Program consists of 2 basic elements: Therapy Care Gap interventions and Adherence and Persistence (A&P) interventions. A) Therapy Care Gap Management Therapy Care Gaps are interventions designed to identify patients who have a gap between their current therapy and the ideal therapy needed to achieve optimal clinical outcomes. Therapy Care Gap recommendations are developed based on current clinical guidelines and clinical evidence. Patients with therapy gaps are identified using full prescription drug claims history as well as patient demographics, concurrent disease states and concurrent medications. Therapy Care Gaps are then reviewed for clinical relevance by clinical pharmacists, and the prescribing physician and patient are notified as appropriate. Patients will also receive educational materials on a quarterly basis. Outcomes reporting at 6 months and annually will quantify the number of Therapy Care Gaps identified, changes in physician prescribing post -identification and communication, and the change in actual patient medication history post -identification. IIIIIIIIIIIIii INI I I I Teclicationa ierence an properly following the prescriber's instruction regarding medications ("adherence") or are not remaining on the prescribed therapy for the recommended time period ("persistence"). The Program targets medication for chronic diseases such as It cholesterol. Additional (greater than 3) disease states can be selected for an additional fee. Potential medication non -adherence is identified in a target patient population using four major parameters: Medication Possession Ratio ("MPR"), Median Gap, Persistence, and Days of Therapy. This service seeks to identify and resolve issues related to compliance an&or persistency by offering patients quarterly progress reports on their adherence and notifications to providers and/or disease management firms for further interventions that foster compliant and persistent behavior. In. addition to the individualized quarterly member progress reports, annual outcomes reports documenting the change in adherence parameters Monroe County PBMSA 082217 TBMSA (fnn 120916) C Envision Phannaceutical Services, LLC Page 33 g.0 for the year as compared to the baseline period, C) Included Reports: Outcomes reports at 6 months and annually on all Therapy Care Gaps-, Disease state specific reports and 6 months and annually regarding chronic medication adherence for those drugs within those disease states; and Quarterly and annual individual personalized member medication adherence reports. Fees for Additional Clinical Pro 1,ram_Services ord at clienVs re uestj Drug Therapy Care Gap Management: $0.55 PMPM Medication Adherence and Persistency (up to three disease states): $0.55 PMPM Monroe County PBMSA 082217 \PBMSA (frmt20916) t.Envision Phannaceutical Services, LLC Page 34 of 48 This Coverage Determination and Appeals Process Addendum (hereinafter "Addendum") is entered into by and between Envision Pharmaceutical Services, LLC (hereinafter "Envision") and Monroe Countv Board of Countv Commissioners hereinafter "Plan Sponsor") as follows. 04 BACKGROUND Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement dated January 1, 2018 (hereinafter "Agreement") under which Envision provides PBM Services to Plan Sponsor, Plan Sponsor wishes for Envision to provide additional services under the Agreement as set forth below. EDWIN H! Initial Coverage Determinations and Appeals: Envision shall administer a Coveragry Determination and Appeals Process under Plan Sponsor's direction as described in Exhibit I -A. The Coverage Determination and Appeals Process will include: (i) Real- time adjudication to determine coverage,/non-coverage status of a Claim; (ii) Initial Determinations (including Clinical Prior Authorizations), and (iii) Redeterminations ('*Internal Appeals"). The Coverage Determination and Appeals Process will meet the requirements of the Department of Labor's Internal Claims and Appeals and External Review Processes under 29 CFR §2590.715-2719. Provided Internally by Envision Coverage Determinations (including Clinical Prior Authorizations) $35.00 per request Redeterminations (Internal Appeals) $125 per request Postage 100% pass -through of all postage All other terms and conditions of the Agreement not modified by this Addendum or any prior amendment or addenda shall remain unchanged. [SIGNATURE PAGE FOLLOWS] Monroe County PBMSA 082217 \PBMSA (ftin I 2091M 0 Envision Pharmaceutical services, LLC Page 35 of 48 IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Addendum as of the Effective Date above. For ENVISION. - For PLAN SPONSOR: DocuSigned by: abs BY: 5F'n;'F­3 By: 730car"T.'row Print Name and Title Print Name and Title Monroe County PBMSA 082217 \PBMSA (fim]20916) CP Envision Phannaceutical Services, LLC Page 36 of'48 131M§11[11�.• P-01MORIEN I i i iF i Envision Coverage Determination and Redetermination (Internal Appeal) Program Description (Revision date 121/04/2012) Envision maintains a process for Coverage Determinations (including Clinical Prior Authorizations), and edeterminations. Envision utilizes a claim adjudication platform to determine real-time coverage./non-coverage status for Claims submitted electronically at the Point -of -Sale. Claims failing one or more Benefit Plan coverage rules are rejected at the Point - of -Sale and information regarding the reject reason(s) is conveyed to the dispensing Pharmacy at the Point -of -Sale. Pharmacy personnel may contact Envision's Customer Service Department to begin the Coverage Determination process or they may info rin the Member of the reason(s) for the rejection and provide the Member with instructions to contact the Customer Service Department in the event the Member would like to initiate a Coverage Determination. CoverageDeterminations (or Clinical Prior An When a Coverage Determination request is initiated, the information connected with the rejected prescription is conveyed by Envision to the Prescriber via fax with a request for specific information regarding the Member's medication history and disease diagnosis. The Prescriber completes the form and returns it to Envision where the information provided by the Prescriber is evaluated by an Envision clinical pharmacist. Expedited Coverage Determinations occur as soon as possible, taking into account medical exigencies, but no later than 24 hours of receipt of the request and standard determinations occur within 72 hours of receipt of the request. If the information provided meets the criteria to allow an override of the initial rejection, an override will be configured in the adjudication system that will allow the Claim to process. If the clinical review determines the prescription fails to meet the coverage criteria, the prescription will remain in rejected status. The result of the Coverage Determination is communicated tote Member by written letter, the Prescriber by fax, and the dispensing Pharmacy by fax. In the event the Coverage Determination results in an Adverse Benefit Determination, as defined below, the notice to the Member and Prescriber includes information identifying the Claim involved, the specific reason for the Adverse Benefit Determination, instructions about the right to initiate a Redetermination (Internal Appeal), a link providing the availability and contact information of an agency offering assistance tots Member with the appeals and external review processes, if one is available, and may contain additional information as directed by Plan Sponsor. An Adverse Benefit Determination is a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well Monroe County P13MSA 082217 \PBMSA (firm 120916) V Envision Pharmaceutical Services, LLC Page 37 of Z Ims, �011 V EUMMIRK03 UFTIRMO I RINVAIM OPINION V I Wt as defined in the regulations restricting rescissions (26 CFR 54.9815-2712T(a)(2), 29 CFR 2590.715-2712(a)(2), and 45 CFR 147.128(a)(2)), whether or not there is an adverse effect on any particular benefit at that time. The availability and contact information of an agency offering assistance to the Member with the appeals and external review processes can be found at: www.healtheare-gov/ . using: insurance' manai3,,inv-/consumer-hel- index.hortI. Monroe County PBMSA 082217 \PBMSA (ftm120916) D Envision Pharmaceutical Services, LLC Page 38 of 48 appeals and external review processes can be found at: www.healtheare-gov/ using- insurance.,.-"managinr-,.�consumer-hely.,-"index.html. Monroe County PBMSA 082217 \PBMSA (frm 120916) Envision Pharmaceutical Services, LLC Page 39 of 48 Exhibit 3 Federal Contractual Provisions Required by 1 CFR part 200 et seq. veteran-ownedThe County strongly encourages the use of women-, minority- and busine enterprises (SBEs) and wishes to see a minimum of it of # awarded pursuant to this REP go to SBEs. Contractors isearch for Florida registered - submitproposes to use su6contractor 77111CU US 3.E)r-s, in rioriul of must of #` receive credit for the use of the SBE. 2a r�LT II . i funyi + i = i i recordsto inspect and review all books and to the Contract for a period of five (5) years after final grant close-out by FEMA or OEM, or as required applicable County,Records shall be made available during normal working for this purpose and in accordance with Section 5.7 of this Agreement. In _ or any other Federalor amountsfindings or rulings that the -Contractor, ineligible or were non -allowable under fedor r a....,.. appeal# or ruling. If such appeal is unsuccessful, the Contractoragree that the amounts paid to the Contractor shall be adjustedand that the Contractor ineligibleshall, within 30 days thereafter, issue a remittance to the County of any payments declared to be non -allowable. Contractor shall comply with federal and/or state laws authorizing an audit of Contractor's operation as a whole, or of specific Project activities. Under no circumstances shall advertising or other communications with the media be presented in such a manner as to County or imply that the Contractor or the Contractor's services are endorsed by the County. 3® TERMINATION Monroe County PBMSA 0822171PBMSA (Sun 120916) 1 Envision Phannaceutical services, LLC Page 40 of 48 A. In the event that the CONTRACTOR shall be found to be negligent in any aspect of service, the COUNTY shall have the right to terminate this agreement after five days written notification to the CONTRACTOR. B. Either of the parties hereto may cancel this Agreement without cause by giving the other party sixty (60) days written notice of its intention to do so. B. Termination for Cause and Remedies: In the event of breach of any material contract terms, the COUNTY retains the right to tenninate this Agreement. The COUNTY may also terminate this agreement for cause with CONTRACTOR should CONTRACTOR materially fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination, prior to termination, the COUNTY shall provide CONTRACTOR with thirty (30) calendar days' notice and provide the CONTRACTOR with an opportunity to cure the breach that has occurred. If the breach is not cured within thirty (30) days of notice, the Agreement will be terminated for cause. The maximum amount due to CONTRACTOR shall not in any event exceed the spending cap in this Agreement. In addition, the COUNTY reserves all rights available to recoup monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the COUNTY's False Claims Ordinance, located at Section 2-721 et al. of the Monroe County Code. C. Termination for Convenience: After the first Contract Year, the COUNTY may terminate this Agreement for convenience, at any time, upon ninety (90) days' notice to CONTRACTOR. . The maximum amount due to CONTRACTOR shall not exceed the spending cap in this Agreement. In addition, the COUNTY reserves all rights available to recoup monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the COUNTY's False Claims Ordinance, located at Section 2-721 et al. of the Monroe County Code. A person or affiliate who has been placed on the convicted vendor list following a Wwx-d-vrtion for sublic entit-,,, crime mau not submit a bid on contracts to Sirovide an-- .,Ooods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017 of the Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. By signing this Agreement, CONTRACTOR represents that the execution of this Monroe County PBMSA 082217 \PBMSA (fitn120916) Envision Pharmaceutical Services, LLC Page 41 of 48 Agreement will not violate the Public Entity Crimes Act (Section 287,133, Florida Statutes). Violation of terms of this contract shall result in termination of this Agreement and recovery of all monies paid hereto, suspension of the ability to bid on and perform County contracts, and may result in debarment from COUNTY's competitive procurement activities. In addition to the foregoing, CONTRACTOR further represents that there has been no detentrination, based on an audit, that it or any subcontractor has committed an acl defined by Section 287.133, Florida Statutes, as a "public entity crime" and that it has not been formally charged with committing an act defined as a "public entity crime" regardless of the amount of money involved or whether CONUSULTANT has been placed on the convicted vendor list. CONTRACTOR will promptly notify the COUNTY if it or any subcontractor or CONTRACTOR is formally charged with an act defined as a "public entity crime" or has been placed on the convicted vendor list. 5. NONDISCRIMINATION (1) The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, or national origin. The contractor will take affirinative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. Such action shall include, but not be limited to the following: Employment, upgrading, demotion, or transfer, recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation-, and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the contracting officer setting forth the provisions of this nondiscrimination clause. 7Z)7TEe contractor win, in a I solicitations or 7,T7FTn7U=R7 TUT F7LTpTvy??TT=T" or on behalf of the contractor, state that all qualified applicants will recei consideration for employment without regard to race, color, religion, sex, sexu orientation, gender identity, or national origin. 11 k)TY17e —contractor win nor uiscnarge or in anj ot fqr employee or applicant for employment because such employee or applicant has inquired about, discussed, or disclosed the compensation of the employee or applicant or another employee or applicant. This provision shall not apply to instances in which an employee who has access to the compensation information Monroe County PBMSA 082217 \PBMSA (fim 120916) �01 Envision Pharmaceutical Services, LLC Page 42 of 48 I ��Igamlnl ;11=:R� of other employees or applicants as a part of such employee's essential job functions discloses the compensation of such other employees or applicants to individuals who do not otherwise have access to such information, unless such disclosure is in response to a formal complaint or charge, in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or is consistent with the contractor's legal duty to furnish information. (4) The contractor will send to each labor union or representative of workers wi which it has a collective bargaining agreement or other contract or understandin a notice to be provided by the agency contracting officer, advising the labor uni or workers' representative of the contractor's commitments under section 202 Executive Order 11246 of September 24, 1965, and shall post copies of the noti in conspicuous places available to employees and applicants for employn (5) The contractor will comply with all provisions of Executive Order 11246 of September 24, 1965, and of the rules, regulations, and relevant orders of the Secretary of Labor. (6) The contractor will famish all information and reports required by Executive Order 11246 of September 24, 1965, and by the rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by the contracting agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations, and orders. (7) In the event of the contractor's non-compliance with the nondiscrimination clauses of this contract or with any of such rules, regulations, or orders, this contract may be canceled, terminated or suspended in whole or in part and the contractor may be declared ineligible for further Government contracts in accordance with procedures authorized in Executive Order 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as provided in Executive Order 11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law. CONTRACTOR and COUNTY covenant that neither presently has any interest, and shall not acquire any interest, which would conflict in any manner or degree with its performance under this Agreement, and that only interest of each is to perform ani receive benefits as recited in this Agreement. 7. CODE OF ETHICS Monroe County PBMSA 082217 TBMSA (fim120916) 0 Envision Phannaceutical Services, LLC Page 43 of 48 The parties recognize and agree that officers and employees of the COUNTY recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. 8. NO SOLTCITATION/PAYMENT The CONTRACTOR and COUNTY warrant that, in respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. Monroe County PBMSA 082217 \PBMSA (fim 120916) 0 Envision Pharmaceutical Services, LLC Page 44 of 48 inspecta format that is compatible with the information technology systems of the County. (5) A request to *......... public records relating to a County contract must be but if the County does n t possess the requested records the County shall immediately notify the C6NTRACTOR of the - request, and the CONTRACTOR must provide the recordsthe County or allow the recordsto be comply The CONTRACTOR shall not transfer custody, release, alter, destroy or otherwise dispose of any public records unless or otherwise provided in this provision or as otherwise provided by law. .. ....... ...... ...... CONTRACTOR A. Contractor agrees to comply• !regulations Controlissued pursuant to the Clean Air Act (42 U.S.C. 7401-7671q) and the Federal Water Pollution amended FENM and the Regional Office of the Environmental Protection Agency (EPA). #' Davis -Bacon ■ct, as ' required Federal program legislation, all prime construction contracts in excess of $2,000 by is F • * '.. 3141-3144, and 3146-3148) as supplemented by Department of Labor regulations (29 F • "Labor Standards Applicable Federally Financed i accordance contractors be pay wageslaborersmechanics less than the prevailing wages specified in a wage determination made by the Secretary of Labor. In addition, contractors must be required to pay wages not less Monroe County PSMSA 0822171PBMSA (ftrn12091M 0, Envision Phannaceutical Services, LLC Page 45 of 48 22mlillonnn IIIIIIIIIIIIIIIInz than once a week. The COUNTY must place a copy of the current prevailing wage determination issued by the Department of Labor in each solicitation. The decision to award a contract or subcontract must be conditioned upon the acceptance of the wage determination. The COUNTY must report all suspected or reported violations to the Federal awarding agency. The contractors must also comply with the Copeland "Anti -KickbackAct (40 U�S.C. 3 145), as supplemented by Department of Labor regulations (29 CFR Part 3, "Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or Grants from the United States"). As required by the Act, each contractor or subrecipient is prohibited from inducing, by any means, any person employed in the construction, completion, or repair of public work, to give up any part of the compensation to which he or she is otherwise entitled. The COUNTY must report all suspected or reported violations to the Federal awarding agency. 9 IN 1111111��qiioi 1� ipi��Ipi I im ........ Tss'LVj F&ISFUTIL LV I I aVu Lil Federal Water Pollution Control Act as amended (33 U.S.C. 1251-1387). Violatio must be reported to the Federal awarding agency and the Regional Office of the Environmental Protection Agency (EPA). i Monroe County PBMSA 082217 \PBMSA (fim 120916) V Envision Pharmaceutical Services, LLC Page 46 of 48 GDebarment and Suspension (Executive Orders 12549 and 12689)—A contract award (see 2 CFR 180.220) must not be made to parties listed on the governmentwide exclusions in the System for Award Management (SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3 CFR part 1989 Comp., p. 235), "Debarment and Suspension." SAM Exclusions contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549. H. Byrd Anti -Lobbying Amendment (31 U.S.C. 1352)--Contractors that apply or bid for an award exceeding $100,000 must file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352, Each tier must also disclose any lobbying with non -Federal funds that takes place in f_-_,,.),nnection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the non -Federal award. 11 if 1 111111, [10 1 A. Americans with Disabilities Act of 1990 (ADA) — The CONTRACTOR will comply with all the requirements as imposed by the ADA, the regulations of the Federal government issued thereunder, and the assurance by the CONTRACTOR pursuant thereto. B. Disadvantaged Business Enterprise (DBE) Policy and Obligation - It is the policy of the COUNTY that DBE's, as defined in 49 C.F.R. Part 26, as amended, shall have the opportunity to participate in the performance of contracts financed in whole or in part with COUNTY funds under this Agreement, The DBE requirements of applicable federal and state laws and regulations apply to this Agreement. The COUNTY and its CONTRACTOR agree to ensure that DBE's have the opportunity to participate in the performance of this Agreement. In this regard, all recipients and contractors shall take all necessary and reasonable steps in DBE's have the opportunity to compete for and perform contracts. The COUNTY and the CONTRACTOR and subcontractors shall not discriminate on the basis of race, color, national origin or sex in the award and performance of contracts, entered pursuant to this Agreement. Monroe County PBMSA 082217 \PBMSA (frm 120916) t Envision Pharmaceutical Services, LLC Page 47 of 48 C. The Contractor shall utilize the U.S. Department of Homeland Security's Verify system to verify the employment eligibility of all new employees hired by t Contractor during the term of the Contract and shall expressly require any subcontracto performing work or providing services pursuant to the Contract to likewise utilize t e U.S. Department of Homeland Security's E-Verify system to verify the employm eligibility of all new employees hired by the subcontractor during the Contraci 11. No Obligation by Federal Government. The federal government is not a party to this contract and is not subject to any obligations or liabilities to the non -Federal entity, contractor, or any other party pertaining to any matter resulting from the contract. 12. Program Fraud and False or Fraudulent Statements or Related Acts. The Contractor acknowledges that 31 U.S.C. Chapter 38 (Administrative Remedies for False Claims and Statements) applies to the Contractor's actions pertaining to this contract. Monroe County PBMSA 082217 \PBMSA (firn 120916) IC) Envision Pharmaceutical Services, LLC Page 48 of 48 0 Envisionploplus So A Medicare Approved prescription Drug Plan K4 (EGWPIWRAP ASO) Envision Insurance Company 2181 East Aurora Road Twinsburg, OH 44087 Toll Free Telephone: (866) 250-2005 EGWP+WRAP SELF -INSURED ASO (2017) Cover Page 1:441 Employer Group Name: Monroe County Board of County Commissioners Notice Address for Employer Group: 1100 Simonton St. A 2-268 Key West, FL 33040 Employer Group Telephone Number: (305) 292 - 4452 Notice Address for Envision Insurance Company: 2181 East Aurora Rd Twinsburg, OH 44087 Effective Date of Service: 12:01 a.m. January 1, 2018 Term of Service: From 12:01 a.m. January 1, 2018 through 11:59 p.m. December 31, 2018, unless otherwise agreed upon by the parties Administrative Fee: $10.00 per Member, per month (PMPM) Covered Benefits: Please refer to the Evidence of Coverage and Summary of Benefits. This Employer Group Agreement (the "Employer Group Agreement") is a legal contract between the Employer Group named above and Envision Insurance Company ("EIC"). This Cover Sheet provides only a brief outline of some of the terms. The provisions below set forth, in detail, the rights and obligations of the Employer Group and EIC. GOMM" a firr.] I I f�r the Term of Service, unless terminated as provided herein. %9;XT#WAft-W;T;W# 1AWKWONW41 FOR ALL CLAIMS AND EXPENSES PROVIDED HEREUNDER. AMOUNTS PAID TO EIC BY EMPLOYER GROUP HEREUNDER ARE NOT INSURANCE PREMIUMS. -1971t=F15 all applicable rules and regulations governing Medicare Part D Plan Beneficiaries, All eligibility, enrollment andother Part D benefit rules applicable to Employer Group Waiver Plans will apply to Employer Group and its enrolled Medicare Eligible retirees. Capitalized terms not defined in this Employer Group Agreement shall have the meaning set forth in the attached schedules and exhibits. 1.1 The terms "Employer Group", "Effective Date of Service", "Term of Service" and Administrative Fee will have the meaning set forth in the attached Cover Sheet, 1.2 "Benefit Specification Form" or "Benefit Specification Change Form" means the forms, submitted by Employer Group, that specify (i) the terms and conditions for coverage of Covered Benefits; (ii) any limitations, conditions, or exclusions; (iii) the EGWP/wrap Formulary tier structure and Cost Share requirements; and (iii) any other terms and conditions associated with the specific services to be rendered by EIC under this Agreement (i.e. Clinical Prior Authorizations DruQ Therary Management, etc.). If there is any�� between the terms of this Agreement and the Benefit Specification Form or any Benefit Specification Change Form submitted in connection with the administrative services to be provided under this Agreement, then the provisions of the most recent signed Benefit Specification Form or Benefit Change Form shall control. 1.3 "Brand Drug" means a Prescription Drug designated as a branded drug product by Medi-Span as indicated by the multisource (i.e. MONY) code attached to the 11 digit NDC for such drug. 1.4 "Contract Year" means the Term of Service set forth on the Cover Sheet, and each subsequent Term of Service should this Employer Group Agreement 1e renewed in accordance with Section 6.1. 1.5 "Claim" means an invoice or electronic submission by a dispensing pharmacy or Member for a Covered Benefit. 1.6 "Covered Benefits" means those prescription drugs and related services covered by, and paid for by Employer Group, as specified by Employer Group on the most recent Benefit Specification Form or Benefit Change Form, as permitted under applicable law, the Evidence of Coverage, and Summary of Benefits incorporated herein. 17 "Cover Sheet" means the page entitled "2018 Plan Year Cover Sheet", attached hereto and incorporat41 herein by this reference, 1.8 `CMS" means the Centers for Medicare and Medicaid Services, which administers the Medicare Part D program and with which EIC maintains a contract as a Medicare Part D Prescription Drug Plan. 1.9 "CIMS Receipts" means all premiums, subsidies, catastrophic reinsurance, and other amounts paid to EIC by CMS connected with Employer Group under the Medicare Part D program. 1.10 TGWP" means the Employer Group's Medicare Part D Employer Group Waiver Plan (Series 800 Plan) administered by EIC hereunder, 111 "EIC Formulary" means the list of drugs, filed by EIC and approved by CMS, which are covered under the EGWP. Employer Group acknowledges that the EIC Formulary may be modified from time -to -time by EIC's ........... OM11111 011111111 M 1m;I IZMIR] we RNIII 11017.19 0 IBM I I R11119 L914111 I I I L.7111 1.11M-�4 LMILTI I I `B, '017-1wro"I R-ol-In, kds upipubuu lu lur rillptuyul tolulp d[IU U111ut cl�, Ullell[s) IT111 Utj yvruli w r-111plujtt uluilp Uy clu 1w 2nd approval prior to EIC's transmittal to Employer Group's Members, 1.14 dence of Coverage" or TOC" means the CMS approved document setting out the rules of coverage for Members under the EGWP, along with any riders, amendments, or endorsements thereto. 1.15 "Financial Contribution" means any monthly or other payment required under the Employer Group's Retiree Benefit Plan to be made by a Member for coverage under the EGWP, including without limitation, a contribution Page 3 of 29 I I Wil I ''iii !I Ili lillil 1 1111 50-TWOTINIMANII M., required under the Retiree Benefit Plan for Medicare Part D coverage (the "Group Coverage Fee"), a deductible payment, Copayment, Coinsurance and Late Enrollment Penalty ("LEP"). 1.16 "Generic Drug" means a Prescription Drug that is not a Brand Drug. 1.17 "Limited Distribution Drugs" means Prescription Drugs that are distributed by manufacturers through a limited number of pharmacies and wholesalers which have been selected by the manufacturer based on approved participation criteria. 118 "Medicare Part Y means the Medicare Part D Prescription Drug Program regulated by CMS and its associated regulations under 42 U.R. 423.100, at. seq. 1.19 "Medicare Eligible" means the individual is eligible for coverage for Medicare Part D benefits at all times during the Term of Service. If, at any time during the Term of Service, an individual is no longer eligible for coverage for Medicare Part D benefits (e.g. fails to make required payments to the Social Security Administration), such individual shall be dis-enrolled by EIC. 1.20 "Member" means an Eligible Individual who has been enrolled in the EGWP by Employer Group and accepted for membership by CMS, as further described in Section 3.1.1. 1.21 "Network Providers" means those pharmacies (including retail, mail order, specialty, long term care, and home infusion pharmacies) that have entered into a contract with EIC to dispense Covered Benefits to Members. EIC maintains a national network of contracted pharmacies, and Members may obtain Covered Benefits from any Network Provider regardless of the Member's residence. Employer Group acknowledges that the list of Network Providers may change from time -to -time. However, BIG agrees that any such change will not violate CMS access requirements. EIC will maintain a current directory of Network Providers on its website. 1.22 "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. 1.23 "Retiree Benefit Plan" means the Employer Group's employment -based benefit plan for coverage of retiree prescription drug benefits. 1.24 "Summary of Benefits" means a description of the prescription drug benefits, as set forth in Exhibit "A", to be administered by EIC under this Employer Group Agreement. 1.25 "Wrap" means a prescription drug benefit plan design that provides commercial, non -Medicare EGWP coverage that is supplemental to the standard Medicare Part D benefits. IN III LO liarmass m ski F'r9d r, rJUVA Od 7111MMMMMEM *ther health insurance coverage, and as such, discounts provided under the Medicare Coverage Gap Discount Prt.gram ai-8 apA-Iiel �itfitrit a6,,Lai4ititnal c#,�eragd ity*nii the stailiarf - i Wenefits7-ha��t W6en takaig into account, 2.1.2 If a Member has other insurance coverage, identified by CIVIS or through information proved by the Member or the Employer Group, EIC will coordinate benefits with these other carriers. 2.2 Evidence of Coverage, and Summary of Benefits: Additional rules governing the provision of Coveret] Benefits under the EGWP/wrap are stated in the Evidence of Coverage (EOC) and the Summary of Benefits, as interpreted by EIC to comply with applicable law. Employer Group acknowledges that adherence to these rules by Members is required to receive Covered Benefits hereunder. 2.3 EIC Formulary: The EIC Formulary shall be used to determine Covered Benefits for the EGITP. Employer Group shall identify on the Benefit Specification Form those items and services that will be processed under the Wrap. Unless otherwise specified, drugs covered under the Wrap may not be eligible for coverage under the Medicare Part D program. Notices of any changes removing drugs from the EIC Formulary will be mailed by EIC to Members. gjl�g nmolum Fian are en 1 1 fr,07wrap. E77Z—y7r"7UMup also Ina NOT eligible to be a Member in the EGWP/wrap: (i) Spouses or dependents who are not eligible for Medicare Part D coverage, even if they are the spouses or dependent of an Eligible Individual; or (ii) Current employees of Employer Group (i.e., active employees) or their eligible spouses and dependents, even if eligible for Medicare Part D. lint, F. 1 =42UTF. M 11 M14 0 ra 21 1 Me Hfulitju H rm_: confi�mation that the date incarceration began was prior to the Effective Date of Service. Each Medicare Eligible retiree is an individual Member, regardless of whether that individual is a spouse or dependent of another Medicare Eligible retiree. 3.1.2 Attestation of Eligibility. In executing this Employer Group Agreement, Employer Group submits the attestation of eligibility identified in Section 5.1 attesting that the individuals submitted by Employer Group for enn ta# L -illmei-A in thd EGV1/1;Vr, mte�kia a�#,�e-3tat&t &MES elijiWifty r&�4 yifaimjt&nts ai-Cjt-i-pttio�t Employer's notice of opt -out rights. 3.1.3 Removal of Medicare Eligible Individuals From Other Medicare Coverage. Employer Group acknowledges that any Medicare Eligible retiree who appears on the eligibility file supplied to EIC will be automatically dis-enrolled by CIVIS from his or her current Medicare plan, if any, upon EIC's submission of his or her name to CIVIS for coverage under the EGWP/wrap. 3.1.4 No Waiting Period. Employer Group may not impose a waiting period before individuals are eligible for coverage under the EGWP/wrap. 3.2 • 321 Timing of Enrollment, Eligible Individuals may be enrolled by Employer Group only during the Employer Group's annual open enrollment period ("Open Enrollment Period") or specialty enrollment period upon Employer Group acknowledges that each Eligible Individual may be required to complete and provide Employer Group and/or EIC with certain eligibility information, including, without limitation, the individual's Medicare ID Number. 322 Compliance with Enrollment and Disenrollment Procedures. Employer Group and EIC agree to by CIVIS. 3.3 Eligibility and Enrollment Procedures 3.3.1 After EIC receives Employer Group's EGWP/wrap file of Eligible Individuals, EIC will submit the information to CMS, and CIVIS will confirm or reject each Eligible Individual's enrollment into the EGWP/wrap, An Eligible Individual must be enrolled based on his or her state of residence. The Eligible Individual's address used for enrollment must be his or her permanent residence. A mailing address may be provided in a separate field on the EGWP/wrap Eligibility file. If a Member moves to a new permanent state of residence, his or her new residence address must be communicated to EIC. CMS may reject an Eligible Individual's enrollment into the EGWP/wrap for various reasons. EIC will inform Employer Group if EIC receives a CIVIS rejection and work with Employer Group to determine why the Eligible Individual was rejected and to obtain the information needed to enroll the Eligible Individual into the EGWP/wrap, if possible. 3.3.2 The number of Eligible Individuals and composition of the Employer Group, the identity and status of the EmQloyer Groug, the elioibi ltv reguirements used to determine membershio in the Emolover Grour), and the liot, U11111Y tile left[] Ul UUrelaye alluel Ullb r-lllPlUJel OlUllp ^YleelllellL, llluuq-�Ipell 0-111011111011t rrenoTT" other eligibility requirements as described in the EOC and on the Summary of Benefits, for the purposes of enrolling Eligible Individuals in the EGWP/wrap, unless EIC agrees to the modification in writing. 3.4 Maintenance of Eligibility and Eligibility Updates 3.4.1 Once enrolled by Employer Group and accepted by CIVIS, Members will continue to be enrolled until any •: the following • I 41 kTA 10T, Me ffm 2 11651 ITU Ta , I =-1 I N 0 19 "1 (ii) The Member's death; (fli) The Member fails to timely pay Financial Contributions; (iv) The Employer Group notifies BIG of the disenrollment of the Member from the /wrap because the Member no longer qualifies for coverage; or M The Eligible Individual notifies the Employer Group or EIC that the Eligible Individual is dis- enrolling. @1111OWNW, 111111IN11111111i - I I I" . , I IIII exom 1111111111 ffild IM 116 MR01I - - -- - - - - - __ - - - I 3.4.2 Disenrollment. For purposes of this Employer Group Agreement, the effective date of termination, eligible for coverage under the EGWP/wrap. In the case of a Member's death, the effective date of termination will be the date of death as indicated by CMS. notifies EIC to process retroactive enrollment or retroactive disenrollment. MININ LIM211121 10-01INFORMti (I) EIC will invoice Employer Group the negotiated contractual amount payable to the dispensing pharmacy (plus any applicable taxes, assessments, or fees) for a Covered Benefit without any mark-up or spread; hi) Employer Group is ultimately liable for 100% of all costs of Covered Benefits; (III) Employer Group is also ultimately liable for 100% of the PMPM Administrative Fee identified in the Cover Sheet and any Additional Fees as agreed upon in writing by the parties and identified in Exhibit C; (iv) EIC will perform the administrative services necessary to collect all amounts connected with the EGWP/wrap, including CIVIS Receipts, premium revenue from State Pharmaceutical Assistance Programs ("SPAPs") and amounts due from other payers, as further described below; (v) EIC will also perform the administrative services necessary to collect all Direct and Indirect Remuneration ("DIR") from pharmaceutical manufacturers and other third parties, as required by CMS; (vi) The Employer Group will need to establish a reserve equal to three (3) weeks of pharmacy claims payments due from Employer Group under item (I) above, and the reserve amount will be: (x) invoiced fifteen (15) days prior to the Benefit Effective Date, and (y) repaid upon final settlement with CMS which occurs approximately eleven (111) months after the end of the Contract Year; (vii) Monthly, EIC will invoice the Employer Group for (a) all amounts owed under items (I) and (ii) above, minus (b) all amounts collected under item (iv) and (v) above; MRS (viii)EIC will make all payments due pharmacies for Covered Benefits in accordance with Medicare Part D prompt payment rules for the EGWP and in accordance with applicable state prompt pay laws and regulations for the Wrap. EIC and the Employer Group agree that (i) Employer Group is responsible for assuring that it provides the prescription coverage that it is obligated to provide to its Members; and (ii) EIC, as the administrator of the oloyer's Group's cover-9ge 1rogr2m. is resootsible for co-tiDIViTQ goolic2ble fe1er,91 gid st,?.te stq-tutes. ru es q W I I W I'm I _=Mn e ITCeT-TITeULWe-r-dlL 2 1 ell� I H el I lei I is, I I I eb1FAAITO' - dIC If I CIVIS reinsurance or subsidized by CMS, shall be deemed accepted by Employer Group and Employer Group shall be bound by the settlements made by EIC. -.nd of the Contract Year to be paid by CMS. 4.2.1 EIC's Statement Oblig2�R. EIC shall provide Employer Group with an invoice statement once each month. The invoice statement will show: (i) amounts owed for Covered Benefits; (ii) amounts collected from all third parties, itemizing each such amount; (iii) the difference between item (i) less item (ii); and (iv) any balance remaining to be paid by Employer Group to EIC. Any collected amounts remaining will be refunded to the Employer Group by EIC. A separate invoice statement will be provided for the amounts owed for the Administrative and idditiotal Fees. all I D WYARRIUMINIMNI 9 (OKINI a i r 'Rt WNW-, EIC, in addition to the full amount of the Claims invoice, a processing fee of $1,500.00. 4.2.3 Employer Group's Administrative Fee Payment Obligations: Beginning with the first month under this Employer Group Agreement, EIC shall provide Employer Group with an invoice of Administrative Fees prior to the first day of each month. Administrative Fees are due within seven (7) calendar days of receipt of EIC's invoice. The monthly Administrative Fee is calculated by multiplying the number of Members 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 forth on the Cover Sheet (except for the initial invoice which is based on Employer delivery of the invoice by mail, e-mail, fax, or courier. Page 8 of 29 �, �1�1111101 1.111:1111 IlRglzffi�= dUMIUMUOYUS Uldt IL Ri, d11U [U111dillZi 1UZSPUf161UJe U, Me PdJ[11U111 U1 all 111TOlUU6 101 UUTUIUU DUHUIRS U]Sperlz5t�u lu Members, along with any associated amounts not timely paid by Members, together with any dispensing fees and taxes. 4.4 Financial Contributions and Refund of Low Income Subsidies (LIS): Employer Group shall comply with the following conditions with respect to any subsidization of Financial Contributions by the Members: 4.4.1 Limitations on Employer Group Subsidies, Employer Group may subsidize different amounts for different classes of Members, provided such classes are reasonable and based on objective business criteria, such as years of service, business location, job category, and nature of compensation (e.g., salaried vs. hourly). However, .... ... . . . . . . . . Z>1 IM111U URI, ILI 1-0 TorYT-TJTe k�D) UaJ5 of MU S reGelpt 01 Null arn CMS, document how the LIPs amounts were refunded, and provide an attestation to EIC that the LIPs amounts have been properly refunded. Employer Group acknowledges that it may be liable to CIVIS for any inappropriate retention of LIPs, and Employer Group will forward to EIC any funds that it is not entitled to retain. is LICs. EIC will be responsible for providing LICs to Members at the point • sale. In the event that incorrect amounts of LICs are paid to Members, and additional amounts need to be paid or withheld thereafter, EIC lw'41 �-e s6� cuvec&#1?s are Inaie-eDi ot&Fmt a eec#ei *f sic;-*mTsad'*-nrs a&-�8�6�mt �,y CIVIS. NZERAUNNIMM mr-mmm zz�r_'Iw and Employer Group will forward to EIC any funds that it is not entitled to retain. 4.6 Additional Financial Contributions from Members: 4.61 Late Enrollment Penalty ("LEPI: Employer Group acknowledges that CMS requires Plan included in amounts received by EIC from CMS or other payors, EIC will invoice Employer Group for any LEP that is owed by a Member, identifying at the time of the invoice the name of the Member, and the amount owed. The Employer Group will be obligated to pay the LEP amount invoiced to EIC. However, the Employer Group may collect the LEP from the Member, EIC will notify Employer Group of Members owing LEPs, as EIC is notified by CMS of these Members, and such notice will be provided on or before the date when EIC invoices the Employer Group for the LEPs. If Employer Group or any Member has documentation that the Member did have continuous creditable coverage, Employer Group may attest to same and EIC will submit a request for rescission of the LEP and a refund from CMS. EIC will pass through to Employer Group any LEP amounts reimbursed by CMS, In the event that CIVIS determines and notifies EIC that a LEP was wrongly or inaccurately assessed, EIC will notify Employer Group and pass through to the Employer Group any LEP amounts reimbursed • CMS. 4.6.2 Federal Income Related Monthly Adjustment Amount ('IRMAA"): Employer Group acknowledges t�gw4er INWO* - ded, iihe Member is .4,uired to pay Medicare a higher monthly fee for Medicare benefits. This payment is made by the Member directly to Medicare and is not included in amounts received by EIC from CMS or other payors. 4.6.3 Member's Non -Payment of Financial Contributions: Employer Group acknowledges that failure of a Member to pay any Financial Contributions required under Employer Groups' Retirement Benefit Plan shall not release Employer Group's financial obligations hereunder. If a Member is to be terminated from the EGWP/wrap for non-payment of Financial Contributions, Employer Group must give the Member at least twenty one (21) days Qdew i" totice. As Aotiw uil be wieived W the Member at least twent� one (21 days from the effective, date of disenroliment. I his should oe taKen into consideration wnen estaDiisning me timing Tor payment Or Hnancial Contributions under Employer Group benefit rules. Wromm 0 =A6 I M 1 0 terminations or status c nges.. IC will not be liable to Members for the fulfillment of any obligation prior to information being received in a form satisfactory to EIC. IY7=71717741 rATtfj t-1 in=66 Specification Form and such data as necessary for EIC to set up the benefit and to commence the provision of ;ervices for the EGWP/wrap. Page 10 of 29 Employer Group certifies, based on its best knowledge, information and belief, that all enrollment and eligibility information that has been or will be supplied to EIC is accurate, complete and truthful. Employer Group acknowledges that EIC can and will rely on such enrollment and eligibility information in determining whether an individual is eligible for Covered Benefits under the EGWP/wrap. 52 Maintenance of Information and Records: Employer Group and EIC shall maintain Information and Records (as such terms are defined in Section 5.3 below) for the longer of: (i) a period of ten (10) years from the end of the final contract period under which EIC offers Covered Benefits hereunder, or (ii) the date the U.S. Department of Health and Human Services, the Comptroller General or their designees complete an audit. This Section 5.2 shall survive the termination of this Employer Group Agreement, regardless of the cause of the termination. 5.3 Access to Information and Records: Employer Group and EIC shall provide to federal, state and local 4. r t iit triti .9 EIC also agrees to provide Auditors with all requested and reasonable access to Information and Records. This Section 5.3 shall survive the termination of this Employer Group Agreement, regardless of the cause of termination. 5.4 Policies and Procedures; Compliance Verification: Employer Group shall substantially comply with all reasonable policies and procedures established by EIC in administering and interpreting this Employer Grou� Agreement. Employer Group shall, upon request, provide a certification of its substantial compliance with EIC's participation and contribution requirements and the requirements for a group as defined under 42 C.F.R. 423.100, et. seq. 5.5 Forms: Unless otherwise agreed, and with the exception of the initial letter transmitted by Employer Group to Members to provide Members with an opt -out right from Employer Group's Medicare Part D program, EIC shall distribute all materials to Members regarding enrollment, plan features, including Covered Benefits and exclusions and limitations of coverage. Employer Group shall, within no fewer than thirty (30) calendar days of receipt from an Eligible Individual, forward all completed enrollment information and other required information to EIC. Coverage in V4444." and the individual has been accepted for membership by CMS. 5.6 Member Correspondence: Once an Eligible Individual is enrolled in the EGWP/wrap, the Eligible Individual will receive documents and correspondence from EIC as required by CMS. This may be new to Members previously covered by the Employer Group's prior benefit plan, Members will receive an Evidence of Coverage (EOC) thal explains the rules for coverate under the EGWP/wra , an annual notice of ank_Q�es jANOQ1 to the benefits and other correspondence related to Covered Benefits under the EGWP/wrap (i.e. Medication Therapy Management). 5.7 Employer Group Acknowledgments: Employer Group acknowledges and agrees that it may not mak- changes to the Employer Group's Retiree Benefit Plan during the Term of Service without EIC's prior writter, approval, 1 TOWN 11 LMZVI 0 4 ,A)'Zi pllUl 11•) 111H FflerIRP UaW Or Terfuluam 11 permit EIC to cure the breach. If EIC reasonably cures the breach within the thirty (30) day notice period, this Employer Group Agreement shall not be terminated. (i) Immediately upon notice to Employer Group if Employer Group has performed any material act or practice that constitutes fraud or made any intentional misrepresentation of a material fact relevant to the coverage provided under the EGWP/wrap (The parties agree that inadvertent eligibility errors by Employer Group shall not be characterized by EIC as such acts); (it) Upon 7 days written notice to Employer Group if Employer Group fails to timely make any payment due EIC, and Employer Group has not cured its failure within seven days; (iii) Upon 30 days written notice to Employer Group, if Employer Group ceases to meet Medicare Part D requirements for an employer group; (iv) Upon 180 days written notice to Employer Group (or such shorter notice as may be permitted by applicable law, but in no event less than 30 days) if EIC ceases to offer a product or coverage in a market in which Members covered under the EGWP/wrap reside, (v) Upon 30 days written notice to Employer Group for any other reason consistent with the Health Insurance Portability and Accountability Act of 1996 ("HIPAX) or by applicable federal rules and regulations, as amended. .W MWER11111 R. a I I py rerminaleu, UIR5 r1liplij FeIll—dir-f7dRFbeT;; —;;..I Tr�i U-r?" F:�7' - Wit 11:59 p,m. on the effective date of termination. 6.5 Notices to Members: It is the responsibility of Employer Group to notify the Members of the termination of this Employer Group Agreement in accordance with applicable laws, CIVIS requirements, and EIC's policies and procedures. EIC reserves the right to notify Members of termination of this Employer Group Agreement for any reason, including non-payment of amounts due to EIC by Employer Group; however, EIC's Notice must be presented and approved by Employer Group prior to mailing to Members. In addition, Employer Group shall provide written notice to Members of their rights upon termination of coverage in accordance with the EOC and applicable CIVIS requirements. ISOM Lqr-1421VA@Jlrm;r4ly Amur. 4IrgK41114101MIN4O4 to the (�ntrary, "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. of H I PAA. 7.4 Brokers and Consultants: To the extent any broker or consultant engaged by Employer Group receives PHI in the underwriting process or for any other reason, Employer Group understands and agrees that such broker or consultant is acting on behalf of Employer Group and not EIC. EIC is entitled to rely on Employer Group'� representations that any such broker or consultant is authorized to act on Employer Group's behalf and entitled ti have access • the PHI under the relevant circumstances. 114V 11111 1 1 1 TII777r, 77M, or repriels" 11 1-4clure, OT mineumer iol ani I asull, U1 11 L)IU Iu[ RIM WIIIIIIIZOIUIR mm, the part of the • are neither agents nor employees of EIC, nor is EIC an agent or employee of any Network Provider. Network Providers dispense covered drugs to Members, and EIC administers and determines plan benefits. EIC negotiates contracts with pharmacies, pharmaceutical manufacturers, and vendors on its own behalf and not specifically or ir quality of services of any Network Provider. A Network Provider's participation may be terminated at any time without advance notice to the Employer Group or Members, subject to applicable law, MMUNIMMIUM was caused solely, directly and independently by EIC fraud, willful misconduct, criminal misconduct, negligence, or material breach of this Employer Group Agreement, Employer Group shall indemnify and hold harmless EIC for that portion of any liability, settlement and related expense (including the reasonable cost of legal defense) which was caused solely, directly and independently by Employer Group's fraud, willful misconduct, criminal misconduct, negligence (including, without limitation, untimely, inaccurate, incomplete, or conflicting eligibility information), or material breach of this Employer Group Agreement. The party seeking indemnification must notify the indemnifying party promptly in writing of any actual or threatened action, suit or proceeding to which it claims such indemnity applies. Failure promptly to so notify the indemnifying party shall be deemed a waiver of the right to seek indemnification. liability, settlement and related expense caused by (a) EIC acts or omissions undertaken at the direction of Employer Group or Employer Group's agent; • (b) r♦ Group's act or omission •' at EIC's expressed written iirectio-ii. .......... •; their occurrence. Except in cases of fraud or the inappropriate disclosure of PHI, the rights of the parties hereto for indemnification relating to this Employer Group Agreement or the transactions contemplated herein shall be strictly limited to the respect to any matter arising under or in connection with this Employer Group Agreement. The indemnification obligations of the parties shall terminate upon the expiration of this Employer Group Agreement Weatn5sali8i ty-nttiitit ti Sit tsfur expiration or within 365 days thereafter. 8.4 Delegation and Subcontracting: Employer Group acknowledges and agrees that EIC may enter into qualifip assurance and provider credentialing as wt r-ir. g atrt n EIC deems appropriate. EIC shall remain responsible for the performance of any such delegated functions. 8.5 Prior Agreementsm Severability: As of the Effective Date of Service, this Employer Group Agreement replaces and supersedes all other prior agreements between EIC and Employer Group, as well as any other prior written ♦ oral understandings, negotiations, discussions or arrangements between the parties, related to matters �,this Employ,�Q�Qreement or the documents incorporated herein, If an-... . rovision of this Erngloger Group Agreement is deemed to be invalid or illegal, that provision shall be fully severable and the remaining provisions of this Employer Group Agreement shall continue in full force and effect. 8.6 Amendments: This Employer Group Agreement may be amended as follows: This Employer Group Page 14 of 29 or individual has the authority to (I) modify this Employer Group Agreement; (ii) waive any of its provisions, conditions, or restrictions; (III) extend the time for making a payment; or (iv) bind EIC by making any other commitment or representation or by giving or receiving any information. 8.7 Clerical Errors: Clerical errors or delays by EIC in keeping or reporting data relative to coverage will not reduce or invalidate a Member's coverage. Upon discovery of an error or delay, an adjustment of Administrative Fee shall be made to reflect the cost of the error or delay. BIC may also modify or replace an Employer Group Agreement, EOC or other document issued in error. 8.8 Claim Determinations and Administration of Covered Benefits: EIC has complete authority to review all claims for Covered Benefits as defined in the EOC under this Employer Group Agreement. In exercising such responsibility, BIC shall have discretionary authority to determine whether and to what extent Members are entitled to coverage and to construe any disputed or doubtful terms under this Employer Group Agreement, the EOC or any other document incorporated herein. The administration of Covered Benefits and of any appeals filed by Members related to the processing of claims for Covered Benefits shall be conducted in accordance with the EOC and CMS regulations. 8.9 Third Pad y Billing: EIC may engage a third party entity to provide billing services on behalf of BIC under this Employer Group Agreement. The third party entity is not and should not be considered a third -party beneficiary. 8.10 Misstatements: If any fact as to Employer Group or a Member is found to have been misstated, an equitable adjustment of Administrative Fee may be made. If the misstatement affects the existence or amount of coverage, the true facts will be used in determining whether coverage is or remains in force and its amount. 8.11 Incontestability: Except as to a fraudulent misstatement, or issues concerning Administrative Fees due, no statement made by Employer Group or any Member shall be the basis for voiding coverage or denying coverage or be used in defense of a claim unless it is in writing. 8.12 Assignability: No rights or benefits under this Employer Group Agreement are assignable by either EIC or Employer Group to any third party unless approved, in writing, by all parties. 8.13 Waiver: EIC's failure to implement, or insist upon compliance with, any provision of this Employer Group Agreement or the terms of the EOC incorporated hereunder, at any given time or times, shall not constitute a waiver of EIC's right to implement or insist upon compliance with that provision at any other time or times. This includes, but is not limited to, the payment of Premiums or Covered Benefits. This applies whether or not the circumstances are the same. 814 Third Parties: This Employer Group Agreement shall not confer any rights or obligations on third parties except as specifically provided herein. 8.15 Non -Discrimination: Employer Group agrees to make no attempt, whether through differential contributions or otherwise, to encourage or discourage enrollment of Eligible Individuals in EIC based on health status or health risk. 8.16 Applicable Law: This Employer Group Agreement shall be governed and construed in accordance with applicable federal law and the applicable law, if any, of the State of Ohio, without regard to its conflict principles. Employer Group acknowledges that EGWPs are governed by federal law and the regulations promulgated by CIVIS for Medicare Part D Prescription Drug Plans and Wraps are governed by state law and regulation. 8.17 Use of the EICs Name and all Symbols, Trademarks, and Service Marks: EIC reserves the right to control the use of EICs name and all symbols, trademarks, and service marks presently existing or subsequently tstablished. Employer Group agrees that it will not use such name, symbols, trademarks, or service marks in W I a a a M V2�P Qt Sllr-� fl4i2ti011 Sl12ll We for settleneit nurnoses ot1v aid siall tot be co-tstrued to be 9a admission. A Daft 11=1101 Mm Rgo= Wm JR I if IMIX1111114WOmem WWROW k Inom I Ta M61 to commence mediation within thirty (30) days after written demand. I ne Tees and costs incurred oy Ine party s e in such court order shall be reimbursed by the other party; otherwise, each party shall pay its own costs of mediation. All such mediation proceedings shall be conducted on a confidential basis. The mediation shall be conducted in Monroe County, Florida. 8.19 CMS Contract: This Employer Group Agreement is subject to the annual renewal of EIC's Medicare Part D contract with CMS. Covered Benefits and/or the Administrative Fee and Expenses are also subject to change at the beginning of any subsequent Term of Coverage under this Employer Group Agreement. Except as otherwise provided herein, increases in the Administrative Fee and Expenses and/or •' in Covered Benefits are only permitted at the beginning of a subsequent Term of Coverage under this Employer Group Agreement. Should CMS cancel EIC's contract as a Medicare Part D contractor or should EIC decide not to continue as a Medicare Part D r_#kwLbt7J �_b - I rules and regulations, including, without limitation, CMS requirements. 8.20 Force Maieure: EIC shall not be deemed to have breached this Employer Group Agreement or be held liable for any ilure or delay in the performance of all or any portion of its obligations under this Employer Group Anama Lt if #,rPvPttP0 fritil �jglj �j' i _j jr i litv of tWe Raw. boycotts, lock -outs, acts of terrorism, acts of war or war -operations, restraints of government, power or cannintir.9tiots lite failure or otWer circumstaices bevo-ad suci Q,2t�'s cottrol. or b� reazqa of Ae "iudomen rulin, NEI facilities, riot, civil insurrection, disability of a significant part of EIC's Network Providers or entities with whom EIC has contracted • services under this Employer Group Agreement, or similar causes, the provision of benefits provided under this Employer Group Agreement is delayed or rendered impractical, EIC shall not have any liability or obligation on account of such delay or failure to provide services, except to refund the • of the unearned prepaid Administrative Fee held by EIC on the date such event occurs. EIC is required only to make a good -faith effort to provide or arrange for the provision of services, taking into account the impact of the event. This Section 8.20 shall not be considered to be a waiver of any continuing obligations under this Employer Group Agreement, including, without limitation, the obligation to make payments. 8.21 Notices: Any notice required or permitted under this Employer Group Agreement shall be in writing and shall m ... o h�ve been _iven on the date when delivered in person; or if delivered by first-class United States mail M&W-We- "991 —IMIAR 41 i �4 1 12 ir 1 r oiidr iond ol (z f Page 16 of 29 IMMMIMMEMEM EM 8.22 Representations: Employer Group represents and warrants that to the best of its knowledge (i) it is self - insured for benefits covered under its Retiree Benefit Plan and the Wrap; (H) the entering into this Employer Group Agreement 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 Employer Group Agreement, any and all applicable licenses, governmental authority, or other authorization required to operate an entity of its type. EIC represents that (i) there are no organizational arrangements that could potentially create a conflict of interest that affects clinical or financial decisions; and (ii) it maintains, and shall continue to maintain throughout the term of this Employer Group Agreement, any and all applicable licenses, governmental authority, or other authorization required to operate an entity of its type. 8.23 Federal Contract EIC and Employer Group agree to comply with the federal contractual provisions required under 2 CFR part 200 at seq. and specified in Exhibit D. The following are approved Exhibits to this Employer Group Agreement: Exhibit A: Summary of Benefits Exhibit B: Explanation of Coverage Exhibit C: Fees and Financial Guarantees Exhibit D: Federal Contract Requirements • w4w4elvM A! (EGWP/wrap ASO) MENNUMMUM IN WITNESS WHEREOF, EIC and Employer Group have caused this Employer Group Agreement to be executed by their respective authorized officers. AN MINSOYMURRIGM DocuSigned by, ( M f)7u" By F� By: William C. Epling, President Address: Address: Envision Insurance Company 2181 East Aurora Road Twinsburg, OH 44087 PH: 330-405-8080 PH: FX 330-405-8081 FX E-MAIL FEIN: Page 18 of 29 EXHIBIT C Fees for Additional Services and Miscellaneous Expenses Manual Claims Processing (including DMRs) $1.50 per Claim processed Claim Adjustment Checks (charged to Employer Group for reimbursements made to Members for Claim adjustments $8.50 per check requested by Employer Group.) Manually create or update the Eligibility File $1.00 per Covered Individual data entry Ad Hoc Computer or Report Programming (Recurring Report) $2,500.00 for the development of a recurring, non-standard report (one time standard ad -hoc report included in administrative fee) Clinical Prior Authorizations (Initial Coverage Determinations) $35.00 per authorization Redeterminations (Internal Appeals) $125.00 per determination Independent Review Organization (IRO) Coordination Pass -through of cost of IRO Member Communications Cost of production and postage Customized Formulary $0.20 PMPM with a minimum of $2,000.00 per month Custom Eligibility File layouts (accommodation or development) $1,000.00 per layout Custom Website or Private Label Portal Quoted upon request Replacement by Envision of lost or stolen ID Cards $1.15 per card plus cost of postage Explanation of Benefits (EOB) production and distribution $1.00 per EOB plus postage Medicaid Subrogation Claim Adjudication $3.50 per claim Enhanced Fraud, Waste and Abuse/Benefit Integrity Services Quoted upon request Pharmacy Audits (On -site) $1,500.00 per on -site audit Drug Therapy Care Gap Management $1.50 per Member, per month Medication Adherence and Persistency (up to three disease states) $1.50 per Member, per month e-Prescribing $0.30 per transaction, minimum of $250.00 per month Standard Online Reporting includes access for 3 client users and Standard Online Reporting User Access 1 consultant user. A licensing fee is charged for each user account not accessed over a 60-day period. $1,200.00 per additional unique user Data transfer files (Industry -standard files) $250.00 per transfer $5,000.00 for identified reports: AClaims History Contract Termination Report Fees A files C. Open Refill files (mail and specialty) D. Accumulator files E. Related Participant Data files I Post Termination Run-off Claims I $2.24 per prescription I Drug Pricing and Dispensing Fees(A) Supply/Source BRAND GENERIC Drug Price Peo Dispensing Fee (c) Drug Price(le(c) (Annual Dispensing Fee A For Contract Year 2018 (Annual Average (Annual Average Average Effective Rate (Annual Average Effective Rate Guarantee) Guarantee) Guarantee) Guarantee) Retail Pharmacy (Up to 30 AWP minus 17.00% $1.00 AWP minus 80.00% $1.00 Days' Supply) Retail Pharmacy (31 AWP minus 17.00% $100 AWP minus 80.00% $1.00 Days' to 83 Days' Supply) Retail Pharmacy (84 AWP minus 22.00% $1.00 AWP minus 84.00% $1.00 Days' to 89 Days' Supply) Retail Pharmacy (90 Days' Supply or greater) AWP minus 22.00% N/A AWP minus 84.00% N/A (non -Mail Order) A Mail Order Pharmacy (UP AWP minus 17.00% N/A AWP minus 80.00% N/A to 45 Days' Supply) Mail Order Pharmacy (46 Days' Supply or greater) AWP minus 23.00% N/A AWP minus 85.00% N/A Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) Supply/Source BRAND GENERIC Drug Price Dispensing Fee P Drug Price(B)(c) (Annual Dispensing Fee P (Annual (le(c) (Annual (Annual Average Average Effective Rate Average Guarantee) For Contract Year 2019 Average Guarantee) Guarantee) Effective Rate Guarantee) Retail Pharmacy (Up to 30 AWP minus $1,00 AWP minus 80.25% $1.00 Days' Supply) 17.00% Retail Pharmacy (31 AWP minus $1.00 AWP minus 80.25% $1.00 Days' to 83 Days' Supply) 17.00% Retail Pharmacy (84 AWP minus $1.00 AWP minus 84.00% $1.00 Days'to 89 Days' Supply) 22.00% Retail Pharmacy (90 Days' Supply or greater) AWP minus N/A AWP minus 84.00% N/A (non -Mail Order) (D) 22.00% Mail Order Pharmacy (Up AWP minus N/A AWP minus 80.25% N/A to 45 Days' Supply) 17,00% Mail Order Pharmacy (46 AWP minus NIA AWP minus 85.00% N/A Days' Supply or greater) 23.00% Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) Drug Price Dispensing Fee P Drug Price0l)(c) (Annual AP (Annual (Annual Average Average Effective Rate A For Contract Year 2020 Average Guarantee) Guarantee) : Effective Rate Guarantee) AWP minus 80.50% AWP minus 80.50% AWP minus 84.00% se AWP minus 84.00% AWP minus 80.50% NIA Annual Average Effective Rate and Annual Average Dispensing Fee Guarantee Employer Group acknowledges that the Annual Average Effective Rates and Annual Average fispensing Fees specified in this ExhibT C are conditioned upon Employer Group's adherence to certain conditions under this Agreement and that the actual Annual Average Effective Rates and Annual Average Dispensing Fees will also depend on Employer Group's drug utilization and mix of Participating Pharmacies. The Annual Average Effective Rates and Annual Average Dispensing Fees guarantees set forth in Exhibit C shall be -41 itz f*r o oi SIMON a IN= More i OPUNSUF lu =11TI"51ull luf ^UI [III IIZ)II CILITU I Ues M-t A any payment due Envision under this Agreement for any amounts Employer Group believes are owed by Envision for financial • Annual Average Manufacturer Derived Revenue Guarantee (EMR(G),N) For • Year 2018: • For up to 83 days'supply of Brand Drugs at a Retail Pharmacy - $23.15 per paid Brand Drug Claim • For 84 days' supply or greater of Brand Drugs at a Retail Pharmacy- $ 85.63 per paid Brand Drug Claim • For up to 45 days'supply of Brand Drugs at the Mail Order Pharmacy- $23.15 per paid Brand Drug Claim • For 46 days'supply or greater of Brand Drugs at the Mail Order Pharmacy- $118,34 per paid Brand Drug Claim • For Specialty Brand Drugs - $234.46 per paid Specialty Brand Drug Claim P Manufacturer Derived Revenue guarantees are stated as annual average amounts per Contract Year, laramees reqIF11, 5113 Share between preferred Brand Drugs and non -preferred Brand Drugs. AAA"A""liWW 41161111661 U011116, Ulu,), W, I k� Ully udilliti We CAUCAILJVII U Vale!LK; M61,1111 ZSITI�,ZS dIllIffelelb-y or affiliated pharmacy which is not a Participating Pharmacy, shall be excluded from the calculation of the guarantees above. (H) Guarantees require Employer Group to utilize current EIC • II �_rub Wrac- nv ir, Wn", "so Ian 'T Ir -2 franutacturer I 0_MP11y_e_r_iZ9UkQ_Uy_jhP W P after application of any additional offset allowed under this Agreement. (b) It the Manufacturer Derived Revenue earned by Employer Group for the Contract Year is, overall, lower than the annual Employer Group, after application of any additional offset allowed under this Agreement. Notwithstanding anything herein to the contrary, Envision shall not be liable to Employer Group for any shortfall in guaranteed Manufacturer Derived Revenue if: (i) Plan Sponsor makes a change to the Covered Benefits at any time (regardless of whether or not such change is required by law); (ii) the configuration of System edits is modified by Employer Group; (iii) Employer Group does not adhere to the Formulary; (iv) the utilization data provided by Employer Group (or Employer Group's agent) upon which the calculation of guarantees were based is inaccurate, incomplete; (v) there is a change +/- 20% in drug utilization patterns of Members; (vi) there is ..q ,Vijp to niarnaceuticaLuatufacturer drug ia Qateit eynir2t, -is. juniff,20urpr bat�ruQtcv. or removal of a drug rom the- i1I - WIR1110 IWO I applicable, Contract Year. Employer Group agrees that Envision's liability to Employer Group for shortfalls in financial guarantees, in 2 WIN 1912 "102 any amounts Employer Group believes are owed by Envision for financial guarantees. * Envision reserves the right to modify the pricing if the actual enrollment on the EGWP/wrap decreases by 20% or more from tota: enrollment on the effective date of this Agreement. INNUTUTW-1 LIBJNII�tolziiikrm EXHIBIT D . . . .... . . . .............. . .. ........ Any proposal submitted in which the vendor is certified as an SBE, or in which the vendor proposes to use subcontractors that are certified as SBEs, in Florida or another jurisdiction, must submit proof of the registration or certification from the local authority in order • receive credit for the use of the SBE. FAMENTINOT47.1-9ROWTIN TM -2 11M NEW 10 r, Contract for a period of five (5) years after final grant close-out by FEMA or DEM, or as required by applicable County, State and Federal law. Records shall be made available during normal working hours for this purpose and in accordance with Section 5 of Agreement. CONTRACTOR shall comply with federal and/or state laws authorizing an audit of CONTRACTOR's operation as a whole, or of specific Project activities. 11 till 111111 !11�li 1111 11111 ; !!1 11 110I I Mill iraw-o],Lll I.M.1141 111114111 10441410 11 MI III it; I V UP i III R % 6 W I ON A i Le Lei MITI I - ------ — --- M I fig to] ATI [01 ft I I KI � to] M Q WIN — on contracts to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017 of the Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. By signing this Agreement, CONTRACTOR represents that the execution of this Agreement will not violate the Public Entity Crimes Act ♦ 287,133, Florida Statutes). ability to bid on and perform County contracts, and may result in debarment from COUNTY's competitive procurement activities. In addition to the foregoing, CONTRACTOR further represents that there has •__ no determination, based on an audit, that it or any subcontractor has committed an act defined by Section 287.133, Florida Statutes, as a "public entity crime" and that it has not been formally charged with committing an act defined as a "public entity crime" regardless of the amount of money involved or whether CONUSULTANT has been placed on the convicted vendor list. CONTRACTOR will promptly notify the COUNTY if it or any subcontractor or CONTRACTOR is formally charged with an act defined as a "public entity crime" or has been placed on the convicted vendor list. R� �, 1411 1 111in; Ill 11111091-1192 IT 111111 M *01019MIR F. The contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, and by the rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by the contracting agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations, and orders. G. In the event of the contractor's non-compliance with the nondiscrimination clauses of this contract or with any of such rules, regulations, or orders, this contract may be canceled, terminated or suspended in whole or in part and the contractor may be declared ineligible for further Government contracts in accordance with procedures authorized in Executive Order 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as provided in Executive Order 11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law. 11 Kel ilL I M an." 11#1 H11 recited in this Agreement. F-11 fill] l 11:1-IM MALIN company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement, For the breach or violation of the provision, the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. Public Records Compliance. Pursuant to F.S. 119,0701 and the terms and conditions of this contract, if the Contractor is an individual, partnership, corporation or business entity that enters into a contract for services with a public agency and is acting on behalf of the public agency as provided under F.S. 119.011(2), the CONTRACTOR is required to: A. Keep and maintain public records that would be required by the County to perform the service. B. Upon receipt from the County's custodian of records, provide the County with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in this chapter or as otherwise provided by law. C. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the CONTRACTOR does not transfer the records to the County. D. Upon completion of the contract, transfer, at no cost, to the County all public records in possession of the CONTRACTOR or keep and maintain public records that would be required by the County to perform the service. If the CONTRACTOR transfers all public records to the County upon completion of the contract, the CONTRACTOR shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the CONTRACTOR keeps and maintains public records upon completion of the contract, the CONTRACTOR shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the County, upon request from the County's custRR ian of records, in a format that is compatible with the information technology systems of the County. E. A request to inspect or copy public records relating to a County contract must be made directly to the County, but if the County does not possess the requested records, the County shall immediately notify the CONTRACTOR of the request, and the )• s -s9111x �•111 IMMM CONTRACTOR must provide the records to the County or allow the records to be inspected or copied within a reasonable time. The CONTRACTOR shall not transfer custody, release, alter, destroy or otherwise dispose of any public records unless or otherwise provided in this provision or as otherwise provided by law. The CONTRACTOR and its subcontractors must follow the provisions as set forth in Appendix II to Pad 200, as amended, including but not limited to: i w t t � t� i,, i .' i ` 'i` - ■i M i i t i i'• i . • ii . i • ': i `r � �/� i i .il . = . i. 1 4' i` ii `i . i 'i i : . = r= t + t �� i,, i . i = i= r r ` ■i i i i t . .; ` i=i ii i i` i ` i i... • i'.....' . i i r i` '..... i `�` i i '..... � i �`i. _ r • i' i = _ �;i` �� r i iii t i . i =_ • M% �' i i` .i` i. `• ! I ii '. . i= _: i = i t r 1 .i` = t = • it ` i i` . ■ ii r il` _ � i` ti ■ it iii i i i !i •i . i........ ii i».. ii• i i i �_!. _ r i : i` i......... t. i i'. -..r ` , _::. i i. i`i... `i '. i` i` i....,. _ � i` �� i i t iii i t ' ` • i r•i'' i i i i . . i ` =.1 i, �r �� N�� . =i `i i . i . .ii :. � i, i r i =i .i';. .ii ii `i i i i.. r i' i i i i. i i - i i i i _ �-, i • - ii -- i' .i,` . ` i` i i i ` i i ! i == is i i • �. = i i " i . _ i` i '; i i ` i; - i - i1 . : '.: i ` = r i . i - . i - . . � i ` 1 • : . 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Monroe County Board of County Commissioner 2018 SUMMARY OF BENEFITS Understanding Your Medicare -Approved Prescription Drug Plan (PDP) GET ANSWERS TO QUESTIONS Q"% Contact your 1-844.293-4760 (TTY: 711) employer 24 hours a day, 7 days a week Log in at envisionrxplus-com, select Member and choose Group Retiree Members A PART D PRESCRIPTION DRUG FLAN (PDP) DESIGNED FOR YOU ,�..::'::'EnvisionRxPlus MEDICARE. APPROVED PRESCRIP7tON DRUG PLAN AmountINITIAL COVERAGE STAGE • pay until youand the plan pay r totalof $3,750 Coverage (includes deductible) for covered Part D prescription drug expenses Drug it Supply for Retail or Mail Order i — Preferred Generic i —$37.50 i — Preferred Brand Tier — Non -preferred r — Specialty 20%<$250i(30-day supply only) Generic COVERAGE GAP STAGE Amount of out-of-pocket costs you pay between $3,750 and $5,000 in total prescription drug expenses You pay 4 % of the cost Brand You pay 35% of the negotiated price and a portion of the dispensing fee CATASTROPHIC STAGE t • /.7TATF, it i / •! Generic covered prescription drug expenses 5% coinsurance or $3.35 copay Brand 5% coinsurance or $8.35 copay EnvisionRxPlus is a Prescription Drug Plan with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request an Evidence of Coverage by calling Member Services or visit envisionrxplus.com. Cost -Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy specific cost -sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. For information about your Supplemental Benefits from your employer, please refer to your Supplemental Summary Plan Description. ENVISICNR PL S ^ SUMMARY OF BENEFITS 1 COVERAGE GAP STAGE Amount of out-of-pocket costs you pay between $3,750 and $5,000 in total prescription drug expenses Generic Brand You pay 35% of the negotiated price and a portion of the dispensing fee CATASTROPHIC STAGE t • /.7TATF, it i / •! Generic EnvisionRxPlus is a Prescription Drug Plan with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request an Evidence of Coverage by calling Member Services or visit envisionrxplus.com. Cost -Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy specific cost -sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. For information about your Supplemental Benefits from your employer, please refer to your Supplemental Summary Plan Description. ENVISICNR PL S ^ SUMMARY OF BENEFITS 1 This information is not a complete description of benefits. Contact the plan for more information. Limitations, coat' eats, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. This information is available for free in other languages. Please call our customer service number at 1-844-293-4760 (TTY: 711) 24 hours a day, 7 days a week. Este informaci6n est6 disponible gratuitamente an otros idiomas, Liame a nuestro Cmdado al Clients, al 1-844-293-4760 (tel6fono de texto/TTY: 711), las 24 hares del dia, los 7 dies de Is semana. Other pharmacies are available in our network. The formulary or pharmacy network may change at any time. You will receive notice when necessary. If you want to know more about the coverage and costs of Original Medicare or to compare plans, look in your current "Medicare & You" handbook, You can also view it online at http://www.medicare.gov, You can also call 1-800-MEDICARE to order your booklet. You can see the complete plan formulary (list of Part D covered prescription drugs) and any restrictions, as well as view the pharmacy directory on our wetwite at envisionrxplus.com. If you qualify for Extra Help, you get help paying for any Medicare drug plan's monthly premium, yearly deductible, and prescription coinsurance. This "Extra Help" also counts toward your out-of-pocket costs. People with limited income and resources may qualify for "Extra Help." Some people automatically qualify for "Extra Help" and don't need to apply. Medicare mails a letter to people who automatically qualify for "Extra Help," You may be able to get "Extra Help' to pay for your prescription drug premiums and costs. To see if you qualify for getting "Extra Help," call: a 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week; 0 The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778. EnvisionRxPlus complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. EnvisionRxPlus does not exclude people or treat the differently because of race, color, national origin, age, disability, or sex. EnvisionRxPlus: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Written information in other formats (large print and accessible electronic formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters c) Information written in other languages D1_ ENVISIONRXPLUS , SUMMARY OF BE 1 3 January I — December 31, 2018 Evidence of Coverage: Your Medicare Prescription Drug Coverage as a Member of EnvisionRxPlus Employer Group Retiree PDP This booklet gives you the details about your Medicare prescription drug coverage from January I — December 31, 2018. It explains how to get coverage for the prescription drugs you need. This is an important legal document. Please keep it in a safe place. This plan, EnvisionvxPlus Employer Group Retiree PRE, is offered by Envision Insurance Company. (When this Evidence of Coverage says "we," "us," or "our," it means means Envision Insurance Company. When it says "plan" or "our plan," it means EnvisionRxPlus Employer Group Retiree PRE) EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. Please contact our Member Services number at 1-844-293-4760 for additional information. (TTY users should call 711.) Hours are 24 hours a day, 7 days a week. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-844-293-4760 (TTY: 711). ATENCION: Si habla espafiol, tiene a an disposici6n servicias gratuitos de asistencia lingnistica. Llame al 1-844-293-4760 (TTY 711). This information is available in a different fanner, including large print, Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, 2019. The formulary and pharmacy network may change at any time. You will receive notice when necessary. S7694 2018 EGWP EOC CE Reviewed 10/30/17 Form 15MS 10260-ANOC/EOC OMB Approval 0938-1051 (Expires: May 31, 2020) (Approved 05/2017) EXHIBIT 7rRrF707 Table of Contents This list of chapters and page numbers is your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics the beginning of each chapter. I Chapter 1. Getting started as a member ....... ..................................... .................... ZI an; ALI a iwuulual CT-Irl 101V to use this booklet. Tells about materials we will send you, your plan premium, the Part D late enrollment penalty, your plan membership card, and keeping your membership record up to date. State Health Insurance Assistance Program (SHIP), the Quality Improvement Organization, Social Security, Medicaid (the state health insura cc ro, ram foL-ueonle wijj = 71 ................ .............................................. Explains rules you need to follow when you a get your Prt D drugs. Tells Me t5ff�'s lixo�C-W�_Pmgs q,# fmd *UMKO*� drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan's programs for drug safety and managing medications. Tells about the 4 stages of drug coverage (Deductible Stage (if applicable), Initial Coverage Period, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains t�te 5 e&A-sharing tiffs for your ?I-art-D dxrxgs-�rd-tehs wirdi yucrairast7-1rdy-fb-f a drug in each cost -sharing tier. Chapter 6. Your rights and [gaponsibilities ........................................................... 8" 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 3 Table of ■ Chapter 7. What to do if you have a problem or c Tells you step-by-step what to do if you are having problems or concerns as a member of our plan. Explains how to ask for coverage decisions and make appeals if you are having trouble getting the prescription drugs you think are covered by our i is to -anakfe Xcel 0.1 '&ti*1s to e miles an-ii/*r eyfrn FROMIUMMIUMM- I .. i Explains how to make complaints about quality of care, waiting times, customer service, and other concerns. Legal, notices ........................................................................................ 126 Includes notices about governing law and about non-discrimination. Chapter 10. Definitions of important words ....... ___ ........................................ ...... 134 Explains key terms used in this booklet. CHAPTER 1 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 5 Chapter 1. Getting started as a member AWN 4. ... ... ... ... ... ... ... ... ... ... ... ... ... .. .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. It J� SECTION I Introduction .........®............ -- ............. - ........... ............... .................. 7 Section 1.1 You are enrolled in EnvisionRxPlus Employer Group Retiree PDP, which is a Medicare Prescription Drug Plan 7 Section 1.2 at is the Evidence of Coverage booklet about? ..... ............... -- ............. 7 Section 1.3 Legal information about the Evidence of Coverage ........................................ 7 SECTION 2 What makes you eligible to be a plan member? .............................. 8 Section 2.1 Your eligibility requirements ......... -- ........ — ................................................ 8 Section 2.2 at are Medicare Part A and Medicare Part B? . . - . . ............. — .............. 8 Section 2.3 Here is the plan service area for EnvisionRxPlus Employer Group RetireePRE ........... ............... — ............. ................................... 9 Section 2.4 U.S. Citizen or Lawful Presence .......... -- ...................................................... 9 SECTION 3 What other materials will you get from us? ................................... 10 Section 3.1 Your plan membership card — Use it to get all covered prescription drugs .. 10 Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network. . ......... 10 Section 3.3 The plan's List of Covered Drugs (Formulary) . .............. -- .............. -- ....... 11 Section 3.4 The Part D Explanation ofBeneflits (the "Part D E0R"): Reports with a summary of payments made for your Part D prescription drugs . ...... ......... I I SECTION 4 Your monthly premium for EnvisionRxPlus Employer GroupRetiree PDP., .............. ---- ...... - ..... - .................................. 12 Section 4.1 How much is your plan premium? .... ...................... .............. — ........... --- 12 SECTION 5 Do you have to pay the Part D "late enrollment penalty"? ........... 13 Section 5.1 What is the Part D "late enrollment penalty"? .............................................. 13 Section 5.2 How much is the Part D late enrollment penalty? ...................... — ................ 13 Section 5.3 In some situations, you can enroll late and not have to pay the penalty ....... 14 Section 5.4 What can you do if you disagree about your Part D late enrollment penalty? . ................................. -- .............................. - ............................. -- 15 SECTION 6 Do you have to pay an extra Part D amount because of your income? ...................... ............... ...................................................... 15 Section 6.1 Who pays an extra Part D amount because of income? ............. -- ............... 15 Section 6.2 How much is the extra Part D amount? .......... ................. -- ........... -- .......... 16 Section 6.3 What can you do if you disagree about paying an extra Part D amount? ..... 16 Section 6.4 What happens if you do not pay the extra Part D amount? ........................... 17 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 6 Chapter 1. Getting started as a member SECTION 7 More information about your monthly premium .................. .... 17 Section 7.1 There are several ways you can pay your plan premium .............................. 17 Section 7.2 Can we change your monthly plan premium during the year? ...................... 18 SECTION 8 Please keep your plan membership record up to date ......... -- .... 18 Section 8.1 How to help make sure that we have accurate information about you .......... 18 SECTION 9 We protect the privacy of your personal health information ........ 19 Section 9.1 We make sure that your health information is protected ............................... 19 Section 10. 1 Which plan pays first when you have other insurance? ............... ................ 19 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 7 Chapter 1. Getting started as a member SECTION 1 Introduction Section 1.1 You are enrolled in EnvisionRxPlus Employer Group Retiree PDP, is is a Medicare Prescription Drug Plan .... . ....... .... ■ •I YUI,tl 171C(Ilkwalr, P1CN;.A1PL1U11 uixg 777777rF, triougn 777 pian, Llivisro—HATTYU-3 Em—ployer Group Retiree PDP. There are different types of Medicare plans. EnvisionRxPlus Employer Group Retiree PDP is a Medicare prescription drug plan (PDP). Like all Medicare plans, this Medicare prescription drug plan is approved by Medicare and run by a private company. Section 1.2 What is the Evidence of Coverage booklet about? This Evidence of Coverage booklet tells you how to get your Medicare prescription drug coverage through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member oft e plan. The word "coverage" and "covered drugs" refers to the prescription drug coverage available to you as a member of Envision RxPlus Employer Group Retiree PDP. If you are confused or concerned or just have a question, please contact our pIan's Member Services (phone numbers are printed on the back cover of this booklet), Section 1.3 Legal information about the Evidence of Coverage This Evidence of Coverage is part of our contract with you about how EnvisionRxPlus Employer Group Retiree PDP covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called "riders" or "amendments." I E - Group Retiree PDP between January 1, 2018, and December 31, 2018. Each calendar year, Medicare allows us to make changes to the plans that we offer. This mean-t U1 kuvu ex -A.; Chapter 1. Getting started as a member December 31, 201& We can also choose to stop offering the plan, or to offer it in a different service area, after December 31, 2018. Medicare (the Centers for Medicare & Medicaid Services) must approve EnvisionRxPlus Employer Group Retiree PDP each year. You can continue to get Medicare coverage as a member of our plan as t-'mplz., aja!*AWj��� approval of the plan. SECTION 2 What makes you eligible to be a plan member? Section 2.1 Your eligibility requirements You are eligible far membership in ourplan as long as: You have Medicare Part A or Medicare Part B (or you have both Part A and Part B) (Section 2.2 tells you about Medicare Part A and Medicare Part B) 0 -- and -- you are a United States citizen or are lawfully present in the United States -- and -- you live in our geographic service area (Section 2.3 below describes our service area) Section 2.2 What are Medicare Part A and Medicare Part B? As discussed in section 1. 1 above, you have chosen to get your prescription drug coverage !;iwm4time.� �-J*d 14*"-vice Pxr*W-� th-r*vgh--*vx pil�zn. inuolimg r provide you with most of these Medicare benefits. We describe the drug coverage you receive under your Medicare Part D coverage in Chapter 3. 1 When you first signed up for Medicare, you received information about what services ar* covered under Medicare Part A and Medicare Part B. Remextber: It 1-0 Live I L-04 MDR in I Medicare Part B is for most other medical services (such as physician's services and other outpatient services) and certain items (such as durable medical equipment (DME) and supplies), I �'U'Tulayu sul — il pioyer GroulTA-UTFre-730-AW, Chapter 1. Getting started as a member Section 2.3 Here is the plan service area for EnvisionRxPlus Employer Group Retiree PDP Although Medicare is a Federal program, EnvisionRxPlus Employer Group Retiree PRE is available only to individuals who live in our plan service area. To remain a member of our plan, you must continue to reside in the plan service area. The service area is described below. Our service area includes all 50 states, the District of Columbia, Puerto Rico, and Guam. We offer coverage in all states, Puerto Rico and Guam, However, there may be cost or other differences between the plans we offer in each state. If you move out of state or territory and into a state or territory that is still within our service area, you must call Member Services in order to update your information. It is also important that you call Social Security if you move or change your mailing address, You can find phone numbers and contact information for Social Security in Chaj x 5. .2ter 2, Sectio� Section 2.4 U.S. Citizen or Lawful Presence A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United States. Medicare (the Centers for Medicare & Medicaid Services) will notify EnvisionRxPlus Employer Group Retiree PDP if you are not eligible to remain a member on this basis. EnvisionRxPlus Employer Group Retiree PDP must disenroll you if you do not meet this ri.-equirement. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 10 Chapter 1. Getting started as a member SECTION 3 What other materials will you get from us? .............................................................. ................ ...................................... Section 3.1 Your plan membership card — Use it to get all covered prescription drugs .............................................. .................................. .......... 111111111111.1 ......................................................... .............................. While you are a member of our plan, you must use your membership card for our plan for prescription drugs you get at network pharmacies. You should also show the provider your Medicaid card, if applicable. Here's a sample membership card to show you what yours will look like: InvislonWilis Rz Bin: 012312 Ax PCH: PARM Rx GRP- <SCXXX> SAMPLE Issuer: (NW)-- 9151 OU me ID- <EW-XXXXM;w Name: -Mviabk- submit Paper Claim- for 2181 East Amon Rd - suite 201 T w=t,�ag. Ohio 444)87 (An tomer servKe: 1444-2934' : ?6C SAMPLE C la= admu2i!tmed br S764 -1%14zmb:e FBPW' Rx Optom. LLC, a ntbadi&%- of rute Atd C oiporat= Please carry your card with you at all times and remember to show your card when you get covered drugs. If gpur plan membership card is damag-W_ d lost, or stolen ' call right away anwe will send you a new card, (Phone numbers for Member Services are printed on the back cover of this booklet.) You may need to use your red, white, and blue Medicare card to get covered medical care and services under Original Medicare. Section 3.2 The Pharmacy Directory: Your guide to pharmacies in on network Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for our plan members. Mr, TIM =- You can use the Pharmacy Directory to find the network pharmacy you want to use. We included a copy of our Phannacy Directory in the envelope with this booklet. An updated Pharmacy Directory is located on our website at www.envisionrxplus.com. To access this online directory, go to www.envisionrxplus.com and click "sign in" in the top right corner (if you have not yet registered, you will need to click "register now" and follow the registration steps to (troceed). You may also call Member Services for updated provider information or to ask us to 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP Chapter 1. Getting started as a member mail you a Pharmacy Directory. We strongly suggest that you review our current Pharmac Directory to see if your pharmacy is still in our network. This is important because, with fe exceptions, you must get your prescriptions filled at a network pharmacy if you want our plan cover (help you pay for) them. I If you don't have the Pharmacy Directory, you can get a copy from Member Services (phone numbers are printed on the back cover of this booklet). At any time, you can call Member Services to get up-to-date information about changes in the pharmacy network. You can also find this information on our website at www.envisionrxplus.com. To access this online directory, go to www.envisionrxplus.com and click "sign in" in the top right comer (if you have not yet registered, you will need to click "register now" and follow the registration steps to proceed). Section 3.3 The plan's List of Covered Drugs (Formulary) The plan has a List of Covered Drugs (Formulary). We call it the "Drug List" for short, It tells which Part D prescription drugs are covered by EnvisionRxPlus Employer Group Retiree PDP. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare, Medicare has approved the EnvisionRxPlus Employer Group Retiree PDP Drug List. The Drug List also tells you if there are any rules that restrict coverage for your drugs. In addition to the Drug List, your Employer Group may provide coverage for some additional drugs as a supplemental benefit. If so, you will receive a Supplemental Formulary addendum from us. We will send you a copy of the Drug List and your Group's Supplemental Formulary addendum (if applicable). The Drug List we send to you includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the printed Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact Member Services to find out if we cover it. To get the most complete and current information about which drugs are covered, you can visit the plan's website (www.envisionrxplus.com) or call Member Services (phone numbers are printed on the back cover of this booklet). FSe­c_t_­ko­n­3_.4- The Part -,D--E-x-pl-a--n-a-ti—o-n _of_Benefits _(the "Part D_E_OB"_)_:Re_ports_`, with a summary of payments made for your Part D prescription drugs When you use your Part D prescription drug benefits, we will send you a summary report to help you understand and keep track of payments for your Part D prescription drugs. This summary report is called the Part D Explanation of Benefits (or the "Part D E013"). The Part D Explanation ofBenefits tells you the total amount you, or others on your behalf, have spent on your Part D prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the month. Chapter 4 (91hat you pay for your Part D prescription 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 12 Chapter 1. Getting started as a member drugs) gives more information about the Part D Explanation of Benefits and how it can help you keep track of your drug coverage. fflg"W Elk TANNaLUSIUMN INIM11,41 You can also get your Explanation of -Benefits on our website at www,envisionrxplus.com. To access this information online, go to www.envisionrxplus.com and click "sign in" in the to right corner (if you have not yet registered, you will need to click "register now" and follow the registration steps to proceed). SECTION 4 Your monthly premium for Envisionftfslus Employer Group Retiree POP Section 4.1 How much is your plan premium? Your coverage is provided through a contract with your current employer or former employer or union, Your current employer or former employer or union will pay monthly premiums to the plan. You may be required to contribute a portion of the premium. If so, this amount is collected by your employer (or former employer or union). Please contact the employer's or union�s Benefits Administrator for information about your plan premium. There are programs to help people with limited resources pay for their drugs. These include "Extra Help" and State Pharmaceutical Assistance Programs. Chapter 2, Section 7 tells more about these programs. If you qualify, enrolling in the program might lower your monthly plan premium. premiums in this Evidence of Coverage may not apply to you. We have included a separate insert, called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tells you about your drug coverage. If you don't have this insert, please call Member Services and ask for the "'LIS Rider." (Phone numbers for Member Services are printed on the back cover of this booklet.) In some situations, your plan premium could be more than the amount listed above in Section 4. 1. Some members are required to pay a Part D late enrollment penalty because they did not join a Medicare drug plan when they first became eligible or because they had a continuous period of 63 days or more when they didn't have "creditable" prescription drug coverage. ("Creditable" means the drug coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.) For these members, the Part D late Chapter2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 13 _ member If you are required to pay the Part D late enrollment penalty, the amount of your penalty depends on how months you were without drug coverage after you became eligible. Chapter 1, Section 5 explains the Part D late enrollment penalty. If you have a Part D late enrollment Penalty and do not pay it, you could be disenrolled from the Plan. If you have a late enrollment penalty but have had creditable coverage through your employer or Group as a retiree or working aged, please contact your Benefit Administrator for proof of coverage. Upon submission of creditable coverage documentation to the plan your Late Enrollment Penalty will be either be reduced or eliminated. SECTION 5 Do you have to pay t "late II t penalty"? Section 5.1 What is the Part D "late enrollment penalty"? Note: If you receive "Extra Help" from Medicare to pay for your prescription drugs, you will not .pay a late enrollment penalty. The late enrollment penalty is an amount that is added to you Part D premium. You may owe a Part D late enrollment penalty drug coverage. "Creditable prescription drug coverage" is coverage that meets Medicare's minimum standards since it is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. The amount of the penalty depends# # to enroll in a creditable prescription coverage plan any time after the end of your initial creditableenrollment period or how many fall calendar months you went without prescription drug pena# Part D coverage. Your Part D late enrollment penalty is considered part of your plan premium. our employer (or former employer or union) will pay your monthly premiums, butthey may bill you for the late enrollment enalty. Section 5.2 How much is the Part D late enrollment penalty? Medicare detennines the amount oft e penalty. Here is how it works: 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 14 Chapter 1. Getting started as a member First count the number of full months that you delayed enrolling in a Medicare drug plan after you were eligible to enroll. Or count the number of full months in which you did not have creditable prescription drug coverage, if the break in coverage was 63 days or more. The penalty is 1% for every month that you didn't have creditable coverage. For example, if you go 14 months without coverage, the penalty will be 14%. Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the nation from the previous year. For 2018, this average premium amount is $35,02. To calculate your monthly penalty, you multiply the penalty percentage and the average monthly premium and then round it to the nearest 10 cents. In the example here it would be 14% times $35.02, which equals $39.92. This rounds to $39.90. This amount would be added to the monthly premium for someone with a Part D late enrollment penalty. There are three important things to note about this monthly Part D late enrollment penalty: First, the penalty may change each year, because the average monthly premium can change each year. If the national average premium (as determined by Medicare) increases, your penalty will increase. Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan that has Medicare Part D drug benefits. Third, if you are under 65 and currently receiving Medicare benefits, the Part D late enrollment penalty will reset when you to 65. After age 65, your Part D late enrollment penalty will be based only on the months that you don't have coverage after your initial enrollment period for aging into Medicare. Section 5.3 In some situations, you can enroll late and not have to pay the penalty You will not have to pay a penalty for late enrollment if you are in any of these situations: If you already have prescription drug coverage that is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. Medicare calls this "creditable drug coverage." Please note: o Creditable coverage could include drug coverage from a former employer or union, TRICARE, or the Department of Veterans Affairs. Your insurer or your human resources department will tell you each year if your drug coverage is creditable coverage. This information may be sent to you in a letter or included in a newsletter from the plan, Keep this information, because you may need it if you join a Medicare drug plan later. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP Chapter 1. Getting started as a member Please note: If you receive a "certificate of creditable coverage" when your health coverage ends, it may not can your prescription drug coverage was creditable. The notice must state that you had "creditable" prescription drug coverage that expected to pay as much as Medicare's standard prescription drug plan pays, o The following are not creditable prescription drug coverages prescription drug discount cards, free clinics, and drug discount websites, o For additional information about creditable coverage, please look in your Medicare & You 2018 Handbook or call Medicare at 1-800-MEDICARE (1-800- 633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week. If you were without creditable coverage, but you were without it for less than 63 days in a row. 0 If you are receiving "Extra Help" from Medicare. Fse dtio n5Aw'hat can you do if you disagree about your Part D late enrollment penalty? If you disagree about your Part D late enrollment penalty, you or your representative can ask for a review of the decision about your late enrollment penalty. Generally, you must request this review within 60 days from the date on the letter you receive stating you have to pay a late enrollment 12enality. Call Member Services to find out more about how to do this (phone nurn,!=� are printed on the back cover of this booklet). Important: Do not stop paying your Part D late enrollment penalty while you're waiting for a review of the decision about your late enrollment penalty. If you do, you could be disenrolled for failure to pay your plan premiums. SECTION 6 Do you have to pay an extra Part D amount because of your income? Section 6.1 Who pays an extra Part D amount because of income? Most people pay a standard monthly Part D premium. However, some people pay an extra amount because of their yearly income. If your income is $85,000 or above for an individual (or married individuals filins seftarateI4 or $170,000 or above for married cou% on must ican an extra amount directly to the government for your Medicare Part D coverage. If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be and how to pay it. The extra amount will be withheld from your Social Security, Railroad Retirement Board, or Office of Personnel Manapement benefit Aeck- iotiatterb*w v*uusua1I%;*,a,%,y_�&ur I -lax AL2rtbum,,,��, =#a -d'g-c-717C Chapter 1. Getting started as a member W7 monthly benefit isn't enough to cover the extra amount owed, If your benefit check isn't enough to cover the extra amount, you will get a bill from Medicare. You must pay the extra amount to the government. It cannot be paid with your monthly plan premium. Section 6.2 How much is the extra Part D amount? If your modified adjusted gross income (NLALGI) as reported on your IRS tax return is above a certain amount, you will pay an extra amount in addition to your monthly plan premium. If you filed an individual tax return and your income in 2016 was: Less than or equal to $85,000 Greater than $85,000 and less than or equal to $107,000 Greater than $107,000 and less than or equal to $133,500 Greater than $133,500 and less than or equal to $160,000 Greater than $160,000 Section-6.3 If you were If you filed a joint tax This is the monthly married but return and your cost of your extra filed a separate income in 2016 was: Part D amount (to be tax return and paid in addition to your income in your plan premium) 2016 was: Less than or equal Less than or equal to $0 to $85,000 $170,000 Greater than $170,000 and less than or equal to $13.00 $214,000 Greater than $214,000 and less than or equal to $33.60 $267,000 Greater than $267,000 and less than or equal to $54.20 $320,000 Greater than Greater than $320,000 $74.80 $85,000 What can you do if you disagree about paying an extra Part D amount? If you disagree about paying an extra amount because of your income, you can as Social Security to review the decision. To find out more about how to do this, contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778). 2018 Evidence of Coverage for EnvisioriRsiolus Employer Group Retiree Pop 17 Chapter 1. Getting started as a member Section 6.4 What happens if you do not pay the extra Part D amount? e T51m) for T*wr Mn)k-nru Part D coverage. If you are required to pay the extra amount and you do not pay it, you will be disenrolled from the plan and lose prescription drug coverage. SECTION 7 More information about your monthly premium In addition to paying the monthly plan premium, many members are required to pay other Medicare premiums. Some plan members (those who aren't eligible for premium -free Part A) pay a premium for Medicare Part A. And most plan members pay a premium for Medicare Part B. Some people pay an extra amount for Part D because of their yearly income, this is known Income Related Monthly Adjustment Amounts, also known as IRMAA. If your income is greater than $85,000 for an individual (or married individuals filing separately) or greater than $170,000 for married couples, you must pay an extra amount directly to the government (not the Medicare plan) for your Medicare Part D coverage. • If you are required to pay the extra amount and you do not pay it, you will be disenrolled from the plan and lose prescription drug coverage. • If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a letter telling you what that extra amount will be. For more information about Part D premiums based on income, go to Chapter 1, Section 6 of this booklet. You can also visit https://www.medicare.gov on the Web or call 1-800� MEDICARE (1 -800-633-4227), 24 hours a day, 7 days a week. TTY users should call I - 877-486-2048. Or you may call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. Your copy of Medicare & You 2018 gives information about the Medicare premiums in the section called "2018 Medicare Costs." This explains how the Medicare Part B and Part D premiums differ for people with different incomes. Everyone with Medicare receives a copy of Medicare & You each year in the fall, Those new to Medicare receive it within a month after first signing up. You can also download a copy of Medicare & You 2018 from the Medicare website (https://www.medicare.gov). Or, you can order a printed copy by phone at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. T`FY users call 1-877-486-2048. Section 7.1 There are several ways you can pay your plan premium . . . . ....... _ - I 20 18 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 18 Chapter 1. Getting started as a member Section 7.2 Can we change your monthly plan premium during the year? No. Please note that your employer (or formere layer or union) will pay monthly premiums tote plan. You may be required to contribute a portion of the premium. If so,, this amount is collected by your employer (or former employer or union), However, in some cases the part of the premium that you have to pay can change during the year. This happens if you become eligible for the "Extra Help" program or if you lose your eligibility for the "Extra Help" program during the year. If a member qualifies for "Extra Help" with their prescription drug costs, the "Extra Help" program will pay part of the member's monthly plan premium. A member who loses their eligibility during the year will need to start paying their full monthly premium. You can find out more about the "Extra Help" program in Chapter 2, Section 7. SECTION 8 Please keep your plan membership record up to daft, Section 8.1 How to help make sure that we have accurate information about you . .... . ..... Your membership record has information from your enrollment form, including your address and telephone number. It shows your specific plan coverage. The pharmacists in the plan's network need to have correct information about you. These network providers use your membership record to know what drugs are covered and the cost -sharing amounts for you. Because of this, it is very important that you help us keep your information up to date. • Changes to your name, your address, or your phone number • Changes in any other medical or drug insurance coverage you have (such as from your employer, your spouse's employer. workers' compensation, or Medicaid) • If you have any liability claims, such as claims from an automobile accident • If you have been admitted to a nursing home • If your designated responsible party (such as a caregiver) changes If any of this information changes, please let us know by calling Member Services (phone numbers are printed on the back cover of this booklet). It is also important to contact Social Security if you move or change your mailing address. You can find phone numbers and contact information for Social Security in Chapter 2, Section 5. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 19 Chapter 1. Getting started as a member Read over the information we send you about any other insurance coverage you have That's because we must coordinate any other coverage you have with your benefits under our plan. (For more information about how our coverage works when you have other insurance, see Section 10 in this chapter.) Once each year, we will send you a letter that lists any other medical or drug insurance coverage that we know about... lease read over this information carefully. If it is correct, you don't need to do anything. If the information is incorrect, or if you have other coverage that is not listed, please call Member Services hone numbers are printed on the back cover of this booklet). SECTIONa protect the privacy information informationWe make sure that your health .: requiredFederal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as by these laws. For more information about how we protect your personal health information, please go to Chapter 6, Section 1.4 of this booklet. SECTION 10 How other insurance works with our plan Section 10.1 Which plan pays first when you have other insurance? otherWhen you have insuranceemployer y re rules set by Medicare that decide whether our vlan or j,,our other insurance ytaj;Ls first. The insurance that aya first is called the "primary payer" and pays up to the limits of its coverage. The one that pays second, called the "secondary payer," only pays if there are costs left uncovered by the primary coverage. The secondary payer may not pay all of the uncovered 0 If you have retiree coverage, Medicare pays first. 0 If your group health plan coverage is based on your or , family member's current employment, who pays first depends on your age, the number of people employed by your employer, and whether you- based on , disability, Renal Disease 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 2# Chapter 1. Getting started as a member o If you're over 65 and you or your spouse is still working, your group health plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan that has more than 20 employees. If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you become eligible for Medicare. • No-fault insurance (including automobile insurance) • Liability (including automobile insurance) • Black lung benefits • Workers' compensation Medicaid and TRICARE never pay first for Medicare -covered services. They only pay after Medicare, employer group health plans, and/or Medigap have paid. If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, call Member Services (phone numbers are printed on the back cover of this booklet). You may need to give your plan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time. OIL. --win ........ 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 2:� Chapter 2. Important phone numbers and resources SECTION I EnvisionRxPlus Employer Group Retiree PDP contacts (how to contact us, including how to reach Member Services at ;iECTION 2 Medicare (how to get help and information directly from the SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) ............ 27 SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for people with Medicare) ....................... 27 SECTION 5 Social Security~,~,,~~,,~,,~,,,~,,~~,,~~,,,~,,~~~,,~~,,,,,~~,.~~,,~,,,~~,,,,,~~,,,~,,~~,,~,,~~,,.28 SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and SECTION 7 Information about programs to help people pay for their SECTION 8 How to contact the Railroad Retirement Board .................. - ......... 32 SECTION 9 Do you have "group insurance" or other health insurance 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 23 Chapter 2. Important phone numbers and resources SECTION I EnvisionRxPlus Employer Group Retiree PDP contacts (how to contact us, including how to reach Member Services at the plan) For assistance with claims, billing, or member card questions, please call or write to EnvisionRxPlus Employer Group Retiree FEE Member Services. We will be happy to help you. Method Member Services — Contact Information CALL 1-844-293-4760 Calls to this number are free. Member Services, including TTY/TDD, is open 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for non-English speakers. TTY 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The TTY/TDD is available 24 hours a day, 7 days a week. FAX 1-866-250-5178 WRITE EnvisionRxPlus 2181 E. Aurora Rd., Suite 201 Twinsburg, OH 44087 customerservice@envisionrxplus.com WEBSITE www.envisionrxplus.com 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 24 Chapter 2. Important phone numbers and resources How to contact us when you are asking for a coverage decision about your Part D prescription drugs, or when you are making an appeal or complaint about your Part D prescription drugs --j'- --.- - - ---- we will pay for your prescription drugs covered under the Part D benefit included in your plan. For more inforination on asking for coverapeA:leci-�i;xaia61kwA"x-r P" Chapter 7 (JThat to do ifyou have a problem or complaint (coverage decisions, appeals, complaints)), You may call us if you have questions about our coverage decision process. You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This type of complaint does not involve coverage or payment disputes. (If your problem is about the plan's coverage or payment, you should look at the section above about makinZ,.�e�). For more information on making a comvJamtabw.At.Ww.T Part D prescription drugs, see Chapter 7 ("at to do ifyou have a problem or complaint (coverage decisions, appeals, complaints)). Method Coverage Decisions, Appeals and Complaints for Part D Prescription Drugs — Contact Information CALL 1- 844-293-4760 Calls to this number are free. Hours are 24 hours a day, 7 days a week. TTY 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Hours are 24 hours a day, 7 days a week. FAX 1-877-503-7231 WRITE EnvisionRxPlus 2181 E. Aurora Rd., Suite 201 Twinsburg, OH 44087 WEBSITE www.envisionrxplus.com 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 25 Chapter 2. Important phone numbers and resources Method Coverage Decisions, Appeals and Complaints for PartJ. Prescription Drugs — Contact Information MEDICARE You can submit a complaint about EnvisionRxPlus Employer Group WEBSITE Retiree PDP directly to Medicare. To submit an online complaint to Medicare go to www.medicare.gov/MedicareComplaintFomi/home.aspx. Where to send a request asking us to pay for our share of the cost of a drug you have received Please note: If you send us a payment request and we deny any part of your request, you can appeal our decision. See Chapter 7 (K'hat to do ifyou have a problem or complaint (coverage decisions, appeals, complaints)) for more infon-nation. CALL 1- 844-293-4760. Member Services is open 24 hours a day, 7 days a week. Calls to this number are free. TTY 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. The TTY/TDD is open 24 hours a day, 7 days a week. FAX 1-866-250-5178 WRITE EnvisionRxPlus 2181 E. Aurora Rd., Suite 201 Twinsburg, OH 44087 Attn: Direct Member Reimbursement WEBSITE www.envisionrxplus.com 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 26 Chapter 2. Important phone numbers and resources (how to get help and information directly from the Federal Medicare program) iidn'ey failure requiring dialysis or a kidney transplant), The Federal agency in charge of Medicare is the Centers for Medicare A, Medicaid Services (sometimes called "CMS"), This agency contracts with Medicare Prescription Drug Plans, including us. Method Medicare — Contact Information CALL 1-800-MEDICARE, or 1-800-633-4227 Calls to this number are free. 24 hours a day, 7 days a week. TTY 1-877-486-2048 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. This is the official government website for Medicare. It gives you up-to-date information about Medicare and current Medicare issues. It also has information about hospitals, nursing homes, physicians, home health agencies, and dialysis facilities. It includes booklets you can print directly from your computer. You can also find Medicare contacts in your state. The Medicare website also has detailed information about your Medicare eligibility and enrollment options with the following tools: Medicare Eligibility Tool: Provides Medicare eligibility status information. Medicare Plan Finder: Provides personalized information about available Medicare prescription drug plans, Medicare health plans, a] Medigap (Medicare Supplement hisurance) policies in your area. These tools provide an estimate of what your out-of-pocket costs might be in different Medicare plans. 2#14 Eviience-0 (,-4weraj@-fcr- Chapter 2. Important phone numbers and resources WERSITE You can also use the website to tell Medicare about any complaints you have (continued) about EnvisionRxPlus Employer Group Retiree PDE- Tell Medicare about your complaint: You can submit a complaint about EnvisionexPlus Employer Group Retiree PDP directly to Medicare. To submit a complaint to Medicare, go to https:/,,'www.medicare.gov/N4edicareComplaintForni/home.aspx. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you don't have a computer, your local library or senior center may be able to help you visit this website using its computer, Or, you can call Medicare and tell them what information you are looking for. They will find the information on the website, print it out, and send it to you, (You can call Medicare at 1-800-MEDICAR-E (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.) SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. You can find the name of your state SHIP in Appendix A at the end of this document. SHIP is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. SHIP counselors can help you with your Medicare questions or problems. They can help you understand your Medicare rights, help you make complaints about your medical care or treatment, and help you straighten out problems with your Medicare bills. SHIP counselors can also help you understand your Medicare plan choices and answer questions about switching plans. SECTION 4 Quality Improvement Organization (paid by Medicare to check on the quality of care for peopI e with Medicare) There is a designated Quality Improvement Organization for serving Medicare beneficiaries in each state. You can find the name of your state's Quality Improvement Organization in Appendix B at the end of this document, W, 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree Pap Chapter 2. Important phone numbers and resources A Quality Improvement Organization has a group of doctors and other health care professionals who are paid by the Federal government. This organization is paid by Medicare to check on and help improve the quality of care for people with Medicare. A Quality Improvement Organization is an independent organization. It is not connected with our plan. You should contact the Quality Improvement Organization if you have a complaint about the quality of care you have received. For example, you can contact the Quality Improvement Organization if you were given the wrong medication or if you were given medications that interact in a negative way, SECTION 5 Social Security Social Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens and lawful permanent residents who are 65 or older, or who have a disability or End -Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have toenroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office. Social Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a letter from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life -changing event, you can call Social Security to ask for reconsideration. If you move or change your mailing address, it is important that you contact Social Security to let the know. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 29 Chapter 2. Important phone numbers and resources Method Social Security — Contact Information CALL 1-800-772-1213 Available 7-00 am to 7:00 pro, Monday through Friday. You can use Social Security's automated telephone services to get recorded information and conduct some business 24 hours a day. TTY 1-800-325-0778 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Available 7:00 am ET to 7:00 pm, Monday through Friday. WEBSITE https://www.ssa.gov/ SECTION 6 Medicali,:i7 (a joint Federal and state program that helps with medical costs for some. people with limited income and resources) Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Some people with Medicare are also eligible for Medicaid. VM3 �TLYM%," 1.11AM&N TTYMMalu LT their Medicare costs, such as their Medicare premiums. These "Medicare Savings Programs" help people with limited income and resources save money each year: Qualified Medicare Beneficiary (QNM): Helps pay Medicare Part A and Part B premiums, and other cost -sharing (like deductibles, coinsurance, and copayments), (Some people with QMB are also eligible for full Medicaid benefits (QMB+).) Specifted Low -Income Medicare Beneficiary (SLMI): Helps pay Part B premiums. (Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).) • Qualified Individual (QD: Helps pay Part B premiums. • Qualified Disabled & Working Individuals (QDWI)- Helps pay Part A premiums. Him, QUIRUCA, YOUI SUILC cala agency listed at the end of this document in Appendix C. Chapter 2. Important phone numbers and resoLrces SECTION 7 Information about programs to help people pay for their prescription drugs Medicare's "Extra Help" Program am you qualify, you get help paying for any Medicare drug plan's monthly premium, yearly deductible, and prescription copayments or coinsurance. This "Extra Help" also counts toward your out-of-pocket costs. ME People with limited income and resources may qualify for "Extra Help." Some people automatically qualify for "Extra Help" and don't need to apply. Medicare mails a letter to people who automatically qualify for "Extra Help." You may be able to get "Extra Help" to pay for your prescription drug premiums and costs. To see if you qualify for getting "Extra Help," call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week-, The Social Security Office at 1-800-772-1213, between 7 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778 (applications); or Your State Medicaid Office (applications), (See Section 6 of this chapter for contact information.) If you believe you have qualified for "Extra Help" and you believe that you are paying an incorrect cost -sharing amount when you get your prescription at a pharmacy, our plan has For assistance obtaining evidence of your proper cost -sharing level, please contact Member Services. We may be able to help you identify the documentation you need. Once you have obtained the proper evidence, you may mail or fax the documentation to our Member Services department for processing. The documentation that you send must include an effective date for the current plan year, .. . rC7fZVCT - - "ITuig joj_r copal-m-enT ievei, 177 wili upraTe--our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. If the pharmacy hasn't collected a copayment from you and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy. If a state paid on your behalf, we may make payment directly to the state. Please contact Member Services if you have questions (phone numbers are printed on the back cover of this booklet). r018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 3 1 Chapter 2. Important phone numbers and resources American Samoa to help people with limited income and resources pay their Medicare costs. Programs vary in these areas, Call your local Medical Assistance (Medicaid) office to find out more about their rules (phone numbers are in Section 6 of this chapter). Or call 1 -800- MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week and say "Medicaid" for more information. TTY users should call 1-877-486-2048. You can also visit hLtps://www.medicare.gov for more information. drugs to Part D members who have reached the coverage gap and are not receiving "Extra Help." For brand name dru th unjjjojijjA11,,j-,nj 10MMM i i0/1- i6ci for brand name drugs. •�#Lwn muff -In$ VARIT4FOUNWHI-i 11MINTE2111061 IW,111110ANN WRITS&IFUNIN I :: A L11L PrOVIUCU 001n Lne arUOUELL YOU Pay unu Me amoum u1scounted Wbyme Wmanuac rer count toward your out-of-pocket costs as if you had paid them and move you through the coverage gap. The amount paid by the plan (15 %) does not count toward your out-of-pocket costs. You also receive some coverage for generic drugs, If you reach the coverage gap, the plan pa 56% of the price for generic drugs and you pay the remaining 44% of the price. For generic drugs, the amount paid by the plan (56%) does not count toward your out-of-pocket costs. Ord the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee included as part of the cost of the drug. I Nv 11 im I w WHY If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than "Extra Help"), you still get the 50% discount on covered brand name drugs. Also, the plan pays 15% of the costs of brand drugs in the coverage gap. The 50% discount and the 15% paid by the plan are both applied to the price of the drug before any SPA P or other coverage. What if you have coverage from an AIDS Drug Assistance Program (ADAP)? What is the AIDS Drug Assistance Program (ADAP)? The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 32 Chapter 2. Important phone numbers and resources are also covered by ADAP qualify for prescription cost -sharing assistance. You can find the name of your state ADAP in Appendix F at the end of this document. Note: To be eligible for the ADAP operating individuals residence # HIV status, low income as defined by If you are currently enrolled in an r` it can continue to provide you with Medicare assistance,prescription cost-sharing-4 assistance for dru! s on the ADAP fic continue receiving this pleaser changes enrollment worker of any # - Part D planor state ADAP in Appendix F at the end of this document. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call your state ADAP in Appendix F at the end of document. What if you get "Extra Help" from Medicare to help pay your prescription drug costs? Can you get the discounts? o. If you fret "Extra Help," you already get coverage for your prescription drug costs during the coverage gap. F If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, you • • review your_ *should contact us to make _ that your prescriptionareup-to-date. If we don't agree that you _ owed a discount, you can appeal.! an appeal ProgramState Health Insurance Assistance # (telephone numbers chapter) or by 4 TTY users should call i, Many states have State Pharmaceutical some people pay for prescription drugs based on financial need, age, medical condition, or disabilities. Each state has different rules to provide drug coverageto its members. You can find out if your state has a State Pharmaceutical Assistance Program by looking in Appendix at the end of this document. SECTION 8 How to contact the Railroad Retirement Board agency v RT MI, '7W M ar IT V%7"A "TNPUT Chapter 2. Important phone numbers and resources KK If you receive your Medicare through the Railroad Retirement Board, it is important that you let them know if you move or change your mailing address. Method CALL TTY WEBSITE . .. ....... 1-877-772-5772 Calls to this number are free. Available 9:00 am to 3:30 pm, Monday through Friday If you have a touch-tone telephone, recorded information and automated services are available 24 hours a day, including weekends and holidays. 1-312-751-4701 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are not free. https:Hsecure.ffb.gov/ Do you have "group insurance" or other heall..... -insurance from an employer? one num ers or em er ervices a on the back cover of this booklet.) You may also call 1-800-MEDICARE (1 -800-63 3 -4227; TTY- 1-877-486-2048) with questions related to your Medicare coverage under this plan. ILF"111 Mr.) 01#01 CHAPTER 3 Using x art D .......... t .......... all - =,11310,10931ROT L 9 KM Chapter 3. Using the,plan's tosveMefor your Part Q p[2§�E� dry_qs SECTION 1 Introduction ............................................................................. ........ 37 Section 1.1 This chapter describes your coverage for Part D drugs ................................. 37 Section 1.2 Basic rules for the plan's Part D drug coverage ........ _ ................... ............ 37 SECTION 2 Fill your prescription at a network pharmacy or through the plan's mail-order service ................................................................. 38 Section 2.1 To have your prescription covered, use a network pharmacy ....................... 38 Section 2.2 Finding network pharmacies... ....... ____ ........ ......... __ ............... 38 Section 2.3 Using the plan's mail-order services . ............... __ ...................... ........ ___ 39 Section 2.4 How can you get a long-term supply of drugs?............................................. 40 Section 2.5 When can you use a pharmacy that is not in the plan's network? ................. 40 SECTION 3 Your drugs need to be on the plan's "Drug List . .......................... 41 Section 3.1 The "Drug List" tells which Part D drugs are covered ..... __ ................. __. 41 Section 3.2 There are 5 "cost -sharing tiers" for drugs on the Drug List ......... __ ............ 42 Section 3.3 How can you find out if a specific drug is on the Drug List? ............. __ .... 42 SECTION 4 There are restrictions on coverage for some drugs ...................... 43 Section 4.1 Why do some drugs have restrictions? .......................................................... 43 Section 4.2 at kinds of restrictions? ............ ___ .................... ............... __ ___ ........ 43 Section 4.3 Do any of these restrictions apply to your drugs? ......... __ ................... _ ....... 44 SECTION 5 What if one of your drugs is not covered in the way you'd like it to be covered? .......... _ ................. ..................................... .... 45 Section 5.1 There are things you can do if your drug is not covered in the way you'd like it to be covered ......... _ ............... _ .................... __ .... ............. .............. 45 Section 5.2 at can you do if your drug is not on the Drug List or if the drug is restricted in some way? .... __ .................. _ .................. _ .......... ........ _ ........... 45 Section 5.3 What can you do if your drug is in a cost -sharing tier you think is too high? ...... _ ................. ................. ___ ................ _ .............. __ .............. __ .... 48 SECTION 6 What if your coverage changes for one of your drugs? ............... 48 Section 6.1 The Drug List can change during the year ............................. __ .................. 48 Section 6.2 at happens if coverage changes for a drug you are taking? ..................... 49 SECTION 7 What types of drugs are not covered by the plan?... .............. ..... 50 Section 7.1 Types of drugs we do not cover ....... ............... __ .............. __ ............... 50 2018 Evidence of Coverage for EnvlsjonRxPlus Employer Group Retiree Pop 36 Chapter 3. Using the plan's coverage for your Part D prescription drugs SECTION 8 Show your plan membership card when you fill a prescription....................................................................................... 51 Section 8.1 Show your membership card ....................... _ ................. _ ................. __ ....... 51 Section 8.2 What if you don't have your membership card with you? . . . . . .............. _ ...... 51 SECTION 9 Part D drug coverage in special situations . ................ .............. 52 Section 9.1 What if you're in a hospital or a skilled nursing facility for a stay that is covered by Original Medicare? .................... ................ ............. _ .. _ ......... 52 Section 9.2 What if you're a resident in a long-term care (LTC) facility? ...................... 52 Section 9.3 at if you are taking drugs covered by Original Medicare? ............. __ .... 53 Section 9.4 at if you have a Medigap, (Medicare Supplement Insurance) policy with prescription drug coverage? ... __ .............. __ ................ ___ ................ 53 Section 9.5 What if you're also getting drug coverage from an employer or retiree groupplan? .............................................. _ ............... ............... ............... _ 54 Section 9.6 at if you are in Medicare -certified Hospice?........................................... 54 SECTION 10 Programs on drug safety and managing medications .................. 55 Section 10.1 Programs to help members use drugs safely ................................................. 55 Section 10.2 Medication Therapy Management (MTM) program to help members manage their medications......................... __ .................. _ ............... 55 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 37 Chapter3. Using the plan's coverage for your Part D prescription drugs 10 Did you know there are programs to help people pay for their drugs? There are programs to help people with limited resources pay for their drugs. These include "Extra Help" and State Pharmaceutical Assistance Programs. For more information, see Chapter 2, Section 7. If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We have included a separate insert, called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tells you about your drug coverage. If you don't have this insert, please call Member Services and ask for the "LIS Rider." (Phone numbers for Member Services are printed on the back cover of this booklet.) . ..... . .. 7-7 SECTION 1 Introduction Section 1.1 This chapter describes your coverage for Part D drugs W&M, In addition to your coverage for Part D drugs through our plan, Original Medicare (Medicare Part A and Part 13) also covers some drugs: Medicare Part A covers drugs you are given during Medicare -covered stays in the hospital or in a skilled nursing facility. Medicare Part B also provides benefits for some drugs. Part B drugs include certain chemotherapy drugs, certain drug injections you are given during an office visit, and drugs you are given at a dialysis facility. The two examples of drugs described above are covered by Original Medicare. (To find out more about this coverage, see your Medicare & You Handbook.) Your Part D prescription drugs are covered under our plan. Section 1.2 Basic rules for the plan's Part D drug coverage • You must have a provider (a doctor, dentist, or other prescriber) write your prescriptio • Your prescriber must either accept Medicare or file documentation with CNIS showing that he or she is qualified to write prescriptions, or your Part D claim will be denied. Y should ask your prescribers the next time you call or visit if they meet this condition. If] 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PER 38 Chapter 3. Using the plan's coverage for your Part D prescription drugs not, please be aware it takes time for your prescriber to submit the necessary paperwork to be processed. You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill your prescriptions at a networkpharmacy or through the plan's mail-order service.) • Your drug must be on the plan's List of Covered Drugs (Formulary) (we call it the "Drug List" for short). (See Section 3, Your drugs need to be on the plan's "Drug List. ") • Your drug must be used fora medically accepted indication. A "medically accepted indication" is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. (See Section 3 for more information about a medically accepted indication.) SECTION 2 Fill your prescription at a network pharmacy or through the plan's mail-order service F Section 2.1 To have your prescription covered, use a network pharmacy In most cases, your prescriptions are covered only if they are filled at the plan's network pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled at out -of -net -work pharmacies.) A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs. The term "covered drugs" means all of the Part D prescription drugs that are covered on the plan's Drug List, I Section 2.2 Finding network pharmacies To find a network pharmacy, you can look in your pharmacy Directory, visit our we site (w-ww.envisionrsplus.con) and click "sign in" in the top right corner (if you have not yet registered, you will need to click "register now" and follow the registration steps to proceed), or call Member Services (phone numbers are printed on the back cover of this booklet). You may go to any of our network pharmacies. If you switch from one network pharmacy to another, and you need a refill of a drug you have been taking, you can ask either to have a new prescription written by a provider or to have your prescription transferred to your new network pharmacy, titf the pharmacy you have been using leaves the network? If the pharmacy you have been using leaves the plan's network, you will have to find a new pharmacy that is in the network. To find another network pharmacy in your area, you can get help from Member Services one numbers are printed on the back cover oft is booklet) or use 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 39 Chapter3. Using the plan's coverage for your Part D prescription drugs the Pharmacy Directory. You can also find information on our website at www.envisionrxplus.com. To access the Pharmacy Directory online, go to www.envisionrxplus.com and click "sign in" in the top right corner (if you have not yet registered, you will need to click "register now" and follow the registration steps to proceel Sometimes prescriptions must be filled at a specialized pharmacy, Specialized pharmacies include - Pharmacies that supply drugs for home infusion therapy. The Infusion drugs may be covered under Medicare Part D. 1%13 tj long-term care facility (such as a nursing home) has its own pharmacy. If you are in an LTC facility, we must ensure that you are able to routinely receive your Part D benefits through our network of LTC pharmacies, which is typically the pharmacy that the LTC facilit i uses. If you have ani difficulti accessina vour Part D benefits in an LTC facilit J?FICUSC UVIRMA IVIVIIISUI OUI VIUCS. _r 1VbkA1PL1kJ11Z5 101 717mmary Ztrugs are avananic up to ) i days in these types of pharmacies depending upon the dispensing increments of each LTC facility. Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program (not available in Puerto Rico). Except in emergencies, only Native Americans or Alask Natives have access to these pharmacies in our network. Please contact Member Serviell to ensure your pharmacy is contracted. Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that require special handling, provider coordination, or education on their use. (Note: This scenario should happen rarely.) To locate a specialized pharmacy, look in your Pharmacy Directory or call Member Services (phone numbers are printed on the back cover of this booklet). Section 2.3 Using the plan's mail-order services Our plan's mail-order service allows you to order at least a 30-day supply of the drug and a 90-day supply if your benefit plan covers a 90-day benefit. To get order forms and information about filling your prescriptions by mail please call Members Services at 1-844-293-4760. If you use a mail-order pharmacy not in the plan's network, your prescription will not be covered, Usually a mail-order pharmacy order will get to you in no more than 14 days. If your mail-ord is delayed, you may be able to receive a temporary supply at your local pharmacy. Please contact Member Services at 1-844-293-4760, 24 hours a day, 7 days a week for more information. I 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 40 Chapter 3. Using the plan's coverage for your Part D prescription drugs New prescriptions the pharmacy receives directly from your doctor's office. After the pharmacy receives a prescription from a health care provider, it will contact you to see if you want the medication filled immediately or at a later time. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if needed, allow you to stop or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted byte pharmacy, to let the know what to do with the new prescription and to prevent any delays in shipping, Refills on mail-order prescriptions, For refills of your drugs, you have the option to sign up for an automatic refill program. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use our auto refill program, please contact your pharmacy 14 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time, To opt out of our program that automatically prepares mail-order refills, please contact us by calling 1-844-296-4760 (TTY/TDD 711) 24 hours a day, 7 days a week. Section on How can you get a long-term supply of drugs? If your plan allows you to obtain a long-term supply of drugs (i.e. up to 90 days), your cost sharing may be lower. "Maintenance drugs" are the type of drugs that can be obtained for a long term -supply. You are able to order your supply through the mail order service or perhaps from a retail pharmacy. All retail pharmacies do not provide a prescription for a long-term supply. See Section 2.3 on how to use the mail order service. If you are uncertain if your plan allows for a long-term supply, please contact Member Services. Section 2.5 When can you use a pharmacy that is not in the plan's network? Generally, we cover drugs filled at an out -of -network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out -of - network phannacy: If there are no participating pharmacies near you, we will cover prescriptions filled at an out -of -network pharmacy in the event of an emergency as determined by the plan. We will cover up to a 30-day supply only. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 41 Chapter3. Using the plan's coverage for your Part D prescription drugs folio �__ pilaf 1077�=VIMMUI 11 LJC1 S Wf XICHIL)CI 3 U1 V IQCS 41U PIILILCU V11 Ult: UUL;K QvVur 01 MIS w J9, lim, 11,111116, �41 . �--s Kai If you must use an out -of -network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost, (Chapter 5, Section 2.1 explains how to ask the plan to pay you back.) SECTION 3 Your drugs need to be on the plan's "Drug List" -Section 3.1 The "Drug List" tells which Part D drugs are covered The plan has a "List of Covered Drugs (Formulary). " In this Evidence of Coverage, we call it the "Drug List" for short. The drugs on the Drug List are only those covered under Medicare Part D (earlier in this chapter, Section 1.1 explains about Part D drugs). 111 WV11111W11111110111' Approved by the Food and Drug Administration. (That is, the Food and Drug Administration has approved the drug for the diagnosis or condition for which it is being prescribed.) -- or -- Supported by certain reference books. (These reference books are the American Hospital Formulary Service Drug Information; the DRUGDEX Information System; and the USPDI or its successor; and, for cancer, the National Comprehensive Cancer Network and Clinical Pharmacology or their successors.) A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, it works just as well as the brand name drug and usually costs less. There are generic drug substitutes available for many brand name drugs. 0"018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 42 Chapter2l. Using the plan's coverage for your Part D prescription drugs In some cases, the law does not allow any Medicare plan to cover certain types of drugs (for more about this, see Section 7.1 in this chapter). Section 3.2 There are 5 "cost -sharing tiers" for drugs on the Drug List Every drug on the plan's Drug List is in one of 5 cost -sharing tiers. In general, the higher the cost -sharing tier, the higher your cost for the drug.- • Tier 1 drugs are preferred generic drugs and are the lowest cost -sharing tier, • Tier 2 drugs are higher cost generic drugs. • Tier 3 drugs are preferred brand drugs and includes some generic drugs. • Tier 4 drugs are non -preferred brand drugs and non -preferred generic drugs, and are the highest cost -sharing tier. • Tier 5 drugs are specialty drugs. The amount you pay for drugs in each cost -sharing tier is shown in Chapter 4 (What you pay fear your Part D prescription drugs). [Sote: If your Group offers coverage of Non -Part D drugs this will be outlined in the Supplemental Formulary from your Employer Group. These drugs are excluded from th-i above cost -sharing tiers and also from any out-of-pocket costs. Section 3.3 How can you find out if a specific drug is on the Drug List? You have 3 ways to find out: I . Check the most recent Drug List we sent you in the mail. (Please note: The Drug List we send includes information for the covered drugs that are most commonly used by our members. However, we cover additional drugs that are not included in the printed Drug List. If one of your drugs is not listed in the Drug List, you should visit our website or contact Member Services to find out if we cover it.) 2. Visit the plan's website (www,envisionrxplus.com), The Drug List on the websito is always the most current. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 43 Chapter3. Using the plan's coverage for your Part D prescription drugs 3. Call Member Services to find out if a particular drug is on the plan's Drug List or to ask for a copy of the list. (Phone numbers for Member Services are printed on the back cover of this booklet.) SECTION 4 There are restrictions on coverage for some drugs Section 4.1 Why do some drugs have restrictions of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower -cost drug will work just as well medically as a higher - cost drug, the plan's rules are designed to encourage you and your provider to use that lower -cost option. We also need to comply with Medicare's rules and regulations for drug coverage and cost -sharing. If there is a restriction for your drug, it usually means that you or your provider will have to take extra steps in If ",,jm&,vn(Am*o you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.) Please note that sometimes a drug may appear more than once in our drug list. This is because different restrictions or cost -sharing may apply based on factors such as the strength, amount, or form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg, one per day versus two per day; tablet versus liquid). --Section 4.2restrictions?_­ L Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The sections below tell you more about the types of restrictions we use for certain drugs. Generally, a "generic" drug works the same as a brand name drug and usually costs less. In most cases, when a generic version of a brand name drug is available, our network pharmacies will provide you the generic version. We usually will not cover the brand name drug when a generic version is available. However, if your provider has told us the medical reason that neither the v nor other covered drugs that treat the same condition will work for you, then we will cover the brand name drug. (Your share of the cost may be greater for the brand name drug than for the generic drug.) 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 44 Chapter 3. Using the plan's coverage for your Part D prescription drugs -CMya7l=lgS,—YU#TUr-yUlr-PTUVRIerMeeU LO gCL 7,7yrovai Twin Me re we win agrmemelmo cover the drug for you. This is called "prior authorization." Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan. M This requirement encourages you to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a different drug first is called "step therapy." 17=rugs, we mija Me amount ne rug Trial you can nave oy limiting now mucT or a drug you can get each time you fill your prescription. For example, if it is nortnally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. Section 4.3-- The plan's Drug List includes information about the restrictions described above. To find out if any of these restrictions apply to a drug you take or want to take, check the Drug List. For the most up-to-date information, call Member Services (phone numbers are printed on the back cover of this booklet) or check our website (www.envisionrxplus.com). i**vir f*r ��"rfrug, I C X1 hwe to take extra steps in order for us to cover the drug. If there is a restriction on the drug you want to take, you should contact Member Services to learn what you or your provider would need to do to get coverage for the drug. If you want us to waive the restriction for you, you will need to use the coverage decision process and ask us to make an exception. We may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.) 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 45 Chapter 3. Using the plan's coverage for your Part D prescription drugs SECTION 5 What if one of your drugs is not covered in the way you'd like it to be covered? Section 5.1 There are things you can do if your drug is not covered in the way you'd like it to be covered We hope that your drug coverage will work well for you. But it's possible that there could be a 3rescription druWou are currently taking, or one 'iwfi yiff.6r4m9t#nr M,r*vi(ktr 2t-d4w,,xmm6#,uld '*+ taking that is not on our formulary or is on our formulary with restrictions. For example: • The drug might not be covered at all. Or maybe a generic version of the drug is covered but the brand name version you want to take is not covered. • The drug is covered, but there are extra rules or restrictions on coverage for that drug. As explained in Section 4, some of the drugs covered by the plan have extra rules to restrict their use. For example, you might be required to try a different drug first, to see if it will work, before the drug you want to take will be covered for you. Or there might be limits on what amount of the drug (number of pills, etc.) is covered during a particular time period. In some cases, you may want us to waive the restriction for you. • The drug is covered, but it is in a cost -sharing tier that makes your cost -sharing more expensive than you think it should be. The plan puts each covered drug into one of 5 different cost -sharing tiers. How much you pay for your prescription depends in part on which cost -sharing tier your drug is in. There are things you can do if your drug is not covered in the way that you'd like it to bt; covered. Your options depend on what type of problem you have: If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn what you can do. Section 5.2 What can you do if your drug is not on the Drug List or if the drug is restricted in some way? If your drug is not on the Drug List or is restricted, here are things you can d- You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered. am=. You can request an exception and ask the plan to cover the drug or remove restrictions from the drug. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 46 Chapter 3. Using the plan's coverage for your Part D prescription drugs Note: Drugs excluded from Medicare Part D coverage or Non -Part D drugs may be offered as a supplemental benefit by your employer group, but they are neither covered nor guaranteed under the Medicare program. i1i ei iiii , 1 11, i� �hhin : ii off, la.,Iem . rar - 1 10, tt 1 1 f To be eligible for a temporary supply, you must meet the two requirements below: I i I 1!! 11 1111 111 Jill I I -- or -- The drug you have been taking is now restricted in some way (Section 4 in this chapter tells about restrictions). For those members who are new or who were in the plan last year and aren't in a long-term care (LTC) facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of 30 days. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30 days of medication. The prescription must be filled at a network pharmacy. For those members who are new or who were in the plan last year and reside in a long-term care (LTC) facility: We will cover a temporary supply of your drug during the flrst 90 days of your membership in the plan if you are new and during the first 90 days of the calendar year if you were in the plan last year. The total supply will be for a maximum of 98- days depending on the dispensing increment. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 98-day supply of medication. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) For those members who have been in the plan for more than 90 days and reside in long-term care (LTC) facility and need a supply right away: We will cover one 3 1 -day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.1 I KUKI-IL4111-two cl Evidence2018 • Chapter 3. Using the plan's coverage for your Part D prescription drugs long-term to a 3 1 -day supply in the are on formulary but require prior authorization, step therapy, or are subject to quantity limit restrictions). This does not apply for short-term leaves of absences (i.e. holidays or vacations) from LTC or hospital facilities. coveredIf you are outside of your 90-day transition period, we will still provide an emergency 30- day supply in the retail setting or up to a 3 1 -day supply in the long-term care setting of Part D covered non -formulary medications (including Part D t our formulary that otherwise limit restrictions), on a case by basis, ", an exception To ask for a temporary supply, call Member Services hone numbers are printed on the back cover oft isbooklet). temporaryDuring the time when you are getting a provider to decide what to do when your . different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you more about these options. PerhapsStart by talking with your provider. different drug covered by the plan that might work just as well for you. You can call Member S ervices to ask for a list of covered dru that treat the same medical condition. This list can help your provider find a covered drug that milit work for pQu_�fPhone numbers for Mem'110�4 UW;kmWih*wkw*mr *f uhil- You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even thoughplan's Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions. If your employer group # r E r no exceptions allowed for Non-Partany D drugs 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 48 Chapter 3. Using the plan's coverage for your Part D prescription drugs advance for next year, We will tell you about any change in the coverage for your drug for next year. You can ask for an exception • -next year, and we will give you an answer within 72 hours after we receive your request (or your prescriber's supporting statement). If we approve your request, we will authorize the coverage before the change takes effect. If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do, It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. I Section 5.3 What can you do if your drug is in a cost -sharing tier you think is too high? If your drug is in a cost -sharing tier you think is too high, start by talking with your provider. PeAwpo-&aoa ic--. a fo You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your provider find a covered drug that might work for you. (Phon numbers for Member Services are printed on the back cover of this booklet.) I If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly. Drugs of our Specialty Tier (Tier 5) are not eligible for this type of exception. We do not lower the cost -sharing amount for drugs in this tier. SECTION 6 What if your coverage changes for one of your drugs? .................................................................................................................................................................... ............... "I'l""I'll""I'll'll""I'll""I'll",lI ...... Section 6.1 The Drug List can change during the year ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ­____,_ ... ... ... ... .. ............... .................................................................................................. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 49 Chapter 3. Using the plan's coverage for your Part D prescription drugs However, during the year, the plan might make changes to the Drug List. For example, the plan might: • Add or remove drugs from the Drug List. New drugs become available, including new generic drugs. Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove a drug from the list because it has been found to be ineffective. • Move a drug to a higher or lower cost -sharing tier. • Add or remove a restriction on coverage fora drug (for more information about restrictions to coverage, see Section 4 in this chapter). • Replace a brand name drug with a generic drug. In almost all cases, we must get approval from Medicare for changes we make to the plan's Drug List. Section 6.2 What happens if coverage changes for a drug you are taking? How will you find out if your drug's coverage has been changed? If there is a change to coverage for a drug you are taking, the In will send you a notice to tell you. Normally, we will let you know at least 60 days ahead of time. Once in a while, a drug is suddenly recalled because it's been found to be unsafe or for other reasons. If this happens, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. Your provider will also know about this change, and can work with you to find another drug for your condition. If any of the following types of changes affect a drug you are taking, the change will not affe you until January I of the next year if you stay in the plan: i If we remove your drug from the Drug List, but not because of a sudden recall or because a new generic drug has replaced it. If any of these changes happens for a drug you are taking, then the change won't affect your use or what you pay as your share of the cost until January I of the next year. Until that date, you probably won't see any increase in your payments or any added restriction to your use of the drug. However, on January I of the next year, the changes will affect you. 14jim.0 MW=11EM# 411210.1 TIN, I In some cases, you will be affected by the coverage change before January 1: If a brand name drug you are taking is replaced by a new generic drug, the plan must give you at least 60 days' notice or give you a 60-day refill of your brand name drug at a network pharmacy. o During this 6-day period, you should be working with your provider to switch to the generic or to a different drug that we cover. o Or you and your provider can ask the plan to make an exception and continue to cover the brand name drug for you. For information on how to ask for an exception, see Chapter 7 (net to do if you have a problem or complaint (coverage decisions, appeals, complaints)). Again, if a drug is suddenly recalled because it's been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Drug List. We will let you know of this change right away. o Your provider will also know about this change, and can work with you to find another drug for your condition. SECTION 7 What types of drugs are not covered by the plan? Section 7.1 Types of drugs we do not cover If you get drugs that are excluded, you must pay for them yourself We won't pay for the drugs that are listed in this section. The only exception: If the requested drug is found upon appeal to be a dru that is not excluded under Part D and we should havi jjiLj lor covered it because of drug, go to Chapter 7, Section 5.5 in this booklet.) Our plan's Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. MMME89=11111 �44 Rl USIS IVW,� 11 N. rEft; tt,7440611 W K! I I RIM&IN r. 1 we o Generally, coverage for "off -label use" is allowed only when the use is supported by certain reference books. These reference books are the American Hospital Formulary Service Drug Information, the DRUGDEX Information System, for 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 5 Chapter 3. Using the plan's coverage for your Part D prescription drugs or their successors. If the use is not supported by any of these reference books, then our plan cannot cover its "off -label use." W • Non-prescription drugs (also called over-the-counter drugs) • Drugs when used to promote fertility • Drugs when used for the relief of cough or cold symptoms • Drugs when used for cosmetic purposes or to promote hair growth • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations • Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject • Drugs when used for treatment of anorexia, weight loss, or weight gain • Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale If you receive "Extra Help" paying for your drugs, your state Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please contact your state Medicaid program to determine what drug coverage may be available to you. (You can find phone numbers and contact information for Medicaid in Chapter 2, Section 6.) SECTION 8 Show your plan membership card when you fill a prescription ...... . . .. Section 8.1 Show your membership card To fill your prescription, show your plan membership card at the network pharmacy you choose. When you show your plan membership card, the network pharmacy will automatically bill the plan for ours are of your covered prescription drug cost. You will need to pay the pharmacy your share oft e cost when you pick up your prescription. 8.2 What if you don't have your membership card with you? n yoll OTT nave your men =11 snip cara wan you wnen y—o-771Tr—y—our prescription, 7Ie pharmacy to call the plan to get the necessary information. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 55 Chapter 3. Using the plan's coverage for your Part D prescription drugs If the pharmacy is not able to get the necessary information, you may vet pay the full cost of the prescription when you pick it up. (You can then as us to reimburse you for our share. See Chapter 5, Section 2.1 for information about how to ask the plan for reimbursement.) SECTION 9 Part D drug coverage in special situations Section 9.1 What if you're in a hospital or a skilled nursing facility for a stay that is covered by Original Medicare? .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. .. ... ... ... ... . If you are admitted to a skilled nursing facility for a stay covered by Original Medicare, Medicare Part A will generally cover your prescription drugs during all or part of your stay. If Won are still in the skilled nursin facilit and Part A is no lo rn c6cr will cover your drugs as long as the drugs meet all of our rules or coverage. See the previous parts of this chapter that tell about the rules for getting drug coverage. Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a Special Enrollment Period. During this time period, you can switch plans or change your coverage. (Chapter 8, Ending your membership in the plan, tells when you can leave our plan and join a different Medicare plan.) LSection 9.2 T What if you're a resident in a long-term care (LTC) facility? Usually, a long-term care facility (LTC) (such as a nursing home) has its own pharmacy, or a pharmacy that supplies drugs for all of its residents. If you are a resident of a long-term care facility, you may get your prescription drugs through the facility's pharmacy as long as it is part of our network. Check your Pharmacy Directory to find out if your long-term care facility's pharmacy is part of our network. If it isn't, or if you need more information, please contact Member Services (phone numbers are printed on the back cover of this booklet). What if you're a resident in a long-term care (LTC) facility and become a new member of the plan? t IN frF1,r-JLTU. I T. I - Is., M T. S-1- - -.,-,Tfle plan will COT er.7 temporary supply of your drug during the first 90 days of your membership. The total supply will be for a maximum of 98 days, or less if your prescription is written for fewer days. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.) If you have been a member of the plan for more than 90 days and need a drug that is not on our Drug List or if the plan has any restriction on the drug's coverage, we will cover one 3 1 -day supply, or less if your prescription is written for fewer days. During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the plan that might work just as well for you. Or you and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If you and your provider want to ask for an exception, ■ 7, Section 5.4 tells what to do. Section 9.3 What if you are taking drugs covered by Original Medicare? Your enrollment in EnvisionRxPlus Employer Group Retiree PDP doesn't affect your coverage for drugs covered under Medicare Part A or Part B. If you meet Medicare's coverage requirements, your drug will still be covered under Medicare Part A or Part B, even though you are enrolled in this plan. In addition, if your drug would be covered by Medicare Part A or Part B, our plan can't cover it, even if you choose not to enroll in Part A or Part B. Some drugs may be covered under Medicare Part B in some situations and through EnvisionRxPlus Employer Group Retiree PDP in other situations. But drugs are never covered by both Part ■ and our plan at the same time. In general, your pharmacist or provider will determine whether to bill Medicare Part B or EnvisionRxPlus Employer Group Retiree ■ for the drug. Each year your Medigap insurance company should send you a notice that tells if your prescription drug coverage is "creditableand the choices you have for drug coverage. (If the coverage from the Medigap policy is "creditable," it means that it is expected to pay, on averag , at least as much as Medicare's standard prescription drug cDiLerage) The notice will also explain how much your premium would be lowered if you remove the prescription drug coverage portion of your Medigap policy. If you didn't get this notice, or if you can't find it, contact your Medigap insurance company and ask for another copy. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 54 Chapter 3. Using the plan's coverage for your Part D prescription drugs Section 9.5 What if you're also getting drug coverage from an employer or retiree group plan? . .. . ... . ......... Do you currently have other prescription drug coverage through your (or your spouse's) employer or retiree group? If so, please contact that group's benefits administrator, He or she can help you determine how your current prescription drug coverage will work with our plan. In general, if you are currently employed, the prescription drug coverage you get from us will be secondary to your employer or retiree group coverage. That means your group coverage would pay first, MEANIN11 If the coverage from the group plan is "creditable," it means that the plan has drug coverage that is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage. Keep these notices about creditable coverage, because you may need them later. If you enroll in a Medicare plan that includes Part D drug coverage, you may need these notices to show that you have maintained creditable coverage. If you didn't get a notice about creditable coverage from your employer or retiree group plan, you can get a copy from the employer or retiree group's benefits administrator or the employer or union. Section 9.6 What if you are in Medicare -certified Hospice? Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in Medicare hospice and require an anti -nausea, laxative, pain medication, or antianxiety drug that is not covered by your hospice because it is unrelated to your terminal illness and related conditions, our plan must receive notification from either the prescriber or your hospice provider that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any unrelated drugs that should be covered by our plan, you can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription. hi the event you either revoke your hospice election or are discharged from hospice, our plan should cover all your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, you should bring documentation to the pharmacy to verify your revocation or dischar�3e. See the j=Yious_#arts of this section that tell about the rules for Z_e�, -drm Ow under Part D. Chapter 4 (What you pay for your Part D prescription drugs) gives more information about drug coverage and what you pay. 2018 Evidence of Coverage for EnvislonoxPlus Employer Group Retiree PDP 55 Chapter 3. Using the plan's coverage for your Part D prescription drugs SECTION 10 Programs on drug safety and managing medications Section 10.1 Programs to help members use drugs safely V#_r MoInUCrS LO sTre ing saic an appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs. We do a review each time you fill a prescription. We also review our records on a regular basis. During these reviews, we look for potential problems such as: • Possible medication errors • Drugs that may not be necessary because you are taking another drug to treat the same medical condition • Drugs that may not be safe or appropriate because of your age or gender • Certain combinations of drugs that could harm. you if taken at the same time • Prescriptions written for drugs that have ingredients you are allergic to • Possible errors in the amount (dosage) of a drug you are taking If we see a possible problem in your use of medications, we will work with your provider to correct the problem. action 10.2 Medication Therapy Management (MTM) to help members manage their medications We have a program that can help our members with complex health needs, For example, some members have several medical conditions, take different drugs at the same time, and have high drug costs. This program is voluntary and free to members. A team of pharmacists and doctors developed the program for us. This program can help make sure that our members get the most benefit from the drugs they take. Our program is called a Medication Therapy Management (MTM) program. Some members who take medications for different medical conditions may be able to get services through an MTM program. A pharmacist or other health professional will give you a comprehensive review of all your medications. You can talk about how best to take your medications, your costs, and any problems or questions you have about your prescription and over-the-counter medications. You'll get a written summary of this discussion. The summary has a medication action plan that recommends what you can do to make the best use of your medications, with space for you to take notes or write down any follow-up questions. You'll also get a personal medication list that will include all the medications you're taking and why you take them. 2018 Evidence of Coverage for Env1sionRxPlus Employer Group Retiree PDP 5t Chapter3. Using the plan's coverage for your Part D prescription drugs It's a good idea to have your medication review before your yearly "Wellness" visit, so you can talk to your doctor about your action plan and medication list. Bring your action plan and medication list with you to your visit or anytime you talk with your doctors, pharmacists, and other health care providers, Also, keep your medication list with you (for example, with your ID) in case you go to the hospital or emergency room. If we have a program that fits your needs, we will automatically enroll you in the program and send you information, If you decide not to participate, please notify us and we will withdraw you from the program. If you have any questions about these programs, please contact Member Services (phone numbers are printed on the back cover of this booklet). What you pay for your Part D rkQ1 -f yu LOA" NiAm -6. ;Iwai" "j. MFVJM�- k4lrtl WAS11-weg-VAL01—�V141110 W11401*1 &W. T."71 *I-itell me III a .................................................................................................................... M-AN ............................ �j 0 ............................................................................ RE -- SECTION 1 Introduction ...................................................................................... 60 Section 1.1 Use this chapter together with other materials that explain your drug gulf= I SECTION 2 What you pay for a drug depends on which "drug payment Section 2.1 What are the drug payment stages for EnvisionRxPlus Employer Group Retiree PDP rtew�bers?_. .... ....................................................... 62 SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in .............................................. 62 Section 3.1 We send you a monthly report called the "Part D Explanation of Benefits" (the "Part D EOB") ....................................................................... 62 Section 3.2 Help us keep our information about your drug payments up to date .... ... __ 63 SECTION 4 During the Deductible Stage, you pay the full cost of your drugs (this stage may not apply to you if your employer group plan does not have a deductible) ......................................... &t Section 4.1 You stay in the Deductible Stage (if applicable) until you have paid the deductible amount for your drugs (this amount may differ or not apply, based on ifyour employer group plan has a deductible or not) ................. 64 SECTION 5 Section 5.1 Section 5.2 Section 5.3 Section 5.4 Section 5.5 During the Initial Coverage Stage, the plan pays its share of What you pay for a chug depends on the drug and where you fill your MEEMIM Your costs for a one -month supply of a drug ........................................... If your doctor prescribes less than a full month's supply, you may not have to pay the cost oft e entire month's supply .................................... Your costs for a long-term 90-day supply of a drug.. ..... ........................ You stay in the Initial Coverage Stage until your total drug costs for the year reach $3,750 .............................................. I a SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 44% of the costs for generic drugs .............. .......................................................... 67 Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $5,000............................................................................................................ 67 Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs... 68 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree Pop 59 Chapter 4. What you pay for your Part D prescription drugs SECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the cost for your drugs ...................................................... 70 Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year ........................... ......................... 70 SECTIOR 8 Additional benefits information ............. -- ..................................... 70 Section 8.1 Our plan offers additional benefits ....... 70 SECTION 9 What you pay for vaccinations covered by Part D depends on how and where you get them ..................................................... 70 Section 9.1 Our plan may have separate coverage for the Part D vaccine medication itself and for the cost of giving you the vaccine ............................................ 71 Section 9.2 You may want to call us at Member Services before you get a vaccination. 72 Los NEI *]XIMMVITHIMR. 11.r.­ "I'V401 11 ituialm" 1:141410111PUR .11:1, Vo 0 Did you know there are programs to help people pay for their drugs? There are programs to help people with limited resources pay for their drugs. These include "Extra Help" and State Pharmaceutical Assistance Programs. For more information, see Chapter 2, Section 7. W If you are in a program that helps pay for your drugs, some information in this Evidence tf Coverage about the costs for Part D prescription drugs may not apply to you. We have included a separate insert, called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider"), which tells you about your drug coverage. If you don't have this insert, please call Member Services and ask for the "LIS Rider." (Phone numbers for Member Services are printed on the back cover of this booklet.) . .. .... .. . .... .. - SECTION 1 Introduction Section 1.1 Use this chapter together with other materials that explain your drug coverage This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple, we use "drug" in this chapter to mean a Part D prescription drug. As explained in Chapter all drugs are Part D drugs — some drugs are covered under Medicare Part A or Part B and other drugs are excluded from Medicare coverage by law. To understand the payment information we give you in this chapter, you need to know the basics of what drugs are covered, where to fill your prescriptions, and what rules to follow when you get your covered drugs. Here are materials that explain these basics: The plan's is of were Drugs (Formulary). To keep things simple, we call this the "Drug List." * This Drug List tells which drugs are covered for you. * It also tells which oft e 5 "cost -sharing tiers" the drug is in and whether there are any restrictions on your coverage for the drug. o If you need a copy of the Drug List, call Member Services (phone numbers are printed on the back cover of this booklet). You can also find the Drug List on our website at www.envisionrxplus.com. The Drug List on the website is always the most current. Chapter 3 of this booklet. Chapter 3 gives the details about your prescription drug coverage, including rules you need to follow when you get your covered drugs. Chapter 3 also tells which types of prescription drugs are not covered by our plan. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 61 Chapter 4. What you pay for your Part D prescription drugs The plan's Pharmacy Directory. In most situations you must use a network pharmacy to get your covered drugs (see Chapter 3 for the details). The Pharmacy Directory has a list of pharmacies in the plan's network. It also tells you which pharmacies in our network can give you a long-term supply of a drug (such as filling a prescription for a three- month's supply). Section 1.2 Types of out-of-pocket costs you may pay for covered drugs . - - . . .... .... . To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services. The amount that you pay for a drug is called "cost -sharing," and there are three ways you may be asked to pay. The "deductible" is the amount you must pay for drugs before our plan begins to pay its share. "Coinsurance" means that you pay a percent of the total cost of the drug each time you fill a prescription. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree Pop 62 Chapter 4. What you pay for your Part D prescription drugs SECTION 2 What you pay for a drug depends on which "drug payment stage" you are in when you get the drug Section 2.1 What are the drug payment stages for EnvisionRxPius Employer Group Retiree PDP members? As shown in the table below, there are "drug payment stages" for your prescription drug coverage under Envision Employer Group Retiree PDP. How much you pay for a drug depends on which of these stages you are in at the time you get a prescription filled or refilled. Stage 1 Stage 2 Stage 3 Stage 4 Yearly Deductible Initial Coverage Coverage Gap Catastrophic Coverage Stage Stage Stage Stage This stage may not apply to you. Refer to your Plan Benefit Design Sheet to see if your EnvisionRxPlus Employer Group Retiree PDP has a deductible. If you have a deductible, you begin in this payment stage when you fill your first prescription of the year. During this stage, you pay the full cost of your drugs. You stay in this stage until you have paid your deductible amount. (Details are in Section 4 of this chapter.) a"nommilaviWn"M your drugs and you pay your share of the cost. You stay in this stage until your year-to-date "total Oetai sare in OSction!� or this chapter.) This stage may not apply to you. Refer to your Plan Benefit Design Sheet to see if your Envision&xPlus Employer Group Retiree PDP has a coverage gap. During this stage, you pay 35% of the price for brand name drugs (plus a portion of the dispensing fee) and 44% of the price for generic drugs. You stay in this stage until your year-to-date "out-of- pocket costs" (your payments) reach a total of $5,000. This amount and rules for counting costs toward this amount have been set by Medicare. (Details are in Section 6 of this chapter.) During this stage, the plan will pay most of the cost of your drugs for the rest of the calendar year (through December 31, 2018). (Details are in Section 7 of this chapter.) SECTION 3 We send you reports that explain payments for your drugs and which payment stage you are in F Section 3.1 We send you a monthly report called the "Part D Explanation of Benefits" (the "Part D EOB") Our plan keeps track of the costs of your prescription drugs and the payments you have made when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 62 Chapter 4. What you pay for your Part D prescription drugs when you have moved from one drug payment stage to the next. In particular, there are two types of costs we keep track of: 0 We keep track of how much you have paid. This is called your "out-of-pocket" cost, We keep track of your "total drug costs." This is the amount you pay out-of-pocket or others pay on your behalf plus the amount paid by the plan. Our plan will prepare a written report called the Part D Explanation of Benefits (it is sometimes called the "E013") when you have had one or more prescriptions filled through the plan during the previous month. It includes - Information for that month. This report gives the payment details about the prescriptions you have filled during the previous month. It shows the total drugs costs, what the plan paid, and what you and others on your behalf paid. Section 3.2 Help us keep our information about your drug payments up to date Show your membership card when you get a prescription filled. To make sure we know about the prescriptions you are filling and what you are paying, show your plan membership card every time you get a prescription filled. Make sure we have the information we need. There are times you may pay for prescription drugs when we will not automatically get the information we need to keep track of your out-of-pocket costs. To help us keep track of your out-of-pocket costs, you may give us copies of receipts for drugs that you have purchased. (If you are billed g2,64 Am&-, " G M., 2Av-M?-P lm-A* 7ky e * how to do this, go to Chapter 5, Section 2 of this booklet.) Here are some types of situations when you may want to give us copies of your drug receipts to be sure we have a complete record of what you have spent for your drugs: o When you purchase a covered drug at a network pharmacy at a special price or using a discount card that is not part of our plan's benefit. o When you made a copayment for drugs that are provided under a dru,-4 manufacturer patient assistance program. tO 18 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 64 Chapter 4. What you pay for your Part D prescription drugs o Any time you have purchased covered drugs at out -of -network pharmacies or other times you have paid the fall price for a covered drug under special circumstances. got-IMMM' IrDU VaLumN alm V1 gmimduvm awl IU YUU1 VUL- and help qualify you for catastrophic coverage, For example, payments made by a State Pharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the Indian Health Service, and most charities count toward your out-of-pocket costs. You should keep a record of these payments and send them to us so we can track your costs. Check the written report we send you. When you receive a Part D Explanation of Benefits (an EOB) in the mail, please look it over to be sure the information is complete and correct. If you think something is missing from the report, or you have any questio, please call us at Member Services (phone numbers are printed on the back cover of this booklet). You can also get your Explanation of Benefits on our website at www.envisionrxplus.com. To access this information online, go to www.envisionrxplus.com and click "sign in" in the top right comer (if you have not yet registered, you will need to click "register now" and follow the registration steps to proceed). Be sure to keep these reports, They are an important record of your drug I . .... . ........ SECTION 4 During the Deductible Stage, you pay the full cost of your drugs [Se,ction 4.1 You stay in the Deductible Stage until you have paid the deductible amount (if applicable) for your drugs This section may not apply to you because of your plan's participation in EnvisionRxPlus Employer Group Retiree PDP. Refer to your Plan Benefit Design Sheet for more information. The Deductible Stage is the first payment stage for your drug coverage, This stage begins when you fill your first prescription in the year. When you are in this payment stage, you must pay the full cost of your drugs until you reach the plan's deductible amount, if applicable. 0 Your "full cost" is usually lower than the normal full price of the drug, since our plan has negotiated lower costs for most drugs. The "deductible" is the amount you must pay for your Part D prescription drugs before the plan begins to pay its share. sitsia-M) nin "LawKernual laws W_ 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 6 zC, Chapter 4. What you pay for your Part D prescription drugs S ECTION 5 During the Initial Coverage Stage, the plan pays its share of your drug costs and you pay your share Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription Every drug on the plan's Drug List is in one of 5 cost -sharing tiers. In general, the higher the cost -sharing tier number, the higher your cost for the drug: • Tier I drugs are preferred generic drugs and are the lowest cost -sharing tier. • Tier 2 drugs are higher cost generic drugs. • Tier 3 drugs are preferred brand drugs and includes some generic drugs. • Tier 4 drugs are non -preferred brand drugs and non -preferred generic drugs, and are the highest cost -sharing tier. • Tier 5 drugs are specialty drugs. For more information about these pharmacy choices and filling your prescriptions, see Chapter 3 in this booklet and the plan's Pharmacy Directory. Section 5.2 Your costs for a one month supply of a drug During the Initial Coverage Stage, your share of the cost of a covered drug will be either a copayment or coinsurance. "I "Copayment" means that you pay a fixed amount each time you fill a prescription. Evidence2018 .verage for EnvisionRxPlus Employer Group Retiree ;DP 66 Chapter 4. What you pay for your Part D prescription drugs "Coinsurance" means that you pay a percent of the total cost of the drug each time you fill a prescription. Refer to your Plan Benefit Design Sheet for cost -sharing information on a one -month supply of a drug. Section-- 5.3 If yourdoctor prescribes less than a full month's supply, youmonth'1 may not have to pay the cost of the entiren' I seriousTypically, the amount you pay for a prescription drug covers a full month's supply of a covered drug. However, your doctor can prescribe less than a month's supply of drugs. There may be times when won want to ask wour doctor about ltrescribingi less than a month's so 1-61 of a druo (for example, when you are trying a medication for the first time that is known to have side effects). If your doctor prescribes less than a full month's supply, you will not have to pay for the full month's supply for certain drugs. The amount you pay when you get less than a full month's supply will depend on whether you are responsible for paying coinsurance (a percentage of the total cost) or a cope ent (a flat dollar amount). If you ' responsible regardlessYou pay the same percentage supply,supply or for fewer days. However, because the entire drug cost will be lower if you get less than a full month's If you are responsible for a copayment for the drug, your copay will be based on the number of days oft e drug that you receive. We will calculate the amount you pay per day for your drug (the "daily cost -sharing rate") and multiply it by the number of days of the drug you receive. o Here's an example: Let's say the copay for your drug for a full month's supply (a 0 #. This means that the amount you pay per day for your drug supply o. the drug, your payment will be $1 per day multiplied by 7 days, for a total payment of $7. Daily before t to pay E entire month's supply. You can also ask your doctor dispense, less than or drugs, if this will help youbetter plan refill dates for different prescriptions so thatcan ■::ke fewer trips to the pharmacy.amount you pay will depend upon the days' supply you receive. Section 5.4 Your costs for a long-term�90-day supply of a drug I:. . supply drug. 2018 Evidence of Coverage for EnvisionRxPIca Employer Group Retiree Pop 67 Chapter 4. What you pay for your Part D prescription drugs Section 5.5 You stay in the Initial Coverage Stage until your total drug costs for the year reach $3,750 i.11111 i'1111111 1111 111 ljili�llll !, : . - Your total drug cost is based on adding together what you have paid and what any Part D plan has paid: What vou have paid for all the covered drugs you have gotten since you started with your first drug purchase of the year. (See Section 6.2 for more information about how Medicare calculates your out-of-pocket costs.) This includes: o If applicable to your employer group plan, the amount you paid when you were in the Deductible Stage. o The total you paid as your share of the cost for your drugs during the Initial Coverage Stage. What the ELan has paid as its share of the cost for your drugs during the Initial Coverage Stage. (If you were enrolled in a different Part D plan at any time during 2018, the amount that plan paid during the Initial Coverage Stage also counts toward your total drug costs.) The Explanation ofBenefits (EOB) that we send to you will help you keep track of how much you and the plan, as well as any third parties, have spent on your behalf during the year. Many people do not reach the $3,750 limit in a year. SECTION 6 During the Coverage Gap Stage, you receive a discount on brand name drugs and pay no more than 44% of the costs for generic drugs Section 6.1 You stay in the Coverage Gap Stage until your out-of-pocket costs reach $5,000 Your Employer Group Plan may provide additional coverage during the Coverage Gap Stage. Refer to the Plan Benefit Design Sheet. When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. You pay 35% of the negotiated price and a portion of the dispensing fee for brand name drugs. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and move you through the coverage gap. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 64- Chapter 4. What you pay for your Part D prescription drugs You also receive some coverage for generic drugs. You pay no more than 4% of the cost for generic drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (56%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. You continue paying the discounted price for brand name drugs and no more than % of the costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2018, that amount is $5,000. Medicare has rules about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket limit of $5,0 0, you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage. Section 6.2 How Medicare calculates your out-of-pocket costs for l prescription drugs :........................................................................................................................ Here are Medicare's rules that we must follow when we keep track of your out-of-pocket costs for your drags. These payments are included in yourout-of-pocket costs When you add up your out-of-pocket costs,you can includethe payments listed below {as long as they are for fart D covered drugs and you followed the rules for drug coverage that are explained in Chapter 3 oft this booklet): The amount you pay for drugs when you are in any of the following drug payment stages, Any payments you made during this calendar year as a member of a different Medicare prescription drug plan before you joined our plan. If you make these payments yourself, they are included in your out-of-pocket costs. These payments programs,individuals or organizations. This includes payments for your drugs made by a friend or relative, by most charities, by AIDS drug assistance Pharmaceutical Assistance Program that is qualified by i or a 2018 Evidence of Coverage for EnvislonRsPlus Employer Group Retiree PDP 69 Chapter 4. What you pay for your Part D prescription drugs Health Service. Payments made by Medicare's "Extra Help" Program are also included. 0 Some of the payments made by the Medicare Coverage Gap Discount Program are included. The amount the manufacturer pays for your brand name drugs is included. But the amount the plan pays for your generic drugs is not included. When you (or those paying on your behalf) have spent a total of $5,000 in out-of-pocket costs within the calendar year, you will move from the Coverage Gap Stage to the Catastrophic Coverage Stage. .illill jiijg�ii 111111111 INTENT[ ...................... . When you add up your out-of-pocket costs, you are not allowed to include any of these types of payments for prescription drugs: • The amount you pay for your monthly premium (if applicable to your group plan). • Drugs you buy outside the United States and its territories. • Drugs that are not covered by our plan. • Drugs you get at an out -of -network pharmacy that do not meet the plan's requirements for out -of -network coverage. • Non -Part D drugs, including prescription drugs covered by Part A or Part B and other drugs excluded from coverage by Medicare. • Payments you make toward prescription drugs not normally covered in a Medicare Prescription Drug Plan. • Payments made by the plan for your brand or generic drugs while in the Coverage Gap. • Payments for your drugs that are made by group health plans including employer health plans. • Payments for your drugs that are made by certain insurance plans and government - funded health programs such as TRICARE, and Veterans Affairs. • Payments for your drugs made by a third -party with a legal obligation to pay for prescription costs (for example, Workers' Compensation). Reminder.- If any other organization such as the ones listed above pays part or all of your out-of-pocket costs for drugs, you are required to tell our plan. Call Member Services to let us know (phone numbers are printed on the back cover oft °s booklet). 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 70 Chapter 4. What you pay for your Part D prescription drugs We will help you. The Part D Explanation ofBenefits (Part D EOB) report we send to you includes the current amount of your out-of-pocket costs (Section 3 in this chapter tells about this report). When you reach a total of $5,000 in out-of-pocket costs for the year, this report will tell you that you have left the Coverage Gap Stage and have moved on to the Catastrophic Coverage Stage. Make sure we have the information e need. Section 3.2 tells what you can do to help make sure that our records of what you have spent are complete and up to date. SECTION 7 During the Catastrophic Coverage Stage, the plan pays most of the cost for your drugs Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this stage for the rest of the year Catastrophic Your share of the cost for a covered drug will be either coinsurance or a copy exit, whichever is the larger amount: o — either — Coinsurance of 5% of the cost of the drug o —or— $[Insert 2018 catastrophic cost -sharing a aunt for genericslpreferred ultisource drugs] for a generic drug or a drug that is treated like a generic and $[insert 2018 catastrophic cost -sharing a aunt for all other drugs] for all other drugs. SECTION 8 Additional Section 8.1 Our plan offers additional benefits -� r 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree Pop 71 Chapter 4. What you pay for your Part D prescription drugs SECTION 9 What you pay for vaccinations covered by Part D depends on how and where you get them Section 9.1 Our plan may have separate coverage for the Part IS vaccine medication itself and for the cost of giving you the vaccine . .... . .. ... .. Our plan provides coverage of a number of Part D vaccines, There are two parts to our coverage of vaccinations: The first part of coverage is the cost oft vaccine medication itself. The vaccine is a prescription medication. The second part of coverage is for the cost of giving you the vaccine. (This is sometimes called the "administration" of the vaccine.) FUMIJIVIIII!=11�1 1. The type of vaccine (what you are being vaccinated for), * Some vaccines are considered Part D drugs. You can find these vaccines listed in the plan's List of Covered Drugs (Formulary), * Other vaccines are considered medical benefits. They are covered under Original Medicare. qwf RMITMUM17=1 3. Who gives you the vaccine. What you pay at the time you get the Part D vaccination can vary depending on the circumstances. For example: Sometimes when you get your vaccine, you will have to pay the entire cost for both the vaccine medication and for getting the vaccine. You can ask our plan to pay you back for our share of the cost. Other times, when you get the vaccine medication or the vaccine, you will pay only your share of the cost. KNI ti M U1,11 014142 11m u! trio I J--_641 A q _0 M- Situation 1: You buy the Part D vaccine at the phannacy and you get your vaccine at the network pharmacy. (Whether you have this choice depends on where you live. Some states do not allow pharmacies to administer a vaccination.) iF, W".4 a I I I kn VA KU DIM I I-S i I M.-I A GEA 4] 1W 114:1014RA111,10 Ma- M-2 UMIM1101n. You will have to pay the pharmacy the amount of your coinsurance or copayment for the vaccine and the cost of giving you the vaccine. * Our plan will pay the remainder of the costs. When you get the vaccination, you will pay for the entire cost of the vaccine and its administration. You can then ask our plan to pay our share of the cost by using the procedures that are described in Chapter 5 of this booklet (Asking us to pay our share of the costsfor covered drugs). You will be reimbursed the amount you paid less your normal coinsurance or copayment for the vaccine (including administration .1 less any difference between the amount the doctor charges and wh we normally pay. (If you get "Extra Help," we will reimburse you this difference.) Situation 3.- You buy the Part D vaccine at your pharmacy, and then take it to your doctor's office where they give you the vaccine. • You will have to pay the phannacy the amount of your coinsurance or copayment for the vaccine itself. • When your doctor gives you the vaccine, you will pay the entire cost for this service, You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 5 of this booklet. • You will be reimbursed the amount charged by the doctor for administering the vaccine less any difference between the amount the doctor charges and what we normally pay. (If you get "Extra Help," we will reimburse you for this difference.) Section 9.2 You may want to call us at Member Services before you get a vaccination The rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us first at Member Services whenever you are planning to get a vaccination. (Phone numbers for Member Services are • on the back cover of this booklet.) We can tell you about how your vaccination is covered by our plan and explain your share of the cost. We can tell you how to keep your own cost down by using providers and pharmacies in our network. it you are not atne to use a networK prUv—Mef ant-7=77177j, 1 7 %77 yol IV L-T" need to do to get payment from us for our share of the cost. CHAPTER 5 x: Asking�share ofx costs for covered drugs Ml SECTION 1 Situations in which you should ask us to pay our are of the cost of your covered drugs ....................................................... 75 Section 1.1 If you pay our pla's share of the cost of your covered drugs, you can ask usfor payment ......... __ ..................... ___ ........................ _ ..................... _. 75 SECTION 2 How to ask us to pay you back ....................................................... 76 Section 2.1 How and where to send us your request for payment ................................... 76 SECTION 3 We will consider your request for payment and say yes or no.................. __ ...................... ........................... — .......................... . 77 Section 3.1 We check to see whether we should cover the drug and how much we owe... ........................... ___ ................................. ........................... __ ........ 77 Section 3.2 If we tell you that we will not pay for all or part of the drug, you can makean appeal .................................................. ................................... ... 77 SECTION 4 Other situations in which you should save your receipts and send copies to us ............................. ........................................ 78 Section 4.1 In some cases, you should send copies of your receipts to us to help us track your out-of-pocket drug costs ............................................................... 78 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 7 ul Chapter 5. Asking us to pay our share of the costs for covered drugs SECTION 1 Situations in which you should ask us to pay our share of the cost of your covered drugs . . . ..... .. . . .......... . ... .... . ------ Section 1.1 If you pay our plan's share of the cost of your covered drugs, you can ask us for payment Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back (paying you back is often called "reimbursing" you). Here are examples of situations in which you may need to ask our plan to pay you back. All of these examples are types of coverage decisions (for more information about coverage decisions, go to Chapter 7 of this booklet). 11 ili�illillillill��l�iiiliiiiiiiliilliiiil��i�illill�l�iiiii�ililI 111111;111 11111111111111p I If you go to an out -of -network pharmacy and try to use your membership card to fill a prescription, the pharmacy may not be able to submit the claim directly to us, When that happens, you will have to pay the full cost of your prescription. (We cover prescriptions filled at out -of -network pharmacies only in a few special situations, Please go to Chapter 3, Section 2.5 to learn more.) Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. 2. When you pay the full cost for a prescription because you don't have your plan membership card with you If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or look up your enrollment information. However, if the pharmacy cannot get the enrollment information they need right away, you may need to pay the full cost of the prescription yourself. Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost. You may pay the full cost of the prescription because you find that the drug is not covered for some reason. For example, the drug may not be on the plan's List of Covered Drugs (Formulary); ar it could have a requirement or restriction that you didn't know about or don't think should apply to you. If you decide to get the drug immediately, you may need to pay the full cost for it. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 76 Chapter 5. Asking us to pay our share of the costs for covered drugs Save your receipt and send a copy to us when you ask us to pay you back. In some situations, we may need to get more information from your doctor in order to pay you back for our share of the cost. Sometimes a person's enrollment in the plan is retroactive. (Retroactive means that the first day oft eir enrollment has already passed. The enrollment date may even have occurred last year.) If you were retroactively enrolled in our plan and you paid out-of-pocket for any of your drugs after your enrollment date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork for us to handle the reimbursement. numbers -for Member Services are %xinted oii7 the back cover of this booklet.) .01111ARMA7111111=1 - - - - W" I yV*1W submit your request for reimbursement with your receipts (the receipt(s) that is normally is attached to the bag and shows the National Drug Code) no later than 3 months from the date the prescription was processed by the pharmacy. Requests received outside of this timeframe (but must be within the last 3 years) will be handled on a case -by -case basis per Medicare guidance but will require management approval prior to processing. In most cases, your reimbursement will be based on the network pharmacy rate not the cash price you paid at the pharmacy. If you fill a prescription at an out -of -network pharmacy, you may be responsible for the difference in cost between what you paid and the network pharmacy rate. All of the examples above are types of coverage decisions. This means that if we deny your request for payment, you can appeal our decision. Chapter 7 of this booklet ("at to do if have a problem or complaint (coverage decisions, appeals, complaints)) has information about how to make an appeal. SECTION 2 How to ask us to pay you bacn Section 2.1 w How and where to send us your request for payment __j Sena us your request Yor payment, a Mir, 1 771 y%717- Tecelyt uoularnerrang Hrent yut-nav-V made. It's a good idea to make a copy of your receipts for your records. To make sure you are giving us all the information we need to make a decision, you can fill out our claim form to make your request for payment. 11 FV=. E018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 77 Chapter 5. Asking us to pay our share of the costs for covered drugs Either download a copy of the form from our website (www.envisionrxplus.com) or call Member Services and ask for the form. (Phone numbers for Member Services are printed on the back cover of this booklet.) EnvisionRxPlus 2181 E. Aurora Rd., Suite 201 Twinsburg, OH 44087 Attn: Direct Member Reimbursement You must submit your claim to us within 90 days of the date you received the service, item, or drug. Contact Member Services if you have any questions (phone numbers are printed on the back cover of this booklet). If you don't no what you should have paid, we can help. You can also call if you want to give us more infonnation about a request for payment you have already sent to us. SECTION 3 We will consider your request for payment and say Section 3.1 We check to see whether we should cover the drug and how much we owe When we receive your request for payment, we will let you know if we need any additional atwatjsrn-��;�ou- ttherwise. we will consiier vour reguest and make a coverage decision. If we decide that the drug is covered and you followed all the rules for getting the drug, we will pay for our share of the cost. We will mail your reimbursement of our share of the cost to you. (Chapter 3 explains the rules you need to follow for getting your Part D prescription drugs covered.) We will send payment within 30 days after your request was received. If we decide that the drug is not covered, or you did not follow all the rules, we will not pay for our share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending the payment you have requested and your rights to appeal that decision. . .......... .. ...... Section 3.2 If we tell you that we will not pay for all or part of the drug, you can make an appeal If you think we have made a mistake in turning down your request for payment or you don't agree with the amount we are paying, you can make an appeal. If you • make an appeal, it means P-018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 78 Chapter 5. Asking us to pay our share of the costs for covered drugs you are asking us to change the decision we made when we turned down your request for payment. For the details on how to make this appeal, go to Chapter 7 of this booklet ("at to do ifyou appealhave a problem or complaint (coverage decisions, appeals, complaints)), The appeals process is a formal process with detailed procedures and important deadlines. If making an Sectionyou, you will find it helpful to start by reading i' introductory section that explains the process for coverage decisions and appeals and gives definitions of terms such as "appeal." 5.5 in Chapter 7 for r step-by-step explanation of how to file an appeal. OtherSECTION 4 situations receipts Section 1 r receipts to us to help us track t- - t drug costs There are some situations when you should let us know about drugs. In these cases, you are not asking us for payment, Instead, you are telling us about your payments so that we can calculate your out-of-pocket qualify for the Catastrophic Coverage Stage more quickly. I Here are two situations when you should send us copies of receipts to let us know about payments you have made for your drugs: twis R i r - example, a pharmacy might offer a special price on the drug. discount card that is outside our benefit that offers a lower price. Unless special conditions apply, you must use a network pharmacy in these situations and your drag must be on our Drug List, LAIRtualb * ■ Please note: If you - in the Deductible Stage . ■ CovStage, we may not pay for any share of these erage copy of the receipt allows us to calculate your out-of-pocket costs correctly 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 79 Chapter 5. Asking us to pay our share of the costs for covered drugs 2. When you get a drug throughi Itance program offered drug manufacturer Some members are enrolled in a patient assistance program offered by a drug manufacturer that is outside the plan benefits. If you get any drugs through a program offered by a drug manufacturer, you may pay a copayment to the patient assistance program. • Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count toward qualifying you for the Catastrophic Coverage Stage. • Pleasenote: Because you are getting your drug through the patient assistance program and not through the plan's benefits, we will not pay for any share of these drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify for the Catastrophic Coverage Stage more quickly. Since you are not asking for payment in the two cases described above, these situations are not considered coverage decisions. Therefore, you cannot make an appeal if you disagree with our decision. CHAPTER 6 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 8' Chapter 6. Your rights and responsibilities ... ... ... ... ... ... ... ... SECTION 1 Our plan must honor your rights as a member of the plan .......... 82 Section 1.1 We must provide information in a way that works for you (in Spanish and largeprint) ................ -- ........................... --- ............ ............ - ................. — 82 Section 1.2 We must treat you with fairness and respect at all times .............................. 82 Section 1.3 We must ensure that you get timely access to your covered drugs ............... 83 Section 1.4 We must protect the privacy of your personal health infon-nation . . .............. 83 Section 1.5 We must give you information about the plan, its network of pharmacies, and your covered drugs ... --- ... --- ................. - ....................................... -- 84 Section 1.6 We must support your right to make decisions about your care ............. — ... 85 Section 1.7 You have the right to make complaints and to ask us to reconsider decisions we have made.. ............. -- .............. ............................ .............. 86 Section 1.8 at can you do if you believe you are being treated unfairly or your rights are not being respected? ............... - .................. — .......................... .... 87 Section 1.9 How to get more information about your rights ............................................ 87 SECTION 2 You have some responsibilities as a member of the plan ............ 88 Section 2.1 at are your responsibilities? ...... -- ........................................................... 88 IN Chapter 6. Your rights and responsibilities SECTION 1 Our plan must honor your rights as a member of thl pIan Section 1.1 We must provide information in a way that works for you (in Spanish and large print) ...... . . . . . . .... ........ ................ To get information from us in a way that works for you, please call Member Services (phone numbers are printed on the back cover of this booklet). Our plan has people and free interpreter services available to answer questions from disabled and non-English speaking members. We can also give you information in large print or Spanish at no cost if you need it. We are required to give you information about the plan's benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Member Services and ask for a supervis6r (phone number; - are printed on the back cover of this booklet). If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with us at 1-844-293-4760. You may also file a complaint with Medicare by calling 1-800-MEDIC1RE (1 -800-633-4227), or directly with the ifflij loi I ijjj ojtj nform tion is included in this Evidence of Coverage or with this nl,,rm Secci6n 1.1 Debernos proveer informaci6n de una manera que funcione para usted (en espatiol, en letra grande) Para o5tener intormacion ae nosorm. Tv 175 ManUT a qTe il-LIC10,11t; pala LbLZU� pul lavul Servicios Para Miembros (los n4meros esUm en la contraportada de este folleto). Nuestro plan cuenta con personas y servicios de int6rprete disponibles Para contestar preguntas de rniembros con discapacidades o que no hablan ingl6s. Tambi6n podemos darle infonnaci6n en Braille, en letra grande o en espaRol sin costo alguno si lo necesita. Tenemus que brindarle infonnaci6n sobre los beneficios del plan en un formato que sea accesible y apropiado Para usted. Para obtener informaci6n de nosotros de una manera que funcione Para usted, flame a Servicios Para Miembros y solicite un supervisor (los ninneros de tel&fono estAn impresos en la contraportada de este folleto). Si tiene algdn problema Para obtener informaci6n de nuestro plan en un formato que sea accesible y apropiado Para usted, Ilame Para presentar una queja con nosotros al 1-844-293- 4760. Tambi6n puede presentar una quej a ante Medicare llamando al 1-800-MEDICARE (1-800- 633-4227), o directamente a la Oficina de Derechos Civiles. La informaci6n de contacto estd incluida en esta Evidencia de Cobertura o con este envio, o puede comunicarse con nuestros Servicios Para Miembros Para obtener informaci6n adicional. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 8 3) Chapter 6. Your rights and responsibilities Section 1.2 We must treat you with fairness and respect at all times Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate based on a person's race, et `city, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location within the service area. If you want more information or have concerns about discrimination or unfair treatment, please call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 (TTY 1-800-537-7697) or your local Office for Civil Rights. If you have a disability and need help with access to care, please call us at Member Services (phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a problem with wheelchair access, Member Services can help. Section 1.3 We must ensure that you get timely access to your covered drugs As a member of our plan, you have the right to get your prescriptions filled or refilled at any of our network pharmacies without long delays. If you think that you are not getting your Part D drugs within a reasonable amount of time, Chapter 7, Section 7 of this booklet tells what you can do. (If we have denied coverage for your prescription drugs and you don't agree with our decision, Chapter 7, Section 4 tells at you can do.) Section 1.4 We must protect the privacy of your personal health information Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws. • Your "Personal health information" includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information. • The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a "Notice of Privacy Practice," that tells out these rights and explains how we protect the privacy of your health information. How do we protect the privacy of your health information? 0 We make sure that unauthorized people don't see or change your records. In most situations, if we give your health information to anyone who isn't providing yo care or paying for your care, we are required to get written permission from y I 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 84 Chapter 6. Your rights and responsibilities Written permission can be given by you or by someone you have given legal power to make decisions for you. There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. • For example, we are required to release health information to government agencies that are checking on quality of care. • Because you area member of our plan through Medicare, we are required to give Medicare your health infonnation, including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations. You can see the information in your records and know how it has been shar with others I You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us - to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Member Services (phone numbers are printed on the back cover of this booklet). In order to release information we require a written request from the member or their Power of Attorney or Legal Representative. Section 1.5 We must give you information about the plan, its network of pharmacies, and your covered drugs As a member of EnvisionRxPlus Employer Group Retiree PDP, you have the right to get several kinds of information from us. (As explained above in Section 1. 1, you have the right to get information from us in a way that works for you. This includes getting the information in languages other than English and in large print.) If you want any of the following kinds of information, please call Member Services (pho numbers are printed on the back cover of this booklet): I Information about our plan. This includes, for example, information about the financial condition. It also includes information about the number of appeals made by members and the plan's performance ratings, including how it has been rated by plan members and how it compares to other Medicare prescription drug plans. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 85 Chapter 6. Your rights and responsibilities * For example, you have the right to get information from us about the pharmacies in our network. * For a list of the pharmacies in the plan's network. see the pharmacy directory. * For more detailed information about our pharmacies, you can call Member Services (phone numbers are printed on the back cover of this booklet) or visit our website at www,envisionrxplus.com. 0 Information about your coverage and the rules you must follow when using your Hwa� • To get the details on your Part D prescription drug coverage, see Chapters 3 and 4 of this booklet plus the plan's List of Covered Drugs (Formulary). These chapters, together with the List of Covered Drugs (Formulary), tell you what drugs are covered and explain the rules you must follow and the restrictions to your coverage for certain drugs. • If you have questions about the rules or restrictions, please call Member Services one numbers are printed on the back cover of this booklet). Information about why something is not covered and what you can do about it. o If a Part D drug is not covered for you, or if your coverage is restricted in some way, you can ask us for a written explanation. You have the right to this explanation even if you received the drug from an out -of -network pharmacy. * If you are not happy or if you disagree with a decision we make about what Part D drug is covered for you, you have the right to ask us to change the decision. You can ask us to change the decision by making an appeal. For details on what to do if something is not covered for you in the way you think it should be covered, see Chapter 7 of this booklet. It gives you the details about how to make an appeal if you want us to change our decision. (Chapter 7 also tells about how to make a complaint about quality of care, waiting times, and other concerns.) * If you want to ask our plan to pay our share of the cost for a Part D prescription drug, see Chapter 5 oft is booklet. Section 1.6 We must support your right to make decisions about your care j You have the right to give instructions about what is to be done if you are noi able to make medical decisions for yourself Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You have the right to say what you want to happen if you are in this situation. This means that, if you want to, you can: Fill out a written form to give someone the legal authority to make medical decisioww for you if you ever become unable to make decisions for yourself. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 86 Chapter 6. Your rights and responsibilities Give your doctors written instructions about how you want them to handle your medical care if you become unable to make decisions for yourself. TMOMM doeummt timm-A hywt-w-nme iTW I situat..kons are called "advance directives." There are different types of advance directives and different names for them. Documents called "living will" and "power of attorney for health care" are examples of advance directives. If you want to use an "advance directive" to give your instructions. here is what to do - et the form. If you want to have an advance directive, you can get a form from your lawyer, from a social worker, or from some office supply stores. You can sometimes get advance directive forms from organizations that give people information about Medicare. • all it out and sign it. Regardless of where you get this form, keep in mind that it is a legal document. You should consider having a lawyer help you prepare it. • Give copies to appropriate people. You should give a copy of the form to your doctor and to the person you name on the form as the one to make decisions for you if you can't. You may want to give copies to close friends or family members as well. Be sure to keep a copy at home. If you know ahead of time that you are going to be hospitalized, and you have signed an advance directive, take a copy with you tote hospital. • If you are admitted to the hospital, they will ask you whether you have signed an advance directive form and whether you have it with you. • If you have not signed an advance directive form, the hospital has forms available and will ask if you want to sign one. Remember, it is your choice whether you want to fill out an advance directive (including whether you want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate against you based on whether or not you have signed an advance directive. If you have signed an advance directive, and you believe that a doctor or hospital did not follow the instructions in it, you may file a complaint with the appropriate state -specific agency as listed in Appendix E. Section 1.7 You have the right to make complaints and to ask us to - -- reconsider decisions we have made If you have any problems or concerns about your covered services or care, Chapter 7 of this booklet tells what you can do. It gives the details about how to deal with all types of problems and complaints. at you need to do to follow up on a problem or concern depends on the 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 87 Chapter 6. Your rights and responsibilities situation. You might need to ask our plan to make a coverage decision for you, make an appeal to us to change a coverage decision, or make a complaint. Whatever you do — as for a coverage decision, make an appeal, or make a complaint — we are required to treat you fairly. You have the right to get a surnmary of information about the appeals and complaints that other members have filed against our plan in the past. To get this information, please call Member Services (phone numbers are printed on the back cover of this booklet). Section 1.8 What can you do if you believe you are being treated unfairly or your rights are not being respected? If it is about discrimination, call the Office for Civil Rights If you believe you have been treated unfairly or your rights have not been respected due to your race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should call the Department of Health and Human Services' Office for Civil Rights at 1-800-368-1019 or TTY 1-800-537-7697, or call your local Office for Civil Rights. ly y*U )rei 1:,Af-w ly aw�iotor rigIrlo ho u�-vwW46&�,m_res�iected, and it's not about discrimination, you can get help dealing with the problem you are having: • You can call Member Services (phone numbers are printed on the back cover of this booklet). • You can call the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3. • Or, you can call Medicare at 1-800-MEDICAR-E (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Section 1.9 ^ How to get more information about your rights MERE NINE • You can call Member Services (phone numbers are printed on the back cover of this booklet). • You can it the State Health Insurance Assistance Program. For details about this organization and how to contact it, go to Chapter 2, Section 3. o You can visit the Medicare website to read or download the publication "Your Medicare Rights & Protections." (The publication is available at: https:Hwww,medicare.gov/Pubpdf/I 1534.pdf) 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 88 Chapter 6. Your rights and responsibilities o Or, you can call 1-800-MEDICARE(1-800-633-4227),24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. :....:......:........:.TEAM ME Section 2.1 What are your responsibilities? _�- Things you need to do as a member of the plan are listed below. If you have any questions, please call Member Services (phone numbers are printed on the back cover of this booklet). We're here to help. Get familiar with your covered s and the rules you must follow to get these covered r s. Use this Evidence of Coverage booklet to learn what is covered for you d the rules you need to follow to get your covered drags. o Chapters 3 and 4 give the details about your coverage for Part D prescription drugs. If you have any other prescription drug coverage in addition to our plan, you arem required tell us. 'numbers requiredprinted on the back cover of this booklet). o We are to follow rules set by Medicare to make sure that you are usinplan. This is called all of your coverage in combination when you get your covered drugs from ou "coordination �: benefits" becauseinvolves the drug benefits you* r benefits you. We'll • o coordinateo r-moreabout coordination* . Tell your doctor �:..:. , M:. enrolled our plan. Show your , membership card whenever you get your prescription Help your doctors and other providers help you by giving them information, asking questions, and followingyour care. o To help your doctors and other health providers give you the best care, learn as much as you are able to about your health problems and give them the information they need about you and your health. Follow the treatment plans and instructions that you and your doctors agree upon. a Make sure your doctors know all of the drugs you are taking, including over-the- counter drugs, vitamins, and supplements. o If you have any questions, be sure to ask. Your doctors and other health care providers are supposed to explain things in a way you can understand. If you ask a question and you don't understand the answer you are given, ask again. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 89 Chapter 6. Your rights and responsibilities Pay what you e. As a plan member, you are responsible for these payments: o You must pay your plan premiums to continue being a member of our plan. o For most of your drugs covered by the plan, you must pay your share of the cost when you get the drug. This will be a copa et (a fixed amount) or coinsurance (a percentage of the total cost) Chapter 4 tells what you must pay for your fart prescription drugs. o If you get any drugs that are not covered by our plan or by other insurance you may have, you must pay the full cost. If you disagree with our decision to deny coverage for a drug, you can make an appeal. Please see Chapter 7 oft this booklet for information about how to make an appeal. o If you are required to pay a late enrollment enaty, you must pay the penalty to remain a member of the plan. a If you are required to pay the extra amount for Part D because of your yearly income, you must pay the extra amount directly tot e government to remain a member of the plan. goingip Tell us if you move. If you are printedMember Services (phone numbers are on the back cover of this booklet). plan.o If you move outside of our plan service area, you cannot remain a member our tellsWe can Periodwhether you are moving outside our service area. If you are leaving our service area, you will have a Special Enrollment when you can join any Medicar plan available in your new area. .Mwe have a plan in your I o If you v i i our service area, we still need to know so we can keep your membership record up to date and know how to contact you. o If you move, it is also important to tell Social Security (or the Railroad RetirementBoard). You can find phone numbers and contact information for these organizations in Chapter 2. Call Member Services for help if you have questions or concerns, We also welcome any suggestions you may have for improving our plan. o Phone numbers and calling hours for Member Services are printed on the back cover of this booklet. o For more information on how to reach us, including our mailing address, please see Chapter 2. CHAPTER 7 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 91 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 1111111111 iIIIIIJ�I *3 IIIQ ................ (q2y2Lage decisions, appea!s, corriRlaints-1 BACKGROUND. .................... .......... ...................................... ................................... 93 SECTION1 Introduction .......... ............................................... .......... ................ 93 Section 1.1 at to do if you have a problem or concern .... _ .......... .......... .......... ........ 93 Section 1.2 at about the legal terms? ........................................... _ .......... ........ __ ..... 93 SECTION 2 You can get help from government organizations that are not connected with us... ................... ............................................... 94 Section 2. I Where to get more information and personalized assistance ......... _ ........... . 94 SECTION 3 To deal with your problem, which process should you use? ....... 94 Section 3,1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? .. ..................... _ ......... 94 COVERAGE DECISIONS AND APPEALS ................. ................................................ 95 SECTION 4 A guide to the basics of coverage decisions and appeals.. ........ 95 Section 4.1 Asking for coverage decisions and making appeals- the big picture .......... _ 95 Section 4.2 How to get help when you are asking for a coverage decision or making anappeal....,.,...._.........._ ............................... _ .......... _ ................................. . 96 SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal ............................ ................................ 97 Section 5.I This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug .................... __ ........ 97 Section 5.2 at is an exception? .......... _ .................. .......... .................... .................. 99 Section 5.3 Important things to know about asking for exceptions ............................... 100 Section 5.4 Step-by-step: How to ask for a coverage decision, including an exception 101 Section 5.5 Step-by-step: How to make a Level I Appeal (how to ask for a review of a coverage decision made by our plan) .... _ ........ _ .......... .......... _ .............. 104 Section 5.6 Step-by-step: How to make a Level 2 Appeal ......... ........ __ ....................... 107 SECTION 6 Taking your appeal to Level 3 and beyond .................................. 109 Section 6.1 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals ............................... 109 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 92 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) H&DUG COUPLAIVIS ..................................................... ............... ............. 1111 SECTION 7 How to make a complaint about quality of care, waiting times, customer service, or other concerns ................................ Section 7.1 What kinds of problems are handled by the complaint process? ...... _ ....... 110 Section 7.2 The faunal name for "making a complaint" is "filing a grievance".... ....... 112 Section 7.3 Step-by-step: Making a complaint .............................................................. 113 Section 7.4 You can also make complaints about quality of care to the Quality Improvement Organization. . . . . . ............ ... _ ................ _ ................... ......... 114 Section 7.5 You can also tell Medicare about your complaint....... ................... __ ......... 114 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 93 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 1 Introduction Section 1.1 Y What to do if you have a problem or concern For some types of problems, you need to use the process for coverage decisions and appeals. Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Which one do you use? That depends on the type of problem you are having. The guide in Section 3 will help you identify the right process to use. Section 1.2 What about the legal terms? There are technical legal terms for some of the rules, procedures, and types of deadlines explained in this chapter. any of these terms are unfamiliar to most people and can be and to understand. To keep Wings simple, tnis cliapter exp ams ruies anu pcll - - kk " ( in place of certain legal terms. For example, this chapter generally says "making a complaint" rather than "filing a grievance," "coverage decision" rather than "coverage detennination," and "Independent Review Organization" instead of "Independent Review Entity." It also uses abbreviations as little as possible. However, it can be helpful — and sometimes quite important — for you to know the correct lega wrmo fir ghw.4i- ' -wit owinN which terms to use will heIII you commut clearly and accurately when you are dealing with your problem and get the right help or information for your situation. To help you know which terms to use, we include legal terms when we give the details for handling specific types of situations. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 94 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) SECTION 2 You can get help from government organizations that are not connected with us Section 2.1 Where to get more information and personalized assistance Sometimes it can be confusing to start or follow through the process for dealing with a problem. This can be especially true if you do not feel well or have limited energy. Other times, you may not have the knowledge you need to take the next step. 1=0 � 1 1-111121 11111111111V 2117101i.� We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has trained counselors i every state. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. I The services of SHIP counselors are free. You will find SHIP phone numbers in Appendix A of this booklet. For more information and help in handling a problem, you can also contact Medicare. Here are two ways to get information directly from Medicare: You can call 1-800-MEDICARE (1-800-633-4227),24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. 0 You can visit the Medicare website (hUps://www.medicare.gov). SECTION 3 To deal with your problem, which process should you use? Section 3.1 Should you use the process for coverage decisions and appeals? Or should you use the process for making complaints? If you have a problem or concern, you only need to read the parts of this chapter that apply to your situation. The guide that follows will help. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 9 01 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) To figure out which part of this chapter will help with your specific problem or concern, START HERE KE= � covereu Of HoLl uIr, rVay III 7VIw-;II uluj dic (A)VCMU, alm plUDIU1116 MIULVT LU medical care or prescription drugs.) Yes. My problem is about benefits or coverage. Go on to the next section of this chapter, Section 4, "A guide to the basics of coverage decisions and appeals." No. My problem is not about benefits or coverage. Skip ahead to Section 7 at the end of this chapter: "How to make a complaint about quality of care, waiting times, customer service or other concerns." SECTION 4 A guide to the basics of coverage decisions and appeaIs picture big 7 Section 4.1 Asking for coverage decisions and making appeals: the The process for coverage decisions and appeals deals with problems related to your benefits and coverage for prescription drugs, including problems related to payment. This is the process you use for issues such as whether a drug is covered or not and the way in which the drug is covered. � _ •E A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and In some cases, we 0 0 r v red by Medicare for you. If you disagree with this coverage decision, you can make an appeal. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 96 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) .� : '*: � . .s: # is If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision, An appeal is a formal way of asking us to review and change a coverage decision we have made. When you appeal a decision for the first time, this is called a Level I Appeal. In this appeal, we review the coverage decision we made unfavorable decision. When we have completed the review we give you our decision. Under certain circumstances. which we discuss later, you can request an expedited or "fast coverage decision" or fast appeal of a properly. Your appeal is handled by different reviewers than those who made the original If we say no to all or part of your Level I Appeal, you can ask fora Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal. I Section 4.2 How to get help when you are asking for a coverage decision i or making an appeal Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of coverage decision or appeal a decision: • You can call s at Member Services hone numbers are printed on the back cover of this booklet). • To get free help from an independent organization that is not connected with our plan, contact your State Health Insurance Assistance Program (see Section 2 oft this chapter). • Your doctor or other prescriber can make a request for you. For Part D prescription drugs, your doctor or other prescriber can request a coverage decision or a Level I or Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other prescriber must be appointed as your representative. • You can ask someone to act on your e al . If you want to, you can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal. o There may be someone who is already legally authorized to act as your representative under State law. prescriber,0 If you want a friend, relative, your doctor or other Representative"your representative, call Member Services (phone numbers are printed on the back cover of this booklet) and ask for the "Appointment of form. (The form is also available on Medicare's website at https:,,'I,'www.cms.hhs.gov/cmsforms/downloads/cms.. d 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 97 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) www.envisionrxplus.com.) The form gives that person pentrission to act on your behalf It must be signed by you and by the person who you would like to act on your behalf You must give us a copy of the signed form. You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision. SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal Have you read Section 4 of this chapter (A guide to "the basics" of coverage decisions and appeals)? If not, you may want to read it before you start this section. Section 5.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to our plan's List of Covered Drugs (Formulary). To be covered, the drug must be used a medically accepted indication. (A "medically accepted indication" is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 3, Section 3 for more information about a medically accepted indication.) I • This section is about your Part D drugs only. To keep things simple, we generally say "drug" in the rest of this section, instead of repeating "covered outpatient prescription drug" or "Part D drug" every time. • For details about what we can by Part D drugs, the List of Covered Drugs (Formulary), rules and restrictions on coverage, and cost information, see Chapter 3 (Using our plan's coverage for your Part D prescription drugs) and Chapter 4 ("atyou pay for your Part D prescription drugs). 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree Pop 98 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Part D coverage decisions and appeals As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. Legal Terms An initial coverage decision about your Part D drugs is called a "coverage determination." 0 You ask us to make an exception, including: o Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs (Formulary) o Asking us to waive a restriction on the plan's coverage for a drug (such as limits on the amount of the drug you can get) o Asking to pay a lower cost -sharing amount for a covered drug on a higher cost - sharing tier o Please note.- If your pharmacy tells you that your prescription cannot be filled as written, you will get a written notice explaining how to contact us to ask for a coverage decision. You ask us to pay for a prescription drug you already bought. This is a request for a coverage decision about payment. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 99 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) This section tells you both how to ask for coverage decisions and how to request an appeal. Use the chart below to help you determine which part has information for your situation: 6�.� Do you need a drug that isn't on our Drug You can ask us to make an exception. (This is a List or need us to waive a rule or restriction type of coverage decision.) on a drug we cover? Do you want us to cover a drug on our Drug List and you believe you meet any plan rules or restrictions (such as getting approval in advance) for the drug you need? Do you want to ask us to pay you back for a drug you have already received and paid for? Start with Section 5.2 of this chapter You can ask us for a coverage decision. Skip ahead to Section 5.4 of this chapter. You can as us to pay you back, (This is a type of coverage decision.) Skip ahead to Section 5.4 of this chapter. Have we already told you that we will not You can make an appeal. (This means you are cover or pay for a drug in the way that you asking us to reconsider.) want it to be covered or paid for? Skip ahead to Section 5.5 of this chapter. Section 5.2 What is an exception? If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception." An exception is a type of coverage decision, Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. We will then consider your request. Here are three examples of exceptions that you or your doctor or other prescriber can ask us to make: 1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulaf:j�i- (We call it the "Drug List" for short.) Legal Terms Asking for coverage of a drug that is not the Drug List is sometimes called asking for a "formulary exception." i 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 100 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If we agree to make an exception and cover a drug that is not on the Drug List, you will need to pay the cost -sharing amount that applies to drugs in Tier 4. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 2. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more information, go to Chapter 3). Legal Terms Asking for removal of a restriction on coverage for a drug is sometimes called asking for a "formulary exception." 0 The extra rules and restrictions on coverage for certain drugs include: • Being required to use the generic version of a drug instead of the brand name drug. • getting plan approval in advance before we will agree to cover the drug for you. (This is sometimes called "prior authorization,") • Being required to try a different drugfirst before we will agree to cover the drug you are asking for. (This is sometimes called "step therapy.") • Quantity limits. For some drugs, there are restrictions on the amount of the drug you can have. If we agree to make an exception and waive a restriction for you, you can ask for an I t nuit we 3. Changing coverage of a drug to a lower cost -sharing tier. Every drug on our Drug List is in one of 5 cost -sharing tiers. In general, the lower the cost -sharing tier number, the less you will pay as your share of the cost of the drug. Legal Terms Asking to pay a lower price for a covered non -preferred drug is sometimes called asking for a "tiering exception." You cannot ask us to change the cost -sharing tier for any drug in Specialty Drug Tier (Tier 5). Section 5.3 Important things to know about asking for exceptions 1 11 2 1 t fill M_11M1:11N111111 gymm IF,$ m all ogwyj Or.4 K"T11 V-d I 2018 Evidence of Coverage for EnvisionRxP]us Employer Group Retiree PDP 10 1 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Typically, our Drug List includes more than one drug for treating a particular condition. These different possties are called "alternative" drugs. If an alternative drug would be just as effective as the drug you are requesting and would not cause more side effects or other health problems, we will generally not approve your request for an exception. If you ask us for a tiering exception, we will generally not approve your request for an exception unless all the alternative drugs in the lower cost -sharing tier(s) won't work as well for you. If we approve your request for an exception, our approval usually is valid until the end of the plan year, This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. If we say no to your request for an exception, you can ask for a review of our decision making an appeal. Section 5.5 tells you how to make an appeal if we say no, I The next section tells you how to ask for a coverage decision, including an exception. Section 5.4 Step-by-step: How to ask for a coverage decision, including an exception ...............1 Step 1: You ask us to make a coverage decision about the drug(s) or payment you need. If your health requires a quick response, you must ask us to make a "fast coverage decision." You cannot ask for a fast coverage decision if you are asking us to pay you back for a drug you already bought. What to do • Request the type of coverage decision you want. Start by calling, writing, or taxing us to make your request. You, your representative, or your doctor (or other prescriber) can do this. You can also access the coverage decision process through our website. For the details, go to Chapter 2, Section I and look for the section called How to contact us when you are asking far a coverage decision about your Part D prescription drugs, or when you are making an appeal or complaint about your Part D prescription drugs. Or if you are asking us to pay you back for a drug, go to the section called nere to send a request that asks us to pay for our share of the cost for a drug you have received. • You or your doctor or someone else who is acting on your behalf can ask for a coverage decision. Section 4 of this chapter tells how you can give written permission to someone else to act as your representative. You can also have a lawyer act on your behalf. If you want to as us to pay you back for a drug, start by reading Chapter 5 of this booklet: Asking us to pay our share of the costs for covered drugs. Chapter 5 describes the situations in which you may need to ask for reimbursement. It also tells how to send us the paperwork that asks us to pay you back for our share of the cost of a drug you have paid for. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 102 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If you are requesting an exception, provide the "supporting statement." Your docto or other prescriber must give us the medical reasons for the drug exception you are reiuestin.g. IiWe call this t he "sunnortinQ statement.") Your doctor or other prescriber cal tax or man it) statement to us. Ur Your UOQLO1- Ol- OL11C1- PfUISUFlOCI UU11 LCH " 011 UIU P11011* and follow up by taxing or mailing a written statement if necessary. See Sections 5.2 an 5.3 for more information about exception requests. I We must accept any written request, including a request submitted on the CMS Model Coverage Determination Request Form, which is available on our website. Legal Terms A "fast coverage decision" is called an "expedited coverage determination." When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. A standard coverage decision means we will give you an answer within 72 hours after we receive your doctor's statement. A fast coverage decision means we will answer within 24 hours after we receive your doctor's statement. • You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.) • You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. 0 If you ask for a fast coverage decision on your own (without your doctor's or other prescriber's support), we will decide whether your health requires that we give you a fast coverage decision. o If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will send you a letter that says so (and we will use the standard deadlines instead). o This letter will tell you that if your doctor or other prescriber asks for the fast coverage decision, we will automatically give a fast coverage decision. o The letter will also tell how you can file a complaint about our decision to give you a standard coverage decision instead of the fast coverage decision you requested. It tells how to file a "fast"' complaint, which means you would get our answer to your complaint within 24 hours of receiving the complaint. (The process for making a complaint is different from the process for coverage 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 103 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) decisions and appeals. For more information about the process for making complaints, see Section 7 of this chapter.) Dera dlinesfor a '!fast" coverage decision 0 If we are using the fast deadlines, we must give you our answer within 24 hours. • Generally, this means within 24 hours after we receive your request. If you are requesting an exception, we will give you our answer within 24 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to. • If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent outside organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2. If our answer is yes to part or all of at you requested, we must provide the coverage we have agreed to provide within 24 hours after we receive your request or doctor's statement supporting your request. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal. M =MMMMUMMEM If we are using the standard deadlines, we must give you our answer within 72 hours. * Generally, this means within 72 hours after we receive your request. If you are requesting an exception, we will give you our answer within 72 hours after we receive your doctor's statement supporting your request. We will give you our answer sooner if your health requires us to. * If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2. 0 If our answer is yes to part or all of what you requested — o If we approve your request for coverage, we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor's statement supporting your request. If our answer is no to part or all of what you requested, we will send you a written statement that explains why we said no. We will also tell you how to appeal. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 104 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Deadlines for a "standard" coverage decision about paymentfair a drugyou have already bought 0 We must give you our answer within 14 calendar days after we receive your request. o If we do not meet this deadline, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an independent organization. Later in this section, we talk about this review organization and explain what happens at Appeal Level 2. If our answer is yes to part or all of what you requested, we are also required to make payment to you within 14 calendar days after we receive your request. Step 3: If we say no to your coverage request, you decide if you want to make an [® - If we say no, you have the right to request an appeal. Requesting an appeal means asking us to reconsider — and possibly change — the decision we made. Section 5.5 Step-by-step: How to make a Level 1 Appeal (how to ask for a review of a coverage decision made by our plan) Legal Terms An appeal to the plan about a Part D drug coverage decision is called a plan "redetermination." Step I - You contact us and make your Level I Appeal. If your health requires a quick response, you must ask for a "fast appeal." 91MM72M, To start your appeal, you (or your representative or your doctor or other prescriber) must contact us. o For details on how to reach us by phone, fax, or mail, or on our website, for any purpose related to your appeal, go to Chapter 2, Section 1, and look for the section called How to contact us when you are making an appeal about your Part D prescription drugs, or when you are making an appeal or complaint about your Part D prescription drugs. If you are asking for a standard appeal, make your appeal by submitting a writt"'nj request. You may also ask for an appeal by calling us at the phone number shown in Chapter 2, Section I (How to contact us when you are making an appeal about your Pa 2018 Evidence of Coverage for EnvislonRxPlus Employer Group Retiree PDP 100 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) D prescription drugs, or when you are making an appeal or complaint about your Part D prescription drugs). • If you are asking for a fast appeal, you may make your appeal in writing or you may call us at the phone number shown in Chapter 2, Section I (How to contact us when you are making an appeal about your Part D prescription drugs, or when you are making an appeal or complaint aboutyour Part Dprescription drugs). • We must accept any written request, including a request submitted on the CMS Modet Coverage Determination Request Form, which is available on our website. • We also accept requests through our website at www.envisionrxplus.com. Go to our Coverage Determination policy section and click on On-line Coverage Determination to submit your request on our website. • You must make your appeal request within 60 calendar days from the date on the written notice we sent to tell you our answer to your request for a coverage decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of good cause for missing the deadline may include if you had a serious illness that prevented you from contacting us or if we provided you with incorrect or incomplete information about the deadline for requesting an appeal. -as,K- flon in your - information. • You have the right to ask us for a copy of the information regarding your appeal. We are allowed to charge a fee for copying and sending this information to you. • If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. Legal Terms A "fast appeal" is also called an "expedited redetermination." If you are appealing a decision we made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a "fast appeal." The requirements for getting a "fast appeal" are the same as those for getting a "fast coverage decision" in Section 5.4 of this chapter. When we are reviewing your appeal, we take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said no to your request. We may contact you or your doctor or other prescriber to get more information. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 106 Chapter 7. What to do if you have a problem or complaint (coverage decisions, .:paeals, complaints) If we are using the fast deadlines, we must give you our answer within 72 hours after — we receive your appeal. We will give you our answer sooner if your health requires it. o If we do not give you an answer within 72 hours, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. (Later in this section, we talk about this review organization and explain what happens at Level 2 of the appeals process.) If our answer is yes to part or all of what you requested, we must provide the coverage we have agreed to provide within 72 hours after we receive your appeal. f Avil I M WWWWWWA "l-il"r AWN Deadlutes fear a "standard" appeal If we are using the standard deadlines, we must give you our answer within 7 calendar days after we receive your appeal. We will give you our decision sooner if you have not received the drug yet and your health condition requires us to do so. If you believe your health requires it, you should ask for "fast" appeal. o If we do not give you a decision within 7 calendar days, we are required to send your request on to Level 2 of the appeals process, where it will be reviewed by an Independent Review Organization. Later in this section, we tell about this review organization and explain what happens at Level 2 of the appeals process. �.�ll Iiiiii�11!11�l�ll����::�ll!!���l�11!1�11!1111 1 o If we approve a request for coverage, we must provide the coverage we have agreed to provide as quickly as your health requires, but no later than 7 calendar days after we receive your appeal. o If we approve a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive your appeal request. If our answer is o: part or all of what you requested, we will send you a written statement that explains why we said no and how to appeal our decision. Step 3: If we say no to your appeal, you decide if you want to continue with the appeals process and make another appeal. If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals process (see below). 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 107 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 5.6 Step-by-step: How to make a Level 2 Appeal If we say no to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Revie Organization reviews the decision we made when we said no to your first appeal. This organization decides whether the decision we made should be changed. I Legal Terms The formal name for the "Independent Review Organization" is the "Independent Review Entity." It is sometimes called the "IRE." Step 1: To make a Level 2 Appeal, you (or your representative or your doctor or i0fter ;t-III i!uar�-rnyst ciftact th&4rrVa;ta-n,1e--rt R6-Viw,,e *rganizatisn-ant aA- f j).r a review of your case. If we say no to your Level I Appeal, the written notice we send you will include instructions on how to make a Level 2 Appeal with the Independent Review Organization. These instructions will tell who can make this Level 2 Appeal, what deadlines you must follow, and how to reach the review organization. When you make an appeal to the Independent Review Organization, we will send th information we have about your appeal to this organization. This information is call your "case file." You have the right to ask us for a copy of your case file. We are allowed to charge you a fee for copying and sending this information to you. I You have a right to give the Independent Review Organization additional information to support your appeal. Step 2: The Independent Review Organization does a review of your appeal an't gives you an answer. The Independent Review Organization is an independent organization that is hired by Medicare. This organization is not connected with us and it is not a government agency. This organization is a company chosen by Medicare to review our decisions about your Part D benefits with us. Reviewers at the Independent Review Organization will take a careful look at all of the information related to your appeal. The organization will tell you its decision in writing and explain the reasons for it. Deadlinesfear 'fast appeal" at Level 2 III IIIIIIIII IIIIII Imilaiiiiiii Ir 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 108 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) If the review organization agrees to give you a "fast appeal," the review organization must give you an answer to your Level 2 Appeal within 72 hours after it receives your appeal request, M If you have a standard appeal at Level 2, the review organization must give you an, answer to your Level 2 Appeal within 7 calendar days after it receives your appe If the Independent Review Organization says yes to part or all of what you requested If the Independent Review Organization approves a request for coverage, we must provide the drug coverage that was approved by the review organization within 72 hours after we receive the decision from the review organization. If the Independent Review Organization approves a request to pay you back for a drug you already bought, we are required to send payment to you within 30 calendar days after we receive the decision from the review organization. If this organization says no to your appeal, it means the organization agrees with our decision not to approve your request. (This is called "upholding the decision." It is also called "tuming down your appeal.") If the Independent Review Organization "upholds the decision" you have the right to a Level 3 Appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you are requesting must meet a minimum amount. If the dollar value of the drug coverage you are requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The lnxr-��s sient Review OrManization will tell pou the dollar value that must be in dispute to continue with the appeals process. --MM am 11 M There are three additional levels in the appeals process after Level 2 (for a total of five levels of appeal). If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals process, you must decide whether you want to go on to Level 3 and make a third appeal. If you decide to make a third appeal, the details on how to do this are in the written notice you got after your second appeal. Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) The Level 3 Appeal is handled by an administrative law judge. Section 6 in this chapter tells more about Levels 3, 4, and 5 of the appeals process. to-LevelSECTION 6 Taking your appeal Levels of Appeal 3, 4, and 5 for Part D Drug Appeals This section may be appropriate for you if you have made a Level I Appealand a Level Appeal, and both Ir down. levelson to additional of appeal.dollar amount is less, youappeal : - rmmiNw-"Pvr to ask for a Level 3 Appeal. �.,,, 1,,,.. -J For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is who handles the review of your appeal at each of these levels. Level e who works for the Federal government will review your appeal and give you an answer. This judge is called an "Administrative Law Judge." If the answer is yes, the appeals process is over. What you asked for in the appeal has been approved. We must authorize or provide the drug coverage that was approved by the Administrative withinexpedited :I make payment no later than 30 calendar days after we receive the decision. ID If the Administrative Law Judge says no to your appeal, the appeals process may or y not be over. o if you decide to accept this decision that turns down your appeal, the appeals rr �r�4 - 11 o If you do not want to accept the decision, you can continue to the next level of review process. If the administrative law judge says no to your appeal, the notice you get will tell you what to do next if you choose• : r :...... Level r Appeal The AppealsCouncil r rr'.l ani give youan answer. Appeals Council works for the Federal government. If the answer I;. process over. What you asked forappeal been approved. We must authorizeor provide .: drug coverage that was approved by the Appeals Council within 72 hours hours for.rappeals) ,. i.: payment no later than 30 calendar days after we 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 110 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) ��IIJI�IIIIIJJIII 1 1 'jiIIIIIII!,111 11 i I'l, I I • If you decide to accept this decision that turns down your appeal, the appeals process is over. • If you do not want to accept the decision, you might be able to continue to the next level of the review process. If the Appeals Council says no to your appeal or denies your request to review the appeal, the notice you get will tell you whether the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. Immm"m lum"Nem � * This is the last step of the appeals process. MAKING COMPLAINTS SECTION 7 How to make a complaint about quality of care, waDint g times, customer service, or other concerns If your problem is about decisions related to benefits, coverage, or payment, then this section is not foryou. Instead, you need to use the process for coverage decisions and appeals. Go to Section 4 of this chapter. What kinds of problems are handled by the complaint process? Section 7.1 This section explains how to use the process for making complaints. The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. Here are examples of the kinds of problems handled by the complaint process. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Complaint Example Quality of your * Are you unhappy with the quality of the care you have received? medical care Respecting your * Do you believe that someone did not respect your right to privacy privacy or shared information about you that you feel should be confidential? Disrespect, poor 0 Has someone been rude or disrespectful to you? customer service, 0 Are you unhappy with how our Member Services has treated you? or other negative 0 Do you feel you are being encouraged to leave the plan? behaviors Waiting times 0 Have you been kept waiting too long by pharmacists? Or by our Member Services or other staff at the plan? o Examples include waiting too long on the phone or when getting a prescription. Cleanliness 0 Are you unhappy with the cleanliness or condition of a pharmacy? Information you 0 Do you believe we have not given you a notice that we are required get from us to give? 0 Do you think written information we have given you is hard to understand? 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 115 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Complaint Example Timeliness The process of asking for a coverage decision and making appeals is (These types of explained in sections 4-6 of this chapter. If you are asking for a complaints are all decision or making an appeal, you use that process, not the complaint related to the process. timeliness of our However, if you have already asked us for a coverage decision or made actions related to an appeal, and you think that we are not responding quickly enough, coverage decisions you can also make a complaint about our slowness. Here are examples - and appeals) * If you have asked us to give you a "fast coverage decision" or a "fast appeal," and we have said we will not, you can make a complaint. • If you believe we are not meeting the deadlines for giving you a coverage decision or an answer to an appeal you have made, you can make a complaint. • When a coverage decision we made is reviewed and we are told that we must cover or reimburse you for certain drugs, there are deadlines that apply. If you think we are not meeting these deadlines, you can make a complaint. • When we do not give you a decision on time, we are required to forward your case to the Independent Review Organization, If we do not do that within the required deadline, you can make a complaint. Section 7.2 The formal name for "making a complaint" is "filing a L grievance"____ Legal Terms What this section calls a "complaint" is also called a "grievance." Another term for "making a complaint" is "filing a grievance." ,�ffnAmr * mrl-�wftg fte­pj4v complaints" is "using the process for filing a grievance." 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 113 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Section 7.3 Step-by-step: Making a complaint Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. 1-844-293-4760, TTY/TDD 711, 24 hours a day, 7 days a week. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing. Grievances can be filed orally by calling 1-844-293-4760 (TTY./TDD users should call 711) or in writing to EnvisionRxPlus, 2181 E. Aurora Rd., Suite 201, Twinsburg, OH 44087, Attn: Grievances. We are available 24 hours a day, 7 days a week. The grievance must be filed no later than 60 days after the incident that caused your grievance. Once EnvisionRxPlus receives your grievance, it will be resolved as quickly as possible, but no later than 30 days. The 30 is timeframe may be extended up to 14 days if you req"II t!rAms r if & rit'lil �-III3u tires additional information and the delap is in your best interest. You can file an expedited grievance if your grievance is due to EnvisionRxPlus's refusal to grant your request for an expedited coverage determination or expedited redetermination. When filing this type of grievance, state that it is an expedited grievance and it will be responded to within 24 hours Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about. If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" complaint. If you have a "fast" complaint, it means we will give you an answer within 24 hours. Legal Terms What this section calls a "fast complaint" is also called an "expedited grievance." Step 2: We look into your complaint and is you our answeZ If possible, we will answer you right away, If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that. Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar day's total) to answer your complaint. If we decide to take extra days, we will tell you in writing. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 114 Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) 0 If we do not agree with some or all of your complaint or don't take responsibility for tj problem you are complaining about, we will let you know, Our response will include o reasons for this answer. We must respond whether we agree with the complaint or not. Section 7.4 You can also make complaints about quality of care to the Quality Improvement Organization You can make your complaint about the quality of care you received to us by using the step-by- step process outlined above. When your complaint is about quality of care, you also have two extra options: You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to us). • The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. • To fmd the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2, Section 4, of this booklet. If you make a complaint to this organization, we will work with the to resolve your complaint. Or you can make your complaint to of at the same time. If you wish, you can make your complaint about quality of care to us and also to the Quality Improvement Organization. . . ...... .. . . ... ... ... Fse d107.5 You can also tell Medicare about your complaint — You can submit a complaint about EnvisionRxPlus Employer Group Retiree PDP directly to Medicare. To submit a complaint to Medicare, go to complaints seriously and will use this information to help improve the quality of the Medicare program. M y Fial. please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. membership 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 116 Chapter 8. Ending your membership in the plan 18M ... ... ... ... ... ... ... ... ... ... ... ... ... ... . ...................................... SECTION I Introduction ............. - ................. .............. -- ................ ............... 117 Section 1.1 This chapter focuses on ending your membership in our plan .................... 117 SECTION 2 When can you end your membership in our plan? .................... 117 Section 2.1 Usually, you can end your membership during the Annual Enrollment Period.... ................... - .... - ................. --- ..... — ........ — .................... .......... 117 Section 2.2 In certain situations, you can end your membership during a Special EnrollmentPeriod .................. ...................... -- .......................................... 118 Section 2.3 Where can you get more information about when you can end your membership? ............ ................... ... -- ..................... — .............................. 120 SECTION 3 How do you end your membership in our plan'? ......................... 121 Section 3 � I Usually, you end your membership by enrolling in another plan .... .......... 120 SECTION 4 Until your membership ends, you must keep getting your drugs through our plan ......................................................... ........ 122 Section 4.1 Until your membership ends, you are still a member of our plan .. -- ........ 122 SECTION 5 EnvisiomW Plus Employer Group Retiree POP must end your membership in the plan in certain situations ...................... 122 Section 5.1 When must we end your membership in the plan? ..................................... 122 Section 5.2 We cannot ask you to leave our plan for any reason related to your health 123 Section 5.3 You have the right to make a complaint if we end your membership in ourplan..... . ........................ -- ............ ... --- .................. -- ............... -- 124 2018 Evidence of Coverage for EnvislonRxPlus Employer Group Retiree PDP 117 Chapter 8. Ending your membership in the plan SECTION 1 Introduction ... ...... .. Section 1.1 This chapter focuses on ending your membership in our plan Ending your membership in EnvisionRxPlus Employer Group Retiree PDP may be voluntary (your own choice) or involuntary (not your own choice): o There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. Section 2 tells you when you can end your membership in the plan. o The process for voluntarily ending your membership varies depending on at type of new coverage you are choosing. Section 3 tells you how to end your membership in each situation. There are also limited situations where you do not choose to leave, but we are required to end your membership. Section 5 tells you about situations when we must end your membership. If you are leaving our plan, you must continue to get your Part D prescription drugs through our plan until your membership ends. SECTION 2 When can- you end your membership in our plan? You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period, In certain situations, you may also be eligible to leave the plan at other times of the year. Section 2.1 Usually, you can end your membership during the Annual Enrollment Period When is the Annual Enrollment Period? This happens from October 15 to December 7. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP Chapter 8. Ending your membership in the plan What type of plan can you switch to during the Annual Enrollment Period? You can choose to keep your current coverage or make changes to your coverage for the upcoming year. If you decide to change to a new plan, you can choose any of the following types of plans: M236��� o Original Medicare without a separate Medicare prescription drug plan. If you receive "Extra Help" from Medicare to pay for your prescription drugs: If you do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment. o — or — A Medicare health plan. A Medicare health plan is a plan offered by a private company that contracts with Medicare to provide all of the Medicare Part A (Hospital) and Part B (Medical) benefits. Some Medicare health plans also include Part D prescription drug coverage. or a Medicare Cos Ian, you can enroll in that plan and keep EnvisionRxPlus Emploper GroujL Retiree PDP for XQ covers. a. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan or drop Medicare prescription drug KI&WaLm Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty. When will your membership end? Your membership will end when your new plan's coverage begins on January I . Section 2.2 In certain situations, you can end your membership during a --- Special —Enrollment ---,Period In certain situations, members ofEnvisionRxPlus Employer Group Aletirce�&1111'may eligible to end their membership at other times of the year. This is known as a Special Enrollment Period. Who is eligible for a Special Enrollment Period? If any of the following situations apply to you, you are eligible to end your membership during a Special Enrollment Period. These are just examples, for the full list you can contact the plan, call Medic or visit the Medicare website (https://www.medicarc.gov): I 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 119 Chapter 8. Ending your membership in the plan ® If you have moved out of your pIan's service area. • If you have Medicaid. • If you are eligible for "Extra Help" with paying for your Medicare prescriptions. • If we violate our contract with you. • If you are getting care in an institution, such as a nursing home or long-term care (LTC) hospital. • If you enroll in the Program of All-inclusive Care for the Elderly (PACE). PACE is not available in all states. If you would like to know if PACE is available in your state, please contact Member Services (phone numbers are printed on the back cover of this booklet). When are Special Enrollment Periods? The enrollment periods vary depending on your situation. at can you you are engible for a Special EnroMm—enr =-erioa, please call Medicare at 1-800-MEDICAR-E (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. If you are eligible to end your membership because of a special situation, you can choose to change both your Medicare health coverage and prescription drug coverage. This means you can choose any of the following types of plans: ���MNIIIVIIFNN ilillilil iiiiill !111 If you receive "Extra Help" from Medicare to pay for your prescription drugs- If you switch to Original Medicare and do not enro in a separate Medicare prescription drug plan, Medicare may enroll you a drug plan, unless you have opted out of automatic enrollment. I o — or — A Medicare health plan. A Medicare health plan is a plan offered by a private company that contracts with Medicare to provide all of the Medicare P A (Hospital) and Part B (Medical) benefits. Some Medicare health plans also include Part D prescription drug coverage. I and keep EnvisionRxPlus Employer Group Retiree PDP for your drug coverage. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan or to drop Medicare prescription drug coverage. Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage for a continuous period of 63 days or more, you may need to pay a Part D late enrollment penalty if you join a Medicare drug plan later. ("Creditable"' coverage means the coverage is expected to pay, on average, at least as In Chapter 8. Ending your membership in the plan more information about the late enrollment penalty. - When will your membership end? Your membership will usually end on the first day the month after we receive your request to change your plan. Section 2.3 Where can you get more information about when you can end your membership? If you have any questions or would like more information on when you can end your membership: illi�;Jlipjy"Yml o Everyone with Medicare receives a copy of Medicare & You each fall. Those new to Medicare receive it within a month after first signing up. o You can also download a copy from the Medicare website dutps://www.medicare.gov). Or, you can order a printed copy by calling Medicare at the number below. You can contact Medicare at 1-800-MEDICARE (1-800-633-4227),24 hours a day, 7 days a week. TT Y users should call 1-877-486-2048. SECTION 3 How do you end your membership in our PI -an? Section 3.1 Usually, you end your membership by enrolling in another plan Usually, to end your membership in our plan, you simply enroll in another Medicare plan during one of the enrollment periods (see Section 2 in this chapter for information about the enrollment periods). However, there are two situations in which you will need to end your membership in a different way: If you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must ask to be disenrolled from our plan. If you join a Private Fee -for -Service plan without prescription drug coverage, a Medicare Medical Savings Account Plan, or a Medicare Cost Plan, enrollment in the new plan will not end your membership in our plan. In this case, you can enroll in that plan and keep EnvisionRxPlus Employer Group Retiree PUP for your drug coverage. If you do not want to keep our plan, you can choose to enroll in another Medicare prescription drug plan 4r ask to be disenrolled from our plan. -TM Chapter 8. Ending your membership in the plan In If you are in one of these two situations and want to leave our plan, there are two ways you can ask to be disenrolled: • You can make a request in writing to your Group Benefit Administrator or Human Resources. Contact Member Services if you need more information on how to do this (phone numbers are printed on the back cover of this booklet). • --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a Part D late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.) See Chapter 1, Section 5 for more information about the late enrollment penalty. If you would like to switch from our plan to: This is what you should do: •Another Medicare prescription Enroll in the new Medicare prescription drug plan drug plan. between October 15 and December 7. You will automatically be disenrolled from EnvisionfixPlus Employer Group Retiree PfiE when your new plan's coverage begins. • A Medicare health plan. • Enroll in the Medicare health plan. With most Medicare health plans, you will automatically be disenrolled from EnvisionRxPlus Employer Group Retiree PDP when your new plan's coverage begins. If you want to leave our plan, you must either enroll in another Medicare prescription drug plan or ask to be disenrolled. To ask to be disenrolled, you must send a written request to your Group Benefit Administrator or Human Resources or contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY users should call 1 - 877-486-2048). 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 122 Chapter 8. Ending your membership in the plan If you would like to switch from our plan to: This is what you should do: • Original Medicare without a • Send a written request to your Group Benefit separate Medicare prescription Administrator or Human Resources to disenroll. drug plan. Contact Member Services if you need more information Note: If you disenroll from a on how to do this (phone numbers are printed on the Medicare prescription drug plan back cover of this booklet). and go without creditable • You can also contact Medicare at 1-800-MEDICARE prescription drug coverage, you (1-800-633-4227), 24 hours a day, 7 days a week, and may need to pay a late enrollment ask to be disenrolled. TTY users should call 1-877-486- penalty if you join a Medicare drug 2048. plan later. See Chapter 1, Section 5 for more information about the late enrolhnent penalty. SECTION 4 it your membership ends, you must keep getting your drugs through our plan Section 4.1 Until your membership ends, you are still a member of our plan If you leave EnvisionRxPlus Employer Group Retiree PDP, it may take time before your membership ends and your new Medicare coverage goes into effect. (See Section 2 for -T. *u-sinimmumd - Wm Lir new covera4ge beiqins.),,,' Durin this time, pQu must continm _toa et your prescription drugs through our plan. You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. SECTION 5 EnvisionRxPlus Employer Group Retiree POP must end your membership in the plan in certain situations Section _5_._1 ---W—hen—must —we-end —your -membership in the plan? EnvisionRxPlus Employer Group Retiree PDP must end your membership in the plan if any of the following happen: 0 If you move out of our service area. [oil' M-3 Mlim4i"11 o If you move or take a long trip, you need to call Member Services to find out if the place you are moving or traveling to is in our plan's area. (Phone numbers for Member Services are printed on the back cover of this booklet.) • If you become incarcerated (go to prison). • If you are not a United States citizen or lawfully present in the United States. • If you lie about or withhold information about other insurance you have that provides prescription drug coverage. • If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) • If you continuously behave in a way that is disruptive and makes it difficult for us to provide care for you and other members of our plan. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) • If you let someone else use your membership card to get prescription drugs. (We cannot make you leave our plan for this reason unless we get permission from Medicare first.) o If we end your membership because of this reason, Medicare may have your case investigated by the Inspector General. o We must notify you in writing that you have 60 consecutive days (2 calendar months) to pay the plan premium before we end your membership. If • are required to pay the extra Part D amount because of your income and you do not pay it, Medicare will disenroll you from our plan and you will lose prescription drug MoMil You can call Member Services for more information (phone numbers are printed on the back cover of this booklet). Section 5.2 We cannot ask you to leave our plan for any reason related to your health 11!��! 11131111 �ii iii i 11 yoT to Yeav""1111 any reason related to your health. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 124 Chapter 8. Ending your membership in the plan If you feel that you are being asked to leave our plan because of a health -related reason, you should call Medicare at 1-8 -MEDICAL (1-800-633-4227). TTY users should call 1-877- 486-2048, You may call 24 hours a day, 7 days a week. . .. ....... Section 5.3 You have the right to make a complaint if we end your membership in our plan If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you file a grievance or can make a complaint about our decision to end your membership. You can also look in Chapter 7, Section 7 for information about how to make a complaint. CHAPTER 9 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree Pop 126 Chapter 9. Legal notices Chapter 9. Legal notices SECTION 1 Notice about governing law ........................................................... 127 :;WM 11. 111 100, � I W111 SECTION 5 Notice of Privacy Practice ............................................................. 12f Im Chapter 9. Legal notices SECTION 1 Notice about governing law Many laws apply to this Evidence of Coverage and some additional provisions may apply because they are required by law. This may affect your rights and responsibilities even if the laws are not included or explained in this document. The principal law that applies to this document is Title XVIII of the Social Security Act and the regulations created under the Social Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other Federal laws may apply and, under certain circumstances, the laws of the state you live in. SECTION 2 Notice about non-discrimi nation We don't discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, mental or physical disability, health status, claims experience, medical history, genetic infon-nation, evidence of instability, or geographic location. All organizations that provide Medicare prescription drug plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disaties Act, Section 1557 of the Affordable Care Act, all other laws that apply to organizations that get Federal funding, and any other laws and rules that apply for any other reason. FNM=fdff:11... .. ;:� Provides free aids and services to people with disabilities to communicate effectively with us, such as: Provides free language services to people whose primary language is not English, such as, 113MMUM111=6 IM o Information written in other languages I If you believe that EnvisionRxPlus has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: EnvisionRxflus, mailing address: 2181 E. Aurora Rd, Ste. 201, Twinsburg, OH, 44087, Member Services: 1-844-293-4760, TTY: 711, fax: 1-866-250-5178. If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at 91 *c 11 IF, Iiv.isf_ or by mail or johone at: U.S. Department of Health W:1.9 t■;i. 9. Legal notices Complaint forms are available at http.-II'Www.hhs.govlocrilofficelilelindex.htmL SECTION 3 Notice about Medicare Secondary Payer subrogation rights We have the right and responsibility to collect for covered Medicare prescription drugs for which Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462, EnvisionRxPlus Employer Group Retiree PDP, as a Medicare prescription drug plan sponsor, will exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts ■ through D of part 411 of 42 CFR and the rules established in this section supersede any State laws. SECTION 4 Notice about third -party liability Right of Subrogation You explicitly acknowledge EnvisionRxPlus's Right of Subrogation. When ■ fsca"i4ki a-,-"-,:r p&i*- ie�-#r njo responsible, EnvisionRxPlus shall be subrogated to your rights of recovery against any party to the extent of the full cost of all benefits provided by EnvisionRxPlus and may proceed against any party with or without your consent. This means that if prescription drug ■ are provided to you by ■ for injuries or illness for which another party is or may be responsible, then EnvisionRxPlus reserves the right to obtain reimbursement from such other party for the full cost of all prescription drug benefits provided by EnvisionRxPlus on your behalf that are associated with the injury or illness. ■...t of ■ You explicitly acknowledge EnvisionRxPlus's ■ of ■ This means that if prescription drug benefits are provided to you by EnvisionRxPlus for injuries or illness for which another party is or may be responsible and you and/or your representative has recovered any amounts from another party or any ■ making payments on the party's behalf then ■ is herebMranted an assignment of the • of ano settlement 'udgment or other payment received by you to the extent of the full cost of all benefits provided by EnvisionRxPlus. This ■ of Reimbursement is cumulative with and not exclusive of EnvisionRxPlus's Right of Subrogation, and EnvisionRxPlus may choose to exercise either or ■ rights of recovery. Cooperation with EnvisionRxPlus You and your legal representatives agree to fully cooperate with EnvisionRxPlus in its efforts to recover the cost of all benefits provided by EnvisionRxPlus that is the responsibility of another party. It is your duty to notify EnvisionRxPlus within thirty (30) days of the date you provide notice to any party, including an insurance company or an attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation for your injury or illness. You and �Lour aizents or reDresentatives agree to j2rovide EnvisionRxPlus all information reguested by 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 129 Chapter 9. Legal notices • SECTION 5 Notice of Privacy Practice This Notice of Privacy Practices applies to Envision Insurance Company's Medicare Part D Prescription Drug Plans ("Env isionRxPlus"). EnvisionRxPlus is • PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal. Para recibir esta notificaci6n en espaiml or favor Ilarnar al rinmero gratuito de Servicios a Miembros a 1-844-293-4760 (Los usuarios de TT IT deben Hamer al 711). El horario es 24 horns del dia, 7 dies a Is semana. I His 110U 7 U=Mrfiow we may use Ulm w6closc 1111UT11rd benefits, and it explains your legal rights regarding the information. When we use the term personal health information, we mean infennation that identifies you as an individual, such as your name, date of birth, or Social Security number and relates to your medical history, the health carto you receive, or payment for health care services. In order to provide you with insurance coverage, we need personal information about you, and wip obtain that infonnation from many different sources, including Medicare. In administering your •Iwa infh4 Treatment. We may use and disclose your personal health information to doctors, dentists, disclose information to the pharmacies where you receive covered medications. Payment. We • use and disclose your personal health information to manage your pharmacy benefits, such as collecting premiums and calculating cost -sharing amounts. For example, we may use your health information to pay the pharmacies that fill your prescriptions. Operations. We may use and disclose your personal health information to assess and improve quality, license and accredit companies, measure service performance and assess outcomes, determine formulary compliance, provide care management, and respond to complaints and appeals. For example, we may use the information to provide medication therapy management programs for members with specific medical conditions, such as diabetes. We may use and administration of reinsurance, underwriting and rating, detection a12A. iivestigaliw& *f fr,?-ud- waste- a-ui. abuse. administration of -Dharmaceutical services and navinents. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 130 Chapter 9. Legal notices and other general administrative activities. We may use your information, with the exception of genetic information, for underwriting purposes. To Others Involved in Your Health Care. We may disclose your personal health information to a relative, a close friend, or any other person involved in your care, provided the information is directly relevant to that person's involvement with your health care or payment for that care. For example, if a family member or a caregiver calls us with prior knowledge of a claim, we may c onfirm whether or not the claim has been received and paid. You have the right to stop or limit 14k,-kin3@171,17 disclosure by calling Member Services toll -free at 1-844-293-4760 JTTY/TDD users should call 711). Hours are 24 hours a day, 7 days a week, Business Associates. We enter into contracts with third parties known as business associates. These business associates provide services to us or perform functions on our behalf, e.g., accountants, consultants and attorneys. We may disclose your health information to our business associates once they have agreed in writing to safeguard your health inforniation. Business associates are also required by law to secure and protect the privacy of your health information, Special Circumstances. We may use or disclose your personal health information without your authorization in the following circumstances: for any purpose when required by law; for public health activities; to certain government authorities if we reasonably believe you are a victim of abuse, neglect or domestic violence; for health oversight activities; to avert a serious threat to your Maidic or another person;_��,Nations or civil proceedings; if required by a court or administrative tribunal or in response to a subpoena, discovery request or other lawful process under certain circumstances; to law enforcement in limited circumstances; to coroners, medical examiners, and funeral directors or to organizations that handle organ and tissue donation or transplantation consistent with law; for certain specially - approved research projects; for specialized government functions (such as military, national security or intelligence activities or to correctional institutions); for disaster relief efforts; or to workers' compensation agencies if necessary to make a benefit determination. plml�. tF11111111111■"i UIUSIIlg Y0111'Pel-SOILUI 11CUIL11 111101111LIL1011. 1701 CXdl le, We Will NuCK YUL-1 - Jup, foruses or disclosures of psychotherapy notes (ii) uses or disclosures of your personal health information for marketing purposes (iii) disclosures of your personal health inforination that constitute the sale of your health inforination. If you have given us an authorization, you may revoke it at any time, if we have not already acted on it. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 131 Chapter 9. Legal notices Federal regulations concerning the privacy and security of personal health information give you the right to make certain requests regarding your personal health information. By law, you have the right to: You may make any of the requests desechrilie—d—abio—ve, or may request a paper copy ofM_s_n_oTfc__e_, by calling Member Services toll -free at 1-844-293-4760 (TTY/TDD users should call 711). • are 24 hours a day, 7 days a week. 2018 Evidence of Coverage for Enisi onRxis Employer Group Retiree PDP 132 Chapter 9. Legal notices You also have the right to file a complaint if you think your privacy rights have been violated. To do so, please send your inquiry to the following address: EnvisionRxPlus, 2181 E. Aurora Rd., Suite 201, Twinsburg, OH 44087, Attn: Privacy Officer. You also may write to the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Ave. S.W., Room 509F HHH Bldg., Washington DC 20201 (OCRComplaint@hhsgov). You will not , it . "1m*npn'naihCr filin2,4 a co—mylaint and pour benefits under the Plan will not be adversel affected by doing so. Federal privacy regulations require us to keep your personal health information private, to give you notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect. Please note that we do not destroy your personal health infon-nation when you terminate your coverage with us. It may be necessary to use and disclose this information for the purposes will remain in place to protect against inappropriate use or disclosure. State Privacy Laws. Some state privacy laws may give you greater protection than those described in this notice. Depending on the state in which you live, there may be additional law�! regarding the use and disclosure of health infonnation such as that related to genetics, HIVAIDS, mental health, sexually transmitted diseases, and substance abuse. For more information, please contact the EnvisionRxPlus Privacy Officer: FARMENROMIM 2181 E. Aurora Rd., Suite 201 Twinsburg, OH 44087 Attn: Privacy Officer A= This notice is being provided to you herein and is also posted on our website. We may change the terms of this notice and our privacy policies at any time. If we do change the terms of this notice, the revised notice will be available upon request and posted too website. The new terms will be effective for all of the information that we already have about you, as well as any information that we may receive or hold in the future. If you have questions regarding this notice, please contact Member Services toll -free at 1-844- 293-4760 (TTY/TDD users should call 711). Hours are 24 hours a day, 7 days a week. Please include your name, phone number, and fax number. The original version of this notice went into effect on September 10, 2009. The effective date of this notice is August 2, 2017. CHAPTER 10 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 134 Chapter i Definitions of important words Another Party - Any individual or entity, other than EnvisionRxPlus, that is liable or legally responsible to pay expenses, compensation or damages in connection with abeneficiary's injuries or illnesses. Another Party shall include the party or parties who caused the injuries or illness (first or third parties)- the insurer, guarantor or other indemnifier of the party or parties who caused the injuries or illness; a beneficiary's awn insurer, such as uninsured, underinsure , pharmacy payments, no-fault, homeowner's, renter's, or any other liability insurer: a workers' compensation insurer? a pharmacy malpractice or similar ; and any other person, corporation, or entity that is liable or legally responsible for payment in connection with the injuries or illness. Advance Directive — A legal document that controls critical decisions about your health care. You also have the right to give instructions for health care providers to follow if you become unable to direct your own care, an Advance Directive can be used in these circumstances. Appeal— An appeal is something you do if you disagree with our decision to deny a request for coverage of prescription drugs or payment for drugs you already received. For example, you may ask for an appeal if we don't pay for a drug you think you should be able to receive. Chapter 7 explains appeals, including the process involved in making an appeal. Annual Enrollment Period — A set time each fall when members can change their health or drug plans or switch to Original Medicare. The Annual Enrollment Period is from ctober 15 until December 7. Brande Drug — A prescription drug that is manufactured and sold byte pharmaceutical company that originally researched and developed e drug. Brand name drugs have the same active -ingredient formula as the generic version of the drug. However, generic drugs are manufactured and sold by other drug manufacturers and are generally not available until after the patent on the brand name drug has expired. Catastrophic ve t e — The stage in the Part D Drug Benefit where you pay a low cop et or coinsurance for your drugs after you or other qualified parties on your behalf have spent $5,000 in covered drugs during the covered year. Centers for Medicare & MedicaidServices ) — The Federal agency that administers Medicare, Chapter 2 explains how to contact CMS. Coinsurance — An amount you may be required to pay as yours are of the cost for prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). Complaint — The formal name for "making a complaint" is "filing a grievance." The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. See also "'Grievance," in this list of definitions. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP Chapter 10. Definitions of important words Copayment (or "copay") — An amount you may be required to pay as your share of the cost for a prescription drug. A copayment is a set amount, rather than a percentage. For example, you might pay $10 or $20 for a prescription drug. Cost -sharing — Cost -sharing refers to amounts that a member has to pay when drugs are received. (This is in addition to the plan's monthly premium, if applicable.) Cost -sharing includes any combination of the following three types of payments: (1) any deductible amount plan may impose before drugs are covered; (2) any fixed "copayment" amount that a plan requires when a specific drug is received; or (3) any "coinsurance" amount, a percentage of th total amount paid for a drug, that a plan requires when a specific drug is received. A "'daily co sharing rate" may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a copayment. ti Cost -Sharing Tier — Every drug on the list of covered drugs is in one of 5 cost -sharing tiers. In general, the higher the cost -sharing tier, the higher your cost for the drug. Coverage Determination — A decision about whether a drug prescribed for you is covered by the plan and the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered under your plan, that isn't a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage. Coverage determinations are called "coverage decisions" in this booklet. Chapter 7 explains how to ask us for a coverage decision. Covered Drugs — The term we use to mean all of the prescription drugs covered by our plan. for Medicare can generally keep that coverage w t out paying a pena t in Medicare prescription drug coverage later. Daily cost -sharing rate — A "daily cost-sbaring rate" may apply when your doctor prescribes less than a full month's supply of certain drugs for you and you are required to pay a copayment- A daily cost -sharing rate is the copayment divided by the number of days in a month's supply. Here is an example: If your copayment for a one -month supply of a drug is $30, and a one- month's supply in your plan is 30 days, then your "daily cost -sharing rate" is $1 per day. This means you pay $1 for each day's supply when you fill your prescription. Disenroll or Disenrollment — The process of ending your membership in our plan. Disenrollment may be voluntan (your own choice) or involuntary friot Wur own choice). Dispensing Fee — A fee charged each time a covered drug is dispensed to pay for the cost of filling a prescription. The dispensing fee covers costs such as the pharmacist's time to prepare and package the prescription. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 13f Chapter 10. Definitions of important words Emergency — A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. Evidence of Coverage (EOC) and Disclosure Information — This document, along with your enrollment form and any other attachments, riders, or other optional coverage selected, which explains your coverage, at we must do, your rights, and what you have to do as a member of our plan. Exception — A type of coverage determination that, if approved, allows you to get a drug that is not on your plan sponsor's formulary (a formulary exception), or get a non -preferred drug at a lower cost -sharing level (a tiering exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception). Extra Help — A Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance. Generic Drug — A prescription drug that is approved by the Food and Drug Administration (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a "generic" drug works the same as a brand name drug and usually costs less. Grievance — A type of complaint you make about us or one of our network pharmacies, including a complaint concerning the quality of your care, This type of complaint does not involve coverage or payment disputes. Income Related Monthly Adjustment Amount (IRMAA) — If your income is above a certain limit, you will pay an income -related monthly adjustment amount in addition to your In premium. For example, individuals with income greater than $85,000 and married couples with income greater than $170,000 must pay a higher Medicare Part B (medical insurance) and Medicare prescription drug coverage premium amount. This additional amount is called the income -related monthly adjustment amount. Less than 5% of people with Medicare are affected, so most people will not pay a higher premium. Initial Coverage Limit — The maximum limit of coverage under the Initial Coverage Stage. Initial Coverage Stage — This is the stage before your total drug costs including amounts you have paid and what your plan has paid on your behalf for the year have reached $3,750 Initial Enrollment Period — When you are first eligible for Medicare, the period of time when you can sign up for Medicare Part A and Part B. For example, if you're eligible for Medicare when you turn 65, your Initial Enrollment Period is the 7-nionth period that begins 3 months before the month you turn 65, includes the of you turn 65, and ends 3 months after the month you turn 65. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 137 Chapter 10. Definons of important words List of Covered Drugs (Formulary or "Drug List") — A list of prescription drugs covered by the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes both brand name and generic drugs. Low Income Subsidy (LIS) — See "Extra Help." Medicaid (or Medical Assistance) — A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Medicaid programs vary from state to state, but most health care costs are covered if you qualify for both Medicare and Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state. Medically Accepted Indication — A use of a drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 3, Section 3 for more information about a medically accepted indication. Medicare — The Federal health insurance program for people 65 years of age or older, some people under age 65 with certain disabilities, and people with End -Stage Renal Disease (generally those with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their Medicare health coverage through Original Medicare, a Medicare Cost Plan, a PACE plan, or a Medicare Advantage Plan, Medicare Advantage (MA) Plan — Sometimes called Medicare Part C. A plan offered by a private company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee -for -Service (PFFS) plan, or a Medicare Medical Savings Account (MSA) plan, If you are enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare Advantage Plans with Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join any Medicare health plan that is offered in their area, except people with End -Stage Renal Disease (unless certain exceptions apply). Medicare Cost Plan — A Medicare Cost Plan is a plan operated by a Health Maintenance Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost -reimbursed contract under section 1876(h) of the Act. Medicare Coverage Gap Discount Program — A program that provides discounts on most covered Part D brand name drugs to Part D members who have reached the Coverage Gap Stage and who are not already receiving "Extra Help." Discounts are based on agreements between the Federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted. Medicare -Covered Services — Services covered by Medicare Part A and Part B. Medicare Health Plan — A Medicare health plan is offered by a private company that contracts with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 1M- Chapter 10. Definitions of important words Medicare Prescription Drug Coverage (Medicare Part D) — Insurance to help pay for outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part A or Part B. "Medigap" (Medicare Supplement Insurance) Policy — Medicare supplement insurance sold by private insurance companies to fill "gaps" in Original Medicare. Medigap policies only work with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.) Member (Member of our Plan, or "Plan Member") — A person with Medicare who is eligible to get covered services, who has enrolled in our plan and whose enrollment has been confirmed by the Centers for Medicare & Medicaid Services (CMS). Member Services — A department within our plan responsible for answering your questions RIM xmidi� #mm(ftuWyievances.. and—pAyeals. See Chapter 2 for information about how to contact Member Services. Network Pharmacy — A network Pharmacy is a Pharmacy where members of our plan can get their prescription drug benefits. We call the "network pharmacies" because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Original Medicare ("Traditional Medicare" or "Fee -for -service" Medicare) — Original Medicare is offered by the government, and not a private health plan like Medicare Advantage Plans and prescription drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals, and other health care providers payment amounts established by Congress. You can see any doctor, hospital, or other health care provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the Medicare -approved amount, and you pay your share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States. 1=11 Pali: L;L)V1WU1aLV, 01 PIUVRIC UUVULUIt ft1&?,ZS LV HICRIUCIS U1 VU1 PIU11. CAP'laxicu I Coverage, most drugs you get from out -of -network pharmacies are not covered by our plan unless certain conditions apply. Out-of-pocket Costs — See the definition for "cost -sharing" above. A member's cost -sharing requirement to pay for a portion of drugs received is also referred to as the member's "out-of- pocket" cost requirement. PACE plan — A PACE (Program of All -Inclusive Care for the Elderly) plan combines medical, social, and long-term care (LTC) services for frail people to help people stay independent and living in their community (instead of moving to a nursing home) as long as possible, while getting the high -quality care they need. People enrolled in PACE plans receive both their 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 131, Chapter 10. Definitions of important words i 10 M1 us I WOMAU 1IKU to MIOW it IN OC-1 "'C"74 numbers are printed on the back cover of this booklet). Part C — see "Medicare Advantage (MA) Plan." Part D — The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer to the prescription drug benefit program as Part D.) Part D Drugs — Drugs that can be covered under Part D. We may or may not offer all Part D drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were specifically excluded by Congress from being covered as Part D drugs. Part D Late Enrollment Penalty — An amount added to your monthly premium for Medicare drug coverage if you go without creditable coverage (coverage that is expected to pay, on average, at least as much as standard Medicare prescription drug coverage) for a continuous period of 63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some exceptions. For example, if you receive "Extra Help" from Medicare to pay your prescription drug plan costs, the late enrollment penalty rules do not apply to you. If you receive "Extra Help," you do not pay a late enrollment penalty. Premium — The periodic payment to Medicare, an insurance company, or a health care plan for health or prescription drug coverage. Prior Authorization — Approval in advance to get certain drugs that may or may not be on our formulary. Some drugs are covered only if your doctor or other network provider gets "prior authorization" from us. Covered drugs that need prior authorization are are in the formulary. Quality Improvement Organization (QIO) — A group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state. Quantity Limits — A management tool that is designed to limit the use of selected drugs for quality, safety, or utilization reasons. Limits may be on the amount oft e drug that we cover per prescription or for a defined period of time. Recovery - Any and all money, fund, property, compensation, as well as all rights thereto, or damages paid or available to the beneficiary's by Another Party through insurance payments, settlement proceeds, first or third party payments or settlement proceeds, judgments, reimbursements or otherwise (no matter how those monies may be characterized, designated, or allocated) to compensate for any losses caused by, or in connection with, the injuries or illness. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 140 Chapter 10. Definitions of important words Reimbursement / Reimburse - Repayment to EnvisionRxPlus for pharmacy or other benefits paid or payable toward care and treatment of the illness or injury and for any other expenses incurred by EnvisionRxPlus in connection with benefits paid or payable. Service Area — A geographic area where a prescription drug plan accepts members if it limits membership based on where people live. The plan may disenroll you if you permanently move out of the plan's service area. Special Enrollment Period — A set time when members can change their health or drug plans or return to Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you move outside the service area, if you are getting "Extra Help" with your prescription drug costs, if you move into a nursing home, or if we violate our contract with you. to Therapy — A utilization tool that requires you to first try another drug to treat your medical condition before we will cover the drug your physician may have initially prescribed. Supplemental Security Income (SSI) — A monthly benefit paid by Social Security to people with limited income and resources who are disabled, blind, or age 65 and older. SM benefits are not the same as Social Security benefits. Subrogation / Subrogate - EnvisionRxPlus's right to pursue the beneficiary's claims against Another Party for pharmacy or other charges paid by EnvisionRxPlus. 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 141 Appendices Alabama Alaska Arizona Arkansas Alabama Dept. of Senior Medicare Information Arizona State Health Senior Health Insurance Services Office Insurance Assistance Information Program (SHIIP) 2 01 Monroe St., Ste. 350 400 Gambell St. Program (SHIP) 00 d 12W 3rSt. Montgomery, AL 36104 Anchorage, AK 99501 1789 W. Jefferson St. Little Rock, AR 72201 Phone: (800) 243-5463 Phone: (800) 478-6065 #950a Phone: (800) 224-6330 TTY: (800) 243-5463 TTY: (800) 770-8973 Phoenix, AZ 85007(501) 683-4468 Phone: (800) 432-4040 TTY: 711 California Colorado Connecticut Delaware Health Insurance Counseling Senior Health Insurance i CHOICES ELDERinfo and Advocacy Program Assistance Program 55 Farmington Ave., 10th 841 Silverlake Blvd. (HICAP) (SHIP) Floor Dover, DE 19904 1300 National Dr., Ste. 200 1560 Broadway Hartford, CT 05 Phone: (800) 336-9500 Sacramento, CA 95834 Ste. 850 Phone: (800) 994-9422 Phone: (800) 434-0222 Denver, CO 80202 TTY: (800) 842-4524 TDD: (800) 735-2929 Phone: (888) 696-7213 TTY: (303) 894-7880 Georgia Guam Hawaii GeorgiaCares Guam Medicare Sage PLUS 2 Peachtree St., NW 33rd Assistance Program 250 South Hotel St. Floor (Guam MAP) Ste. 406 Atlanta, GA 30303 130 University Dr., Ste. 8 Honolulu, HI 96813 Phone: (866) 552-4464 University Castle Mall, Phone: (888) 875-9229 TTY: (404) 657-1929 Mangiloa, Guam 96913(866) 810-4379 Phone: (671) 735-7011 or (671) 735-7382 TTY: (671) 735-7415 Idaho Illinois Indiana Iowa Senior Health Insurance Senior Health Insurance State Health Insurance Senior Health Insurance Benefits Advisors (SHIBA) Program (SHIP) Assistance Program Information Program (SHI[P) 700 West State St., 3rd Floor One Natural Resources (SHIP) 601 Locust St., 4th Floor P.O. Box 83720 Way, #100 311 W. Washington St. Des Moines, IA 50309 Boise, ID 83720 Springfield, IL 62702 Ste. 300 Phone: (800) 351-4664 Phone: (800) 247-4422 Phone: (800) 252-8966 Indianapolis, IN 46204 TTY: (800) 735-2942 TTY: (888) 206-1327 Phone: (800) 452-4800 TDD: (866) 846-0139 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 142 Appendices Kansas Kentucky Louisiana Maine Senior Health Insurance State Health Insurance Senior Health Insurance Maine State Health Counseling for Kansas Assistance Program Information Program Insurance Assistance (SHICK) (SHIP) (SHIIP) Program (SHIP) 503 S. Kansas Ave. 275 E. Main St. PO Box 94214 SHS 11 New England Bldg. Frankfort, KY 40621 1702 N. 3rd St. Augusta, ME 04333 Topeka, KS 66603 Phone: (877) 293-7447 P.O. Box 94214 Phone: (877) 353-3771 Phone: (800) 860-5260 Baton Rouge, LA 70802 TTY: 711 Phone: (800) 259-5300 Maryland Massachusetts Michigan Minnesota Senior Health Insurance Serving Health MMAP, Inc. Minnesota State Health Assistance Program (SHIP) Information Needs of 6105 W St. Joseph Hwy, Insurance Assistance 301 West Preston St. Elders (SHINE) Ste. 204 Program Senior Lin Room 1007 1 Ashburton Place, 5th Lansing, MI 48917 Line Baltimore, MD 21201 Floor Phone: (800) 803-7174 PO Box 64976 Phone: (800) 243-3425 Boston, MA 02108 Saint Paul, MN 55164 TTY:711 Phone: (800) 243-4636 Phone: (800) 333-2433 TTY:711 Mississippi Missouri Montana Nebraska MS Dept. of Human Services- CLAIM Montana State Health Nebraska Senior Health Division of Aging & Adult 200 N. Keene St. Insurance Assistance Insurance Information Services Ste. 101 Program (SHIP) Program (SHIIP) 750 N. State St. Columbia, MO 65201 2030 11 th Ave, 9410 St., Ste. 400 Jackson, MS 39202 Phone: (800) 390-3330 Helena, MT 59601 Lincoln, NE 68508 Phone: (800) 948-3090 Phone: (800) 551-3191 Phone: (800) 234-7119 1 TTY: (800) 833-7352 Nevada New Hampshire New Jersey New Mexico State Health Insurance NH SHIP - Servicel-ink & State Health Insurance Benefits Counseling Advisory Program (SHIP) Disability Resource Assistance Program Program 3416 Goni Rd., Ste. D-132 Center (SHIP) 2550 Cerrillos Rd. Carson City, NV 89706 129 Pleasant St. Division of Aging Santa Fe, NM 87505 Phone: (800) 307-4444 Gallen State Office Park Services Phone: (800) 432-2080 Concord, NH 03301 P.O. Box 715 Phone: (866) 634-9412 Mercerville, NJ 08625 Phone: (800) 792-8820 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 143 Appendices New York North Carolina North Dakota Ohio Health Insurance Information Seniors' Health Senior Health Insurance Ohio Senior Health Counseling and Assistance Insurance Information Counseling (SHIC) Insurance Information Program (HIICAP) Program (SHIIP) 600 East Blvd, Program (OSHIIP) 2 Empire State Plaza 11 South Boylan Ave. Bismarck, ND 58505 50 West Town St., 3rd Floor New York City, NY 12223 Raleigh, NO 27603 Phone: (888) 575-6611 Ste. 300 Phone: (800) 701-0501 Phone: (855) 408-1212 TTY: (800) 366-6888 Columbus, OH 43215 TTY: 711 Phone: (800) 686-1578 Oklahoma Oregon Pennsylvania Puerto Rico Senior Health Insurance Senior Health Insurance APPRISE State Health Insurance Counseling Program (SHIP) Benefits Assistance 555 Walnut St. 5th Floor Assistance Program (SHIP) Five Corporate Plaza (SHIBA) Harrisburg, PA 17101 P.O. Box 191179 3625 NW 56th St., Ste. 100 P.O. Box 14480 Phone: (800) 783-7067 San Juan, PR 00919 Oklahoma it, OK 73112 Salem, OR 97309 Phone: (877) 725-4300 Phone: (800) 763-2828 Phone: (800) 722-4134 Rhode Island South Carolina South Dakota Tennessee Senior Health Insurance (I -CARE) Insurance Senior Health Information Tennessee SHIP Program (SHIP) Counseling Assistance & Insurance Education 502 Deaderick St., 9th Floor 74 West Rd., 2nd Floor and Referrals for Elders (SHIINE) Nashville, TIN 37243 Cranston, RI 02920 1301 Gervais S. 700 Governors Dr. Phone: (877) 801-0044 Phone: (401) 462-3000 Ste. 350 Pierre, SD 57501 TTY: (615) 532-3893 TTY: (401) 462-0740 Columbia, SC 29201 Phone: Eastern (800) Phone: (800) 868-9095 536-8197, Central (877) 331-4834, Western (877) 286-9072 Texas Utah Vermont Virginia Texas Dept. of Aging & Senior Health Insurance State Health Insurance Virginia Insurance Disability Services Information Program Assistance Program Counseling and Assistance 701 West 51st St. (SHIP) (SHIP) Program (VICAP) Austin, TX 78751 195 North 1950 West 481 Summer St. 1610 Forest Ave. , Ste. 100 Phone: (800) 252-9240 Salt Lake City, LIT 84116 Suite 101 Henrico, VA 23229 TTY: (800) 735-2989 Phone: (800) 541-7735 St. Johnsbury, VT 05819 Phone: (800) 552-3402 1 1 Phone: (800) 642-5119 1 TTY: 711 ILV I U L-VIUCHUC, V1 Appendices Washington Q'Ait Benefits Advisors (SHIBA) PO Box 40256 Olympia, WA 98504 Phone: (800) 562-6900 TTY: (360) 586-0241 Wyoming Wyoming State Healt Insurance Information Program (WSHIIP) 106 W. Adams Riverton, WY 8250 Washington D.C. Health Insurance Counseling Project (HICP) 650 20th St, NW Washington, DC 20052 West Virginia West Virginia State Health Insurance SHIP) 1900 Kanawha Blvd. harleston, WV 25305 Pione: (8771987-4463 UM W o Wiscnsin iscnsin Wisconsin SHIP (SHI One West Wilson St. Madison, WI 53703 2018 Evidence of Coverage for EnvisionlaxPlus Employer Group Retiree PDP 145 Appendices 111 1111111 11!11� 1,11111111111 1111111 I ....................................U ............... . Pr . ......... ...................... 1! ........ 14 11 . M M-1 Address Toll -free Number Fax Number Livanta, LLC. 866-815-5440 Appeals: 855-236-2423 BFCC-QIO Program TT: 1-866-868-2289 All other reviews: 9090 Junction Drive, Suite 10 844-420-6671 Annapolis Junction, IND 20701 1 1 1 States: District of Columbia, Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia and West Virginia Address Toll -free Number Fax Number KEPRO 844-455-8708 844-834-7129 5201 W. Kennedy Blvd., Suite 900 1 Tampa, FL 33609 ---------- T SkiM Address Toll -free Number Fax Number KEPRO 844-430-9504 844-878-7921 5700 Lombardo Center Dr., Suite 100 Seven Hills, ON 44131 States: Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio and Wisconsin Address Toll -free Number Fax Number KEPRO 855-408-8557 844-834-7130 5201 W. Kennedy Blvd., Suite 900 Tampa, FL 33609 ................................ Address Livanta, LLC. Appeals: 855-694-Ili 929 BFCC-QIO Program All other reviews: 9090 Junction Drive, Suite 10 844-420-6672 Annapolis Junction, MD 20701 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 146 Appendices Alabama Alaska Arizona Arkansas Medicaid Agency of Alabama Alaska Dept. of Health AHCCCS Dept. of Human Services 501 Dexter Ave. and Social Services 801 E. Jefferson St. of Arkansas Montgomery, AL 36104 350 Main S. MD 4100 Donaghey Plaza South Phone: (800) 362-1504 Rm. 103 Phoenix, AZ 85034 P 0 Box 1437, Slot s401 Juneau, AK 99811 Phone: (800) 523-0231 Little Rock, AD 72203 Phone: (907) 465-3347 Phone: (800) 482-5431 Spanish: (800) 482-8988 California Colorado Connecticut Delaware California Dept, of Health Health First Colorado Dept, of Social Services Delaware Health and Services 1570 Grant St. of Connecticut Social Services P 0 Box 997413 Denver, GO 80203 25 Sigourney S. 1901 N. DuPont Highway Sacramento, CA 95899 Phone: (800) 221-3943 Hartford, CT 06106 PC Box 906, Lewis Bldg, Phone: (916) 552-9200 Phone: (800) 842-1508 New Castle, BE 19720 TTY/TDD: (800) 842- Phone: (800) 372-2022 4524) Florida Georgia Hawaii Idaho Agency for Health Care Georgia Dept. of Dept. of Human Services Idaho Dept. of Health and Administration of Florida Community Health of Hawaii Welfare 1317 Winewood Blvd. 2 Peachtree St., 801 Dillingham Blvd. 450 W. State St., 10th Floor Bldg, 1, Room 202 Atlanta, CA 30303 3rd Floor P.O. Box 83720 Tallahassee, FL 32399 Phone: (877-423-4746) Honolulu, HI 96817 Boise, ID 83720 Phone: (888) 419-3456 Phone: (808) 586-5390 Phone: (877) 456-1233 TDD: 1-800-955-8771 TTY: (800) 603-1201 Spanish: (800) 316-8005 Illinois Indiana Iowa Kansas Illinois Dept. of Healthcare Family and Social Dept. of Human Services Kansas Medical and Family Services Services Administration of Iowa Assistance Program 100 South Grand Ave. East of Indiana 100 Army Post Rd. P.O. Box 3571 Springfield, IL 62762 402 W. Washington St. Des Moines, IA 50315 Topeka, KS 66601 Phone: (866) 468-7543 P,O, Box 7083 Phone: (800) 338-8366 Phone: (800) 766-9012 TTY: (877) 204-1012 Indianapolis, IN 46207 Phone: (800) 457-4584 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree17 Appendices Kentucky Louisiana Maine Maryland Cabinet for Health Services Louisiana Dept. of Health Maine Dept. of Health and Dept. of Health and Mental of Kentucky 628 N. 4th St Human Services Hygiene 275 East Main St. Baton Rouge, LA 70821 11 State House Station 201 W. Preston St. Frankfort, KY 40621 Mailing: 242 State St. Baltimore, MD 21201 Phone: (800) 635-2570 P.O. Box 91278 Augusta, ME 04333 Phone: (410) 767-1594 Baton Rouge, LA 70821 Phone: (800) 977-6740 Phone: (888) 342-6207 TTY: 711 Massachusetts Michigan Minnesota Mississippi Office of Health and Human Michigan Dept. of HealthDept, of HumanServices Mississippi Division of Services of Massachusetts & Human Services of Minnesota Medicaid 55 Summer St. 333 S. Grand Ave P.O. Box64838 550 High St., Ste. 1000 Boston, MA 02110 P.O. Box30195 St. Paul, MN 5515 Jackson, MS 39202 Phone: (800) 841-2900 Lansing MI 48909 : ( ) 57-379 Phone: (800) 4212408 TTY: (800) 497-4648 : (17) 73-374 TTY:711 Missouri Montana Nebraska Nevada Dept. of Social Services of MT Dept. of Public Nebraska Dept of Health Nevada Dept. of Health Missouri Health & Human and Human Services and Human Services 615 HowertonCourt Services P.O. Box 95026 Division of Welfare and P.O.o 6500 1400 Broadway Lincoln, NE 68509 Supportive Services Jefferson City, MO 65102 Cogswell Bldg. Phone: (00) 254-402 330 E. Flamingo Rd #55 (573) 751-45 Helena, MT 59620 Las Vegas, NV 89121 (00) 36- 312 : (77) 43-7669 New Hampshire New Jersey New Mexico New York New Hampshire Dept. of Dept. of Human Services Dept. of Human Services NY State Dept. of Health Health and Human Services of New Jersey of New Mexico Office of Medicare 129 Pleasant St. Quakerbridge Plaza P.O. Box 2348 Management Concord, NH 03301 Bldg,7 Sante Fe, NM 87504 800 N Pearl Street Phone: (800) 852-3345 P.O. Box712 Phone: (888) 997-2583 Albany, NY 12204 TDD: (800) 735-2964 Trenton, NJ 0 619 Phone: (800) 541-2831 (0) 356-1561 North Carolina North DakotaOhio Oklahoma North Carolina Dept. of Dept. of Human Services Dept. of Medicaid Health Care Authority of Health and Human Services of North Dakota - 50 West Town St., Ste. Oklahoma 2501 Mail Service Center Medical Services 400 4345 N. Lincoln Blvd. Raleigh, NC 27699 600 E. Blvd, Ave. Columbus, OH 43215 Oklahoma City, NE 73105 Phone: (800) 662-7030 Dept. 325 Phone: (800) 324-8680 Phone: (800) 987-7767 Bismarck, ND 58505 (00) 755-60 TTY:711 2018 Evidence of Coverage for Envialus Employer Group Retiree PDP 148 Appendices Oregon Pennsylvania Puerto Rico Rhode Island Oregon Health Plan Dept. of Human Services Medicaid Office of Puerto Dept. of Human Services 500 Summer St., N.E. of Pennsylvania Rico and Virgin Islands of Rhode Island Salem, OR 97301 P.O. Box 2675 P.O. Box 70184 Louis Pasteur Bldg, Phone: (800) 699-9075 Harrisburg, PA 17105 San Juan, Puerto Rico 57 Howard Ave. Phone: (800) 692-7462 93681 Cranston, RI 02921 TDD: (800) 451-5886 Phone: (787) 765-2929 Phone: (401) 462-5300 South Carolina South Dakota Tennessee Texas South Carolina Dept. of Dept. of Social Services TennCare Health and an Health and Human Services of South Dakota 310 Great Circle Rd. Services Commission of P.O. Box 8206 700 Governors Dr. Nashville, TN 37243 Texas Columbia, SC 29202 Richard F Kneip Bldg. Phone: (855) 259-0701 4900 N Lamar Blvd, Phone: (888) 549-0820 Pierre, SD 57501 TTY: (877) 779-3103 Austin, TX 78751 TDD: (888) 842-3620 Phone: (800) 597-1603 Spanish: (866) 311-4290 Phone: (877) 541-7905 TTY: (512) 407-3250 Utah Vermont Virginia Washington Utah Dept. of Health Agency of Human Dept. of Medical Dept. of Social and Health 288 North 1460 West Services of Vermont Assistance Services Services of Washington Salt Lake City, LIT 84114 280 State Dr. 600 E. Broad St. Cherry St. Plaza Phone: (800) 662-9651 Waterbury, VT 05671 Ste. 1300 626 8th Ave. SE Phone: (800) 250-8427 Richmond, VA 23219 Olympia, WA 98501 TTY: 711 Phone: (804) 786-7933 Phone: (800) 865-7801 TDD: (800) 343-0634 Washington D.C. West Virginia Wisconsin Wyoming Dept. of Health — District of West Virginia Dept. of Wisconsin Dept. of Health Wyoming Dept. of Health Columbia Health & Human Services 2300 Capital Ave, Suite 899 N Capitol Street NE Resources I West Wilson St. 401 Hathaway Bldg Washington, DC 20002 350 Capitol S. Madison, WI 3 Cheyenne, WY 82002 Phone: (202) 442-5955 Charleston, WV 25301 Phone: (800) 362-3002 Phone: (866) 571-0944 Phone: (304) 558-1700 1 TTY: 711 1 1 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree RDP 149 Appendices 1111:1 111 In Colorado Connecticut Delaware Idaho Colorado Bridging the Gap Connecticut Delaware Prescription Idaho AIDS Drug 4300 Cherry Creek Dr. South Pharmaceutical Assistance Program Assistance Program Denver, CO 80246 Assistance Contract to (PDAP) (IDAGAP) Phone: (303) 692-2783 or the Elderly and Disabled PO Box 950. Dept. of Health & Welfare (303) 692-2716 (ConnPACE) New Castle, BE 19720 PO Box 83720 PO Box 5011 Phone: ((800) 996-9969, Boise, ID 83720 Hartford, CT 06102 EXT: 2 Phone: (208) 334-5943 or Phone: (800) 423-5026 (800) 926-2588 or (800) 269-2029 Indiana Maine Maryland Maryland (cont) Hoosier Rx Low Cost Drugs for the Maryland Senior Maryland Kidney Disease 402 W. Washington St., Elderly and Disabled Prescription Drug Program Room W374, MS07 Program Assistance Program 201 W. Preston St., Room Indianapolis, IN 4 242 State St. c/o Pool Administrators SS-3 Phone: (866) 267-4679 Augusta, ME 04333 628 Hebron Ave., Ste. Baltimore, MD 21201 (317) 234-1381 Phone: (866) 796-2463 100 Phone: (800) 767-5000 or TTY: (800) 606-0215 Glastonbury, CT 06033 (410) 226-2142 Phone: (800) 551-5995 Maryland (cont) Massachusetts Missouri Montana Primary Adult Care Program Massachusetts Missouri Rx Plan Big Sky Rx Program (PAC) Prescription Advantage PO Box 6500 PO Box 202915 P.O. Box 386 PO Box 15153 Jefferson City, MO 65102 Helena, BIT 59620 Baltimore, MD 21203 Worcester, MA 01615 Phone: (800) 375-1406 Phone: (866) 369-1233 or Phone: (800) 226-2142 Phone: (800) 243-4636 (406) 444-1233 EXT:2 Nevada New Jersey New Jersey (cont) New Jersey (cont) Nevada Senior Rx Senior Gold Prescription Pharmaceutical Division of Medical Department of Health and Discount Program Assistance to the Aged Assistance and Health Ser. Human Services PO Box 715 and Disabled Program PO Box 712 3416 Goni Rd. Trenton, NJ 08625 (PAAD). Trenton, NJ 08625 Ste. D-1 32 Phone: (800) 792-9745 Dept. of an Services Phone: (800) 356-1561 Carson City, NV 89706 P.O. Box 715 Phone: (866) 303-6323 or Trenton, NJ 08625 (775) 687-4210 Phone: (800) 792-9745 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree Prop 150 Appendices New York North Carolina Pennsylvania Pennsylvania (cont) Elderly Pharmaceutical North Carolina HIV Pharmaceutical PACE Needs Insurance Coverage (EPIC) SPAP Assistance Contract for Enhancement Tier PO Box 15018 1902 Mail Service Center the Elderly (PACE) (PACENET) Albany, NY 12212 Raleigh, NC 27699 PACE/PACENET PACENET Program Phone: (800) 332-3742 Phone: (877) 466-2232 Program P.O. Box 8806 or (919) 733-7301 P.O. Box 8806 Harrisburg, PA 17105 Harrisburg, PA 17105 Phone: (800) 225-7223 or Phone: (800) 225-7223 or (717) 651-3600 (717) 651-3600 Pennsylvania (con) Pennsylvania (cont) Rhode Island Texas Special Pharmaceutical Special Pharmaceutical Rhode Island Prescription Kidney Health Care Benefits Program- HIV/AIDS Benefits Program- Assistance for the Elderly Program (KHC) P.O. Box 8808 Mental Health (RIPAE) Dept of State Health Harrisburg, PA 17105 SPBPMH ATTN: RIFJAL Services, MC 1938 Phone: (800) 922-9384 P.O. Box 8808 Hazard Bldg., 2nd Floor P.O. Box 149347 Harrisburg, PA 17105 74 West Rd. Austin, TX 78714 Phone: (800) 433-4459 Cranston, RI 02920 Phone: (800) 222-3986 or Phone: (401) 462-3000 or (512) 776-7150 (401) 462-0740 Vermont Virginia Washington Wisconsin V-Pharm Virginia HIV SPAP Washington State Health SeniorCare 312 Hurricane Ln. HCS Unit, 1st Floor Insurance of P.O. Box 6710 Ste. 201 James Madison Bldg. PO Box 1090 Madison, WI 53716 Williston, VT 05495 109 Governor S. Great Bend, KS 67530 Phone: (800) 657-2038 Phone: (800) 250-8427 Richmond, VA 23219 Phone: (800) 877-5187 Phone: (855) 362-0658 Wisconsin (cont) Wisconsin (cont) Wisconsin (cont) Chronic Renal Disease Cystic Fibrosis Program Hemophilia Home Care ATTN: Eligibility Unit Chronic Disease Chronic Disease program P.O. Box 6410 program P.O. Box 6410 Madison, WI 53716 P.O. Box 6410 Madison, WI 53716 Phone: (800) 947-9627 or Madison, WI 53716 Phone: (800) 947-9627 or (800) 362-3002 Phone: (800) 947-9627 (800) 362-3002 1 or (800) 362-3002 1 1 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 151 Appendices Alabama Alaska Arizona Arkansas Area Agency on Aging Dept of Health & Social Arizona Attorney General Division of Aging and Adult 4200 Highway 69 North Services Community Outreach Services Northport, AL 35476-0509 Division of Public Health and Education PO Box 1437 Phone: (800) 243-5463 350 Main Street, Room 1275 W. Washington St. Slot S-530 508 Phoenix, AZ 85007-2926 Little Rock, AR 72203-1437 Juneau, AK 99801 Phone: (800) 352-8431 Phone: (501) 682-2441 Phone: (907) 465-3090 or (602) 542-2123 California Colorado Connecticut Delaware California Department of Colorado Commission on Connecticut Dept of Delaware Division of Aging Aging Social Services Services for Aging and 1300 National Drive, Suite 1575 Sherman Street 55 Farmington Ave. Adults with Physical 200 Denver, Colorado 80203 Hartford, CT 06105 Disabilities Sacramento, CA 95834 Phone: (888) 866-4243 Phone: (800) 842-1508 1901 N. Du Pont Highway Phone: (916) 419-7500 or (303) 866-5288 TTY: (800) 842-4524 Main Bldg. TTY: (800) 735-2929 New Castle, DE 19720 Dover, DE 19904 Phone: (800) 223-9074 Florida Georgia Hawaii Idaho Florida Dept of Elder Affairs Georgia DHS Division of Dept of Health Idaho Commission on Aging 4040 Esplanade Way Aging Services Elderly Affairs Division 341 W Washington Tallahassee, FL 32399 2 Peachtree Street, NW Standard Finance Bldg. Boise, ID 83702 Phone: (850) 414-2000 Atlanta, GA 30303-3142 715 South King Street, Phone: (800) 926-2588 or TDD: (850) 414-2001 Phone: (866) 552-4464 Suite 200 (208) 334-3833 or (404) 657-5258 Honolulu, Hawaii 96813 Phone: (808) 768-7700 or (808) 808 768-7705 Illinois Indiana Iowa Kansas Illinois Dept on Aging Indiana Association of Iowa Dept on Aging Dept on Aging One Natural Resources Area Agencies on Aging Jessie M. Parker Bldg New England Bldg. Way, Suite 100 4755 Kingsway Drive 510 East 1 2th St., Ste. 2 503 S. Kansas Ave. Springfield, Illinois 62702- Suite 318 Des Moines, IA 50319 Topeka, KS 66603-3404 1271 Indianapolis, IN 46205 Phone: (800) 532-3213 Phone: (800) 432-3535 Phone: (800) 252-8966 Phone: (317) 205-9201 or (515) 725-3333 TTY: (785) 291-3167 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree152 Appendices Kentucky Louisiana Maine Maryland CHFS Dept of Health and OADS Aging Services Maryland Dept of Aging Dept for Aging and Hospitals Maine Dept of Health 301 West Preston Street Independent Living Office of Aging and Adult and Human Services Suite 1007 400 Old Vine St. Services 11 State House Station Baltimore, MD 21201 Ste. 203 628 N 4th Street 41 Anthony Ave. Phone: (401) 767-1100 Lexington, KY 40507 Baton Rouge, LA 70802 Augusta, ME 04333 Phone: (877) 293-7447 Phone: (225) 219-1917 Phone: (800) 262-2232 or (207) 287-9200 TTY: 711 Massachusetts Michigan Minnesota Mississippi Executive Office of Elder Aging and Adult Services Minnesota Board on Dept of Human Services Affairs Agency Aging Division of Aging and Adult One Ashburton Place, 5th 300 E. Michigan Ave., 3rd Elmer L. Anderson Services Floor Floor Human Services Building 750 North State Street Boston, MA 02108 Lansing, MI 48933 540 Cedar Street Jackson, MS 3902 Phone: (800) 243-4636 or Phone: (517) 373-8230 St. Paul, MN 55155 : (800) 948- 090 or (617) 727-7750 : (800) 882-6262 (601) 359- 929 TTY: (800) 872-0166 or (651) 31-500 (00) 62-9 Missouri Montana Nebraska Nevada Division of Senior and Dept of Public Health and Dept of Health and Dept of Health and Human Disability Services Area Human Services Human Services Services Agencies on Aging Area Agencies on State Unit on Aging Aging and Disability Missouri Department of Agencies P.O. Box 95026 Services Division Health and Senior Services P.O. Box 1717 Lincoln, NE 68509-5026 3416 Goni Road, Suite D- ox 570 Helena, MT 564 Phone: (800) 942-7830 132 Jefferson City, MO 651 : (800) 551-3191 Carson City, NV 89706 (573) 526-452 Phone: (775) 687-4210 New Hampshire New Jersey New Mexico New York New Hampshire Dept of Division of Aging Services New Mexico Aging and NYC Dept for the Aging Health and Human Services New Jersey Department Long -Term Services Office of Public Affairs Bureau of Elderly and Adult of Human Services Toney Anaya Bldg. 2 Lafayette Street Services 12B Quakerbridge Plaza 2550 Cerrillos Rd. New York, NY 10007 129 Pleasant Street PO Box 715 Santa Fe, NM 87505 Phone: (212) 639-9675 Concord, NH 03301 Mercerville, NJ 08625- Phone: (866) 451-2901 Phone: (800) 351-1888 or 0715 or (505) 476-4799 (603) 271-9203 Phone: (877) 222-3737 TDD: (800) 735-2964 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 153 Appendices North Carolina North Dakota Ohio Oklahoma NC Health and Human Dept of Human Services Ohio Dept of Aging Oklahoma Dept of Human Services 1237 W Divide Ave., Suite 246 N. High Street, 9th Services Aging and Adult Services 6 Floor Aging Services 2101 Mail Service Center Bismarck, ND 58501 Columbus, Ohio 43215- 2401 NW 23rd Street, Suite Raleigh, NC 27699-2101 Phone: (855) 462-5465 2406 40 Phone: (919) 855-3400 or (701) 328-4601 Phone: (800) 266-4346 Oklahoma City, OK 73107 TTY: (800) 366-6888 TTY: 711 Phone: (405) 521-2281 Oregon Pennsylvania Rhode Island South Carolina Oregon Department of Pennsylvania Dept of Rhode Island Dept of Office on Aging Human Services Aging Human Service, Division 1301 Gervais St. Seniors and People with 555 Walnut Street, 5th of Elderly Affairs Ste. 350 Disabilities Floor 74 West Road Columbia, SC 29201 0 Summer Street NE E12 Harrisburg, PA 17101- Hazard Bldg, 2nd Floor Phone: (800) 868-9095 or Salem, OR 9701-173 1919 Cranston, RI 02920 (803) 734-9900 ( 00) 2 - 096 Phone: (717) 783-1550 Phone: (401) 462-3000 (00) 2 - 096 TTY: (401) 462-0740 South Dakota Tennessee Texas Utah Adult Services and Aging Tennessee Commission Texas Dept of Agingand Health and Human Services 700 Governors Drive on Aging and Disability Disability Services Aging and Adult Services Pierre, SD 57501 502 Deaderick Street, 9th 701 W. 510 St. 195 North 1950 West Phone: (605) 773-3165 Floor Austin, TX 7 751 Salt Lake City, UT 84116 Nashville, TN 37243-0860 : (51) 4 -3011 Phone: (877) 424-4640 or Phone: (615) 741-2056 (801) 538-3910 Vermont Virginia Washington Washington, D.C. Vermont Dept of Disabilities, Virginia Dept for the Washington State Dept D.C. Office on Aging Aging and Independent Aging of Social and Health500 K Street NE Living 1610 Forest Ave. Ste. 100 Services, Aging and Washington, DC 20002 103 South Main Street Richmond, VA 23229 Long -Term Support Phone: (202) 724-5622 Weeks Building Phone: (800) 552-3402 Administration Waterbury, VT 05671 TTY: 711 Area Agency on Agin Phone: (0) 71-3065 50 Simon Street S East Wenatchee, WA 02 (00) 57-4459 Appendices 17717-RE= West Virginia Bureau of Senior Services 1900 Kanawha Blvd E Charleston, WV 25305 Fhan6: (877) 987-364, *r (304) 558-3317 I West Wilson St. Madison, WI 53703 Wlui yoming Dept of Health, Aging Division 401 Hathaway Bldg. Cheyenne, WY 82002 Phone: (866) 571-0944 or (307) 777-7656 1111111 11111 1111 jjp;�I� 11111�111 W1 Alabama Alaska Arizona Arkansas HIV/AIDS Division Alaskan AIDS Assistance Arizona Dept of Health Arkansas Dept of Health Alabama Dept of Public Association Services 4815 West Markham Street Health 3601 C Street, Suite 540 150 N. 18th Avenue, Little Rock, Arkansas 72205 The RSA Tower Anchorage, Alaska 99503 Suite 110 Phone: (888) 499-6544 or 201 Monroe Street, Suite Phone: (907) 269-8000 Phoenix, AZ 85007 (501) 661-2408 1400 Phone: (602) 364-3610 Montgomery, Alabama Alaskan Statewide AIDS 36104 Helpline: (800) 478-AIDS Phone: (866) 574-9964 California Colorado Connecticut Delaware Office of AIDS CDPHE Care and Dept of Social Services Delaware HIV Consortium PO Box 997377, MS 0500 Treatment Program Medical Operations Unit 100 W. 1 Oth St., Suite 415 Sacramento, CA 95899- 4300 Cherry Creek Drive #4 Wilmington, DE 19801 7377 South 25 Sigourney Street Phone: (302) 654-5471 Phone: (916) 558-1784 Denver, CO 80246 Hartford, CT 06106 MCI TDD (800) 735-2929 or Phone: (800) 886-7689 Phone: (800) 233-2503 MCI voice telephone (800) or (303) 692-2000 TDDITYY: 800-842-4524 735-2922; Sprint TDD (888) TDD: (303) 691-7700 877-5378 or Sprint voice telephone (888) 877-5379 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 155 Appendices Florida Georgia Guam Hawaii Section of HIV/AIDS Health and Human Bar. Guam Medicare STD/AIDS Prevention AIDS Drug Assistance 2 Peachtree St., NW Assistance Program Branch HIV Drug Program 15th Floor (Guam MAP) Assistance Program 4052 Bald Cypress Way Atlanta, GA 30303 130 University Drive, 3627 Kilauea Avenue, Tallahassee, FL 32399 Phone: (800) 551-2728 University Castle Mail, Room 306 Phone: (800) 352-2437 Room 156 Honolulu, Hawaii 96816- Spanish: (800) 545-7432 Guam, 96913 2399 Creole: (800) 243-7101 Phone: (671) 735-7421 Phone: (808) 732-0026 TTY: (888) 503-7118 TTY: (671) 735-7415 Idaho Illinois Indiana Iowa Idaho AIDS Drug Illinois ADAP Office Indiana State Dept of Iowa Dept of Public Health Assistance Program 525 West Jefferson Health 321 E. 12th Street (IDAGAP) Street, First Floor 2 N. Meridian St., 6-C Lucas State Office Bldg 5th 40 West State Street Springfield, IL 62761 Indianapolis, IN 46204 Fir Boise, ID 83720 Phone: (217) 782-4977 Phone: (866) 588-4948 Des Moines, IA 50319 Phone: (208) 334-6527 or TTY: (800) 547-0466 Phone: (800) 445-2437 (800-926-2588 Kansas Kentucky Louisiana Maine Kansas Dept of Health and KY Cabinet for Health and Louisiana Dept of Health Maine ADAP Environment Family Services and Hospitals 40 State House Station 1000 SW Jackson, HIV/AIDS Branch 628 N. 4th Street Augusta, ME 04330-9758 Suite 210 275 E Main Street, HS2E- Baton Rouge, LA 70802 Phone: (207) 287-3747 Topeka, KS 66612 C Phone: (225) 342-9500 Phone: (785) 296-8701 Frankfort, KY 40621 Phone: (866) 510-0005 Maryland Massachusetts Michigan Minnesota Maryland AIDS Massachusetts Attn: Michigan Drug HIV/AIDS Programs Administration Community Research Assistance Program HIV Dept of Human Services 500 North Calvert Street, Initiative of New Care Section PO Box 64972 5th Floor England/HD iv. of Health, Wellness St. Paul, MN 55164 Baltimore, MD, 21202 38 Chauncy Street, and Disease Control, Phone: (800) 657-3761 or Phone: (800) 205-6308 or Suite 500 Michigan Dept of Health (651) 431-2414 (410) 767-6535 Boston, MA 02111 and Human Services TTY: (800) 627-3529 TTY: (800) 735-2258 Phone: (800) 228-2714 109 Michigan Avenue, or (617) 502-1700 9th Floor Lansing, Ml 48913 Phone: (888) 826-6565 2018 Evidence of Coverage for EnvislonRxPlus Employer Group Retiree PDP 156 Appendices Mississippi Missouri Montana Nebraska State Dept. of Health Missouri Dept. of Health HIV Treatment Nebraska Dept. of Health & 570 East Woodrow Wilson and Senior Services Assistance Program Human Services Dr. PO Box 570 Cogswell Building P.O. Box 95026 Jackson, MS 39216 Jefferson City, MO 65102 Room C-211 Lincoln, Nebraska 68509 Phone: (866) 458-4948 or Phone: (573) 751-6439 1400 Broadway Phone: (402) 559-4673 or AIDS Hotline: (800) 826- Helena, MT 59620 (800) 782-2437 2961 Phone: (406) 444-3565 Nevada New Hampshire New Jersey New Mexico Nevada State Health DHHS- NH CARE NJ AIDS Drug New Mexico HIV/AIDS Division Program Assistance Program Services Program —AIDS 4150 Technology Way, 29 Hazen Drive (ADAP) - NJ Drug Assistance Program Suite 106 Concord, NH 03301 PO Box 722 (ADAP) Carson City, NV 89706 Phone: (603)271-4502 Trenton, NJ 08625 1190 St. Francis Dr. Phone: (800) 842-2437 or Phone: (800) 624-2377 Runnels Bldg S-1207 (775) 684-3499 Santa Fe, NM 87502 Phone: (888) 882-2497 New York North Carolina North Dakota Ohio New York HIV Uninsured N.C. Dept, of Health and North Dakota Dept. of Ohio HIV Drug Assistance Care Programs Human Services Health Program (OHDAP) Empire Station Division of Public Health HIV/AIDS Program HIV Care Services Section P.O. Box 2052 Purchase of Medical Care 2635 East Main Ave Ohio Dept of Health Albany, NY 12220-0052 Services Bismarck, ND 58506 246 N. High Street Phone: (800) 542-2437 1907 Mail Service Center Phone: (701) 328-2378 Columbus, OH 43215 TTY: (518) 459-0121 Raleigh, NC 27699 or (800) 472-2180 Phone: (800) 777-4775 Phone: (919) 733-9576 Oklahoma Oregon Pennsylvania Rhode Island Oklahoma State Dept. of CARE Assist Bureau of Epidemiology RI Dept. of Health, Health 800 NE Oregon Street, Health and Welfare Office of HIV/AIDS & Viral HIV/STD Services Division Suite 1105 Building, Room 933 Hepatitis 1000 NE 1 Oth, Room 614 Portland, OR 97232 Harrisburg, PA 17108 3 Capitol Hill, Room 302 Oklahoma City, OK 73117 Phone: (800) 805-2313 Phone: (717) 783-4677 Providence, RI 02908 Phone: (405) 271-4636 or (971) 673-0144 Phone: (401) 222-4610 South Carolina South Dakota Tennessee Texas South Carolina Dept. of South Dakota Dept of TN Dept of Health Texas HIV State Pharmacy Health and Environmental Health 425 5th Ave. North, Assistance Program (SPAP) Control 615 East 4th Street Cordell Hull Bldg. 3rd I. ATTN: MSJA, MC 1873 2600 Bull Street Pierre, SD 57501 Andrew Johnson Tower PO Box 149347 Columbia, SC 29201 Phone: (650) 773- 3737 Nashville, TN 37243 Austin, Texas 78714 Phone: (800) 856-9954 Phone: (615) 741-7500 Phone: (800) 255-1090 or I 1 (512) 533-3000 2018 Evidence of Coverage for Ennisi onRxPlus Employer Group Retiree PDF` 157 Appendices Utah Vermont Virginia Washington Utah Dept. of Health Division of Alcohol & Drug Virginia Dept. of Health Washington State Dept, of Bureau of Epidemiology Abuse Programs, 109 Governor Street Health 288 North 1460 West Vermont Dept of Health Richmond, Virginia HIV Client Services PO Box 142104 108 Cherry Street, Rm 23219 P.O. Box 47890 Salt Lake City, Utah 84114 202 Phone: (855) 362-0658 Olympia, Washington 98504 Phone: (801) 538-6397 P.O. Box 70, Drawer 27 Phone: (360) 236-3426 Burlington, AT 05402- 0070 Phone: (802) 651-1550 Washington, D.C. West Virginia Wisconsin Wyoming Washington, DO Dept. of Office of Epidemiology & Wisconsin Dept. of Wyoming Dept. of Health Health Prevention Services Health Services 401 Hathaway Building 899 North Capitol Street, 350 Capitol Street Division of Public Health Cheyenne, WY 82002 NE Room 125 Attn: ADAP Phone: (307) 777-5856 Washington, DC 20002 Charleston, WV 25301 1 West Wilson Street Phone: (202) 671-4900 Phone: (800) 642-8244 Madison, WI 53703 TTY: 711 Phone: (800) 991-5532 or (608) 267-6875 2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree POP 158 Appendices R1NRM%z"U9= I I'llillill Z 1 11111 ll� 1111111111 1 CALL 1-844-293-4760 Calls to this number are free. Member Services, including TTY/TDD, is open 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for non-English speakers. TTY 711 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. FAX 1-866-250-5178 WRITE EnvisionRxPlus 2181 E. Aurora Rd., Suite 201 Twinsburg, 011 44087 customerservice@envisioDrxplus.com WEBSITE www.envisionrxplus.com 4 W11 1. 71i State Health Insurance Assistance Program is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. You can find the name of your state SHIP in Appendix A. PAA_Fhjc)uozvil �i.4,44o#r67g, 4 respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1051. If you have comments or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Q 0 0 N PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT ']'his Pharmacy Benefit Management Services Agreement (the "Agreement") is effective the 1st day of October, 2011 (the "Effective Date") by and between Envision Pharmaceutical Services, Inc., an Ohio Corporation (hereinafter "Envision"), and Monroe County Board of County Commissioners, a political subdivision of the State of Florida (hereinafter "Plan Sponsor"). BACKGROUND Envision is a URAC accredited Pharmacy Benefit Management (PBM) company engaged in the business of providing comprehensive pharmacy benefit management services nationwide to various employers, unions, and health plans which sponsor or administer 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: I. DEFINITIONS Ll "Administrative Fee" means the amount that Envision charges Plan Sponsor for included services under this Agreement. Envision represents and warrants that the Administrative Fee and any fees for Additional Services and Miscellaneous Expenses set forth in Exhibit I are its sole compensation for the services rendered hereunder, and that it retains no revenues, directly or indirectly, from any other source, 1 2 "Annual Average Effective Rate" means, for the category of drugs being reviewed, the 1= result calculated by the following formula: (IC/AWP)-], where "IC" is the sum of all amounts paid by Plan Sponsor for the ingredient cost of the Covered Medications dispensed during the calendar year, and AWP is the sum of the Average Wholesale Price amounts associated with the same Covered Medications. 1, 3 "Average Wholesale Price" or -AWP" shall mean the average wholesale price of a Covered Medication 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 I I 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 once a week. 1 A "Benefit Plan" means the group health plan, insurance plan, prescription drug plan, or other benefit plan sponsored or administered by Plan Sponsor that covers the cost of Covered Medications dispensed to Members. ............. \111IN4SA (Ifrni0607( 1 )(fina12) F.nvision Pharmaceutical services, Inc, Page I ot'24 a 1.5 -Benefit Specification Form" means the form that is completed by Plan Sponsor, in conjunction with Envision, which details the specifics of the Benefit Plan such as which prescription medications 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. prior authorizations, drug therapy management, etc.), 1.6 "Brand Drug" means a drug where the Medi-Span multisource ("MONY") code attached to the I I digit NDC for such drug indicates an "N" (a single -source brand name drug product available from one 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 manufacturers), or an "0" (an original branded drug product available from one or more 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 including the calculation of drug price or rebate guarantees. L7 -Claim" means an invoice or transaction (electronic or paper) for a Covered Medication dispensed to a Member that has been submitted to Envision by the dispensing pharmacy or a Member (including transactions where the Member 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 ­( ' 'onipound Drug" means a Covered Medication that requires compounding by a pharmacist because it is not available from the 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 recognized under federal law as a Legend Drug (i.e. a drug that bears the legend: "Caution: Federal law prohibits dispensing without a prescription.") L9 "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. 1,10 "Cost Share" means the amount of money that a Member must pay to the Participating Pharmacy to obtain a Covered Medication 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. 1,11 "Covered Medication" means a prescription drug, medication, or device that meets the requirements for coverage under the Benefit Plan, after applying all conditions and exclusions set forth in the Benefit Specification Form, and which is dispensed to a Member pursuant to a written or electronic prescription order or allowable refill. 1.12 "Eligibility File" means that electronic communication supplied to Envision by Plan Sponsor which identifies the Members covered under Plan Sponsor's Benefit Plan, along with other eligibility information necessary for Envision to provide PBM Services hereunder. Plan ,P14NISA 4 frm06071 1 )(fina12) C' Fnvision Pharmaceutical Services, Inc. Page 2 of 24 Sponsor acknowledges that eligibility begins on the first day the Member is reported by Plan Sponsor (or its designee) to be effective and continues through the last day the Member appears on the Eligibility File. 1,13 "Employee" means an Employee of Plan Sponsor covered under Plan Sponsor's Benefit Plan, together with such Employee's eligible dependents. 1,14 "Generic Drug" means a drug where the Medi-Span multisource code attached to the I I digit NDC For such drug indicates a "Y" (a generic drug product available from one or more 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 including the calculation of drug price or rebate guarantees. 1.15 "141PAA" means the Health Insurance Portability and Accountability Act of 1996, as amended. L16 "Licensed 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. L17 "Manufacturer Derived Revenue" means any discounts, rebates, pharmaceutical manufacturers administrative fees, and any other revenue received by Envision from pharmaceutical manufacturers (whether as a result of the number of covered lives, other incentives or other amounts received) for Covered Medications dispensed to Members. 1.18 "MAC List" means a proprietary list of Generic Drugs for which Envision establishes a maximum price ("MAC Price") payable to the dispensing pharmacy, which includes most, but not all Generic Drugs. 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 Generic Drugs come on the market or come off the market, or as their availability changes due to market circumstances. Generic Drugs that are excluded from the MAC List include Newly Available Generic Drugs, Single - Source Generic Drugs, and Limited Availability Generic Drugs ("Excluded Generics"). For purposes of this definition, a Newly Available Generic Drug is one which, at the time the drug is dispensed, is subject to the Ilatch-Waxman 180 day market exclusivity provision, a Single - Source Generic Drug is one which, at the time the drug is dispensed, is available from only one manufacturer, and a Limited Availability Generic Drug is one which, at the time the drug is dispensed, is priced higher than normal due to supply limitations or limited market competition. 1.19 "Member" means each individual (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 Medications, \P13%4SA (frmO6071 1)(finaI2) '0 Envision Pharmaceutical Services, Inc. Page 3 of 24 1.20 ­NCPDP" shall mean the National Council for Prescription Drug Programs Standard Claims Billing Tape and Payment Format 2.0, or a revised and then current version. 1.21 "Participating Pharmacy" means a pharmacy (including a designated mail order or specialty pharmacy) that has entered into a negotiated pricing agreement with Envision to dispense Covered Medications to Members. A "Retail Pharmacy" is a pharmacy that dispenses medications to outpatients. 1.22 "Plan Sponsor" means the entity (identified above as Plan Sponsor) which (i) has created and maintains the Benefit Plan on behalf of the Members, and has determined the rules by which the Benefit Plan is to be administered, and (ii) is financially responsible for the payment of Administrative Fees, Fees for Additional Services and Miscellaneous Expenses, and Covered Medications dispensed to Members hereunder. 1.23 "Point -of -Sale" means the location and time that a Covered Medication is dispensed to a Member, and the corresponding Claim is submitted by the dispensing pharmacy for adjudication by Envision's on-line computerized claims processing system (hereinafter "Claims Adjudication System"). 1.24 "Specialty Drug" means those high -cost injectable, infused, oral, inhaled, or biotech drugs which require special ordering, handling and/or patient intervention. Specialty Drugs will be priced based on where the drug is dispensed (i.e. retail, mail order, or specialty pharmacy). 2. PBM SERVICES Envision shall perform the following pharmacy benefit management services ("PBM Services"): 11 Identification Card: Envision shall provide Plan Sponsor with Envision approved identification cards ("ID Cards"), up to two per family, for distribution to Members by Plan Sponsor. If requested by Plan Sponsor, Envision shall provide ID Cards directly to Members at no additional cost, except for the cost of postage and handling. 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 I . 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 Medications (i) submitted electronically by Participating Pharmacies in National Council for Prescription Drug Programs (NCPDP) formats; (ii) submitted by Members 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). 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 fors TIAMSA ( frmO607 I I t{ fina12) 0 Envision Pharmaccutia Services, Inc, Page 4 of 24 ineligible payments, will incur a fee as set forth in Exhibit 1. After termination of this Agreement, Envision shall process Claims 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 timely payment of invoices as provided herein. 2.3 Direct Member Reimbursement (DMR): Envision shall provide, via its website, a DMR form, for use by Members to obtain reimbursement for amounts paid out-of-pocket (other than Cost Share) for Covered Medications (e.g. Covered Medications dispensed at a non -Participating Pharmacy). 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 Member until Plan Sponsor provides funds for such purpose. 2.4 Fuss -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 charged to Plan Sponsor shall be determined as follows and as specified in Exhibit 1: 14,1 For Brand Drugs: Envision shall charge Plan Sponsor the calculated negotiated amount payable to the Participating Pharmacy based on the drug pricing fields (i.e. AWP, MON Y code, etc.) for the 11 digit NDC of the drug dispensed, less any applicable Manufacturer Derived Revenue (plus applicable dispensing fees); or, if lower, the Participating Pharmacy's reported usual and customary price (except for mail order and specialty pharmacies). For purposes of this Agreement, the usual and customary price ("U&C Price") is the retail amount the pharmacy charges its cash paying customers for the drug dispensed, as reported to Envision by the dispensing pharmacy. 2.4.2 For Generic Drugs: For Generic Drugs included on the then current Envision MAC List, Envision shall charge Plan Sponsor the MAC Price for the drug dispensed; for Generic Drugs not on the MAC List (i.e. Excluded Generics), Envision shall charge Plan Sponsor the calculated negotiated amount payable to the Participating Pharmacy based on the drug pricing fields (i.e. AWP, MONY code, etc.) for the I I digit NDC of the drug dispensed (Plus applicable dispensing fees); or, if lower, the Participating Pharinacy's reported U&C Price (except for mail order and specialty pharmacies). 14.3 Modifications by Plan Sponsor: Plan Sponsor's Benefit Plan may contain certain programs (e.g. mandatory generic program) and/or rules which determine the way in which Claims are adjudicated (i.e. what portion of a Claim is payable by Plan Sponsor and what portion is payable by Members). The rules by which Plan Sponsor's Claims arc adjudicated are detailed by Plan Sponsor as set forth in the Benefit Specification Form. To the extent Plan Sponsor's Benefit Plan modifies the standard Claims adjudication process, the Claims Adjudication System will be configured accordingly. However, such modifications shall not result in the reclassification of a Claim. \1113MSA (finP00071 1)(fina]2) (), Envision Pharmaceutical Services, Inc. Page 5 of 24 2.4.4 For Dispensing Fees: Envision shall charge Plan Sponsor the actual dispensing fee amount payable to the Participating Pharmacy for both Brand Drugs and Generic Drugs as applicable. 2.4.5 Drug, Pricing and Dispensing Fees: Unless otherwise stated herein, the Annual Average Effective Rates and Annual Average Dispensing Fees set forth in Exhibit I shall be deemed to have been achieved if, overall, the amounts paid by Plan Sponsor for all Claims during the Contract Year are equal to or more favorable than the amounts paid for each drug type or category individually. 2.5 Manufacturer Derived Revenue 2.5.1 Pass -Through of Manufacturer Derived Revenue: Envision has negotiated contracts with pharmaceutical manufacturers to obtain Manufacturer Derived Revenue for eligible Brand 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 such eligible Brand Drugs. Envision shall include such eligible Brand Drugs on the Formulary, subject to approval by Envision's Pharmacy & Therapeutics Committee. Plan Sponsor acknowledges that its yield of Manufacturer Derived Revenue is dependent on certain factors including, without limitation, the following: (i) whether the terms and conditions of Plan Sponsor's Benefit Plan are consistent with the application of Envision's Formulary; (ii) the structure of Plan Sponsor's Benefit Plan; and (iii) the drug utilization patterns of Members. 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 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 flan (e.g. tier structure and Cost Share differentials) on the overall yield of market share rebates. Manufacturer Derived Revenue for Claims paid entirely by Members (e.g. a Claim occurring while the Member has not yet met his or her deductible) and 340B Claims are ineligible for Manufacturer Derived Revenue, and no Manufacturer Derived Revenue shall be payable to Plan Sponsor for such Claims. 2.5.2 Pass -Through Methodology: Manufacturer Derived Revenue shall be advanced to Plan Sponsor by adjusting the Claim for an eligible Brand Drug by the estimated Manufacturer Derived Revenue using Envision's patent pending 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 expected earned Manufacturer Derived Revenue. (Plan Sponsor acknowledges that, unless otherwise indicated by Plan Sponsor on the Benefit Specification Form, if a Member 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 Member at the Point -of -Sale). Any earned Manufacturer Derived Revenue (including market share rebates) not applied to Claims at the Point -of -Sale shall be paid to Plan Sponsor when collected by Envision. 2.5.4 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 Manufacturer Derived \PB',,ISA (frinO6011 ()(finaQ) Envision Pharmaceutical Services, Inc. Page 6 of 24 Revenue 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 Manufacturer Derived Revenue or create a situation which would cause a 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 advanced to Plan Sponsor by Envision which is connected with any Claims for which Plan Sponsor received Manufacturer Derived Revenue from any other source or for amounts advanced to Plan Sponsor by Envision which have been withheld by a manufacturer due to the ineligibility of such Claims for Manufacturer Derived Revenue (i.e. 340B Claims) or breach of these provisions by Plan Sponsor, 2 4-5.5 Early Termination: Notwithstanding anything herein to the contrary, if this Agreement is terminated for any reason by Plan Sponsor prior to the end of the Initial Term (other than for a material breach by Envision), Plan Sponsor agrees (i) to reimburse Envision for any Manufacturer Derived Revenue advanced to Plan Sponsor that Envision has not collected from pharmaceutical manufacturers within nine months from the effective date of termination; and (n) all market share rebates payable as of the date of delivery by Plan Sponsor of the notice of termination shall be forfeited by Plan Sponsor. 2.6 Pharmacy Network: Envision shall arrange for the dispensing of Covered Medications to Members pursuant to contracts with a network of Participating Pharmacies. Plan Sponsor understands and agrees that the network of Participating Pharmacies may change from time to time, including the designated mail order provider and/or specialty pharmaceuticals 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 Medications shall not be dispensed to Members without a prescription order by a Licensed Prescriber•, and (iii) the availability of drugs are subject to market conditions and that Envision cannot, and does not, assure the availability of any drug from any Participating Pharmacy. 2.7 Formulary: Envision shall maintain a list of commonly prescribed drugs and supplies ("Formulary") which has been reviewed by Envision's Pharmacy & Therapeutics Committee (using evidence -based evaluation criteria for safety and efficacy in accordance with URAC standards and. when applicable, CMS guidelines) to be used by Plan Sponsor, Licensed Prescribers, Participating Pharmacies, and Members to guide the selection of cost effective Covered Medications. "The Formulary may be modified from time to time as new medications and/or new clinical information become available, is constantly updated to reflect any changes, and is accessible via Envision's website. Plan Sponsor acknowledges that adherence to the Formulary is necessary to maximize cost savings and yields in Manufacturer Derived Revenue, however, the determination of which Formulary and non -Formulary drugs are covered, limited, or excluded are governed by Plan Sponsor's Benefit Plan. Any customization of the Formulary desired by Plan Sponsor for its use must be approved, in writing, by Envision, and Plan Sponsor acknowledges that such modifications may affect yields in Manufacturer Derived Revenue. \PIMSA OrmO6071 1)(fina12) C, Envision Pharmaceutical Services, Inc. Page 7 of 24 R 2.8 Generic Substitution: Unless other -wise specified by Plan Sponsor in the Benefit Specification Form, the Claims Adjudication System will permit Participating Pharmacies to dispense a Generic Drug when a prescription is written for a Brand Drug. The decision to substitute a Generic Drug for a Brand Drug and the choice of drug is at the discretion of the dispensing pharmacy and subject to the law of the state in which the pharmacy is located. 2.9 Prior Authorizations; Drug Utilization Review• and Drug Therapy Management 2.9. 1 System Generated Prior Authorizations: Envision shall configure the Claims Adjudication System to require prior authorization before Covered Medications are dispensed in certain circumstances which have been specified by Plan Sponsor in the Benefit Specification Form. Examples of system generated prior authorizations include requests for lost or stolen drugs, vacation supplies, certain package sizes, dosage changes, and invalid days' supply. System generated prior authorizations are included in the Administrative Fee. 2.9.2 Clinical Prior Authorizations: If Plan Sponsor has elected to receive Clinical Prior Authorization services from Envision, for those Covered Medications 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, 2.93 Concurrent Drug Utilization Review: Envision shall program edits into the Claims Adjudication System which are applied to Claims during the adjudication process to identify the following: duplicate prescriptions; over-utilization/refill too soon; under -utilization; drug interactions; pediatric warnings; geriatric warnings; acute/maintenance dosing; formulary compliance, therapeutic duplication; drug inferred health state; drugs exceeding maximum dose; drugs below minimum daily dosage, and other financial and cost limitations which are specified by Plan Sponsor in the Benefit Specification Form. The Claims Adjudication System will provide the dispensing pharmacy with the appropriate messaging to advise the pharmacy of Concurrent Drug Utilization Review issues. 2.9.4 Retrospective Drug Utilization Review: Envision may review Claims retrospectively, as specified in the Benefit Specification Form, to determine the drug utilization patterns of Members, and report the results of retrospective reviews to Plan Sponsor. Retrospective Drug Utilization Review reports may include, but are not limited to: high cost/high utilization of a particular drug class, or therapeutic appropriateness of drug for a particular disease state, and other agreed upon reports. 2.9.5 Drug Therapy Management (DTM) and other Clinical Programs: Envision provides certain clinical programs such as Drug Therapy Management, Drug Therapy Care Gap Management, and Formulary Adherence. Plan Sponsor may elect to receive some or all of these services at an additional charge by indicating so in the Benefit Specification Form. A description and cost of these programs will be provided upon request. M \111IMSA Jnn06071 1)(fina12) �ij Envision Pharmaceutical Services, Inc. Page 8 of 24 110 Business Associate Agreement: Envision shall execute a HIPAA Business Associate Agreement, attached as Exhibit 2. Ill 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, Members, Licensed Prescribers, and Participating Pharmacies. 2.12 '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 Medications and the provision of services by Envision under this Agreement. 2.13 Re -ports: Envision shall provide Plan Sponsor with access to 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 111PAA 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 t'ee for any other reports requested by Plan Sponsor. 2.14 Distribution of Materials: Envision shall bulk ship printed materials produced by Envision as agreed hereunder to Plan Sponsor at no additional charge. If` Plan Sponsor requests ID Cards or other printed materials to be mailed directly to Members, Plan Sponsor shall reimburse Envision its costs of postage and handling. 215 Retiree Drug Subsidy (RDS) Reports: For Plan Sponsors which submit requests for drug subsidies tinder 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 Members who Plan Sponsor has identified on the appropriate form as Medicare eligible retirees. Plan Sponsor acknowledges that any estimated 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. 116 Additional Services: Any services to be rendered under this Agreement which are not included in the Administrative Fee shall be itemized in the Exhibits and Addendums hereto along with any associated costs or charges. \1113MSA ffrrn0007I 10=12) G Envision Pharmaceutical Smices, Inc. Page 9 of 24 117 performance Guarantees: Envision shall provide PBM Services in accordance with the Performance Guarantees specified in Exhibit 3. Failure to meet targets will be determined by means of reports produced by Envision. If Envision fails to meet any of the Performance Guarantees, and Plan Sponsor desires to assess penalties, payment to Plan Sponsor is payable by Envision within thirty (30) business days. 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. Upon approval from Plan Sponsor, payment of penalties may be credited towards future Administration Fees. Failure to meet Performance Guarantees shall not be deemed to be a breach of this Agreement. 3. PLAN SPONSOR RESPONSIBILITIES 3.1 Eli ibilitv 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 Members. 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 Member 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. 3.2 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 conditions provided by Plan Sponsor on the Benefit Specification Form. The Benefit Specification Form may be changed from time to time by Plan Sponsor; provided, however, that the form must be signed by Plan Sponsor and any changes to the Benefit Plan must be communicated to Envision, in writing, 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 (e.g. mandatory generic program, coverage of over-the-counter drugs or medications, etc,) may affect yields in Manufacturer Derived Revenue and average drug pricing, and that Envision will not be liable to Plan Sponsor for a reduction of such yields or increase in pricing which result from any change in the Benefit Plan. M \1113\1SA (fi-m06071 [)(finaQ) V Envision Pharmaceutical Services, Inc. Page 10 of 24 1for Payment: Plan Sponsor shall timely pay, or cause its designee to timely pay, Envision o services rendered hereunder in accordance with Section 4 below and Exhibit 1. 3.4 Coopc� ration: Plan Sponsor shall provide such cooperation and support as reasonably necessary to ensure that Envision can provide all services described hereunder in a timely, responsible, and professional manner. 4. TERMS OF PAYMENT 4.1 Fees and Drug Pricing: Envision and Plan Sponsor agree that fees for PBM Services and drug pricing payable by Plan Sponsor hereunder are as set forth in Exhibit I hereto, as may be amended in writing from time to time. Plan Sponsor acknowledges that (i) Exhibit I has been reviewed and approved by Plan Sponsor; (ii) the rates specified in Exhibit I are conditioned upon Plan Sponsor's adherence to certain conditions under this Agreement; and (iii) the rates specified in Exhibit I are subject to adjustment for Contract Years after the Initial Term due to, among other factors, changes to administrative costs, changes in the negotiated discounts with Participating Pharmacies, and/or changes in Manufacturer Derived Revenue amounts with pharmaceutical manufacturers. 4,2 Payments for Claims: Envision shall provide Plan Sponsor with an invoice of payable Claims once each week and Plan Sponsor shall pay Envision's invoices no later than 12:00 pm. on the thirtieth (3 01h) calendar day from receipt of said invoices and backup containing a breakdown of the claims paid. 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. 43 Financial Responsibility: Plan Sponsor understands and agrees that Envision cannot obligate Participating Pharmacies to continue to dispense Covered Medications without receiving payment for past Claims and Envision shall not be obligated to pay Participating Pharmacies if Plan Sponsor fails to timely pay Envision as required under this Agreement. Plan Sponsor understands that, if Plan Sponsor has not paid within seven (7) calendar days of written notice by Envision of a past due Claims invoice. Envision may notify Participating Pharmacies that Plan Sponsor has not timely paid amounts due for Claims. Further, Envision may suspend the provision of services until any unpaid balance is received and, as a condition of continuing to perform set -vices under this Agreement, require Plan Sponsor to deposit with Envision a reasonable amount to ensure the timely payment of future invoices and/or discontinue advancing Manufacturer Derived Revenue to Plan Sponsor using Envision's Point -of -Sale Technology. Plan Sponsor further agrees that Envision shall not be liable for any consequences resulting from the untimely payment of Participating Pharmacies, including, without limitation, failure to meet any applicable prompt payment laws, due to the failure of Plan Sponsor to timely pay Envision as required under this Agreement. Notwithstanding anything herein to the contrary, Plan Sponsor shall be and remain responsible for the payment of all invoices for Covered Medications dispensed to Members, along with any associated Cost Share not timely paid by Members, and dispensing fees and taxes. If Plan Sponsor should fail to pay any amounts due Envision hereunder due to insolvency, bankruptcy, termination of business, sale, or rebuff, Envision reserves the right to pursue payment from Members to the extent permitted by law. TRNISA (fraiO6071 0(final2) 4,) Envision Pharmaceutical Services, Inc. Page 1 1 of 24 4.4 Payment of Administrative Fee: Envision shall provide Plan Sponsor with an invoice of Administrative Fees on or about the first day of each month following delivery of services. Administrative Fees are due within thirty (30) calendar days of receipt of Envision's invoice. the monthly Administrative Fee is calculated by multiplying the number of 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 forth in Exhibit 1. 4.5 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 I hereunder, within thirty (30) calendar days of receipt of an invoice and supporting documentation. 4.6 Retroactive Disenrollment: Retroactive termination or disenrollment of a group, Employee, or Member shall not release Plan Sponsor of its obligation to pay Claims incurred, at any time, on behalf of such Member, or Administrative Fees due to Envision for such Member during any period for which services were renderable hereunder based on the then current eligibility. 4.7 Taxes. Any sales or use taxes for Covered Medications sold to Members shall be charged, collected, and paid to state and local taxing authorities by the dispensing pharmacy. Plan Sponsor shall reimburse Envision or the dispensing pharmacy for taxes paid as part of the reimbursement for Claims. Other than as stated herein, the Plan Sponsor is not liable under Florida law for sales or use taxes. 4,8 Financial Audit by Plan Sponsor: Plan Sponsor, at its sole expense, may audit Envision's records of Claims adjudicated under this Agreement. 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 Medication 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, subject to requirements of Florida public records law in the Florida Constitution and Chapter 119 of the Florida Statutes. If Plan Sponsor utilizes an independent auditor, sucli auditor shall execute a conflicts of interest disclosure and confidentiality agreement with Fnvision prior to the audit. Audits shall only be made during normal business hours following ten (10) 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 or by a secure website, 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. If an auditor employed by the County or Clerk determines that monies 0 11PBMSA Jrm0607I 1)(finaQ) 0 Envision Pharmaceutical Services, Inc. Page 12 of 24 paid to Envision pursuant to this Agreement were spent for purposes not authorized by this Agreement, Envision shall repay the monies together with interest calculated pursuant to Sec. 55.03, FS, running from the date the monies were paid to Envision. 5. TERM AND TERMINATION 5.1 Teriti: The term of this Agreement shall commence on the Effective Date and shall remain in full force and effect for an initial term of three (3) 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; unless, at least sixty (60) days prior to the end of such term, either party hereto notifies the other, in writing, of its intent that the Agreement terminate at the end of the current term. 5.2 Termination: This Agreement may be terminated as follows: 5,2.1 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; 5 . 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, (6) 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; 5.23 Failure to Pay: By Envision, upon reasonable notice, in the event Plan Sponsor fails to pay Envision according to terms of this Agreement. 5.2.4 'Fermi - nation Without Cause. By either party, effective no sooner than the end of the second Contract Year, by providing the other party with at least sixty (60) days written notice. 53 Notices: All notices required in this Section 5 shall be reasonably specific concerning the cause for termination and shall specify the effective date and time of termination, 54 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. All services required to be performed under the terms of this Agreement shall be provided \11[IMSA (frrn0607 I 1)(final2) �'O Envision Pharmaceutical Services, Inc, Page 13 of 24 through the effective date of termination. Except as otherwise agreed, in writing, no services shall be provided by Envision after the effective date of termination. All payments required to be paid under the terms of this Agreement shall be paid in full. 6. CONFIDENTIAL INFORMATION 6,1 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 Linder 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. 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. 6.2 Protected Health Information: Plan Sponsor will have access to Protected Health Information (PI 11) (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 PIll 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. 7. INDEMNIFICATION 7.1 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. 7.2 Limited Indemnification by Plan Sponsor: Subject to the limitations of Section 768.28, Florida Statutes, 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 erroneous information; or (ii) Plan Sponsor's failure to comply with state or federal law in the operation of its Benefit Plan. T3 Limitation of Liability: Except for the indemnification obligations set forth above, 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. In no event will either party or any of their 4414NISA (frrn060'7I 1)(final21 k, Envision Pharmaceutical Services. Inc. Page 14 of 24 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. T4 Survival: This Section 7 shall survive the expiration or termination of this Agreement for any reason. 8. RELATIONSHIP WITH CONTRACTED PHARMACIES 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 Members. 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 Members. Plan Sponsor releases Envision from any liability arising from the dispensing of drugs or medical supplies by any pharmacy to Members. 9. GENERAL 9.1 Le If Status: Nothing in this Agreement shall be deemed to confer upon Envision the status of a fiduciary (as defined in the Employee Retirement Income Security Act of 1974, as amended ("ERISA"), the Americans with Disabilities Act, as amended ("ADA"), or by any other definition), except to extent, in the performance of its obligations under this Agreement, Envision exercises actual discretionary control over the property of Plan Sponsor, or as required tinder applicable law. Further, Plan Sponsor retains the sole responsibility for the terms and/or validity of the Benefit Plan; the interpretation and determinations of coverage under the Benefit Plan, and for the disclosing or reporting of information regarding the Benefit Plan or changes in the Benefit Plan (e.g., calculation of Cost Share or creditable coverage) as may be required by law to be disclosed to governmental agencies or Members. 92 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. 93 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. 9.4 Assiatiment: Except as follows, this Agreement may not be assigned by either party hereto without the prior express written consent of the other party, which may not be unreasonably withheld. 9.5 Binding Fffect: 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. ITRMSA (frM060'71 I)if=12) 'U, [--'nvision Pharmaceutical Services, Inc. Page 15 of 24 M 9.6 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. 9,7 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. 9.8 Severability: The invalidity or non -enforceability of any term or provision of this Agreement shall in no way affect the validity or enforceability of any other term or provision. 9.9 Chans-)e 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 the Agreement), either now existing or subsequently occurring, affects the ability of either patty 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 the 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. 9.10 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. 9.11 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. 9.12 Acceptance of Offer: Notwithstanding anything herein to the contrary, this Agreement shall not be binding upon the parties hereto unless and until the 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. TFINISA (fnn0601 I I }(finaQ) 0 Envision Pharmaceutical Services, Inc. Page 16 of 24 9.13 Mediation: If either party to this Agreement should declare a breach of this Agreement, or if any dispute arises from this Agreement or the subject of this Agreement, the parties shall first submit the matter to non -binding mediation (not arbitration) and attempt to resolve the matter, in good faith, prior to the institution of any arbitration or any other legal action. Any statements made at such mediation shall be for settlement purposes only and shall not be construed to be an admission. A party demanding mediation shall be entitled to obtain a court order mandating mediation if the other party does not agree to commence mediation within thirty (30) days after written demand. The fees and costs incurred by the party seeking such court order shall be reimbursed by the other party; otherwise, each party shall pay its own costs of mediation. All such mediation proceedings shall be conducted on a confidential basis. The mediation shall be conducted in Key West, Florida. 9.14 Choice of Law: This Agreement shall be construed, interpreted, and governed according to the laws of the State of Florida, except to the extent such laws are preempted by applicable Federal law, 9.15 Force Maieure: 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 or 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 cause preventing performance ceases, the party affected thereby shall fulfill its obligations as set forth under this Agreement. This Section 9.15 shall not be considered to be a waiver of any continuing obligations under this Agreement, including, without limitation, the obligation to make payments. 9. 16 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. 9. 17 Rep -esentations: 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. Envision further represents that there are no organizational arrangements that could potentially create a conflict of interest that affects clinical or financial decisions. plan Sponsor further represents and warrants that (i) the entering into this Agreement \1113MSA (firm()6071 I )(finaQ) 0 Envision Pharmaceutical Services, Inc. Page 17 of for PBM Services is not in violation of any other agreement; (ii) has no undisclosed conflicts of interest; and (iii) 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. 9.18 Conflict of Interest: Envision warrants that, with respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, Envision agrees that the Plan Sponsor shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. Envision also warrants that it has not employed, retained or otherwise had act on its behalf any former Monroe County officer or employee in violation of Section 2 of Ordinance No. 10-1990 or any Monroe County officer or employee in violation of Section 3 of Ordinance No. 10-1990. For breach or violation of this provision Monroe County may, in its discretion, terminate this contract without liability and may also, in its discretion, deduct from the contract or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former Monroe County officer or employee. IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Agreement as of the Effective Date above. For ENVISION: By: 12. 4,4 ,,. Jose h R. Schauer COO Print Name & Title Address: Envision Pharmaceutical Services, Inc 2181 East Aurora Road Twinsburg, OH 44087 PH: 330-405-8080 FX: 330-405-808I MON E COUNTY ATTORNEY AP OV ASO VNITHIA L. ALL ASSISTANT �OUI�TY�4T'ORNEY Date .5 j( \PBMSA (frtn060711)(fina12) For PLAN SPONSOR: '-1 (a�rs,�—� Print Name & Title '(n L � ( L" e-- : �. rft L MCkvj (D(- CVY:t_ C yyva ►� Address: MCBOCC 1100 Simonton Street Key West, FL 33040 PH: 305-292-4452 FX: E-MAIL: FEIN: 6)o n . ti EAL) 1 �� T T: DANNY L. KOLHAGE B DEPUTY CLERK Envision Ph 5erwices, Inc. Page 18 of 24 EXHIBIT I DRUG PRICING AND FEES I Drug Pricing and Dispensing FeeS1 Al i Supply/Source BRAND GENERIC' Based On 3 Year Drug Pricers) Dispensing Drug Price(C) Dispensing Contract Fee (D) Fee (D) Annual Average Effective Rate of Annual Annual Average Annual 30 Days' Supply at a AWP minus 13.55% Average Effective Rate of Average I Retail Pharmacy (Equivalent to Pre- $1.40 AWP minus 73% $1.50 Settlement discount of 17%) Annual Average 90 Days' Supply at a Effective Rate of Annual Average Retail Pharmacy AWP minus 19.75% None Effective Rate of None (non -Mail Order) (Equivalent to Pre- AWP minus 74% Settlement discount of 22%) Annual Average Mail Order (at Orchard Effective Rate of AWP minus 19.8% Annual Average Pharmaceutical $9.50 Effective Rate of $9.50 Services) (Equivalent to Pre- Settlement discount of AWP minus 86% 23%) Specialty (at Walgreens Specialty (Pass -through of negotiated price with dispensing pharmacy) Pharmacy) IAI Calculated price using the applicable negotiated contract rate (i.e. AWP or MAC rate, or U&C Price). In order to illustrate economic neutrality to the 2009 McKesson/First Data Bank Settlement, the pre - settlement AWP values noted in this exhibit have been adjusted to restore the relationship between WAC and AWP as it was prior to September 26'h, 2009. Only the post -settlement AWP values are used to calculate the Average Annual Effective Rates as set forth in Exhibit 1. If the calculated price is lower than the allowable amount under any state Medicaid -Favored Nations" rule, Frivision shall pass -through, and Plan Sponsor shall pay, the Medicaid allowable amount, (14 ) Annual Average Effective Rate for Brand Drugs is calculated using actual price paid to pharmacies by Envision (betbre deducting Manufacturer Derived Revenue) for all Brand Drug Claims (including Claims paid at the U'&C Price) during a Contract Year, excluding (i) Compound Drugs, (ii) Specialty Drugs, (iii) Claims from non- Participating Pharmacies, (iv) Claims paid at the Medicaid allowable amount, (v) 340B Claims. (( 'v Annual Average Effective Rate for Generic Drugs is calculated using actual price paid to pharmacies by F rivision for all Generic Drug Claims (including Claims paid at the U&C Price) during a Contract Year, excluding (i) Excluded Generics, (ii) Compound Drugs, (iii) Specialty Drui-)s. (iv) Claims from non- \Pt3MSA (firm06071 1)(fina12) 0 Envision Pharmaccuticai Services, Inc. Page 19 of 24 Participating Pharmacies, (v) Claims paid at the Medicaid allowable amount, (vi) 340B Claims. to) Annual Average Dispensing Fee is the average per Claim fee for all Claims (including Claims paid at the U&C Price) during a Contract Year, excluding (i) Compound Drugs, (ii) Specialty Drugs, (iii) Claims from non -Participating Pharmacies, (iv) Claims paid at the Medicaid allowable amount. Administrative Fee (Payable to Envision; not including fees payable to Plan Sponsor's TPAs, consultants, or brokers, if any) For Contract Year 1: $3.75 Per Employee, Per Month (PEPM) For Contract Year 2: $3.75 PEPM For Contract Year 3: $3.75 PEPM [Fees far Additional Services and Miscellaneous Expenses 1. Replacement by Envision of lost or stolen ID Cards $1.00 per card plus cost of postage 2. Manual Claims Processing and Direct Member Reimbursements (DMRs) $1.50 per Claim processed 3. Manually create or update the Eligibility File $L 00 per Member data entry 4. Ad Hoc Computer or Report Programming $150.00 per hour 5. Clinical Prior Authorizations $8.00 per authorization \PBMSA (fnnO6071 I)(finaQ) ',0 Envision Pharmaceutical Services, Inc. Page 20 of 24 EXHIBIT, 3 Minimum Performance Standards *TOTAL DOLLAR CATEGORV/ AMOUNT MEASURE TARGET DEFINITION AT RISK System Availability 99.5% Calculated as the amount of time the $1,000 POS system is available to process claims. System Response time/ <4 seconds Calculated as the time commencing $1,000 measured annually immediately after receipt of the last character of a transaction submitted by a pharmacy until the first character of the response is sent to the pharmacy. Retail Paper Claims Processing Time Percent of direct member 95% Calculated as the number of claims $1,000 submitted prescription reimbursed or responded to within 10 drugs claims reimbursed business days, divided by the total or responded to within number of prescription drugs for a 10 business days specified time period Mail Order Claims Processing Time Turnaround time for 95% within 2 Measured in business days from the $1,0001 prescription drugs business days date a prescription drug claim is requiring no intervention received by the PBM (either via paper, phone, fax, or Internet) to the date it is mailed I'Llmaround time for 98% within 5 Measured in business days from the $1,000 prescription drugs business days date a prescription drug claim is requiring administrative or less received by the PBM (either via paper, /clinical intervention phone, fax, or Internet) to the date it is mailed \IIBMSA (tran)6071 1)(finaQ) V Envision Pharmaceutical Services, Inc. Page 22 of 24 Retail and Mail Claims Processing Accuracy Percent of all claims paid >99.98% with no errors I Retail >99.98% Mail Customer Service Based on PBM's internal quality review. Calculated as all claims audited and found to be without error of any form, divided by all claims audited $1.000 Percent of calls that will 95% The amount of time that elapses $1,000 he answered within 30 answered in between the time a call is received seconds an average of into a customer service queue to the 30 seconds or time the phone is answered by a less Customer Service Representative (CSR) Percent of calls <4% Percentage of calls that are not $1.000 abandoned answered by PBM (caller hangs up before call is answered). Calculated as the number of calls that are not answered divided by the number of calls received Percent of calls blocked <2% Percentage of all calls made to PBM $1,0001 vendor that were not answered because the calls did not enter phone system due to excess volume Percent of calls with >90% Percentage of all calls made to PBM $1,000 resolution at end of first that were resolved by initial CSR. call (i.e. no turther Calculated as the total calls to PBM inquiry by caller required minus total number of unresolved to obtain requested calls divided by the total number of information or action) calls received. Percent of written 99% Response time for all written inquiries 1$1,000 inquiries responded to by will be based on the number of paper within 10 business business days subtracting the date days or responded to received at PBM from the date the electronically within 2 response was sent business days Pharmacy Network >95% Based on network pharmacy access $1,000 Access within, 10 miles for Plan Sponsor's participants. \1113MSA (firnftff? I I )(F=12) 'G, Envision Pharmaceutical Services, Inc. Page 23 of 24 Account Management Account Sponsor satisfaction Results will Plan Sponsor satisfaction results will $1,000 with Account be based on be measured by the response to the Management overall results following question: Overall, how of all Plan satisfied are you with the Account Sponsor Team Service level? "Overall Plan contacts with Sponsor Satisfaction" for the purpose direct contact of this guarantee includes the with Account following responses: Satisfied and Team Very Satisfied. Administration Enrollment Processing Two (2) Eligibility information submitted to $1.000 business days vendor will become effective within 2 business days. Assumes complete and accurate information is sent to vendor. --1000 Ongoing ID card Five (5) Measured as the time from receipt of $I, production business days complete and accurate eligibility information to the time vendor deposits ID cards into the mail. Standard reporting cycle Mutually Measured as the time from the last day $1,000 agreed upon of the end of a reporting cycle to the timeline day standard reports are sent to Plan Sponsor. NOTE: Failure to meet targets will be determined by means of reports produced by Envision. For purposes of calculating time with the respect to these Performance Guarantees, the day of receipt shall be excluded and the day of delivery will be included in the calculation as long as delivery occurs prior to 4:00 PM local time. If Envision fails to meet the above listed Performance Guarantees and Plan Sponsor desires to assess penalties, payment to Plan Sponsor is payable within thirty (30) business days. 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. Upon approval from Plan Sponsor, payment of penalties may be credited towards future Administration Fees. Failure to meet Performance Guarantees shall not be deemed to be a breach of this Agreement. M TUNSA (frm0607I 1)(finaQ) ,,C) Envision Pharmaceutical Services, Inc, Page 24 of 24 i. A AMENDMENT NO. 1 TO PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT This Amendment No. 1 (this "Amendment"), is entered into by and between Envision Pharmaceutical Services, LLC ("Envision"), and Monroe County Board of County Commissioners ("Plan Sponsor"). BACKGROUND Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement dated October 1", 2011 (the "Agreement"), under which Envision provides PBM Services to Plan Sponsor; and The parties desire to amend the Agreement, and therefore Envision and Plan Sponsor agree as follows: 1. The term of the Agreement shall extend to September 30t", 2017. 2. Section 2.4.5 shall be deleted in its entirety. 3. Exhibit 1 shall be deleted in its entirety and replaced with the following: EXHIBIT 1 DRUG PRICING AND FEES Administrative Fee (Payable to Envision; not including fees payable to Plan Sponsor's TPAs, consultants, or brokers, if any) For Contract Year 2014: $3.50 Per Employee, Per Month (PEPM) For Contract Year 2015: $3.65 PEPM For Contract Year 2016: $3.65 PEPM Fees for Additional Services and Miscellaneous Expenses 1. Replacement by Envision of lost or stolen ID Cards $1.00 per card plus 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 /Monroe County 130C Am. 1 073114 k) Envision Pharmaceutical Services, LLC Page l of 4 C nical Prior Authorizations (Initial Coverage erminations) P $8.00 per authorization ricing and Dispensing Fees Supply/Source BRAND GENERIC For Contract Year Drug Price (A) Dispensing Drug Price (A) Dispensing 2014 (Annual Average Fee (B) (Annual' Average Fee (B) (based on 3 year Effective Rate Annual Effective Rate (Annual Agreement) Guarantee) Average g Guarantee ) Average Guarantee) Guarantee) 30 Days' Supply at a Retail Pharmacy AWP minus 15.35% $1.30 AWP minus 75% $1.30 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail AWP minus 20% N/A AWP minus 76% N/A Order) Mail Order Pharmacy Acquisition Cost $9.50 Acquisition Cost $9.50 Specialty Pharmacy (Pass -Through of Contract Rate BRAND with Dispensing Pharmacy) GENERIC Supply/Source Drug Price (A) Dispensing Drug Price (A) Dispensing For Contract Year (Annual Average Fee (B) (Annual Average Fee (B) 2015 Effective Rate Guarantee) (Annual Effective Rate (Annual Average Guarantee) Average g Guarantee ) Guarantee) 30 Days' Supply at a Retail Pharmacy AWP minus 15.45% $1.30 AWP moms $1.30 75.50 /o 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail AWP minus 20.10% N/A AWP minus N/A Order) Acquisition Cost $9.50 76.50% Acquisition Cost $9.50 Mail Order Pharmacy Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) Supply/Source BRAND GENERIC Drug Price (A) Dispensing Drug Price (A) Dispensing For Contract Year (Annual Average Fee (B) (Annual Average Fee (B) 2016 Effective Rate Guarantee) (Annual Effective Rate (Annual Average Guarantee) Average g Guarantee ) Guarantee) /Monroe County BOC Am. 1 073114 0 Envision Pharmaceutical Services, LLC Page 2 of 4 30 Days' Supply at a Retail Pharmacy AWP minus 15.55% $1.25 AWP minus 76% $1.25 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail AWP minus 20.20% N/A AWP minus 77% N/A Order) Mail Order Pharmacy Acquisition Cost $9.50 Acquisition Cost $9.50 Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) (A) Annual Average Effective Rate is calculated using actual price paid by Envision to Participating Pharmacies in the designated Network, plus any Cost Share, (the Ingredient Cost) for all Claims for the applicable category (including Claims paid at the U&C Price) during a Contract Year, excluding (i) Compound Drugs; (ii) Limited Distribution Drugs; (iii) drugs dispensed at a Specialty Pharmacy; (iv) Claims from non -Participating Pharmacies, LTC pharmacies, or government owned or operated pharmacies (e.g. Veterans Administration); (v) Claims paid at government required amounts (e.g. Medicaid); (vi) 340B Claims; (vii) vaccines; (viii) non -Prescription Drugs; (ix) Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy; and (x) Excluded Generics. (B) 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) Limited Distribution Drugs; (iii) drugs dispensed at a Specialty Pharmacy; (iv) Claims from non -Participating Pharmacies, LTC pharmacies, or government owned or operated pharmacies (e.g. Veterans Administration); (v) Claims paid at government required amounts (e.g. Medicaid); (vi) 340B Claims; (vii) vaccines; (viii) non -Prescription Drugs; (ix) Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy; and (x) Excluded Generics. Annual Average Effective Rate and Annual Average Dispensing Fee Guarantee Plan Sponsor acknowledges that the Annual Average Effective Rates and Annual Average Dispensing Fees specified in this Exhibit 1 are conditioned upon Plan Sponsor's adherence to certain conditions under this Agreement and that the actual Annual Average Effective Rates and Annual Average Dispensing Fees will also depend on Plan Sponsor's drug utilization and mix of Participating Pharmacies. Within four months after the end of each Contract Year, Envision shall provide Plan Sponsor, upon request, with a report showing the actual Annual Average Effective Rates and Annual Average Dispensing Fees paid by Plan Sponsor for the Contract Year. The Annual Average Effective Rates and Annual Average Dispensing Fees guarantees set forth in Exhibit I shall be deemed to have been satisfied if the discounts passed through to Plan Sponsor for all Claims during the Contract Year are equal to or more favorable, in the aggregate, than the drug pricing and dispensing fee guarantees stated for each drug type or category individually. If the amounts paid by Plan Sponsor for all Claims during the Contract Year are less favorable, in the aggregate, than the combined Annual Average Effective Rates and Annual Average Dispensing Fees stated in Exhibit 1, Envision shall credit Plan Sponsor with the difference. Envision shall not be liable to Plan Sponsor for shortfalls in guaranteed Annual Average Effective Rates or Annual Average Dispensing Fees if (i) Plan Sponsor makes a change to the Benefit Plan at any time (regardless of whether or not such change is required by law); (ii) the configuration of System edits is modified by Plan Sponsor; (iii) Plan Sponsor does not adhere to the Formulary; or (iv) the utilization data provided by Plan Sponsor (or Plan Sponsor's agent) upon which the calculation of guarantees were based is inaccurate, incomplete, or there is a substantial change in drug utilization patterns of Covered Individuals. Plan Sponsor agrees that Envision's liability to Plan Sponsor for shortfalls in financial guarantees, in the aggregate, for any Contract Year shall be limited /Monroe County 130C Am. 1 073114 U Envision Pharmaceutical Services, LLC Page 3 of 4 r' ` L to amounts paid by Plan Sponsor to Envision for Administrative Fees during the applicable Contract Year, and Plan Sponsor has no right of offset to withhold any payment due Envision under this Agreement for any amounts Plan Sponsor believes are owed by Envision for financial guarantees. 4. This Amendment shall be effective October lst, 2014 ("Effective Date"). 5. All other terms or provisions of the Agreement not modified by this Amendment or any other amendments or addenda shall remain unchanged. IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Amendment as of the Effective Date above. For ENVISION: By: Frank J. heehy Chief Executive O 7icer For PLAN SPONSOR: By: s Z���i t4rvhy, �r Print Ttle MONROE COUNTY ATTORNEY AP iRO� P T� FO M: YNTHIA L. HALL ASSISTANT COUNTY ATTORNEY Date /Monroe County 130C Am. 1 073114 6) Envision Pharmaceutical Services, LLC Page 4 of 4 AMENDMENT NO.2 TO PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT This Amendment No. 2 (this "Amendment"), is entered into by and between Envision Pharmaceutical Services, LLC ("Envision"), and Monroe County Board of County Commissioners ("Plan Sponsor"). Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement dated October 1st, 2011 (the "Agreement"), under which Envision provides PBM Services to Plan Sponsor; and The parties desire to amend the Agreement, and therefore Envision and Plan Sponsor agree as follows: 1. The term of the Agreement shall extend to December 31St, 2017. 2. Financial performance guarantees for Contract Year 2016 will include all Claims from October 1 ", 2016 through December 31 st, 2017. 3. This Amendment shall be effective January 111, 2017 ("Effective Date"). 4. All other terms or provisions of the Agreement not modified by this Amendment or any other amendments or addenda shall remain unchanged. IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Amendment as of the Effective Date above. For ENVISION: By: L— atthew A. Gibbs, Pharm D. �ent, Commercial & Managed Markets KEVIN MADOK, CLERK b YPq A�. Deputy C erk , j 11 7 For PLAN SPONSOR: By: Mayor George Neugent Print Name & Title BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA -Y ATTORNEY AJVL.€) d=iS O F?"TALL ASSISTA4 ;0U ATT0RNY /Monroe County BOC Am. 2 113016 C Envision Pharmaceutical Services, LLC Page 1 of I unty of Monroe Co ELj »moo � i� G�, �T� BOARD OF COUNTY COMMISSIONERS � Mayor David Rice, District 4 The Florida Ke slv', y fi i w; \ Mayor Pro Tern Sylvia J. Murphy, District 5 ; ,= _ :'„ j Danny L. Kolhage, District 1 George Neugent, District 2 Heather Carruthers, District 3 County Commission Meeting December 13, 2017 Agenda Item Number: C.10 Agenda Item Summary #3644 BULK ITEM: Yes DEPARTMENT: Employee Services TIME APPROXIMATE: STAFF CONTACT: Maria Fernandez -Gonzalez (305) 292-4448 n/a AGENDA ITEM WORDING: Approval of a three (3) year Pharmacy Benefit Management Services Agreement with Envision Pharmaceutical Services, LLC, and approval of a three (3) year Medicare Employer Group Administrative Services Only Agreement with supplemental wrap- around benefits (EGWP/WRAP ASO) with Envision Insurance Company. ITEM BACKGROUND: An RFP was done in early 2017 for Pharmacy Benefit Management (PBM) Services. A total of six (6) proposals were received. Gallagher Benefit Services prepared the Non -technical analysis of each proposal and Health Care Analytics prepared the Technical analysis of each proposal. The RFP's and the analyses received were provided to all Selection Committee Members. The Selection Committee Members met September 13, 2017 and the Envision -Broad Network/Select Formulary proposal was ranked #1 with Blue Cross Blue Shield of Florida (BCBSF)-Prime Therapeutics ranked #2. The Envision -Broad Network/Select Formulary proposal projects approximate savings of over $2.2 million dollars over this three-year period vis-a-vis the current program. Projected savings will come from lower administration fees and higher rebates passed through to Monroe County. One of the changes approved by the BOCC in July 2017 during its review of the plan was to change from a Retiree Drug Subsidy model to an Employer Group Waiver Program with supplemental wraparound benefits program (EGWP/WRAP). Both RDS and EGWP provide the County with reimbursements for claims that have been paid for Medicare -eligible retirees in the Plan. Under RDS, the County receives an annual reimbursement at the end of the plan year. Under EGWP, the County receives reimbursements monthly during the plan year. There is no difference in Plan benefits. As shown in the attached slide, this option was projected to save the County approximately $250K per year. Envision Insurance Company was the only vendor to offer an Administrative Services Only plan to run the Employer Group Waiver Program with a supplemental wraparound benefits program (EGWP/WRAP ASO) which was part of the RFP. This item requests that the MCBOCC approve three-year agreements with Envision Pharmaceutical Services, LLC to provide pharmacy benefit management services and Envision Insurance Company to provide the EGWP/WRAP ASO services. PREVIOUS RELEVANT BOCC ACTION: RFP done in early 2011 — Envision Pharmaceutical Services, LLC was the selected PBM and an agreement for three years (10/1/1 I — 9/31/14) was approved by the MCBOCC. Amendment #1 to Envision agreement approved 10/1/14 extended the contract through 9/30/17 Amendment #2 to Envision agreement approved 1/I/17 extended the contract through 12/31/17. CONTRACT/AGREEMENT CHANGES: Three (3) year Pharmacy Benefit Management Services Agreement and Medicare Employer Group Agreement (EGWP/WRAP ASO). Expected savings with this renewed contract is approximately $2.2 million over three year period. STAFF RECOMMENDATION: Approval DOCUMENTATION: PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT draft rev 11.15.2017 EGWP+WRAP ASO Agt (2018)_MCBOCC draft 11.9.17 ch Option 15, EGWP explanation, Power Point presentation 6-20-2017 2011 ENVISION AGREEMENT AMENDMENT 1 ENVISION AMENDMENT 2 ENVISION FINANCIAL IMPACT: Effective Date: 1/1/18 Expiration Date: 12/31/21 Total Dollar Value of Contract: Estimated $9,648,165 dependent upon claims Total Cost to County: Estimated $9,648,165 dependent upon claims and fees paid by covered lives Current Year Portion: n/a Budgeted: Source of Funds: Primarily Ad Valorem CPI: Indirect Costs: Estimated Ongoing Costs Not Included in above dollar amounts: Revenue Producing: If yes, amount: Grant: County Match: Insurance Required: Additional Details: 12/13/17 502-08003 • GROUP INS CLAIMS rx claims 12/13/17 502-08002 • GROUP INS OPERATIONS adm fees and misc expenses Total: REVIEWED BY: Bryan Cook Completed Assistant County Administrator Christine Hurley 11/28/2017 9:01 AM Cynthia Hall Completed Budget and Finance Completed Maria Slavik Completed Kathy Peters Completed Board of County Commissioners Pending $3,740,165.00 $74,000.00 $3,814,165.00 11/27/2017 12:06 PM Completed 11/28/2017 10:23 AM 11/28/2017 11:14 AM 11/28/2017 12:00 PM 11/28/2017 12:26 PM 12/13/2017 9:00 AM PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT This Pharmacy Benefit Management Services Agreement (hereinafter this "Agreement") is entered into by and between Envision Pharmaceutical Services, LLC, an Ohio Limited Liability Company (hereinafter "Envision"), and Monroe County Board of County Commissioners (hereinafter "Plan Sponsor"). This Agreement is effective January 1, 2018 (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 "Benefit Plan" means the Plan Sponsor's group 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. 1.3 "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 Drugs are covered by Plan Sponsor (including, for example Limited Distribution Drugs or Specialty Drugs), 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.). If there is any inconsistency between the terms of this Agreement and the Benefit Specification Form or any Benefit Specification Change Form submitted in connection with the services to be provided under this Agreement, then the provisions of the most recent signed Benefit Specification Form or Benefit Change Form shall control. A separate Benefit Specification form shall be provided by Plan Sponsor for each unique Benefit Plan, which Benefit Plan shall be identified by a unique group number. 1.4 "Brand Drug" means a Prescription Drug designated as a branded drug product by Medi- Span as indicated by the multisource (i.e. MONY) code attached to the 11 digit NDC for such Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 1 of 49 drug. 1.5 "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. 1.6 "Claims Adjudication System" or "System" means Envision's on-line computerized claims processing system. 1.7 "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. 1.8 "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. 1.9 "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. 1.10 "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. 1.11 "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. 1.12 "Eligible Employee" means an active employee or a Retiree of Plan Sponsor covered under Plan Sponsor's funded Benefit Plan. For purposes of this Agreement, a Retiree is a retired individual who is covered, primarily, by Plan Sponsor and not Medicare Part D. 1.13 "Formulary" means an index of Prescription Drugs and supplies developed by Envision's pharmacy and therapeutics committee, which is hereby adopted by Plan Sponsor, and shall be used in conjunction with the Benefit Plan as a guide in the selection of Covered Drugs. The Prescription Drugs and supplies on the Formulary will be modified by Envision from time to time as a result of factors including, but not limited to, medical appropriateness, manufacturer arrangements and patent expirations. Additions and deletions to the Formulary are hereby Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 2 of 49 adopted by Plan Sponsor. 1.14 "Generic Drug" means a Prescription Drug that is not a Brand Drug. 1.15 "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as amended. 1.16 "Limited Distribution Drugs" means Prescription Drugs that are distributed by manufacturers through a limited number of pharmacies and wholesalers which have been selected by the manufacturer based on approved participation criteria. For purposes of this Agreement, Limited Distribution Drugs are not considered Specialty Drugs. 1.17 "Mail Order Pharmacy" means Orchard Pharmaceutical Services, LLC d/b/a EnvisionPharmacies. 1.18 "Manufacturer Derived Revenue" means retrospective Formulary rebates, discounts, administrative fees, and other revenue payable by pharmaceutical manufacturers that are received by Envision pursuant to the terms of a formulary rebate contract negotiated independently by Envision with a pharmaceutical manufacturer, and which is directly attributable to Claims that comply with the utilization and benefit design requirements of such pharmaceutical manufacturer rebate contracts and that otherwise meet the terms and conditions hereunder. 1.19 "MAC List" means a proprietary list of Prescription Drugs for which Envision establishes a maximum price ("MAC Price") payable to the dispensing pharmacy. Envision utilizes the same MAC List 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 amount paid by Envision to the dispensing pharmacy for the Claim 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. 1.20 "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 and participates in the Network selected by Plan Sponsor. 1.21 "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. 1.22 "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. Monroe County PBMSA 082217 TBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 3 of 49 1.23 "Prescriber" means a licensed health practitioner with independent prescribing authority in the state in which the dispensing pharmacy is located. 1.24 "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. 1.25 "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. 1.26 "Specialty Drug" means a Prescription Drug that is typically a high -cost biotech, injectable, infused, oral, or inhaled Prescription Drug, and/or a Prescription Drug that requires special storage, handling, and/or requires close monitoring of the patient's drug therapy to ensure appropriate use and clinical outcome. For purposes of this Agreement, Specialty Drugs are not considered Limited Distribution Drugs. 1.27 "Specialty Pharmacy" means Orchard Pharmaceutical Services, LLC d/b/a EnvisionPharmacies. 1.28 "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. 2. STANDARD PBM SERVICES Envision shall perform the following pharmacy benefit management services ("PBM Services"). 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 Pharmacy 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 Plan Sponsor's owned pharmacies or Plan Sponsor's contracted Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 4 of 49 pharmacies, if any, (not including 340B Claims, unless such claims are included under a separate 340B Agreement); (iii) submitted by Covered Individuals as Direct Member Reimbursements (DMRs, as defined below); or (iv) 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, (ii) Claims received from third parties, such as Medicaid, for reimbursement by Plan Sponsor for ineligible payments, or (iii) paper Claims, 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 and process DMR Claims within ten (10) business days of receipt of the DMR form, invoice Plan Sponsor for the Claim, and reimburse the Covered Individual upon receipt of funds from Plan Sponsor. 2.2.2 Claims from Non -Participating Pharmacies: Unless otherwise directed by Plan Sponsor, Envision shall accept and process Claims received from non -participating government owned or operated pharmacies (e.g. Veterans Administration). 2.2.3 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 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: Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 5 of 49 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 a separate or attached coverage determination and appeals process addendum. 2.3.2 Drug Therqpy 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 a separate or attached clinical programs exhibit. 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 (each referred to herein as a "Network"). The Network designated for Plan Sponsor to be used by Covered Individuals hereunder shall be specified in the Benefit Specification Form. Plan Sponsor acknowledges that the pharmacies participating in a Network may be changed from time to time by Envision, including the designated Mail Order Pharmacy and/or Specialty Pharmacy provider. Contact information for Participating Pharmacies is constantly updated to reflect any changes 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 any drug from any Participating Pharmacy. 2.4.1 Plan Sponsor Owned Pharmacies. If Plan Sponsor desires to include one or more of its owned or affiliated pharmacies in the network of pharmacies authorized to dispense Covered Drugs to Plan Sponsor's Covered Individuals, it shall indicate same on the Benefit Specification Form. If Plan Sponsor desires its pharmacy to be available to other Envision clients using one or more of Envision's Networks, such pharmacy shall enter into an Envision Participating Pharmacy Agreement (PPA). If the pharmacy will be for the use of Plan Sponsor's employees only, such pharmacy shall complete an Envision -supplied form indicating the amounts to be invoiced to Plan Sponsor for Claims processed. In either case, the pharmacy shall submit all Claims to Envision for processing. Unless indicated otherwise in the Benefit Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 6 of 49 Specification Form, Envision shall invoice Plan Sponsor for Claims received from Plan Sponsor's owned pharmacy. If the pharmacy is a Participating Pharmacy, Claims shall be adjudicated at the Network rates included in the PPA. 2.5 Customer Service: Envision shall maintain and operate a customer service center with toll -free customer service numbers and adequately staffed 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. Upon 0 termination of this Agreement, Envision agrees to provide only industry -standard transfer files to a subsequent pharmacy benefit manager at Plan Sponsor's written request. Plan Sponsor agrees to pay or reimburse Envision for any cost charged by a vendor or pharmacy related to the transfer of files from or to such vendor or pharmacy at any time during this Agreement or connected with 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 UJ cost (other than those available from Envision's web -based reporting program) shall be mutually LU LU 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. W 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). 2.7.1 Access to Third Parties: If Plan Sponsor desires Envision to provide one or more third parties access to web -based or other reports, Plan Sponsor shall complete and submit an Envision provided authorization form. Plan Sponsor acknowledges that any reports to be provided to Plan Sponsor's authorized third parties which are not accessible via the web -based reports generator, shall be provided via a secure FTP server. 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 Manufacturer Derived Revenue which has been passed -through to Plan Sponsor will have been deducted from the Claim Monroe County PBMSA 082217 TBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 7 of 49 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 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. 2.10 Performance Guarantees: Envision shall provide PBM Services in accordance with the Performance Guarantees specified in Exhibit 2 and shall compensate the Plan Sponsor for failure to meet any of the Performance Guarantees. 3. PRICING AND PASS -THROUGH METHODOLOGY 3.1 Pass -Through of Discounts and Dispensing: The amount invoiced to Plan Sponsor shall be the exact drug ingredient cost and applicable dispensing fee which is paid to the dispensing pharmacy when the Claim is adjudicated without any reclassification, mark up, or spread by Envision, 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 Pharmacy or Specialty Pharmacy); less any applicable Manufacturer Derived Revenue and/or any applicable Covered Individual Cost Share. 3.1.2 For Dispensing: Envision shall invoice Plan Sponsor the actual dispensing fee amount payable to the Participating Pharmacy. 3.2 Manufacturer Derived Revenue 3.2.1 Pass -Through of Manufacturer Derived Revenue: Envision shall pass through to Plan Sponsor one hundred percent (100%) of all Manufacturer Derived Revenue earned by Plan Sponsor for eligible Claims. Prescription Drugs eligible for Manufacturer Derived Revenue are included in the Formulary provided by Envision. Plan Sponsor acknowledges that the Manufacturer Derived Revenue earned by Plan Sponsor 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 Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 8 of 49 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. No Manufacturer Derived Revenue shall be payable to Plan Sponsor for 340B Claims, Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy, Claims for which Envision has not been paid in full, and other Claims not eligible for Manufacturer Derived Revenue. 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 an estimated amount for applicable 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 a credit for estimated 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. 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. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 9 of 49 4.2 Eli ig bility 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. If, however, Plan Sponsor provides Envision with an unsigned Benefit Specification Form or Benefit Specification Change Form, Envision shall not be bound by such form and Plan Sponsor shall hold harmless Envision for any consequences resulting from any changes not 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-counter drugs or medications, source of Covered Drugs, use of Plan Sponsor Owned pharmacies, etc.) may affect yields in Manufacturer Derived Revenue and/or average drug pricing. Plan Sponsor agrees that Envision shall not be liable to Plan Sponsor for any reduction of such yields or increase in pricing which result from any such change. Further, any change to the Benefit Plan that affects a material term of this Agreement will require an amendment hereto. Plan Sponsor agrees to execute an amendment, at Envision's request, before implementing the change to the Benefit Plan. 4.4 Formulary: Plan Sponsor hereby adopts and shall adhere to the Formulary identified in the Benefit Specification Form. Plan Sponsor acknowledges the formulary may be modified by Envision from time to time. Any customization of the Formulary by Plan Sponsor or use by Plan Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 10 of 49 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 Manufacturer Derived Revenue. Plan Sponsor agrees that Envision shall not be liable to Plan Sponsor for any reduction in yields of Manufacturer Derived Revenue or increase in drug pricing 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 5 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 0 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 Ck 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 5.2 Payments for Claims: Envision shall invoice Plan Sponsor twice each month for Claims incurred. Plan Sponsor shall pay Envision's invoices in accordance with the Florida Local Government Prompt Pay Act, Section 218.70, Florida Statutes. 5.3 Payment of Administrative Fee: Plan Sponsor agrees that the Administrative Fee set forth in Exhibit 1 shall be added to the invoiced amount for each Invoiced Claim and shall be paid by Plan Sponsor in conjunction with the payment of Claims as set forth in Section 5.2. For purposes of this Section, an "Invoiced Claim" shall be a Claim payable by Plan Sponsor under this Agreement, but shall not include transactions for Claims which have been rejected under the specifications of the Benefit Plan, transactions for previously paid Claims which have been reversed (e.g. as a result of a reversal of a Claim by a Participating Pharmacy or by Envision as a result of an audit), or transactions for reprocessed Claims (e.g. to correct a previously paid Claim). 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 in accordance with the Florida Local Government Prompt Payment Act. 5.5 Retroactive Disenrollment or Termination: Retroactive termination or disenrollment of a 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 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. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 11 of 49 5.6 Financial ResponsibilitX: 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 dispensing fees, taxes, assessments and fees, and Cost Share not ultimately paid by Members). 5.6.1 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 the rate allowed in the Florida Local Government Prompt Payment Act. 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, Plan Sponsor shall deposit with Envision additional amounts to ensure the timely payment of future invoices. Envision may also discontinue advancing 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. 5.6.2 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. 5.7 Financial Audit by Plan Sponsor: Plan Sponsor may, at its sole expense, conduct a financial audit of Envision's records related to the adjudication of Plan Sponsor's Claims for any complete Contract Year hereunder and is limited to one audit per audit scope. Envision shall make financial records available to Plan Sponsor's auditor as reasonably necessary for auditor to verify the financial terms hereunder have been met. 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's auditor shall execute a conflicts of interest disclosure and confidentiality agreement with Envision prior to the audit, subject to the requirements of Florida public records law in the Florida Constitution and Chapter 119, Florida Statutes. Audits shall only be made during normal business hours following thirty (30) days written notice, which is to include the audit scope and time period under examination, be conducted without undue interference to Envision's business activity, and be conducted in accordance with Envision's standard audit policy, a copy of which may be made available to Plan Sponsor and its auditor upon request. 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 finalizing any amounts due to Plan Sponsor. As part of the finalization process, Envision shall be permitted to use as a credit against any amounts due to Plan Sponsor, the total amount of over performance achieved by Envision for any and all financial guarantees. Upon final settlement of audit, Envision shall remit any funds Monroe County PBMSA 082217 TBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 12 of 49 agreed to be due to Plan Sponsor within thirty (30) calendar days in the form of a credit memo to Plan Sponsor. The audit provisions hereunder shall survive the termination of this Agreement for twelve (12) months following the effective date of termination. 5.8 Financial Audit by Envision: Envision may, at its sole expense and at reasonable intervals, request Plan Sponsor to provide records for Envision's inspection which provide supporting documentation for the information contained in the Eligibility File and the data provided by Plan Sponsor (or its designate) upon which the financial terms herein were based. Plan Sponsor agrees to provide such supporting documentation to Envision within ten (10) business days of such request. 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 three (3) 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; 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. Upon request, Envision agrees to provide Plan Sponsor with estimated renewal pricing within one hundred eighty (180) days prior to the end of the Initial 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 Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 13 of 49 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. 6.2.4 Termination Without Cause: After the first Contract Year, Plan Sponsor may terminate this Agreement without cause, by notifying Envision, in writing, at least ninety (90) days prior to the effective date of termination. Envision may terminate this Agreement without cause, by notifiying Plan Sponsor, in writing, at least ninety (90) days prior to the effective date of the termination. 6.2.5 Market Check: Following initial eighteen (18) months of this Agreement (but not before), Plan Sponsor or its designee may provide Envision with a written firm proposal for pharmacy benefit management services offered by a third party PBM provider to Plan Sponsor which includes similar plan design, Formulary, clinical and trend programs, retail pharmacy, mail pharmacy, and specialty pharmacy mix and utilization, demographics and other relevant factors necessary to provide an appropriate comparison ("Plan Sponsor's Current Market Price"). Plan Sponsor's Current Market Price will be measured on the basis of a total, aggregate comparison of the pricing terms, and not on the basis of individual or best price points. Envision shall have a reasonable opportunity to evaluate Plan Sponsor's Current Market Price. If the proposal concludes that Plan Sponsor's Current Market Price would yield an annual three percent (3%) or more savings of "Net Plan Costs" (with Net Plan Costs defined as the sum of the cost of Covered Drugs, dispensing fees, and Claims Administrative Fees, less Rebates received by Plan Sponsor) under the Agreement, and Envision is unable or unwilling to offer new terms and conditions that would result in the savings offered by the competing offer to be within ninety percent (90%) of such offer, then Sponsor may terminate this Agreement upon ninety (90) days prior written notice to Envision. 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 Manufacturer Derived Revenue to Plan Sponsor upon Plan Sponsor's notification of termination. In the event that Plan Sponsor terminates this Agreement prior to completion of the Initial Term, Plan Sponsor shall refund any prorated amounts outstanding for any amount of money that Envision has funded to or on behalf of Plan Sponsor, including but not limited to allowances, credits and fees as set forth herein. 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 Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 14 of 49 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) 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. Envision and Plan Sponsor shall execute a HIPAA Business Associate Agreement. 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, damages, costs, losses and expenses (including without limitation, reasonable costs of investigation and attorneys' fees) incurred in connection with any and all third party claims which were 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: Subject to and without waiving the provisions of Section 768.28, Florida Statutes, 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, damages, costs, losses and expenses (including without limitation, reasonable costs of investigation and attorneys' fees) incurred in connection with any and all third party claims which were 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 in the case of fraud, the rights of the parties hereto for indemnification relating to this Agreement or the transactions contemplated hereby shall be strictly limited to those contained in this Section 8, and such indemnification rights shall be the Monroe County PBMSA 082217 TBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 15 of 49 exclusive remedies of the parties with respect to any matter arising under or in connection with this Agreement. Notwithstanding 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 CONTRACTED PHARMACIES 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 Acknowledgement: Plan Sponsor acknowledges and agrees that it retains the sole responsibility for the terms and conditions of its Benefit Plan; its compliance with applicable law, and that of its Benefit Plan, including, without limitation, the interpretation and applicability of any state or federally mandated requirements; and determinations of coverage under the Benefit Plan; and shall not rely on any advice or recommendations of Envision as a substitute for obtaining its own independent accounting, tax, legal, or regulatory advice. 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 Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 16 of 49 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. 10.5 BindingEfect: 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 or causes the economic benefits derived by Envision from this Agreement to materially decrease 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 Taxes, Assessment or Fees: Any applicable sales, use, excise, gross receipts or other similarly assessed and administered tax, surcharge, or fee imposed on items dispensed, or services provided hereunder, or the fees or revenues generated by the items dispensed or services provided hereunder, or any other amounts Envision or one or more of its subsidiaries or affiliates Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 17 of 49 may incur or be required to pay arising from or relating to Envision's or its subsidiaries' or affiliates' performance of services as a pharmacy benefit manager, third party administrator, or otherwise in any jurisdiction, will be the sole responsibility of Plan Sponsor or the Member. If Envision is legally obligated to collect and remit, or to incur or pay, any such sales, use, excise, gross receipts or other similarly assessed and administered tax, surcharge, or fee in a particular jurisdiction, such amount will be reflected on the applicable invoice or subsequently invoiced at such time as Envision becomes aware of such obligation or as such obligation becomes due. Envision reserves the right to charge a reasonable administrative fee for collection and remittance services provided on behalf of Plan Sponsor. 10.11 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. 10.12 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. 10.13 Acceptance of Offer: Notwithstanding anything herein to the contrary, this Agreement 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. 10.14 Choice of Law: This Agreement shall be construed, interpreted, and governed according to the laws of the State of Florida, without regard to its conflict of laws rules, except to the extent such laws are preempted by applicable Federal law. 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. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 18 of 49 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. 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 health plan; (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. 10.19 Third Party Administrator/Consultants/Brokers: Unless otherwise stated herein, no payments shall be made by Envision to any of Plan Sponsor's Third Party Administrators (TPA), consultants, brokers, or other third party to carry out any of Plan Sponsor's obligations under this Agreement or for any other reason. 11. FLORIDA REQUIRED CONTRACTUAL LANGUAGE 11.1 Florida State Law: Pursuant to Florida Statute (F.S.) 119.071, Envision agrees to the following provisions: 11.1.1 F.S. 119.071 Envision and its subcontractors shall comply with all public records laws of the State of Florida, specifically to: (a) Keep and maintain public records that ordinarily and necessarily would be required by Monroe County in the performance of this Agreement; b) Provide the public with access to public records on the same terms and conditions that Monroe County would provide the records and at a cost that does not exceed the cost provided in Florida Statutes, Chapter 119 or as otherwise provided by law; (cj Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law; Meet all requirements for retaining public records and transfer, at no cost, to Monroe County all public records in possession of the Proposer upon Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 19 of 49 termination of this Agreement and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to Monroe > County in a format that is compatible with the information technology LU systems of Monroe County; and (e,� Upon completion of the contract, transfer, at no cost, to the County all public records in possession of the Contractor or keep and maintain public records that would be required by the County to perform the service. If the Contractor 0 transfers all public records to the County upon completion of the contract, the Contractor shall destroy any duplicate public records that are exempt or > confidential and exempt from public records disclosure requirements. If the " Contractor keeps and maintains public records upon completion of the 0 contract, the Contractor shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the 0 County, upon request from the County's custodian of records, in a format that is compatible with the information technology systems of the County. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY, AT (305) 292-3470, bradley-brian@monroecounty-fl.gov, c/o Monroe County Attorney's Office, 1111 12th St., Suite 408, Key West FL 33040. 12.0 Federal Contractual Provisions. Recoanizina that a portion of the funds used to nav for the services covered by this agreement come from a federal award, as that term is defined in 2 CFR part 200.38, the contractual provisions contained in Exhibit 3, attached hereto, are made part of this agreement. To the extent that any of the federal contractual provisions are inconsistent with a provision in this aareement. the federal contractual provisions contained in Exhibit 3 shall control. [SIGNATURE PAGE FOLLOWS] Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 20 of 49 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: By: Matthew A. Gibbs, Pharm D. President, Commercial & Managed Markets Address: Envision Pharmaceutical Services, LLC 2181 East Aurora Road Twinsburg, OH 44087 PH: 330-405-8080 FX: 330-405-8081 For PLAN SPONSOR: By: Print Name & Title Address: PH: FX: E-MAIL: FEIN: Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 21 of 49 EXHIBIT 1 FEES AND FINANCIAL GUARANTEES* Administrative Fee (Payable to Envision; not including fees payable to Plan Sponsor's TPAs, consultants, or brokers, if any) For Contract Year 1: $1.00 Per Claim For Contract Year 2: $1.04 Per Claim For Contract Year 3: $1.08 Per Claim Fees for Additional Services and Miscellaneous Expenses 1. Manually create or update the Eligibility File $1.00 per Covered Individual data entry 2. Replacement by Envision of lost or stolen ID $1.15 per card plus cost of postage Cards (individual), $2.00 per card (family) plus $0.15 per ID Card packet and cost of postage 3. Ad Hoc Computer or Report Programming (for a one-time, non -recurring report) No charge 4. Coverage Determinations (including Clinical Prior $35.00 per request Authorizations) 5. Manual Claims Processing (including DMRs) $1.50 per Claim processed Fees for Additional Optional Services and Miscellaneous Expenses 1. Custom Eligibility File layouts (accommodation or development) $1,000.00 per layout 2. Member Communications Cost of production and postage 3. Custom Website Quoted upon request 4. Standard Online Reporting User Access Standard Online Reporting includes access for 3 active Plan Sponsor users and 1 consultant user. A licensing fee of $1,200.00 would apply for each additional user. 5. Development of Ad Hoc Non -Standard Recurring report Quoted upon request 6. Incoming Data Transfer Files $250.00 per industry -standard file (non -industry standard file formats will be quoted upon request) 7. Benefit Integrity Enhanced Services (as set forth To be quoted upon request, and based upon C . o� LU o c� M C 0 c� a� 0 0 0 Z Uj LU LU LU LU cc Z LU LU Z LU Z Uj c� a. C 0 c� Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 22 of 49 in the Benefit Integrity Enhanced Services service area Addendum) 8. Submission of Medicare Part D subsidy $1.00 per Member, per month, minimum $2,000 per year 9. Customized Formulary $0.20 per Member, per month, minimum of $2,000 per month 10. Redeterminations (Internal Appeals) $125 per request 11. External Appeals including services of an 100% pass -through of costs incurred Independent Review Organization (IRO) (ranging between $250 to $350 per appeal, average cost is approximately $300 per appeal) 12. e-Prescribing $0.30 per transaction, minimum of $250.00 per month 13. Claim Adjustment Checks (charged to Plan Sponsor for reimbursements made to Covered Individuals for Claim adjustments requested by Plan Sponsor.) $8.50 per check 14. Explanation of Benefits (EOB) production and distribution $1.00 per EOB plus postage 15. Medicaid Subrogation Claim Adjudication $3.50 per Claim 16. Drug Therapy Care Gap Management $0.55 per Member, per month 17. Medication Adherence and Persistency (up to three disease states) $0.55 per Member, per month 18.Outgoing Data Transfer Files (Claims History, Prior Authorization Files, Open Refill Files (Mail and Specialty), Accumulator Files (deductible, out-of-pocket, etc.), and/or related participant data $5,000 for any or all of the identified files (i.e. patient addresses, etc.) reports 19. Retail Pharmacy Audit Program 80% of recoveries passed to Plan Sponsor 20. 21. Drug Pricing and Dispensing Fees (A) Supply/Source BRAND GENERIC For Contract Year 1 (based on 3 year Drug Price (B)(C) (Annual Average Dispensing Fee (o) Drug Price (B)(� (Annual Average Dispensing Fee (C) r_ 0 . o� LU o 0 M 0 0 a� 0 0 W) a� Z W W LU LU LU U) Z LU LU Z LU Z W c� a. C 0 0 M Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 23 of 49 Agreement) Effective Rate (Annual Effective Rate (Annual Guarantee) Average Guarantee) Average Guarantee) Guarantee) Retail Pharmacy (30 AWP minus 17.00% $1.00 AWP minus $1.00 Days' Supply) 80.00% Retail Pharmacy (84 Days' Supply or AWP minus 22.00% N/A AWP minus N/A greater) (non -Mail 84.00% Order) (D) Mail Order Pharmacy A moms (45 Days' Supply or AWP minus 17.00% N/A 8000 /o N/A less) . Mail Order Pharmacy A moms (46 Days' Supply or AWP85minus 23.00% N/A 00 /o N/A greater) . Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) Supply/Source BRAND GENERIC Drug Price (B)(C) Dispensing Drug Price (B)(C) Dispensing For Contract Year 2 (Annual Average Fee (C) (Annual Average Fee (C) (based on 3 year Effective Rate (Annual Effective Rate (Annual Agreement) Guarantee) Average Guarantee) Average Guarantee) Guarantee) Retail Pharmacy (30 AWP minus 17.00% $1.00 AWP minus $1.00 Days' Supply) 80.25% Retail Pharmacy (84 Days' Supply or AWP minus 22.00% N/A AWP minus N/A greater) (non -Mail 84.00% Order) (am) Mail Order Pharmacy A moms (45 Days' Supply or AWP80minus 17.00% N/A 25 /o N/A less) . Mail Order Pharmacy A moms (46 Days' Supply or AWP85minus 23.00% N/A 00 /o N/A greater) . Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) Supply/Source BRAND GENERIC For Contract Year 3 Drug Price (B)(C) Dispensing Drug Price (B)(C) Dispensing (based on 3 year (Annual Average Fee (C) (AnnuaI Average Fee (C) Effective Rate Effective Rate r_ 0 LU o c� M 0 c� a� 0 0 CL Lo a� z Uj LU LU LU LU U) z LU LU z z Uj c� a. C 0 0 M Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 24 of 49 Agreement) Guarantee) (Annual Guarantee) (Annual Average Average Guarantee) Guarantee) Retail Pharmacy (30 AWP minus 17.00% $1.00 AWP minus $1.00 Days' Supply) 80.50% Retail Pharmacy (84 Days' Supply or AWP minus 22.00% N/A AWP minus N/A greater) (non -Mail 84.00% Order) (o) Mail Order Pharmacy A moms (45 Days' Supply or AWP80minus 17.00% N/A 50 /o N/A less) . Mail Order Pharmacy A moms (46 Days' Supply or AWP85minus 23.00% N/A 00 /o N/A greater) . Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) (A) For purposes of this Agreement the "Average Wholesale Price" or "AWP" means 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. (a) For purposes of this Agreement, the "Annual Average Effective Rate" means, for the category of drugs being reviewed, the result calculated by the following formula: 1. (IC/AWP)-1, where IC (the "Ingredient Cost") is the sum of all amounts paid by Plan Sponsor for the ingredient costs of the Covered Drugs paid to Participating Pharmacies in the designated Network during the Contract Year, before deducting applicable Manufacturer Derived Revenue; and 2. AWP is the sum of the Average Wholesale Price amounts associated with the same Covered Drugs during the Contract Year. 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. (c) The Annual Average Effective Rate and Annual Average Dispensing Fee is calculated using actual price paid by Envision to Participating Pharmacies in the designated Network, plus any Cost Share, (the Ingredient Cost) for all Claims for the applicable category above (including Claims paid at the U&C Price) during a Contract Year, excluding (i) compound drugs; (ii) Limited Distribution Drugs; (iii) drugs dispensed at a Specialty Pharmacy; (iv) Claims from non -Participating Pharmacies, LTC pharmacies, home infusion or government owned or operated pharmacies (e.g. Veterans Administration); (v) Claims paid at government required amounts (e.g. Medicaid); (vi) 340B Claims; (vii) vaccines; (viii) non -Prescription Drugs (including OTC); (ix) drugs in limited supply; (x) Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy; (xi) manually processed Claims; (xii) coordination of benefits Claims; and (xiii) Medicaid subrogation Claims. (n) 84 Days' supply or greater at retail pharmacy guarantees apply only if Plan Sponsor's Benefit Plan includes a 90 days' supply at retail benefit for the entire Contract Year. C 0 LU o c� M C 0 c� a� 0 0 CL W) a� z W W LU LU U LU U) z LU LU z LL LU z W a. C 0 c� Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 25 of 49 Plan Sponsor acknowledges that the Annual Average Effective Rates and Annual Average Dispensing Fees specified in this Exhibit 1 are conditioned upon Plan Sponsor's adherence to certain conditions under this Agreement and that the actual Annual Average Effective Rates and Annual Average Dispensing Fees will also depend on Plan Sponsor's drug utilization and mix of Participating Pharmacies. The Annual Average Effective Rates and Annual Average Dispensing Fees guarantees set forth in Exhibit 1 shall be deemed to have been satisfied if the discounts passed through to Plan Sponsor for all Claims during the Contract Year are equal to or more favorable, in the aggregate, than the drug pricing and dispensing fee guarantees stated for each drug type or category individually. If the amounts paid by Plan Sponsor for all Claims during the Contract Year are less favorable, in the aggregate and after application of any additional offsets allowed under this Agreement, than the combined Annual Average Effective Rates and Annual Average Dispensing Fees stated in Exhibit 1, Envision shall credit Plan Sponsor with the difference as set forth below. Envision shall not be liable to Plan Sponsor for shortfalls in guaranteed Annual Average Effective Rates or Annual Average Dispensing Fees if (i) Plan Sponsor makes a change to the Benefit Plan at any time (regardless of whether or not such change is required by law); (ii) the configuration of System edits is modified by Plan Sponsor; (iii) Plan Sponsor does not adhere to the Formulary; (iv) the utilization data provided by Plan Sponsor (or Plan Sponsor's agent) upon which the calculation of guarantees were based is inaccurate, incomplete; (v) there is a substantial change in drug utilization patterns of Covered Individuals; or (vi) Plan Sponsor terminates before completion of the applicable, full Contract Year. As used herein, the term "substantial change" means a change > 20% per year. In addition, Plan Sponsor agrees that Envision's liability to Plan Sponsor for shortfalls in financial guarantees, in the aggregate, for any Contract Year shall be limited to amounts paid by Plan Sponsor to Envision for Administrative Fees during the applicable Contract Year, and Plan Sponsor has no right of offset to withhold any payment due Envision under this Agreement for any amounts Plan Sponsor believes are owed by Envision for financial guarantees. For Contract Year 1: • For 30 day supply of Brand Drugs at a Retail Pharmacy - $102.02 per paid Brand Drug Claim • For 84 days' supply of Brand Drugs at a Retail Pharmacy- $277.12 per paid Brand Drug Claim • For up to 45 days' supply of Brand Drugs at the Mail Order Pharmacy- $102.02 per paid Brand Drug Claim • For 46+ days' supply of Brand Drugs at the Mail Order Pharmacy- $428.98 per paid Brand Drug Claim • For Specialty Brand Drugs - $493.20 per paid Specialty Brand Drug Claim For Contract Year 2: • For 30 day supply of Brand Drugs at a Retail Pharmacy - $105.88 per paid Brand Drug Claim • For 84 days' supply of Brand Drugs at a Retail Pharmacy- $300.21 per paid Brand Drug Claim • For up to 45 days' supply of Brand Drugs at the Mail Order Pharmacy- $105.88 per paid Brand Drug Claim • For 46+ days' supply of Brand Drugs at the Mail Order Pharmacy- $487.54 per paid Brand Drug Claim • For Specialty Brand Drugs - $579.38 per paid Specialty Brand Drug Claim For Contract Year 3: • For 30 day supply of Brand Drugs at a Retail Pharmacy - $117.25 per paid Brand Drug Claim • For 84 days' supply of Brand Drugs at a Retail Pharmacy- $332.51 per paid Brand Drug Claim • For up to 45 days' supply of Brand Drugs at the Mail Order Pharmacy- $117.25 per paid Brand Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 26 of 49 Drug Claim • For 46+ days' supply of Brand Drugs at the Mail Order Pharmacy- $610.46 per paid Brand Drug Claim • For Specialty Brand Drugs - $681.08 per paid Specialty Brand Drug Claim _ 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. (G) 340B Claims, Claims not eligible for Manufacturer Derived Revenue (e.g. Vaccines, Compounds, Direct Member Reimbursement Claims, etc.), OTC drug Claims (with the exception of diabetic testing strips and meters), and Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy, shall be excluded from the calculation of the guarantees above. (,�) Guarantees require Plan Sponsor to utilize current Envision Select Formulary. Plan Sponsor acknowledges that the annual average Manufacturer Derived Revenue guaranteed amounts specified in this Exhibit 1 are conditioned upon Plan Sponsor's adherence to certain conditions under this Agreement. (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, after application of any additional offset allowed under this Agreement. (b) If the Manufacturer Derived Revenue earned by Plan Sponsor for the Contract Year is, overall, lower than the annual average Manufacturer Derived Revenue guaranteed amounts specified above, in the aggregate, Envision shall pay the difference to Plan Sponsor, after application of any additional offset allowed under this Agreement. Notwithstanding anything herein to the contrary, Envision shall not be liable to Plan Sponsor for any shortfall in guaranteed Manufacturer Derived Revenue if: (i) Plan Sponsor makes a change to the Benefit Plan at any time (regardless of whether or not such change is required by law); (ii) the configuration of System edits is modified by Plan Sponsor; (iii) Plan Sponsor does not adhere to the Formulary; (iv) the utilization data provided by Plan Sponsor (or Plan Sponsor's agent) upon which the calculation of guarantees were based is inaccurate, incomplete; (v) there is a substantial change in drug utilization patterns of Covered Individuals; (vi) there is a loss of rebates due to pharmaceutical manufacturer drug patent expirations, manufacturer bankruptcy, or removal of a drug from the market; (vii) there are changes in pharmaceutical manufacturer rebate contracting terms or policies; (viii) Plan Sponsor's Benefit Plan does not meet the conditions for rebates of pharmaceutical manufacturer contracts including market share rebates; (ix) if Plan Sponsor has been excluded by a manufacturer; (x) there is any governmental regulation, ruling, or guidance that impacts Envision's ability to maintain current Manufacturer Derived Revenue yields; or (xi) Plan Sponsor terminates before completion of the applicable, Contract Year. Plan Sponsor agrees that Envision's liability to Plan Sponsor for shortfalls in financial guarantees, in the aggregate, for any Contract Year shall be limited to amounts paid by Plan Sponsor to Envision for Administrative Fees during the applicable Contract Year, and Plan Sponsor has no right of offset to withhold any payment due Envision under this Agreement for any amounts Plan Sponsor believes are owed by Envision for financial guarantees. * Envision reserves the right to modem the pricing if the actual enrollment on the program decreases by 20% or more from total enrollment on the effective date of this agreement. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 27 of 49 EXHIBIT 2 PERFORMANCE GUARANTEES Envision shall provide PBM Services in accordance with the Performance Guarantees specified in this Exhibit. So long as both parties have executed the Agreement, Envision shall provide Plan Sponsor with a Performance Guarantee report within ninety (90) days after the end of each Contract Year. 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 for on -going Performance Guarantees with no more than 20% to be allocated towards one 0 performance area. If not allocated, the total amount at risk shall be evenly distributed across the proposed Performance Guarantees. Failure to meet Performance Guarantees shall not be deemed to be a breach of this Agreement. Unless otherwise noted in this Exhibit, Performance Guarantees shall be measured annually on a client specific basis. Upon receipt of Envision's annual Performance Guarantee report, if Envision failed to meet any of the Performance Guarantees noted in this Exhibit and Plan Sponsor desires to assess penalties, then Plan Sponsor will provide Envision, within forty-five (45) days of receipt, with written notice to assess a penalty. Any penalties assessed against Envision pursuant to this Agreement will be credited against future billings to Plan Sponsor in accordance with the execution of this Agreement and Envision's standard procedures. In the event that any failure by Envision to meet any Performance Guarantee is due to a force majeure as defined in this Agreement, failure by Plan Sponsor to perform its obligations under this Agreement, or actions or inactions of Plan Sponsor that adversely impact Envision's ability to maintain the Performance Guarantee(s), Envision will be excused from compliance with such Performance Guarantee(s) until such circumstances have been resolved and any existing backlogs or other related effects have been eliminated. The following performance guarantees shall apply through 9/30/2020, for services that have been fully delegated to Envision. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 28 of 49 2 3 4 Account Management Account Envision guarantees an average account Annually Up to 20% of Management management satisfaction rate of 3 or total amount at Satisfaction higher per Contract Year, on Envision's risk. standard Account Management survey with a scale of 1 to 5 (5 being the highest). Plan Sponsor employees, who have routine day to day interactions with Envision's account management team, shall promptly complete and return all surveys. Standard Benefit Envision guarantees that it shall modify Annually Up to 20% of Modification standard changes to existing benefits total amount at Turnaround within thirty (30) calendar days or less risk. from the date that Envision receives the signed Benefit Change Form from Plan Sponsor. Plan sponsor understands that urgent and custom requests are excluded from the measurement of this performance guarantee. Help Desk Average Speed Envision shall answer calls to the Annually Up to 20% of of Answer - member service telephone line total amount at Member Service administered by Envision within an risk. average of thirty (30) seconds per Contract Year, measured on a book of business basis. Call Center Envision shall make available a toll free Annually Up to 20% of Abandonment member help desk telephone line. The total amount at Rate Abandonment Rate of the member help risk. desk telephone line will be five percent (5%) or less per Contract Year, measured on a book of business basis. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 29 of 49 6 Blocked Call Rate 1 % or less of calls to Envision's member Annually help desk call centers will receive a busy signal each Contract Year, measured on a book of business basis. "Blocked Call Rate" means the (i) number of incomplete member telephone calls to member help desk call centers each Contract Year which were never received due to the caller receiving a busy signal, divided by (ii) the total number of member telephone calls presented to member help desk call centers during such Contract Year. Mail Order Pharmacy ....Dispensing Annually Accuracy Dispensing Accuracy Rate for each Contract Year will be 99.993% or greater, measured on a book of business basis. "Dispensing Accuracy Rate" means (i) the number of all mail and specialty pharmacy prescriptions dispensed by Envision, less the number of those prescriptions which are reported to Envision and verified by Envision as having been dispensed with the incorrect drug, strength, or form, divided by (ii) the number of all mail and specialty pharmacy prescriptions dispensed by Envision. Up to 20% of total amount at risk. Up to 20% of total amount at risk. C Lh o� LU o c� M 0 c� c� 0 0 CL z Uj W Uj Uj L) Uj U) z W z Uj z Uj c� a. C 0 E c� Monroe County PBMSA 082217 TBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 30 of 49 to 0 9 10 Mail Turnaround Time — Clean Orders Mail Turnaround Time — Intervention Orders Envision shall dispense "Clean Mail Service Orders" within an average of two (2) business days per Contract Year, provided Envision Pharmacies has dispensed a minimum of one thousand (1,000) total mail service orders in such Contract Year. "Clean Mail Service Order" means mail service orders received by Envision Pharmacies that are in stock and which do not require physician or patient contact or other non-standard procedures prior to dispensing by Envision Pharmacies. Envision shall dispense intervention mail service orders within an average of five (5) business days per Contract Year, provided Envision Pharmacies has dispensed a minimum of one thousand (1,000) total mail service orders in such Contract Year. "Intervention Mail Service Order" means mail service orders received by Envision Pharmacies that are not in stock and which do require physician or patient contact or other non-standard procedures prior to dispensing by Envision Pharmacies. Annually Annually Retail Pharmacy Online Claims Except for scheduled maintenance Annually Processing periods, Envision's claims adjudication System system will be available at least ninety Availability nine percent (99%) of the time, measured on a book of business basis. Online Claims Ninety-eight percent (98%) or more of Annually Processing online transactions will be processed System within four (4) seconds based on an Response annual average, measured on a book of business basis. Up to 20% of total amount at risk. Up to 20% of total amount at risk. Up to 20% of total amount at risk. Up to 20% of total amount at risk. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 31 of 49 11 12 Cher Services Eligibility Load Envision guarantees 99.98% of usable Annually Turnaround eligibility files received before 7:00 AM Eastern Time on any business day will be accurately loaded and active in the on-line claims adjudication system within two (2) business days of Envision's receipt. Standard Envision's standard financial reporting Annually Financial package will be made available online Reporting within 30 days following the end of the Package quarter. Turnaround $250 per file, subject to a maximum penalty of 20% of at risk amount per Contract Year. $500 per file, subject to a maximum penalty of 20% of at risk amount per Contract Year. C . o� LU o c� M 0 0 0 CL W) a� z UJ W UJ UJ L) UJ U) z W z UJ z UJ c� a. C 0 E c� Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 32 of 49 CLINICAL PROGRAMS EXHIBIT Envision shall provide the following Clinical Programs to Plan Sponsor: Standard Cost Reduction Services (included in Administrative Fee) Concurrent Drug Utilization Review ("DUR") Program — point of sale system checks to identify contraindicated drugs and drug strengths not recommended Envision's Concurrent DUR Program provides electronic clinical monitoring of prescription drugs at the point -of -sale claims system edits. It is designed to encourage cost-effective, high quality drug therapies by notifying pharmacists of potential drug therapy complications at the point -of -sale before prescriptions are dispensed. The DUR Program is intended to be used by the pharmacist as a screening tool to detect outlying prescription drug utilization patterns, but not substitute for professional judgment. All claims submitted through the Envision Concurrent DUR Program are entered into the IN patient's active drug profile, thus allowing the system to evaluate prescription claims prior to the initiation of drug therapy. The patient's profile is accessed regardless of the participating pharmacy the patient may choose. Drug Utilization Review Listed below are the eleven major Concurrent DUR modules that Envision utilizes during the processing of prescription drug claims. All of the clinical modules use National Council of Prescription Drug Plans ("NCPDP") standard conflict codes: • Duplicate Therapy (drugs from the same therapeutic class) • Drug -Drug Interaction (combinations of drugs with potential for severe adverse effects) • Low Dose Alert (drug doses that fail to meet the suggested minimum daily dose) • High Dose Alert (drug doses that exceed the suggested maximum daily dose) • Excessive Utilization ("Too Soon Refill" Monitoring which monitors refill claims sent before a defined percentage of the previous fill is used) • Geriatric Precautions (drugs inappropriate for patients over the age of 60) • Pediatric Precautions (drugs inappropriate for pediatrics based on the patient's tender age) • Drug Duplication (drugs containing the same ingredients) • Drug -Gender Precaution (drugs not indicated for a specific gender) • Drug -Disease Precaution (drugs inappropriate) • Under -Utilization (Late Refill Monitoring which is a refill for a chronic maintenance drug requested at an interval longer than directed by the prescriber) Each DUR warning is accompanied by the appropriate NCPDP DUR conflict code and message. The message received will be in a format designed by the pharmacy software vendor. Additionally, most pharmacy software may also have editing capability, but may be limited to prescriptions filled at that store or chain. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 33 of 49 Additional Clinical Program Services (priced separately) Medication Therapy Management/Drug Therapy Management Envision's Medication Therapy Management/Drug Therapy Management ("MTM/DTM") Program is designed to achieve appropriate therapeutic outcomes for targeted patients through improved medication use. This includes the involvement of patients, caregivers, care providers, pharmacists, physicians, educators, and care coordinators. The Program is consistent with evidence based -guidelines, including guidance from the Centers for Medicare and Medicaid Services ("CMS"). Prospective candidates for the DTM/MTM Program are those patients who have multiple chronic conditions, are taking multiple medications, and will most likely incur high annual drug costs. In addition, specific patients that fall outside of the previously mentioned identification criteria may be identified as eligible for DTM/MTM intervention due to significant therapy care gaps. The MTM/DTM Program consists of 2 basic elements: Therapy Care Gap interventions and Adherence and Persistence (A&P) interventions. A) Therapy Care Gap Management Therapy Care Gaps are interventions designed to identify patients who have a gap between their current therapy and the ideal therapy needed to achieve optimal clinical outcomes. Therapy Care Gap recommendations are developed based on current clinical guidelines and clinical evidence. Patients with therapy gaps are identified using full prescription drug claims history as well as patient demographics, concurrent disease states and concurrent medications. Therapy Care Gaps are then reviewed for clinical relevance by clinical pharmacists, and the prescribing physician and patient are notified as appropriate. Patients will also receive educational materials on a quarterly basis. Outcomes reporting at 6 months and annually will quantify the number of Therapy Care Gaps identified, changes in physician prescribing post -identification and communication, and the change in actual patient medication history post -identification. B) Medication Adherence and Persistency ( three disease states) Medication Adherence and Persistency ("A&P") interventions identify members who are not properly following the prescriber's instruction regarding medications ("adherence") or are not remaining on the prescribed therapy for the recommended time period ("persistence"). The Program targets medication for chronic diseases such as hypertension, diabetes, and high cholesterol. Additional (greater than 3) disease states can be selected for an additional fee. Potential medication non -adherence is identified in a target patient population using four major parameters: Medication Possession Ratio ("MPR"), Median Gap, Persistence, and Days of Therapy. This service seeks to identify and resolve issues related to compliance and/or persistency by offering patients quarterly progress reports on their adherence and notifications to providers and/or disease management firms for further interventions that foster compliant and persistent behavior. In addition to the individualized quarterly member progress reports, annual outcomes reports documenting the change in adherence parameters Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 34 of 49 for the year as compared to the baseline period. C) Included Reports: • Outcomes reports at 6 months and annually on all Therapy Care Gaps; • Disease state specific reports and 6 months and annually regarding chronic medication adherence for those drugs within those disease states; and • Quarterly and annual individual personalized member medication adherence reports. Fees for Additional Clinical Program Services (only at client's request) • Drug Therapy Care Gap Management: $0.55 PMPM • Medication Adherence and Persistency (up to three disease states): $0.55 PMPM Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 35 of 49 COVERAGE DETERMINATION AND APPEALS PROCESS ADDENDUM This Coverage Determination and Appeals Process Addendum (hereinafter "Addendum") is entered into by and between Envision Pharmaceutical Services, LLC (hereinafter "Envision") and (hereinafter "Plan Sponsor") as follows. This Addendum is effective (hereinafter the "Effective Date"). BACKGROUND Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement dated (hereinafter "Agreement") under which Envision provides PBM Services to Plan Sponsor. Plan Sponsor wishes for Envision to provide additional services under the Agreement as set forth below. NOW THEREFORE, Envision and Plan Sponsor agree as follows: 1. Initial Coverage Determinations and Appeals: Envision shall administer a Coverage Determination and Appeals Process under Plan Sponsor's direction as described in Exhibit 1-A. The Coverage Determination and Appeals Process will include: (i) Real- time adjudication to determine coverage/non-coverage status of a Claim; (ii) Initial Determinations (including Clinical Prior Authorizations); and (iii) Redeterminations ("Internal Appeals"). The Coverage Determination and Appeals Process will meet the requirements of the Department of Labor's Internal Claims and Appeals and External Review Processes under 29 CFR §2590.715-2719. 2. Compensation: Plan Sponsor shall pay Envision the following fees: Provided Internally by Envision Coverage Determinations (including Clinical Prior Authorizations) $35.00 per request Redeterminations (Internal Appeals) $125 per request Postage 100% pass -through of all postage 3. All other terms and conditions of the Agreement not modified by this Addendum or any prior amendment or addenda shall remain unchanged. [SIGNATURE PAGE FOLLOWS] Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 36 of 49 IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Addendum as of the Effective Date above. For ENVISION: M. Print Name and Title For PLAN SPONSOR: By: Print Name and Title Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 37 of 49 EXHIBIT 1-A EnvisionOptions Coverage Determination and Redetermination (Internal Appeal) Program Description (Revision date 12/04/2012) Envision maintains a process for Coverage Determinations (including Clinical Prior Authorizations), and Redeterminations. Envision utilizes a claim adjudication platform to determine real-time coverage/non-coverage status for Claims submitted electronically at the Point -of -Sale. Claims failing one or more Benefit Plan coverage rules are rejected at the Point - of -Sale and information regarding the reject reason(s) is conveyed to the dispensing pharmacy at the Point -of -Sale. Pharmacy personnel may contact Envision's Customer Service Department to begin the Coverage Determination process or they may inform the Member of the reason(s) for the rejection and provide the Member with instructions to contact the Customer Service Department in the event the Member would like to initiate a Coverage Determination. Coverage Determinations (or Clinical Prior Authorizations) When a Coverage Determination request is initiated, the information connected with the rejected prescription is conveyed by Envision to the Prescriber via fax with a request for specific information regarding the Member's medication history and disease diagnosis. The Prescriber completes the form and returns it to Envision where the information provided by the Prescriber is evaluated by an Envision clinical pharmacist. Expedited Coverage Determinations occur as soon as possible, taking into account medical exigencies, but no later than 24 hours of receipt of the request and standard determinations occur within 72 hours of receipt of the request. If the information provided meets the criteria to allow an override of the initial rejection, an override will be configured in the adjudication system that will allow the Claim to process. If the clinical review determines the prescription fails to meet the coverage criteria, the prescription will remain in rejected status. The result of the Coverage Determination is communicated to the Member by written letter, the Prescriber by fax, and the dispensing pharmacy by fax. In the event the Coverage Determination results in an Adverse Benefit Determination, as defined below, the notice to the Member and Prescriber includes information identifying the Claim involved, the specific reason for the Adverse Benefit Determination, instructions about the right to initiate a Redetermination (Internal Appeal), a link providing the availability and contact information of an agency offering assistance to the Member with the appeals and external review processes, if one is available, and may contain additional information as directed by Plan Sponsor. An Adverse Benefit Determination is a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 38 of 49 as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate. 29 CFR 2560.503-1(m). An Adverse Benefit Determination also includes any rescission of coverage as defined in the regulations restricting rescissions (26 CFR 54.9815-2712T(a)(2), 29 CFR 2590.715-2712(a)(2), and 45 CFR 147.128(a)(2)), whether or not there is an adverse effect on any particular benefit at that time. The availability and contact information of an agency offering assistance to the Member with the appeals and external review processes can be found at: www.healthcare.gov/us4-- insurance/mana°nia!r/consu er-holv% index.html. Redetermination (Internal Appeal) Upon initiation of a Redetermination by the Prescriber or Member (or the Member's appointed representative), additional supporting documentation may be requested by Envision from the Prescriber. Expedited Redetermination request evaluations occur as soon as possible, taking into account medical exigencies, but no later than 72 hours of receipt of the request to allow the Member to submit additional information for consideration, and standard evaluations occur within 72 hours of receipt of the request. The evaluation is performed by a clinical pharmacist or pharmacists other than the pharmacist or pharmacists that reviewed the original Coverage Determination request, to maintain impartiality within the review process. Envision will allow a Member to review the claim file and to present evidence and testimony as part of the Internal Appeals process. Envision will provide the Member, free of charge, with any new or additional evidence considered, relied upon, or generated by the Redetermination as soon as possible and sufficiently in advance of the date on which the notice of an Adverse Benefit Determination is required to be provided, to give the Member a reasonable opportunity to respond prior to that date. If the Redetermination information supports an override of an Adverse Benefit Determination, an override will be configured in the adjudication system which will allow the Claim to process. If evaluation determines the Redetermination request fails to meet the coverage criteria, the Claim will remain in rejected status. The result of the Redetermination is communicated to the Member by written letter and the Prescriber by fax. In the event the Redetermination results in an Adverse Benefit Determination, the notice to the Member and Prescriber will include information identifying the Claim, the specific reason for the Adverse Benefit Determination including a discussion of the decision including the plan provision relied upon, instructions about their right to initiate an External Review, if applicable, a statement that the Member has a right to bring a civil action under ERISA Section 502(a) following a denial upon appeal, a link providing the availability and contact information of an agency offering assistance to the Member with the external review process, if one is available, and may contain additional information as directed by Plan Sponsor. The Member may, upon request and free of charge, receive reasonable access to and copies of all documents, records, and other information used in the Coverage Determination Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 39 of 49 The availability and contact information of an agency offering assistance to the Member with the appeals and external review processes can be found at: www.healthcare. ovlusin ins ancel ana 'n lconsu er-hel— -ndex.htrnl. Monroe County PBMSA 082217 TBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 40 of 49 Exhibit 3 Federal Contractual Provisions Required by 2 CFR part 200 et seq. 1 SMALL AND MINORITY BUSINESSES, WOMEN'S BUSINESS ENTERPRISES, AND LABOR SURPLUS AREA FIRMS. The County strongly encourages the use of women-, minority- and veteran -owned business enterprises (SBEs) and wishes to see a minimum of 25% of the contract or subcontracts awarded pursuant to this RFP go to SBEs. Contractors may search for Florida registered SBEs at: htt :11 rw,d s, �f>orida,comla enc ad inistration/office of su rlier diversity osd Any proposal submitted in which the vendor is certified as an SBE, or in which the vendor proposes to use subcontractors that are certified as SBEs, in Florida or another jurisdiction, must submit proof of the registration or certification from the local authority in order to receive credit for the use of the SBE. 2. AUDIT OF RECORDS Contractor shall grant to the County, DEM, FEMA, the Federal Government, and any other duly authorized agencies of the Federal Government or the County where appropriate the right to inspect and review all books and records directly pertaining to the Contract resulting from this RFP for a period of five (5) years after final grant close-out by FEMA or DEM, or as required by applicable County, State and Federal law. Records shall be made available during normal working hours for this purpose. In the event that FEMA. DEM, or any other Federal or State agency, or the County, issues findings or rulings that the amounts charged by the Contractor, or any portions thereof, were ineligible or were non -allowable under federal or state Law or regulation, Contractor may appeal any such finding or ruling. If such appeal is unsuccessful, the Contractor shall agree that the amounts paid to the Contractor shall be adjusted accordingly, and that the Contractor shall, within 30 days thereafter, issue a remittance to the County of any payments declared to be ineligible or non -allowable. Contractor shall comply with federal and/or state laws authorizing an audit of Contractor's operation as a whole, or of specific Project activities. Under no circumstances shall advertising or other communications with the media be presented in such a manner as to County or imply that the Contractor or the Contractor's services are endorsed by the County. 3. TERMINATION A. In the event that the CONTRACTOR shall be found to be negligent in any aspect of Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 41 of 49 service, the COUNTY shall have the right to terminate this agreement after five days written notification to the CONTRACTOR. B. Either of the parties hereto may cancel this Agreement without cause by giving the other party sixty (60) days written notice of its intention to do so. B. Termination for Cause and Remedies: In the event of breach of any contract terms, the COUNTY retains the right to terminate this Agreement. The COUNTY may also terminate this agreement for cause with CONTRACTOR should CONTRACTOR fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination, prior to termination, the COUNTY shall provide CONTRACTOR with five (5) calendar days' notice and provide the CONTRACTOR with an opportunity to cure the breach that has occurred. If the breach is not cured within 24 hours of notice, the Agreement will be terminated for cause. If the COUNTY terminates this agreement with the CONTRACTOR, COUNTY shall pay CONTRACTOR the sum due the CONTRACTOR under this agreement prior to termination, unless the cost of completion to the COUNTY exceeds the funds remaining in the contract; however, the COUNTY reserves the right to assert and seek an offset for damages caused by the breach, including the cost of corrective work. The maximum amount due to CONTRACTOR shall not in any event exceed the spending cap in this Agreement. In addition, the COUNTY reserves all rights available to recoup monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the COUNTY's False Claims Ordinance, located at Section 2-721 et al. of the Monroe County Code. C. Termination for Convenience: The COUNTY may terminate this Agreement for convenience, at any time, upon one (1) weeks' notice to CONTRACTOR. The COUNTY may also terminate this agreement for cause with CONTRACTOR should CONTRACTOR fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination, prior to termination, the COUNTY shall provide CONTRACTOR with five (5) calendar days' notice and provide the CONTRACTOR with an opportunity to cure the breach that has occurred. If the breach is not cured, the Agreement will be terminated for cause. If the COUNTY terminates this agreement with the CONTRACTOR, COUNTY shall pay CONTRACTOR the sum due the CONTRACTOR under this agreement prior to termination, unless the cost of completion to the COUNTY exceeds the funds remaining in the contract. The maximum amount due to CONTRACTOR shall not exceed the spending cap in this Agreement. In addition, the COUNTY reserves all rights available to recoup monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the COUNTY's False Claims Ordinance, located at Section 2-721 et al. of the Monroe County Code. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 42 of 49 4. PUBLIC ENTITIES CRIMES AND DEBARMENT A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on contracts to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017 of the Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. By signing this Agreement, CONTRACTOR represents that the execution of this Agreement will not violate the Public Entity Crimes Act (Section 287.133, Florida Statutes). Violation of terms of this contract shall result in termination of this Agreement and recovery of all monies paid hereto, suspension of the ability to bid on and perform County contracts, and may result in debarment from COUNTY's competitive procurement activities. In addition to the foregoing, CONTRACTOR further represents that there has been no determination, based on an audit, that it or any subcontractor has committed an act defined by Section 287.133, Florida Statutes, as a "public entity crime" and that it has not been formally charged with committing an act defined as a "public entity crime" regardless of the amount of money involved or whether CONUSULTANT has been placed on the convicted vendor list. CONTRACTOR will promptly notify the COUNTY if it or any subcontractor or CONTRACTOR is formally charged with an act defined as a "public entity crime" or has been placed on the convicted vendor list. 5. NONDISCRIMINATION During the performance of this Agreement, the CONTRACTOR agrees as follows: (1) The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, or national origin. The contractor will take affirmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. Such action shall include, but not be limited to the following: Employment, upgrading, demotion, or transfer, recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 43 of 49 employment, notices to be provided by the contracting officer setting forth the provisions of this nondiscrimination clause. (2) The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin. (3) The contractor will not discharge or in any other manner discriminate against any employee or applicant for employment because such employee or applicant has inquired about, discussed, or disclosed the compensation of the employee or applicant or another employee or applicant. This provision shall not apply to instances in which an employee who has access to the compensation information of other employees or applicants as a part of such employee's essential job functions discloses the compensation of such other employees or applicants to individuals who do not otherwise have access to such information, unless such disclosure is in response to a formal complaint or charge, in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or is consistent with the contractor's legal duty to furnish information. (4) The contractor will send to each labor union or representative of workers with which it has a collective bargaining agreement or other contract or understanding, a notice to be provided by the agency contracting officer, advising the labor union or workers' representative of the contractor's commitments under section 202 of Executive Order 11246 of September 24, 1965, and shall post copies of the notice in conspicuous places available to employees and applicants for employment. (5) The contractor will comply with all provisions of Executive Order 11246 of September 24, 1965, and of the rules, regulations, and relevant orders of the Secretary of Labor. (6) The contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, and by the rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by the contracting agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations, and orders. (7) In the event of the contractor's non-compliance with the nondiscrimination clauses of this contract or with any of such rules, regulations, or orders, this contract may be canceled, terminated or suspended in whole or in part and the contractor may be declared ineligible for further Government contracts in accordance with procedures authorized in Executive Order 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as Monroe County PBMSA 082217 TBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 44 of 49 provided in Executive Order 11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law. 6. COVENANT OF NO INTEREST CONTRACTOR and COUNTY covenant that neither presently has any interest, and shall not acquire any interest, which would conflict in any manner or degree with its performance under this Agreement, and that only interest of each is to perform and receive benefits as recited in this Agreement. 7. CODE OF ETHICS The parties recognize and agree that officers and employees of the COUNTY recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. 8. NO SOLICITATION/PAYMENT The CONTRACTOR and COUNTY warrant that, in respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. 9. PUBLIC RECORDS. Public Records Compliance. Pursuant to F. S. 119.0701 and the terms and conditions of this contract, if the Contractor is an individual, partnership, corporation or business entity that enters into a contract for services with a public agency and is acting on behalf of the public agency as provided under F.S. 119.011(2), the CONTRACTOR is required to: (1) Keep and maintain public records that would be required by the County to perform the service. (2) Upon receipt from the County's custodian of records, provide the County with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in this chapter or as Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 45 of 49 otherwise provided by law. (3) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the CONTRACTOR does not transfer the records to the County. (4) Upon completion of the contract, transfer, at no cost, to the County all public records in possession of the CONTRACTOR or keep and maintain public records that would be required by the County to perform the service. If the CONTRACTOR transfers all public records to the County upon completion of the contract, the CONTRACTOR shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the CONTRACTOR keeps and maintains public records upon completion of the contract, the CONTRACTOR shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the County, upon request from the County's custodian of records, in a format that is compatible with the information technology systems of the County. (5) A request to inspect or copy public records relating to a County contract must be made directly to the County, but if the County does not possess the requested records, the County shall immediately notify the CONTRACTOR of the request, and the CONTRACTOR must provide the records to the County or allow the records to be inspected or copied within a reasonable time. If the CONTRACTOR does not comply with the County's request for records, the County shall enforce the public records contract provisions in accordance with the contract, notwithstanding the County's option and right to unilaterally cancel this contract upon violation of this provision by the CONTRACTOR. A CONTRACTOR who fails to provide the public records to the County or pursuant to a valid public records request within a reasonable time may be subject to penalties under section119.10, Florida Statutes. The CONTRACTOR shall not transfer custody, release, alter, destroy or otherwise dispose of any public records unless or otherwise provided in this provision or as otherwise provided by law. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY AT PHONE# 305-292-3470 BRADLEY-BRIAN(i�MONROECOUNTY-FL.GOV, MONROE COUNTY ATTORNEY'S OFFICE 1111 12TH Street, SUITE 408, KEY WEST, FL 33040. 10. FEDERAL CONTRACT REQUIREMENTS The CONTRACTOR and its subcontractors must follow the provisions as set forth in Appendix II to Part 200, as amended, including but not limited to: Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 46 of 49 A. Contractor agrees to comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C. 7401-7671 q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251-1387) and will reports violations to FEMA and the Regional Office of the Environmental Protection Agency (EPA). B. Davis -Bacon Act, as amended (40 U.S.C. 3141-3148). When required by Federal program legislation, all prime construction contracts in excess of $2,000 awarded by non -Federal entities must comply with the Davis -Bacon Act (40 U.S.C. 3141-3144, and 3146-3148) as supplemented by Department of Labor regulations (29 CFR Part 5, "Labor Standards Provisions Applicable to Contracts Covering Federally Financed and Assisted Construction"). In accordance with the statute, contractors must be required to pay wages to laborers and mechanics at a rate not less than the prevailing wages specified in a wage determination made by the Secretary of Labor. In addition, contractors must be required to pay wages not less than once a week. The COUNTY must place a copy of the current prevailing wage determination issued by the Department of Labor in each solicitation. The decision to award a contract or subcontract must be conditioned upon the acceptance of the wage determination. The COUNTY must report all suspected or reported violations to the Federal awarding agency. The contractors must also comply with the Copeland "Anti -Kickback" Act (40 U.S.C. 3145), as supplemented by Department of Labor regulations (29 CFR Part 3, "Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or Grants from the United States"). As required by the Act, each contractor or subrecipient is prohibited from inducing, by any means, any person employed in the construction, completion, or repair of public work, to give up any part of the compensation to which he or she is otherwise entitled. The COUNTY must report all suspected or reported violations to the Federal awarding agency. C. Contract Work Hours and Safety Standards Act (40 U.S.C. 3701-3708). Where applicable, all contracts awarded by the COUNTY in excess of $100,000 that involve the employment of mechanics or laborers must comply with 40 U.S.C. 3702 and 3704, as supplemented by Department of Labor regulations (29 CFR Part 5). Under 40 U.S.C. 3702 of the Act, each contractor must compute the wages of every mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of the standard work week is permissible provided that the worker is compensated at a rate of not less than one and a half times the basic rate of pay for all hours worked in excess of 40 hours in the work week. The requirements of 40 U.S.C. 3704 are applicable to construction work and provide that no laborer or mechanic must be required to work in surroundings or under working conditions which are unsanitary, hazardous or dangerous. These requirements do not apply to the purchases of supplies or materials or articles ordinarily available on the open market, or contracts for transportation or transmission of intelligence. D. Rights to Inventions Made Under a Contract or Agreement. If the Federal award meets the definition of "funding agreement" under 37 CFR §401.2 (a) and the recipient or subrecipient wishes to enter into a contract with a small business Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 47 of 49 firm or nonprofit organization regarding the substitution of parties, assignment or performance of experimental, developmental, or research work under that "funding agreement," the recipient or subrecipient must comply with the requirements of 37 CFR Part 401, "Rights to Inventions Made by Nonprofit Organizations and Small Business Firms Under Government Grants, Contracts and Cooperative Agreements," and any implementing regulations issued by the awarding agency. F. Clean Air Act (42 U.S.C. 7401-7671q.) and the Federal Water Pollution Control Act (33 U.S.C. 1251-1387), as amended —Contracts and subgrants of amounts in excess of $150,000 must comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C. 7401-7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251-1387). Violations must be reported to the Federal awarding agency and the Regional Office of the Environmental Protection Agency (EPA). G. Debarment and Suspension (Executive Orders 12549 and 12689)A contract award (see 2 CFR 180.220) must not be made to parties listed on the governmentwide exclusions in the System for Award Management (SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3 CFR part 1989 Comp., p. 235), "Debarment and Suspension." SAM Exclusions contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549. H. Byrd Anti -Lobbying Amendment (31 U.S.C. 1352)Contractors that apply or bid for an award exceeding $100,000 must file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352. Each tier must also disclose any lobbying with non -Federal funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the non -Federal award. I. Procurement of recovered materials as set forth in 2 CFR § 200.322. Other Federal Requirements: A. Americans with Disabilities Act of 1990 (ADA) — The CONTRACTOR will comply with all the requirements as imposed by the ADA, the regulations of the Federal government issued thereunder, and the assurance by the CONTRACTOR pursuant thereto. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 48 of 49 B. Disadvantaged Business Enterprise (DBE) Policy and Obligation - It is the policy of the COUNTY that DBE's, as defined in 49 C.F.R. Part 26, as amended, shall have the opportunity to participate in the performance of contracts financed in whole or in part with COUNTY funds under this Agreement. The DBE requirements of applicable federal and state laws and regulations apply to this Agreement. The COUNTY and its CONTRACTOR agree to ensure that DBE's have the opportunity to participate in the performance of this Agreement. In this regard, all recipients and contractors shall take all necessary and reasonable steps in accordance with applicable federal and state laws and regulations to ensure that the DBE's have the opportunity to compete for and perform contracts. The COUNTY and the CONTRACTOR and subcontractors shall not discriminate on the basis of race, color, national origin or sex in the award and performance of contracts, entered pursuant to this Agreement. C. The Contractor shall utilize the U.S. Department of Homeland Security's E- Verify system to verify the employment eligibility of all new employees hired by the Contractor during the term of the Contract and shall expressly require any subcontractors performing work or providing services pursuant to the Contract to likewise utilize the U.S. Department of Homeland Security's E-Verify system to verify the employment eligibility of all new employees hired by the subcontractor during the Contract term. 11. No Obligation by Federal Government. The federal government is not a party to this contract and is not subject to any obligations or liabilities to the non -Federal entity, contractor, or any other party pertaining to any matter resulting from the contract. 12. Program Fraud and False or Fraudulent Statements or Related Acts. The Contractor acknowledges that 31 U.S.C. Chapter 38 (Administrative Remedies for False Claims and Statements) applies to the Contractor's actions pertaining to this contract. Monroe County PBMSA 082217 \PBMSA (frm120916) 0 Envision Pharmaceutical Services, LLC Page 49 of 49 Envis *bt, p1m," 2018 MEDICARE EMPLOYER GROUP AGREEMENT (EGWPMRAP ASO) Envision Insurance Company 2181 East Aurora Road Twinsburg, OH 44087 Toll Free Telephone: (866) 250-2005 1EGWP+WRAP SELF -INSURED ASO (2017) CO Packet',Pg. 204 2018 PLAN YEAR COVER SHEET Employer Group Name: Monroe County Board of County Commissioners Notice Address for Employer Group: 1100 Simonton St. # 2-268 Key West, FL 33040 Employer Group Telephone Number: (305) 292 - 4452 Notice Address for Envision Insurance Company: 2181 East Aurora Rd Twinsburg, OH 44087 Effective Date of Service: 12:01a.m. January 1, 2018 Term of Service: From 12:01a.m. January 1, 2018 through 11:59 p.m. December 31, 2018, unless otherwise agreed upon by the parties Administrative Fee: $10.00 per Member, per month (PMPM) Covered Benefits: Please refer to the Evidence of Coverage and Summary of Benefits. This Employer Group Agreement (the "Employer Group Agreement") is a legal contract between the Employer Group named above and Envision Insurance Company ("EIC"). This Cover Sheet provides only a brief outline of some of the terms. The provisions below set forth, in detail, the rights and obligations of the Employer Group and EIC. a� c� . Uj C 0 c� 0 N 0 U) a. Uj c E c� Page 1 of 27 Packet Pg. 205 MEDICARE EMPLOYER GROUP AGREEMENT Administrative Services Only ("ASO") This Employer Group Agreement is entered into by and between Envision Insurance Company (EIC), a Medicare Part D Prescription Drug Plan, and the Employer Group specified in the attached Cover Sheet. This Employer Group Agreement shall be effective on the Effective Date of Service specified in the Cover Sheet and shall continue in force for the Term of Service, unless terminated as provided herein. THIS IS NOT A CONTRACT OF INSURANCE. THE EMPLOYER GROUP IS SELF -INSURED AND RESPONSIBLE FOR ALL CLAIMS AND EXPENSES PROVIDED HEREUNDER. AMOUNTS PAID TO EIC BY EMPLOYER GROUP HEREUNDER ARE NOT INSURANCE PREMIUMS. BACKGROUND The Employer Group desires to enroll its Medicare Eligible retirees into a Medicare Part D Employer Group Waiver Plan ("EGWP") with supplemental wraparound ("Wrap") benefits (EGWP/wrap) to be sponsored by Employer Group and administered by EIC in accordance with the applicable federal and state rules and regulations governing such plans. Employer Group desires to self -insure and be solely responsible for the costs, fees, and expenses associated with the provision and administration of Covered Benefits, as more fully described herein. Notwithstanding the financial responsibility of Employer Group, each retiree enrolled in the plan will be a Member of EIC and be subject to all applicable rules and regulations governing Medicare Part D Plan Beneficiaries. All eligibility, enrollment and other Part D benefit rules applicable to Employer Group Waiver Plans will apply to Employer Group and its enrolled Medicare Eligible retirees. In consideration of the mutual promises hereunder and the receipt of payments required hereunder when due, EIC will provide for the administration of prescription drug benefits in accordance with the terms, conditions, limitations, and exclusions set forth in this Employer Group Agreement. SECTION 1 - DEFINITIONS Capitalized terms not defined in this Employer Group Agreement shall have the meaning set forth in the attached schedules and exhibits. 1.1 The terms "Employer Group", "Effective Date of Service", "Term of Service" and Administrative Fee will have the meaning set forth in the attached Cover Sheet. 1.2 "Benefit Specification Form" or "Benefit Specification Change Form" means the forms, submitted by Employer Group, that specify (i) the terms and conditions for coverage of Covered Benefits; (ii) any limitations, conditions, or exclusions; (iii) the EGWP/wrap Formulary tier structure and Cost Share requirements; and (iii) any other terms and conditions associated with the specific services to be rendered by EIC under this Agreement (i.e. Clinical Prior Authorizations, Drug Therapy Management, etc.). If there is any inconsistency between the terms of this Agreement and the Benefit Specification Form or any Benefit Specification Change Form submitted in connection with the administrative services to be provided under this Agreement, then the provisions of the most recent signed Benefit Specification Form or Benefit Change Form shall control. 1.3 "Brand Drug" means a Prescription Drug designated as a branded drug product by Medi-Span as indicated by the multisource (i.e. MONY) code attached to the 11 digit NDC for such drug. 1.4 "Contract Year' means the Term of Service set forth on the Cover Sheet, and each subsequent Term of Service should this Employer Group Agreement be renewed in accordance with Section 6.1. Page 2 of 27 Packet Pg. 206 1.5 "Claim" means an invoice or electronic submission by a dispensing pharmacy or Member for a Covered Benefit. 1.6 "Covered Benefits" means those prescription drugs and related services covered by, and paid for by Employer Group, as specified by Employer Group on the most recent Benefit Specification Form or Benefit Change Form, as permitted under applicable law, the Evidence of Coverage, and Summary of Benefits incorporated herein. 1.7 "Cover Sheet" means the page entitled "2018 Plan Year Cover Sheet", attached hereto and incorporated herein by this reference. 1.8 "CMS" means the Centers for Medicare and Medicaid Services, which administers the Medicare Part D program and with which EIC maintains a contract as a Medicare Part D Prescription Drug Plan. 1.9 "CMS Receipts" means all premiums, subsidies, catastrophic reinsurance, and other amounts paid to EIC by CMS connected with Employer Group under the Medicare Part D program. 1.10 "EGWP" means the Employer Group's Medicare Part D Employer Group Waiver Plan (Series 800 Plan) administered by EIC hereunder. 1.11 "EIC Formulary" means the list of drugs, filed by EIC and approved by CMS, which are covered under the EGWP. Employer Group acknowledges that the EIC Formulary may be modified from time -to -time by EIC's Pharmacy and Therapeutics (P&T) Committee when it becomes necessary to remove drugs from the EIC Formulary which have been taken off the market or have been determined to not meet safety and/or efficacy standards, or to add new drugs that are required to be covered by Medicare Part D.. 1.12 "Eligible Individual" means an individual who (i) is eligible for coverage of prescription drug benefits under the Employer Group's Retiree Benefit Plan (ii) is Medicare Eligible; and (iii) has retired from Employer Group and is NOT an active employee or a dependent of an active employee. An Eligible Individual may be a Medicare Eligible dependent of an individual who is not Medicare Eligible; a Medicare Eligible dependent survivor of a deceased individual; or such other Medicare Eligible individual who is not covered under the Employer Group's health benefit plan for active employees and dependents; provided that such individual is eligible for prescription drug benefits under the Employer Group Retiree Benefit Plan. 1.13 "Employer Group Agreement" means this document and attachments hereto, including the Cover Sheet, the Summary of Benefits, the Evidence of Coverage (EOC), and any amendments to such attachments, in addition to any riders, amendments, endorsements, inserts, or other documents describing the terms for coverage under the EGWP/wrap, together with the information provided by Employer Group on its application or other written documentation upon which EIC relied to enter into this Employer Group Agreement. EIC agrees that to the extent any such documents are written for all EIC enrollees (including enrollees who are not Plan Beneficiaries of Employer Group), and certain terms in said documents do not describe Employer Group's EGWP/wrap, or certain material terms in Employer Group's EGWP/wrap are not described in the documents, EIC will generate an exhibit or attachment describing any differences. Any document transmitted by EIC to Members that is created for Employer Group (as opposed to for Employer Group and other EIC clients) will be given to Employer Group by EIC for review and approval prior to EIC's transmittal to Employer Group's Members. 1.14 "Evidence of Coverage" or "EOC" means the CMS approved document setting out the rules of coverage for Members under the EGWP, along with any riders, amendments, or endorsements thereto. 1.15 "Financial Contribution" means any monthly or other payment required under the Employer Group's Retiree Benefit Plan to be made by a Member for coverage under the EGWP, including without limitation, a contribution Page 3 of 27 required under the Retiree Benefit Plan for Medicare Part D coverage (the "Group Coverage Fee"), a deductible payment, Copayment, Coinsurance and Late Enrollment Penalty ("LEP"). 1.16 "Generic Drug" means a Prescription Drug that is not a Brand Drug. 1.17 "Limited Distribution Drugs" means Prescription Drugs that are distributed by manufacturers through a limited number of pharmacies and wholesalers which have been selected by the manufacturer based on approved participation criteria. 1.18 "Medicare Part D" means the Medicare Part D Prescription Drug Program regulated by CMS and its associated regulations under42 C.F.R. 423.100, et. seq. 1.19 "Medicare Eligible" means the individual is eligible for coverage for Medicare Part D benefits at all times during the Term of Service. If, at any time during the Term of Service, an individual is no longer eligible for coverage for Medicare Part D benefits (e.g. fails to make required payments to the Social Security Administration), such individual shall be dis-enrolled by EIC. 1.20 "Member' means an Eligible Individual who has been enrolled in the EGWP by Employer Group and accepted for membership by CMS, as further described in Section 3.1.1. 1.21 "Network Providers" means those pharmacies (including retail, mail order, specialty, long term care, and home infusion pharmacies) that have entered into a contract with EIC to dispense Covered Benefits to Members. EIC maintains a national network of contracted pharmacies, and Members may obtain Covered Benefits from any Network Provider regardless of the Member's residence. Employer Group acknowledges that the list of Network Providers may change from time -to -time. However, EIC agrees that any such change will not violate CMS access requirements. EIC will maintain a current directory of Network Providers on its website. 1.22 "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. 1.23 "Retiree Benefit Plan" means the Employer Group's employment -based benefit plan for coverage of retiree prescription drug benefits. 1.24 "Summary of Benefits" means a description of the prescription drug benefits, as set forth in Exhibit "A", to be administered by EIC under this Employer Group Agreement. 1.25 "Wrap" means a prescription drug benefit plan design that provides commercial, non -Medicare EGWP coverage that is supplemental to the standard Medicare Part D benefits. SECTION 2 - SERVICES 2.1 Covered Benefits 2.1.1 EIC will administer Covered Benefits to Members subject to the terms and conditions of this Employer Group Agreement and consistent with applicable law. Members covered under the EGWP/wrap are subject to all of the conditions and provisions required by CMS and contained herein and incorporated documents. Claims are accepted, processed, and adjudicated for Members under the EGWP before they are accepted, processed, and adjudicated for Members under the Wrap. Employer Group acknowledges and agrees that its Wrap must comply with CMS guidelines and cannot diminish the standard Medicare Part D benefit. A Wrap is considered Page 4 of 27 by CMS to be other health insurance coverage, and as such, discounts provided under the Medicare Coverage Gap Discount Program are applied before any additional coverage beyond the standard Medicare Part D benefits have been taken into account. 2.1.2 If a Member has other insurance coverage, identified by CMS or through information proved by the Member or the Employer Group, EIC will coordinate benefits with these other carriers. 2.2 Evidence of Coverage, and Summary of Benefits: Additional rules governing the provision of Covered Benefits under the EGWP/wrap are stated in the Evidence of Coverage (EOC) and the Summary of Benefits, as interpreted by EIC to comply with applicable law. Employer Group acknowledges that adherence to these rules by Members is required to receive Covered Benefits hereunder. 2.3 EIC Formulary: The EIC Formulary shall be used to determine Covered Benefits for the EGWP. Employer Group shall identify on the Benefit Specification Form those items and services that will be processed under the Wrap. Unless otherwise specified, drugs covered under the Wrap may not be eligible for coverage under the Medicare Part D program. Notices of any changes removing drugs from the EIC Formulary will be mailed by EIC to Members. SECTION 3 - ELIGIBILITY AND ENROLLMENT 3.1 Elkgibility 3.1.1 Necessity for Adherinq To Eligibility Standards. Employer Group acknowledges that CMS establishes explicit eligibility standards, which EIC has specifically identified in the Notice of Important Information, and which, if violated, result in the potential imposition of penalties on EIC. Employer Group acknowledges its responsibility to ensure that all such standards are satisfied. Accordingly, Employer Group acknowledges that only Medicare Eligible retirees or Medicare Eligible dependents who are eligible for Employer Group's Retiree Benefit Plan are eligible to enroll in the EGWP/wrap. Employer Group also acknowledges that the following individuals are NOT eligible to be a Member in the EGWP/wrap: (i) Spouses or dependents who are not eligible for Medicare Part D coverage, even if they are the spouses or dependent of an Eligible Individual; or (ii) Current employees of Employer Group (i.e., active employees) or their eligible spouses and dependents, even if eligible for Medicare Part D. To be eligible for enrollment in the EGWP/wrap, the individual must also be eligible for Medicare Part A and/or Medicare Part B and must have a place of permanent residence inside the fifty United States or Washington, D.C. or any territories where EIC is authorized to do business. Individuals who are incarcerated and identified as such by CMS, or by Employer Group, are not eligible for the EGWP/wrap and may be retroactively dis-enrolled if EIC receives confirmation that the date incarceration began was prior to the Effective Date of Service. Each Medicare Eligible retiree is an individual Member, regardless of whether that individual is a spouse or dependent of another Medicare Eligible retiree. 3.1.2 Attestation of Eligibility. In executing this Employer Group Agreement, Employer Group submits the attestation of eligibility identified in Section 5.1 attesting that the individuals submitted by Employer Group for enrollment in the EGWP/wrap meet the above -stated CMS eligibility requirements and did not opt out after receiving Employer's notice of opt -out rights. 3.1.3 Removal of Medicare Eligible Individuals From Other Medicare Coverage. Employer Group acknowledges that any Medicare Eligible retiree who appears on the eligibility file supplied to EIC will be Page 5 of 27 automatically dis-enrolled by CMS from his or her current Medicare plan, if any, upon EIC's submission of his or her name to CMS for coverage under the EGWP/wrap. 3.1.4 No Waiting Period. Employer Group may not impose a waiting period before individuals are eligible for coverage under the EGWP/wrap. 3.2 Enrollment 3.2.1 Timinq of Enrollment. Eligible Individuals may be enrolled by Employer Group only during the Employer Group's annual open enrollment period ("Open Enrollment Period") or specialty enrollment period upon becoming eligible for prescription drug benefits under the Employer Group's Retiree Benefit Plan. Eligible Individuals who opt -out during the Open Enrollment Period may be enrolled only during a subsequent Open Enrollment Period or as permitted under CMS regulations. Coverage under the EGWP/wrap will not become effective until approved by CMS and confirmed by EIC. Employer Group agrees to hold the Open Enrollment Period concurrent with any other open enrollment period applicable to retiree health benefits covering prescription drugs that is being offered to Employer Group's Medicare Eligible retirees or as otherwise required by CMS. The Employer Group shall permit EIC representatives to meet with Eligible Individuals during the Open Enrollment Period unless EIC and Employer Group agree upon an alternate enrollment procedure. As described in the EOC, other special enrollment periods may apply. Employer Group acknowledges that each Eligible Individual may be required to complete and provide Employer Group and/or EIC with certain eligibility information, including, without limitation, the individual's Medicare ID Number. 3.2.2 Compliance with Enrollment and Disenrollment Procedures. Employer Group and EIC agree to comply with the enrollment and disenrollment procedures described in this Employer Group Agreement and required by CMS. 3.3 Eligibility and Enrollment Procedures 3.3.1 After EIC receives Employer Group's EGWP/wrap file of Eligible Individuals, EIC will submit the information to CMS, and CMS will confirm or reject each Eligible Individual's enrollment into the EGWP/wrap. An Eligible Individual must be enrolled based on his or her state of residence. The Eligible Individual's address used for enrollment must be his or her permanent residence. A mailing address may be provided in a separate field on the EGWP/wrap Eligibility file. If a Member moves to a new permanent state of residence, his or her new residence address must be communicated to EIC. CMS may reject an Eligible Individual's enrollment into the EGWP/wrap for various reasons. EIC will inform Employer Group if EIC receives a CMS rejection and work with Employer Group to determine why the Eligible Individual was rejected and to obtain the information needed to enroll the Eligible Individual into the EGWP/wrap, if possible. 3.3.2 The number of Eligible Individuals and composition of the Employer Group, the identity and status of the Employer Group, the eligibility requirements used to determine membership in the Employer Group, and the participation and contribution standards applicable to the Employer Group which exist at the Effective Date of Service are material to the execution and continuation of this Employer Group Agreement by EIC. The Employer Group shall not, during the Term of Coverage under this Employer Group Agreement, modify the Open Enrollment Period, or any other eligibility requirements as described in the EOC and on the Summary of Benefits, for the purposes of enrolling Eligible Individuals in the EGWP/wrap, unless EIC agrees to the modification in writing. 3.4 Maintenance of Eligibility and Eligibility Updates 3.4.1 Once enrolled by Employer Group and accepted by CMS, Members will continue to be enrolled until any of the following occur: CMS notifies EIC that the Member is no longer eligible for Medicare Part D; Page 6 of 27 (ii) The Member's death; (iii) The Member fails to timely pay Financial Contributions; (iv) The Employer Group notifies EIC of the disenrollment because the Member no longer qualifies for coverage; or (v) The Eligible Individual notifies the Employer Group or enrolling. of the Member from the EGWP/wrap EIC that the Eligible Individual is dis- The Employer Group shall provide EIC with a monthly eligibility update showing eligibility changes (new Members or terminated Members), but does not need to provide a full eligibility file each month. EIC will also notify Employer Group of eligibility changes each month, to the extent EIC learns of such changes during that month. 3.4.2 Disenrollment. For purposes of this Employer Group Agreement, the effective date of termination, in all cases except the Member's death, will be the end of the last calendar month in which the Member was listed as eligible for coverage under the EGWP/wrap. In the case of a Member's death, the effective date of termination will be the date of death as indicated by CMS. For disenrollment by Employer Group to be effective, Employer Group must notify EIC of the date of a Member's termination of coverage under the EGWP/wrap. Employer Group must notify EIC of any terminated Members no later than the twenty-fifth of the month in order for the effective date of termination to be effective the end of such month. GIVEN THAT EIC RECEIVES "ERRORS" FROM CMS FOR RETROACTIVE ENROLLMENT OR DISENROLLMENT, MEMBERS MAY NOT BE RETROACTIVELY ENROLLED OR DISENROLLED BY EMPLOYER GROUP. The only instances where retroactive enrollment or disenrollment will take place is when CMS notifies EIC to process retroactive enrollment or retroactive disenrollment. SECTION 4 — FINANCIAL TERMS 4.1 In General: The financial arrangement between EIC and Employer Group is as follows: (i) EIC will invoice Employer Group the negotiated contractual amount payable to the dispensing pharmacy (plus any applicable taxes, assessments, or fees) for a Covered Benefit without any mark-up or spread; (ii) Employer Group is ultimately liable for 100% of all costs of Covered Benefits; (iii) Employer Group is also ultimately liable for 100% of the PMPM Administrative Fee identified in the Cover Sheet and any Additional Fees as agreed upon in writing by the parties and identified in Exhibit D; (iv) EIC will perform the administrative services necessary to collect all amounts connected with the EGWP/wrap, including CMS Receipts, premium revenue from State Pharmaceutical Assistance Programs ("SPAPs") and amounts due from other payors, as further described below; (v) EIC will also perform the administrative services necessary to collect all Direct and Indirect Remuneration ("DIR") from pharmaceutical manufacturers and other third parties, as required by CMS; (vi) The Employer Group will need to establish a reserve equal to three (3) weeks of pharmacy claims payments due from Employer Group under item (i) above, and the reserve amount will be: (x) invoiced fifteen (15) days prior to the Benefit Effective Date, and (y) repaid upon final settlement with CMS which occurs approximately eleven (11) months after the end of the Contract Year; (vii) Monthly, EIC will invoice the Employer Group for (a) all amounts owed under items (i) and (ii) above, minus (b) all amounts collected under item (iv) and (v) above; Page 7 of 27 (viii) EIC will make all payments due pharmacies for Covered Benefits in accordance with Medicare Part D prompt payment rules for the EGWP and in accordance with applicable state prompt pay laws and regulations for the Wrap. EIC and the Employer Group agree that (i) Employer Group is responsible for assuring that it provides the prescription coverage that it is obligated to provide to its Members; and (ii) EIC, as the administrator of the Employer's Group's coverage program, is responsible for complying with applicable federal and state statutes, rules and regulations and therefore shall have the final authority to determine coverage of Part D benefits in accordance with Medicare Part D requirements. All Claims, settlements, loss payments, drug costs or other amounts of any sort payable under Medicare Part D requirements, irrespective of whether such settlements and payments are included in CMS reinsurance or subsidized by CMS, shall be deemed accepted by Employer Group and Employer Group shall be bound by the settlements made by EIC. Employer Group acknowledges that catastrophic reinsurance amounts may take from nine to twelve months after the end of the Contract Year to be paid by CMS. 4.2 EIC's Statement Obligations and Employer Group's Payment Obligations 4.2.1 EIC's Statement Obligations. EIC shall provide Employer Group with an invoice statement once each month. The invoice statement will show: (i) amounts owed for Covered Benefits; (ii) amounts collected from all third parties, itemizing each such amount; (iii) the difference between item (i) less item (ii); and (iv) any balance remaining to be paid by Employer Group to EIC. Any collected amounts remaining will be refunded to the Employer Group by EIC. A separate invoice statement will be provided for the amounts owed for the Administrative and Additional Fees. 4.2.2 Employer Group's Claims Payment Obligations: EIC will provide Employer Group with an invoice of payable Claims once a week and Employer Group agrees to pay EIC's invoices no later than 12:00 p.m. Eastern time on the third (3rd) business day from receipt of said invoices ("Claims Payment Due Date"). Invoices shall be deemed to have been received by Employer Group upon the earliest delivery of the invoice by mail, e-mail, fax, or courier. If payment is received after the Claims Payment Due Date, Employer Group agrees to pay EIC, in addition to any outstanding amounts payable hereunder, a fee of $1,500 to compensate EIC for the calculation of interest penalties or fines required to be paid under CMS regulations for late payments to pharmacies. Employer Group acknowledges that it will be solely responsible for any and all interest penalties and fines assessed by CMS for late payments to pharmacies that result from Employer Group's failure to provide adequate and timely funds. In addition, if EIC has to make an unscheduled Claims payment to avoid further interest penalties and fines, Employer Group agrees to pay EIC, in addition to the full amount of the Claims invoice, a processing fee of $1,500.00. 4.2.3 Employer Group's Administrative Fee Payment Obligations: Beginning with the first month under this Employer Group Agreement, EIC shall provide Employer Group with an invoice of Administrative Fees prior to the first day of each month. Administrative Fees are due within seven (7) calendar days of receipt of EIC's invoice. The monthly Administrative Fee is calculated by multiplying the number of Members 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 forth on the Cover Sheet (except for the initial invoice which is based on Employer Group's initial Eligibility File). Invoices shall be deemed to have been received by Employer Group upon the earliest delivery of the invoice by mail, e-mail, fax, or courier. 4.2.4 Fees for Additional Services and Miscellaneous Expenses: Employer Group agrees to reimburse EIC for Additional Services and Miscellaneous Expenses (e.g. postage) specified in an attached exhibit hereunder, within seven (7) calendar days of receipt of an invoice. Page 8 of 27 4.3 Financial Responsibility: Employer Group understands and agrees that EIC cannot obligate Network Providers to continue to dispense Covered Benefits without receiving payment for past Claims and EIC shall not be obligated to pay Network Providers if Employer Group fails to timely pay EIC as required under this Employer Group Agreement. Employer Group understands that, if Employer Group has not paid within seven (7) calendar days of written notice by EIC of a past due Claims invoice, EIC may notify Network Providers that Employer Group has not timely paid amounts due for Claims. Further, EIC may suspend the provision of services until any unpaid balance is received and, as a condition of continuing to perform services under this Employer Group Agreement, require Employer Group to deposit additional funds with EIC to ensure the timely payment of future invoices. Employer Group further agrees that EIC shall not be liable for any consequences resulting from the untimely payment of Network Providers, including, without limitation, failure to meet any applicable prompt payment laws, due to the failure of Employer Group to timely pay EIC as required under this Employer Group Agreement. Employer Group acknowledges that it is, and remains responsible for, the payment of all invoices for Covered Benefits dispensed to Members, along with any associated amounts not timely paid by Members, together with any dispensing fees and taxes. 4.4 Financial Contributions and Refund of Low Income Subsidies (LIS): Employer Group shall comply with the following conditions with respect to any subsidization of Financial Contributions by the Members: 4.4.1 Limitations on Employer Group Subsidies. Employer Group may subsidize different amounts for different classes of Members, provided such classes are reasonable and based on objective business criteria, such as years of service, business location, job category, and nature of compensation (e.g., salaried vs. hourly). However, Financial Contribution levels cannot vary for Members within a given class, nor can classes of Members be based on eligibility for Low Income Subsidies ("LIS") provided by CMS for certain individuals. 4.4.2 Identification of Low Income Subsidy ("LIS") Eligible Individuals. EIC will identify LIS Part D Eligible Individuals and notify the Employer Group of these Members. Said individuals may be eligible for Low Income Premium subsidy payments ("LIPs") and Low Income Cost subsidy payments ("LICs"). 4.4.3 LIPs. During implementation, Employer Group shall provide its Retiree Benefit Plan to EIC and the parties will review same to determine, among other factors, if any Members are making Premium Contributions. If any Members are doing so, Employer Group will determine whether it wants EIC to issue LIP checks directly to LIP - eligible Members, or issue a check (or credit) to Employer Group for said amounts in the aggregate, in which case Employer Group will have the responsibility to issue checks and thereafter attest to the fact that it has appropriately done so. CMS requires that any LIPs amounts first be used to reduce any portion of Group Coverage Fees paid to Employer Group by the Member (or on the Member's behalf), with any remaining portion of the LIPs amount then applied toward the portion of any monthly insurance premium the Employer Group would have paid for an equivalent fully -insured EGWP/wrap product ("Illustrative Premium"). Any portion of the LIP subsidy greater than the sum of the Group Coverage Fee and the Illustrative Premium must be returned to CMS. EIC will identify for the Employer Group the Illustrative Premium amount. If the Employer Group indicates during implementation that the Employer Group wants to issue checks to LIPs-eligible Members, EIC shall supply data with each invoice statement identifying the name of each LIPs-eligible Member, and the amount of LIPs that must be refunded to said Member. Employer Group must refund the identified LIPs amounts to Members within forty-five (45) days of EIC's receipt of such amounts from CMS, document how the LIPs amounts were refunded, and provide an attestation to EIC that the LIPs amounts have been properly refunded. Employer Group acknowledges that it may be liable to CMS for any inappropriate retention of LIPs, and Employer Group will forward to EIC any funds that it is not entitled to retain. 4.4.4 LICs. EIC will be responsible for providing LICs to Members at the point of sale. In the event that incorrect amounts of LICs are paid to Members, and additional amounts need to be paid or withheld thereafter, EIC will be responsible for ensuring said corrections are made and creating a record of such transactions as required by CMS. Page 9 of 27 4.5 Other Member Financial Assistance: Employer Group understands that some Members are entitled to receive other financial assistance through State Pharmaceutical Assistance Programs (SPAPs) or other programs. Such financial assistance may take the form of premium assistance or assistance to lower the cost of copayments, coinsurance or the cost of drugs. The parties agree that EIC will handle all such premium assistance as described in Section 4.4.3 for LIPs, and EIC will handle all copayment/coinsurance/cost assistance as described in Section 4.4.4 for LICs. Employer Group acknowledges that it may be liable for any inappropriate retention of premium assistance, and Employer Group will forward to EIC any funds that it is not entitled to retain. 4.6 Additional Financial Contributions from Members: 4.6.1 Late Enrollment Penalty ("LEP'T Employer Group acknowledges that CMS requires Plan Beneficiaries to maintain creditable coverage. If a Plan Beneficiary does not maintain creditable coverage for more than 63 days, CMS assesses a 1 % LEP to that beneficiary once creditable coverage is reinstated. This penalty is not included in amounts received by EIC from CMS or other payors. EIC will invoice Employer Group for any LEP that is owed by a Member, identifying at the time of the invoice the name of the Member, and the amount owed. The Employer Group will be obligated to pay the LEP amount invoiced to EIC. However, the Employer Group may collect the LEP from the Member. EIC will notify Employer Group of Members owing LEPs, as EIC is notified by CMS of these Members, and such notice will be provided on or before the date when EIC invoices the Employer Group for the LEPs. If Employer Group or any Member has documentation that the Member did have continuous creditable coverage, Employer Group may attest to same and EIC will submit a request for rescission of the LEP and a refund from CMS. EIC will pass through to Employer Group any LEP amounts reimbursed by CMS. In the event that CMS determines and notifies EIC that a LEP was wrongly or inaccurately assessed, EIC will notify Employer Group and pass through to the Employer Group any LEP amounts reimbursed by CMS. 4.6.2 Federal Income Related Monthly Adjustment Amount ("IRMAXT Employer Group acknowledges that under IRMAA, if a Member's modified adjusted gross income threshold is exceeded, the Member is required to pay Medicare a higher monthly fee for Medicare benefits. This payment is made by the Member directly to Medicare and is not included in amounts received by EIC from CMS or other payors. 4.6.3 Member's Non -Payment of Financial Contributions: Employer Group acknowledges that failure of a Member to pay any Financial Contributions required under Employer Groups' Retirement Benefit Plan shall not release Employer Group's financial obligations hereunder. If a Member is to be terminated from the EGWP/wrap for non-payment of Financial Contributions, Employer Group must give the Member at least twenty one (21) days advance written notice. This notice must be received by the Member at least twenty one (21) days from the effective date of disenrollment. This should be taken into consideration when establishing the timing for payment of Financial Contributions under Employer Group benefit rules. SECTION 5 — EMPLOYER GROUP's AND EIC's ADDITIONAL RESPONSIBILITIES 5.1 Provision of Information: Employer Group shall furnish to EIC, on a monthly basis (or as otherwise required), on EIC's form (or such other form as EIC may reasonably approve) by electronic methods (or such other means as EIC may reasonably approve), such information as EIC may reasonably require to administer this Employer Group Agreement. This includes, but is not limited to, each Member's Health Insurance Claim Number (HICN), Medicare Beneficiary Identifier (MBI) or its equivalent, needed to enroll members of the Employer Group and process Member terminations or status changes. EIC will not be liable to Members for the fulfillment of any obligation prior to information being received in a form satisfactory to EIC. No later than thirty (30) days prior to the Effective Date, Employer Group shall provide EIC with an executed Benefit Specification Form and such data as necessary for EIC to set up the benefit and to commence the provision of services for the EGWP/wrap. Page 10 of 27 Employer Group certifies, based on its best knowledge, information and belief, that all enrollment and eligibility information that has been or will be supplied to EIC is accurate, complete and truthful. Employer Group acknowledges that EIC can and will rely on such enrollment and eligibility information in determining whether an individual is eligible for Covered Benefits under the EGWP/wrap. 5.2 Maintenance of Information and Records: Employer Group and EIC shall maintain Information and Records (as such terms are defined in Section 5.3 below) for the longer of: (i) a period of ten (10) years from the end of the final contract period under which EIC offers Covered Benefits hereunder, or (ii) the date the U.S. Department of Health and Human Services, the Comptroller General or their designees complete an audit. This Section 5.2 shall survive the termination of this Employer Group Agreement, regardless of the cause of the termination. 5.3 Access to Information and Records: Employer Group and EIC shall provide to federal, state and local governmental authorities having jurisdiction, directly or through their designated agents (collectively "Auditors"), upon request, access to all books, records and other papers, documents, materials and other information (including, but not limited to, contracts and financial records) whether in paper or electronic format, relating to this Employer Group Agreement (together "Information and Records"). Employer Group agrees to provide EIC and Auditors with access to Information and Records, at Employer Group's offices during regular business hours and upon reasonable advance request, for as long as such records are maintained as required in Section 5.2 above. Employer Group agrees to supply copies of Information and Records within fourteen (14) calendar days of Employer Group's receipt of the request, where practicable, and in no event later than the date required by any applicable law or regulatory authority. EIC also agrees to provide Auditors with all requested and reasonable access to Information and Records. This Section 5.3 shall survive the termination of this Employer Group Agreement, regardless of the cause of termination. 5.4 Policies and Procedures; Compliance Verification: Employer Group shall substantially comply with all reasonable policies and procedures established by EIC in administering and interpreting this Employer Group Agreement. Employer Group shall, upon request, provide a certification of its substantial compliance with EIC's participation and contribution requirements and the requirements for a group as defined under 42 C.F.R. 423.100, et. seq. 5.5 Forms: Unless otherwise agreed, and with the exception of the initial letter transmitted by Employer Group to Members to provide Members with an opt -out right from Employer Group's Medicare Part D program, EIC shall distribute all materials to Members regarding enrollment, plan features, including Covered Benefits and exclusions and limitations of coverage. Employer Group shall, within no fewer than thirty (30) calendar days of receipt from an Eligible Individual, forward all completed enrollment information and other required information to EIC. Coverage in the EGWP/wrap for any new Eligible Individuals shall not be effective until such information has been provided to EIC and the individual has been accepted for membership by CMS. 5.6 Member Correspondence: Once an Eligible Individual is enrolled in the EGWP/wrap, the Eligible Individual will receive documents and correspondence from EIC as required by CMS. This may be new to Members previously covered by the Employer Group's prior benefit plan. Members will receive an Evidence of Coverage (EOC) that explains the rules for coverage under the EGWP/wrap, an annual notice of any changes (ANOC) to the benefits, and other correspondence related to Covered Benefits under the EGWP/wrap (i.e. Medication Therapy Management). 5.7 Employer Group Acknowledgments: Employer Group acknowledges and agrees that it may not make changes to the Employer Group's Retiree Benefit Plan during the Term of Service without EIC's prior written approval. SECTION 6 — RENEWAL AND TERMINATION 6.1 Renewal of Employer Group Agreement: This Employer Group Agreement is renewable upon the mutual written agreement of EIC and Employer Group and execution of a new Cover Sheet for the subsequent Term of Page 11 of 27 Service. EIC shall, at least sixty (60) days prior to the end of the Term of Coverage, provide Employer Group with a proposal for a subsequent Term of Coverage; unless EIC will no longer offer an EGWP/wrap plan in any service areas covered under this Employer Group Agreement because: (i) CMS terminates or otherwise non -renews EIC's EGWP/wrap contract with CMS, or (ii) EIC provides CMS with notice of its intention to non -renew its EGWP/wrap contract or reduce the service areas referenced in its Medicare Part D contract with CMS. 6.2 Termination by Employer Group: This Employer Group Agreement may NOT be terminated by Employer Group during any Contract Year for any reason other than a material breach of this Employer Group Agreement by EIC. Should Employer Group wish to terminate for material breach, it shall notify EIC, in writing, at least thirty (30) days prior to the effective date of termination. Such notice shall state the material breach with sufficient specificity to permit EIC to cure the breach. If EIC reasonably cures the breach within the thirty (30) day notice period, this Employer Group Agreement shall not be terminated. 6.3 Termination by EIC: This Employer Group Agreement may be terminated by EIC as follows: (i) Immediately upon notice to Employer Group if Employer Group has performed any material act or practice that constitutes fraud or made any intentional misrepresentation of a material fact relevant to the coverage provided under the EGWP/wrap (The parties agree that inadvertent eligibility errors by Employer Group shall not be characterized by EIC as such acts); (ii) Upon 7 days written notice to Employer Group if Employer Group fails to timely make any payment due EIC, and Employer Group has not cured its failure within seven days; (iii) Upon 30 days written notice to Employer Group, if Employer Group ceases to meet Medicare Part D requirements for an employer group; (iv) Upon 180 days written notice to Employer Group (or such shorter notice as may be permitted by applicable law, but in no event less than 30 days) if EIC ceases to offer a product or coverage in a market in which Members covered under the EGWP/wrap reside; (v) Upon 30 days written notice to Employer Group for any other reason consistent with the Health Insurance Portability and Accountability Act of 1996 ("HIPAK) or by applicable federal rules and regulations, as amended. 6.4 Effect of Termination: Except as otherwise stated below, no termination of this Employer Group Agreement will relieve either EIC or Employer Group from any obligation incurred before the date of termination. When terminated, this Employer Group Agreement and all services administered by EIC under the EGWP/wrap will end at 11:59 p.m. on the effective date of termination. 6.5 Notices to Members: It is the responsibility of Employer Group to notify the Members of the termination of this Employer Group Agreement in accordance with applicable laws, CMS requirements, and EIC's policies and procedures. EIC reserves the right to notify Members of termination of this Employer Group Agreement for any reason, including non-payment of amounts due to EIC by Employer Group; however, EIC's Notice must be presented and approved by Employer Group prior to mailing to Members. In addition, Employer Group shall provide written notice to Members of their rights upon termination of coverage in accordance with the EOC and applicable CMS requirements. SECTION 7 — CONFIDENTIALITY AND PRIVACY OF 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 Page 12 of 27 a party in connection with this Employer Group Agreement (including this Employer Group Agreement and the terms of this Employer Group 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) 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 Compliance with Privacy Laws: Employer Group will abide by all applicable laws and regulations regarding the confidentiality of individually identifiable health and other personal information, including the privacy requirements of HIPAX 7.3 Disclosure of Protected Health Information: EIC will not provide protected health information ("PHI"), as defined in HIPAA, to Employer Group, and Employer Group will not request PHI from EIC, unless Employer Group complies with all applicable HIPAA requirements. Employer Group, for itself and its employees, agrees 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 be not shared with non -designated individuals. Employer Group and EIC shall execute a HIPAA Business Associate Agreement. 7.4 Brokers and Consultants: To the extent any broker or consultant engaged by Employer Group receives PHI in the underwriting process or for any other reason, Employer Group understands and agrees that such broker or consultant is acting on behalf of Employer Group and not EIC. EIC is entitled to rely on Employer Group's representations that any such broker or consultant is authorized to act on Employer Group's behalf and entitled to have access to the PHI under the relevant circumstances. SECTION 8 — MISCELLANEOUS 8.1 Independent Contractors: EIC and Employer Group 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. 8.2 Relationship Between EIC and Network Providers: Employer Group acknowledges that the relationship between EIC and Network Providers is a contractual relationship among independent contractors. Network Providers are neither agents nor employees of EIC, nor is EIC an agent or employee of any Network Provider. Network Providers dispense covered drugs to Members, and EIC administers and determines plan benefits. EIC negotiates contracts with pharmacies, pharmaceutical manufacturers, and vendors on its own behalf and not specifically or exclusively for Employer Group. Network Providers are solely responsible for any services rendered to EIC Members. EIC makes no express or implied warranties or representations concerning the qualifications, continued participation, or quality of services of any Network Provider. A Network Provider's participation may be terminated at any time without advance notice to the Employer Group or Members, subject to applicable law. Employer Group further acknowledges that EIC is neither an operator of pharmacies nor exercises control over the professional judgment used by any pharmacist when dispensing drugs or medical supplies to Members. Nothing in this Employer Group 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 Members. EIC does not indemnify Members or Employer Group, and Employer Group hereby releases EIC, from any liability arising from the dispensing of drugs or medical supplies by any pharmacy to Members. Page 13 of 27 8.3 Limited Indemnification and Limitation of Liability: EIC shall indemnify and hold harmless Employer Group for that portion of any liability, settlement and related expense (including the reasonable cost of legal defense) which was caused solely, directly and independently by EIC fraud, willful misconduct, criminal misconduct, negligence, or material breach of this Employer Group Agreement. Employer Group shall indemnify and hold harmless EIC for that portion of any liability, settlement and related expense (including the reasonable cost of legal defense) which was caused solely, directly and independently by Employer Group's fraud, willful misconduct, criminal misconduct, negligence (including, without limitation, untimely, inaccurate, incomplete, or conflicting eligibility information), or material breach of this Employer Group Agreement. The party seeking indemnification must notify the indemnifying party promptly in writing of any actual or threatened action, suit or proceeding to which it claims such indemnity applies. Failure promptly to so notify the indemnifying party shall be deemed a waiver of the right to seek indemnification. The parties agree that in no event shall the indemnity obligations under this Section 8.3 apply to that portion of any liability, settlement and related expense caused by (a) EIC acts or omissions undertaken at the direction of Employer Group or Employer Group's agent; or (b) Employer Group's act or omission undertaken at EIC's expressed written direction. Notwithstanding the indemnification obligations set forth above (i) each parry's liability to the other hereunder will in no event exceed the actual proximate losses or damages caused by breach of this Employer Group 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. Except in cases of fraud or the inappropriate disclosure of PHI, the rights of the parties hereto for indemnification relating to this Employer Group Agreement or the transactions contemplated herein shall be strictly limited to the those contained in this Section 8.3 and such indemnification rights shall be the exclusive remedies of the parties with respect to any matter arising under or in connection with this Employer Group Agreement. The indemnification obligations of the parties shall terminate upon the expiration of this Employer Group Agreement except as to any matter concerning a claim which has been asserted by notice to the other party at the time of such expiration or within 365 days thereafter. 8.4 Delegation and Subcontracting: Employer Group acknowledges and agrees that EIC may enter into arrangements with its affiliates and other subcontractors to perform certain functions hereunder such as the provision of the provider network, utilization management, customer service, quality assurance and provider credentialing, as EIC deems appropriate. EIC shall remain responsible for the performance of any such delegated functions. 8.5 Prior Agreements; Severability: As of the Effective Date of Service, this Employer Group Agreement replaces and supersedes all other prior agreements between EIC and Employer Group, as well as any other prior written or oral understandings, negotiations, discussions or arrangements between the parties, related to matters covered by this Employer Group Agreement or the documents incorporated herein. If any provision of this Employer Group Agreement is deemed to be invalid or illegal, that provision shall be fully severable and the remaining provisions of this Employer Group Agreement shall continue in full force and effect. 8.6 Amendments: This Employer Group Agreement may be amended as follows: This Employer Group Agreement shall be deemed to be automatically amended to conform to all rules and regulations promulgated at any time by any state or federal regulatory agency or authority having supervisory authority over EIC; or by written agreement executed by both EIC and Employer Group. Except for said automatic amendments, all amendments to this Employer Group Agreement must be approved and executed by EIC and Employer Group. No employee, entity, Page 14 of 27 or individual has the authority to (i) modify this Employer Group Agreement; (ii) waive any of its provisions, conditions, or restrictions; (iii) extend the time for making a payment; or (iv)bind EIC by making any other commitment or representation or by giving or receiving any information. 8.7 Clerical Errors: Clerical errors or delays by EIC in keeping or reporting data relative to coverage will not reduce or invalidate a Member's coverage. Upon discovery of an error or delay, an adjustment of Administrative Fee shall be made to reflect the cost of the error or delay. EIC may also modify or replace an Employer Group Agreement, EOC or other document issued in error. 8.8 Claim Determinations and Administration of Covered Benefits: EIC has complete authority to review all claims for Covered Benefits as defined in the EOC under this Employer Group Agreement. In exercising such responsibility, EIC shall have discretionary authority to determine whether and to what extent Members are entitled to coverage and to construe any disputed or doubtful terms under this Employer Group Agreement, the EOC or any other document incorporated herein. The administration of Covered Benefits and of any appeals filed by Members related to the processing of claims for Covered Benefits shall be conducted in accordance with the EOC and CMS regulations. 8.9 Third Party Billing: EIC may engage a third party entity to provide billing services on behalf of EIC under this Employer Group Agreement. The third party entity is not and should not be considered a third -party beneficiary. 8.10 Misstatements: If any fact as to Employer Group or a Member is found to have been misstated, an equitable adjustment of Administrative Fee may be made. If the misstatement affects the existence or amount of coverage, the true facts will be used in determining whether coverage is or remains in force and its amount. 8.11 Incontestability: Except as to a fraudulent misstatement, or issues concerning Administrative Fees due, no statement made by Employer Group or any Member shall be the basis for voiding coverage or denying coverage or be used in defense of a claim unless it is in writing. 8.12 Assi nabili : No rights or benefits under this Employer Group Agreement are assignable by either EIC or Employer Group to any third party unless approved, in writing, by all parties. 8.13 Waiver: EIC's failure to implement, or insist upon compliance with, any provision of this Employer Group Agreement or the terms of the EOC incorporated hereunder, at any given time or times, shall not constitute a waiver of EIC's right to implement or insist upon compliance with that provision at any other time or times. This includes, but is not limited to, the payment of Premiums or Covered Benefits. This applies whether or not the circumstances are the same. 8.14 Third Parties: This Employer Group Agreement shall not confer any rights or obligations on third parties except as specifically provided herein. 8.15 Non -Discrimination: Employer Group agrees to make no attempt, whether through differential contributions or otherwise, to encourage or discourage enrollment of Eligible Individuals in EIC based on health status or health risk. 8.16 Applicable Law: This Employer Group Agreement shall be governed and construed in accordance with applicable federal law and the applicable law, if any, of the State of Ohio, without regard to its conflict principles. Employer Group acknowledges that EGWPs are governed by federal law and the regulations promulgated by CMS for Medicare Part D Prescription Drug Plans and Wraps are governed by state law and regulation. 8.17 Use of the EICs Name and all Symbols, Trademarks, and Service Marks: EIC reserves the right to control the use of EICs name and all symbols, trademarks, and service marks presently existing or subsequently Page 15 of 27 established. Employer Group agrees that it will not use such name, symbols, trademarks, or service marks in advertising or promotional materials or otherwise without EIC's prior written consent and will cease any and all usage immediately upon EICs request or upon termination of this Employer Group Agreement. 8.18 Dispute Resolution 8.18.1 Mediation: If either party to this Employer Group Agreement should declare a breach of this Employer Group Agreement, or if any dispute arises from this Employer Group Agreement or the subject of this Employer Group Agreement, the parties shall first submit the matter to non -binding mediation (not arbitration) and attempt to resolve the matter, in good faith, prior to the institution of any arbitration or any other legal action. The parties agree that arbitration or any other legal action may be initiated only after each party has presented its case to a qualified mediator associated with a professional mediation firm and such mediator has declared an impasse. Any statements made at such mediation shall be for settlement purposes only and shall not be construed to be an admission. A party demanding mediation shall be entitled to obtain a court order mandating mediation if the other party does not agree to commence mediation within thirty (30) days after written demand. The fees and costs incurred by the party seeking such court order shall be reimbursed by the other party; otherwise, each party shall pay its own costs of mediation. All such mediation proceedings shall be conducted on a confidential basis. The mediation shall be conducted in Monroe County, Florida. 8.19 CMS Contract: This Employer Group Agreement is subject to the annual renewal of EIC's Medicare Part D contract with CMS. Covered Benefits and/or the Administrative Fee and Expenses are also subject to change at the beginning of any subsequent Term of Coverage under this Employer Group Agreement. Except as otherwise provided herein, increases in the Administrative Fee and Expenses and/or decreases in Covered Benefits are only permitted at the beginning of a subsequent Term of Coverage under this Employer Group Agreement. Should CMS cancel EIC's contract as a Medicare Part D contractor or should EIC decide not to continue as a Medicare Part D contractor, Members shall be given notice of such termination in accordance with the EOC and any applicable laws, rules and regulations, including, without limitation, CMS requirements. 8.20 Force Maieure: EIC shall not be deemed to have breached this Employer Group Agreement or be held liable for any failure or delay in the performance of all or any portion of its obligations under this Employer Group 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, dots, strikes, boycotts, lock -outs, acts of terrorism, acts of war or war -operations, restraints of government, power or communications line failure or other circumstances beyond such parry'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 Employer Group Agreement. If due to circumstances not within EICs reasonable control, including but not limited to major disaster, epidemic, complete or partial destruction of facilities, riot, civil insurrection, disability of a significant part of EIC's Network Providers or entities with whom EIC has contracted for services under this Employer Group Agreement, or similar causes, the provision of benefits provided under this Employer Group Agreement is delayed or rendered impractical, EIC shall not have any liability or obligation on account of such delay or failure to provide services, except to refund the amount of the unearned prepaid Administrative Fee held by EIC on the date such event occurs. EIC is required only to make a good -faith effort to provide or arrange for the provision of services, taking into account the impact of the event. This Section 8.20 shall not be considered to be a waiver of any continuing obligations under this Employer Group Agreement, including, without limitation, the obligation to make payments. 8.21 Notices: Any notice required or permitted under this Employer Group Agreement shall be in writing and shall be deemed to have been given on the date when delivered in person; or, if delivered by first-class United States mail, on the date mailed, proper postage prepaid, and properly addressed to the address set forth in the Employer Group Page 16 of 27 Application or Cover Sheet, or to any more recent address of which the sending party has received written notice or, if delivered by facsimile or other electronic means, on the date sent by facsimile or other electronic means. 8.22 Representations: Employer Group represents and warrants that to the best of its knowledge (i) it is self - insured for benefits covered under its Retiree Benefit Plan and the Wrap; (ii) the entering into this Employer Group Agreement 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 Employer Group Agreement, any and all applicable licenses, governmental authority, or other authorization required to operate an entity of its type. EIC represents that (i) there are no organizational arrangements that could potentially create a conflict of interest that affects clinical or financial decisions; and (ii) it maintains, and shall continue to maintain throughout the term of this Employer Group Agreement, any and all applicable licenses, governmental authority, or other authorization required to operate an entity of its type. The following are approved Exhibits to this Employer Group Agreement: Exhibit A: Summary of Benefits Exhibit B: Explanation of Coverage Exhibit C: Administrative Expenses and Drug Pricing [SIGNATURE PAGE FOLLOWS] Page 17 of 27 2018 MEDICARE EMPLOYER GROUP AGREEMENT (EGWP/wrap ASO) SIGNATURE PAGE IN WITNESS WHEREOF, EIC and Employer Group have caused this Employer Group Agreement to be executed by their respective authorized officers. EIC By: William C. Epling, President EMPLOYER GROUP: By: Print Name and Title Address: Address: Envision Insurance Company 2181 East Aurora Road Twinsburg, OH 44087 PH: 330-405-8080 PH: _ FX: 330-405-8081 FX: _ E-MAIL: FEIN: Page 18 of 27 EXHIBIT "A" SUMMARY OF BENEFITS a� c� . c CL m 0 1- 0 CM 0 4 0 U) 4 IL IL c E c� Page 19 of 27 Packet Pg. 223 EXHIBIT C (replace with Exhibit 1 from PBM Agreement once finalized) a� c� C D C uj CL M 0 1- 0 CO CV 0 U) UA E t.� Page 20 of 27 Packet Pg. 224 RIDER -- Federal Contract Provisions Recognizing that a portion of the funds that will be used to pay for these services come from a federal award, as that term is defined in 2 CFR part 200.38, the following additional provisions apply. In the event of an inconsistency between a provision in the agreement and a provision in this Rider, the terms and conditions set forth in this Rider shall prevail, 1. SMALL AND MINORITY BUSINESSES, WOMEN'S BUSINESS ENTERPRISES, AND LABOR SURPLUS AREA FIRMS. The County strongly encourages the use of women-, minority- and veteran -owned business enterprises (SBEs) and wishes to see a minimum of 25% of the contract or subcontracts awarded pursuant to this RFP go to SBEs. Contractors may search for Florida registered SBEs at: http://www.dms.myflorida.com/agency_administration/office_of supplier_ diversity osd Any proposal submitted in which the vendor is certified as an SBE, or in which the vendor proposes to use subcontractors that are certified as SBEs, in Florida or another jurisdiction, must submit proof of the registration or certification from the local authority in order to receive credit for the use of the SBE. 2. AUDIT OF RECORDS Contractor shall grant to the County, DEM, FEMA, the Federal Government, and any other duly authorized agencies of the Federal Government or the County where appropriate the right to inspect and review all books and records directly pertaining to the Contract resulting from this RFP for a period of five (5) years after final grant close-out by FEMA or DEM, or as required by applicable County, State and Federal law. Records shall be made available during normal working hours for this purpose. In the event that FEMA. DEM, or any other Federal or State agency, or the County, issues findings or rulings that the amounts charged by the Contractor, or any portions thereof, were ineligible or were non -allowable under federal or state Law or regulation, Contractor may appeal any such finding or ruling. If such appeal is unsuccessful, the Contractor shall agree that the amounts paid to the Contractor shall be adjusted accordingly, and that the Contractor shall, within 30 days thereafter, issue a remittance to the County of any payments declared to be ineligible or non -allowable. Contractor shall comply with federal and/or state laws authorizing an audit of Contractor's operation as a whole, or of specific Project activities. Under no circumstances shall advertising or other communications with the media be presented in such a manner as to County or imply that the Contractor or the Contractor's services are endorsed by the County. TERMINATION A. In the event that the CONTRACTOR shall be found to be negligent in any aspect of service, the COUNTY shall have the right to terminate this agreement after five days written notification to the CONTRACTOR. B. Either of the parties hereto may cancel this Agreement without cause by giving the other party sixty (60) days written notice of its intention to do so. Termination for Cause and Remedies: In the event of breach of any contract terms, the COUNTY retains the right to terminate this Agreement. The COUNTY may also terminate this agreement for cause with CONTRACTOR should CONTRACTOR fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination, prior to termination, the COUNTY shall provide CONTRACTOR with five (5) calendar days' notice and provide the CONTRACTOR with an opportunity to cure the breach that has occurred. If the breach is not cured within 24 hours of notice, the Agreement will be terminated for cause. If the COUNTY terminates this agreement with the CONTRACTOR, COUNTY shall pay CONTRACTOR the sum due the CONTRACTOR under this agreement prior to termination, unless the cost of completion to the COUNTY exceeds the Page 21 of 27 Packet Pg. 225 funds remaining in the contract; however, the COUNTY reserves the right to assert and seek an offset for damages caused by the breach, including the cost of corrective work. The maximum amount due to CONTRACTOR shall not in any event exceed the spending cap in this Agreement. In addition, the COUNTY reserves all rights available to recoup monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the COUNTY's False Claims Ordinance, located at Section 2-721 et al. of the Monroe County Code. Termination for Convenience: The COUNTY may terminate this Agreement for convenience, at any time, upon one (1) weeks' notice to CONTRACTOR. The COUNTY may also terminate this agreement for cause with CONTRACTOR should CONTRACTOR fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination, prior to termination, the COUNTY shall provide CONTRACTOR with five (5) calendar days' notice and provide the CONTRACTOR with an opportunity to cure the breach that has occurred. If the breach is not cured, the Agreement will be terminated for cause. If the COUNTY terminates this agreement with the CONTRACTOR, COUNTY shall pay CONTRACTOR the sum due the CONTRACTOR under this agreement prior to termination, unless the cost of completion to the COUNTY exceeds the funds remaining in the contract. The maximum amount due to CONTRACTOR shall not exceed the spending cap in this Agreement. In addition, the COUNTY reserves all rights available to recoup monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the COUNTY's False Claims Ordinance, located at Section 2-721 et al. of the Monroe County Code. 4. PUBLIC ENTITIES CRIMES AND DEBARMENT A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid on contracts to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017 of the Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. By signing this Agreement, CONTRACTOR represents that the execution of this Agreement will not violate the Public Entity Crimes Act (Section 287.133, Florida Statutes). Violation of terms of this contract shall result in termination of this Agreement and recovery of all monies paid hereto, suspension of the ability to bid on and perform County contracts, and may result in debarment from COUNTY's competitive procurement activities. In addition to the foregoing, CONTRACTOR further represents that there has been no determination, based on an audit, that it or any subcontractor has committed an act defined by Section 287.133, Florida Statutes, as a "public entity crime" and that it has not been formally charged with committing an act defined as a "public entity crime" regardless of the amount of money involved or whether CONUSULTANT has been placed on the convicted vendor list. CONTRACTOR will promptly notify the COUNTY if it or any subcontractor or CONTRACTOR is formally charged with an act defined as a "public entity crime" or has been placed on the convicted vendor list. 5. NONDISCRIMINATION During the performance of this Agreement, the CONTRACTOR agrees as follows: The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, or national origin. The contractor will take affirmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, color, religion, sex, sexual orientation, gender identity, or national origin. Such action shall include, but not be limited to the following: Employment, upgrading, demotion, or transfer, Page 22 of 27 Packet Pg. 226 recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the contracting officer setting forth the provisions of this nondiscrimination clause. The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin. The contractor will not discharge or in any other manner discriminate against any employee or applicant for employment because such employee or applicant has inquired about, discussed, or disclosed the compensation of the employee or applicant or another employee or applicant. This provision shall not apply to instances in which an employee who has access to the compensation information of other employees or applicants as a part of such employee's essential job functions discloses the compensation of such other employees or applicants to individuals who do not otherwise have access to such information, unless such disclosure is in response to a formal complaint or charge, in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or is consistent with the contractor's legal duty to furnish information. The contractor will send to each labor union or representative of workers with which it has a collective bargaining agreement or other contract or understanding, a notice to be provided by the agency contracting officer, advising the labor union or workers' representative of the contractor's commitments under section 202 of Executive Order 11246 of September 24, 1965, and shall post copies of the notice in conspicuous places available to employees and applicants for employment. The contractor will comply with all provisions of Executive Order 11246 of September 24, 1965, and of the rules, regulations, and relevant orders of the Secretary of Labor. The contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, and by the rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by the contracting agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations, and orders. In the event of the contractor's non-compliance with the nondiscrimination clauses of this contract or with any of such rules, regulations, or orders, this contract may be canceled, terminated or suspended in whole or in part and the contractor may be declared ineligible for further Government contracts in accordance with procedures authorized in Executive Order 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as provided in Executive Order 11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law. 6. COVENANT OF NO INTEREST CONTRACTOR and COUNTY covenant that neither presently has any interest, and shall not acquire any interest, which would conflict in any manner or degree with its performance under this Agreement, and that only interest of each is to perform and receive benefits as recited in this Agreement. 7. CODE OF ETHICS The parties recognize and agree that officers and employees of the COUNTY recognize and will be required to comply with the standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or use of certain information. 8. NO SOLICITATION/PAYMENT The CONTRACTOR and COUNTY warrant that, in respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any Page 23 of 27 Packet Pg. 227 person, company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. 9. PUBLIC RECORDS. Public Records Compliance. Pursuant to F.S. 119.0701 and the terms and conditions of this contract, if the Contractor is an individual, partnership, corporation or business entity that enters into a contract for services with a public agency and is acting on behalf of the public agency as provided under F.S. 119.011(2), the CONTRACTOR is required to: (1) Keep and maintain public records that would be required by the County to perform the service. (2) Upon receipt from the County's custodian of records, provide the County with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in this chapter or as otherwise provided by law. (3) Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the CONTRACTOR does not transfer the records to the County. (4) Upon completion of the contract, transfer, at no cost, to the County all public records in possession of the CONTRACTOR or keep and maintain public records that would be required by the County to perform the service. If the CONTRACTOR transfers all public records to the County upon completion of the contract, the CONTRACTOR shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the CONTRACTOR keeps and maintains public records upon completion of the contract, the CONTRACTOR shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the County, upon request from the County's custodian of records, in a format that is compatible with the information technology systems of the County. (5) A request to inspect or copy public records relating to a County contract must be made directly to the County, but if the County does not possess the requested records, the County shall immediately notify the CONTRACTOR of the request, and the CONTRACTOR must provide the records to the County or allow the records to be inspected or copied within a reasonable time. If the CONTRACTOR does not comply with the County's request for records, the County shall enforce the public records contract provisions in accordance with the contract, notwithstanding the County's option and right to unilaterally cancel this contract upon violation of this provision by the CONTRACTOR. A CONTRACTOR who fails to provide the public records to the County or pursuant to a valid public records request within a reasonable time may be subject to penalties under sectionl 19.10, Florida Statutes. The CONTRACTOR shall not transfer custody, release, alter, destroy or otherwise dispose of any public records unless or otherwise provided in this provision or as otherwise provided by law. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY AT PHONE# 305-292-3470 BRADLEY- BRIAN@MONROECOUNTY-FL.GOV, MONROE COUNTY ATTORNEY'S OFFICE III 12TH Street, SUITE 408, KEY WEST, FL 33040. 10. FEDERAL CONTRACT REQUIREMENTS The CONTRACTOR and its subcontractors must follow the provisions as set forth in Appendix II to Part 200, as amended, including but not limited to: A. Contractor agrees to comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C. 7401-7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251-1387) and will reports violations to FEMA and the Regional Office of the Environmental Protection Agency (EPA). B. Davis -Bacon Act, as amended (40 U.S.C. 3141-3148). When required by Federal program legislation, all prime construction contracts in excess of $2,000 awarded by non -Federal entities must comply with the Davis -Bacon Act (40 U.S.C. 3141-3144, and 3146-3148) as supplemented by Department of Labor regulations (29 CFR Part 5, "Labor Standards Provisions Applicable to Contracts Covering Federally Financed and Assisted Construction"). In accordance with the statute, contractors must be required to pay wages to laborers and mechanics at a rate not less than the prevailing wages specified in a wage determination made by the Secretary of Labor. In addition, contractors must be required to pay wages not less than once a week. The COUNTY must place a copy of the current prevailing wage determination issued by the Department of Labor in each solicitation. The decision to award a Page 24 of 27 Packet Pg. 228 contract or subcontract must be conditioned upon the acceptance of the wage determination. The COUNTY must report all suspected or reported violations to the Federal awarding agency. The contractors must also comply with the Copeland "Anti -Kickback" Act (40 U.S.C. 3145), as supplemented by Department of Labor regulations (29 CFR Part 3, "Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or Grants from the United States"). As required by the Act, each contractor or subrecipient is prohibited from inducing, by any means, any person employed in the construction, completion, or repair of public work, to give up any part of the compensation to which he or she is otherwise entitled. The COUNTY must report all suspected or reported violations to the Federal awarding agency. C. Contract Work Hours and Safety Standards Act (40 U.S.C. 3701-3708). Where applicable, all contracts awarded by the COUNTY in excess of $100,000 that involve the employment of mechanics or laborers must comply with 40 U.S.C. 3702 and 3704, as supplemented by Department of Labor regulations (29 CFR Part 5). Under 40 U.S.C. 3702 of the Act, each contractor must compute the wages of every mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of the standard work week is permissible provided that the worker is compensated at a rate of not less than one and a half times the basic rate of pay for all hours worked in excess of 40 hours in the work week. The requirements of 40 U.S.C. 3704 are applicable to construction work and provide that no laborer or mechanic must be required to work in surroundings or under working conditions which are unsanitary, hazardous or dangerous. These requirements do not apply to the purchases of supplies or materials or articles ordinarily available on the open market, or contracts for transportation or transmission of intelligence. D. Rights to Inventions Made Under a Contract or Agreement. If the Federal award meets the definition of "funding agreement" under 37 CFR §401.2 (a) and the recipient or subrecipient wishes to enter into a contract with a small business firm or nonprofit organization regarding the substitution of parties, assignment or performance of experimental, developmental, or research work under that "funding agreement," the recipient or subrecipient must comply with the requirements of 37 CFR Part 401, "Rights to Inventions Made by Nonprofit Organizations and Small Business Firms Under Government Grants, Contracts and Cooperative Agreements," and any implementing regulations issued by the awarding agency. F. Clean Air Act (42 U.S.C. 7401-7671q.) and the Federal Water Pollution Control Act (33 U.S.C. 1251-1387), as amended — Contracts and subgrants of amounts in excess of $150,000 must comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C. 7401-7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251- 1387). Violations must be reported to the Federal awarding agency and the Regional Office of the Environmental Protection Agency (EPA). G. Debarment and Suspension (Executive Orders 12549 and 12689)—A contract award (see 2 CFR 180.220) must not be made to parties listed on the governmentwide exclusions in the System for Award Management (SAM), in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3 CFR part 1989 Comp., p. 235), "Debarment and Suspension." SAM Exclusions contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549. H. Byrd Anti -Lobbying Amendment (31 U.S.C. 1352)--Contractors that apply or bid for an award exceeding $100,000 must file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant or any other award covered by 31 U.S.C. 1352. Each tier must also disclose any lobbying with non -Federal funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the non -Federal award. I. Procurement of recovered materials as set forth in 2 CFR § 200.322. Other Federal Requirements: A. Americans with Disabilities Act of 1990 (ADA) — The CONTRACTOR will comply with all the requirements as imposed by the ADA, the regulations of the Federal government issued thereunder, and the assurance by the CONTRACTOR pursuant thereto. B. Disadvantaged Business Enterprise (DBE) Policy and Obligation - It is the policy of the COUNTY that DBE's, as defined in 49 C.F.R. Part 26, as amended, shall have the opportunity to participate in the performance of contracts financed in whole or in part with COUNTY funds under this Agreement. The DBE requirements of applicable federal and state laws and regulations apply to this Agreement. The COUNTY and its CONTRACTOR agree to ensure that DBE's have the opportunity to participate in the performance of this Agreement. In this regard, all recipients and contractors shall take all necessary and reasonable steps in accordance with applicable federal and state laws and regulations to ensure that the DBE's have the opportunity to compete for and perform contracts. The COUNTY and the CONTRACTOR and subcontractors shall not discriminate on the basis of race, color, national origin or sex in the award and performance of contracts, entered pursuant to this Agreement. Page 25 of 27 Packet Pg. 229 C. The Contractor shall utilize the U.S. Department of Homeland Security's E-Verify system to verify the employment eligibility of all new employees hired by the Contractor during the term of the Contract and shall expressly require any subcontractors performing work or providing services pursuant to the Contract to likewise utilize the U.S. Department of Homeland Security's E- Verify system to verify the employment eligibility of all new employees hired by the subcontractor during the Contract term. 11. No Obligation by Federal Government. The federal government is not a party to this contract and is not subject to any obligations or liabilities to the non -Federal entity, contractor, or any other party pertaining to any matter resulting from the contract. 12. Program Fraud and False or Fraudulent Statements or Related Acts. The Contractor acknowledges that 31 U.S.C. Chapter 38 (Administrative Remedies for False Claims and Statements) applies to the Contractor's actions pertaining to this contract. Page 26 of 27 Packet Pg. 230 IBAOiddv} LGOZ-QZ-9 uOilque aid 4ulOd JGmOd °uoi}eue'dxG dM 3 6 G uopd ;4uew4oej}v c� 0 Q 0 W 0 N LL PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT ']'his Pharmacy Benefit Management Services Agreement (the "Agreement") is effective the 1st clay of October, 2011 (the "Effective Date") by and between Envision Pharmaceutical Services, Inc., an Ohio Corporation (hereinafter "Envision"), and Monroe County Board of County Commissioners, a political subdivision of the State of Florida (hereinafter "Plan Sponsor"). BACKGROUND Envision is a URAC accredited Pharmacy Benefit Management (PBM) company engaged in the business of providing comprehensive pharmacy benefit management services nationwide to various employers, unions, and health plans which sponsor or administer 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: I. DEFINITIONS Ll "Administrative Fee" means the amount that Envision charges Plan Sponsor for included services under this Agreement. Envision represents and warrants that the Administrative Fee and any fees for Additional Services and Miscellaneous Expenses set forth in Exhibit I are its sole compensation for the services rendered hereunder, and that it retains no revenues, directly or indirectly, from any other source, 1 2 "Annual Average Effective Rate" means, for the category of drugs being reviewed, the result calculated by the following formula: (IC/AWP)-], where "IC" is the sum of all amounts paid by Plan Sponsor for the ingredient cost of the Covered Medications dispensed during the calendar year, and AWP is the sum of the Average Wholesale Price amounts associated with the same Covered Medications. 1, 3 "Average Wholesale Price" or -AWP" shall mean the average wholesale price of a Covered Medication indicated on the most current pricing file provided to Envision by Medi- z LU Span (or other applicable industry standard reference on which pricing hereunder is based) for the actual drug dispensed using the I I 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 once a week. E 1 A "Benefit Plan" means the group health plan, insurance plan, prescription drug plan, or other benefit plan sponsored or administered by Plan Sponsor that covers the cost of Covered Medications dispensed to Members. \111IN4SA (Ifrni0607( 1 )(fina12) 'Q Envision Pharmaceutical Services, Inc, Page I ot'24 I Packet Pg. 232 1.5 **Benefit Specification Form" means the form that is completed by Plan Sponsor, in conjunction with Envision, which details the specifics of the Benefit Plan such as which prescription medications 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. prior authorizations, drug therapy management, etc.), 1.6 "Brand Drug" means a drug where the Medi-Span multisource ("MONY") code attached to the I I digit NDC for such drug indicates an "N" (a single -source brand name drug product available from one 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 manufacturers), or an "0" (an original branded drug product available from one or more 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 including the calculation of drug price or rebate guarantees. L7 -Claim" means an invoice or transaction (electronic or paper) for a Covered Medication dispensed to a Member that has been submitted to Envision by the dispensing pharmacy or a Member (including transactions where the Member 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 ' 'onipound Drug" means a Covered Medication that requires compounding by a pharmacist because it is not available from the 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 recognized under federal law as a Legend Drug (i.e. a drug that bears the legend: "Caution: Federal law prohibits dispensing without a prescription.") L9 "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. 1,10 "Cost Share" means the amount of money that a Member must pay to the Participating Pharmacy to obtain a Covered Medication 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. 1,11 "Covered Medication" means a prescription drug, medication, or device that meets the requirements for coverage under the Benefit Plan, after applying all conditions and exclusions set forth in the Benefit Specification Form, and which is dispensed to a Member pursuant to a 0c: written or electronic prescription order or allowable refill. E 1.12 "Eligibility File" means that electronic communication supplied to Envision by Plan Sponsor which identifies the Members covered under Plan Sponsor's Benefit Plan, along with other eligibility information necessary for Envision to provide PBM Services hereunder. Plan ,P14NISA 4 frm06071 1 )(fina12) i� Fnvision Pharmaceutical Services, Inc. Page 2 ( I " - Packet Pg. 233 1 Sponsor acknowledges that eligibility begins on the first day the Member is reported by Plan Sponsor (or its designee) to be effective and continues through the last day the Member appears on the Eligibility File. 1,13 "Employee" means an Employee of Plan Sponsor covered under Plan Sponsor's Benefit Plan, together with such Employee's eligible dependents. 1,14 "Generic Drug" means a drug where the Medi-Span multisource code attached to the I I digit NDC For such drug indicates a "Y" (a generic drug product available from one or more 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 including the calculation of drug price or rebate guarantees. 1.15 "141PAA" means the Health Insurance Portability and Accountability Act of 1996, as amended. L16 "Licensed 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. L17 "Manufacturer Derived Revenue" means any discounts, rebates, pharmaceutical manufacturers administrative fees, and any other revenue received by Envision from pharmaceutical manufacturers (whether as a result of the number of covered lives, other incentives or other amounts received) for Covered Medications dispensed to Members. M 1.18 "MAC List" means a proprietary list of Generic Drugs for which Envision establishes a > maximum price ("MAC Price") payable to the dispensing pharmacy, which includes most, but not all Generic Drugs. 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 z LU negotiated AMOUnt payable by Envision to the dispensing pharmacy without any markup or 2 LU spread. Envision updates the MAC List from time -to -time as Generic Drugs come on the market LU W or come off the market, or as their availability changes due to market circumstances. Generic Drugs that are excluded from the MAC List include Newly Available Generic Drugs, Single - Source Generic Drugs, and Limited Availability Generic Drugs ("Excluded Generics"). For 0 purposes of this definition, a Newly Available Generic Drug is one which, at the time the drug is dispensed, is subject to the Ilatch-Waxman 180 day market exclusivity provision, a Single- z Source Generic Drug is one which, at the time the drug is dispensed, is available from only one manufacturer, and a Limited Availability Generic Drug is one which, at the time the drug is dispensed, is priced higher than normal due to supply limitations or limited market competition. C: 0 E 1.19 "Member" means each individual (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 Medications, \P13%4SA (frmO6071 1)(finaI2) 0 Envision Pharmaceutical Services, Inc. Page 3 f 24 I Packet Pg. 234 1.20 ­NCPDP" shall mean the National Council for Prescription Drug Programs Standard Claims Billing Tape and Payment Format 2.0, or a revised and then current version. 1.21 "Participating Pharmacy" means a pharmacy (including a designated mail order or specialty pharmacy) that has entered into a negotiated pricing agreement with Envision to dispense Covered Medications to Members. A "Retail Pharmacy" is a pharmacy that dispenses medications to outpatients. 1.22 "Plan Sponsor" means the entity (identified above as Plan Sponsor) which (i) has created and maintains the Benefit Plan on behalf of the Members, and has determined the rules by which the Benefit Plan is to be administered, and (ii) is financially responsible for the payment of Administrative Fees, Fees for Additional Services and Miscellaneous Expenses, and Covered Medications dispensed to Members hereunder. 1.23 "Point -of -Sale" means the location and time that a Covered Medication is dispensed to a Member, and the corresponding Claim is submitted by the dispensing pharmacy for adjudication by Envision's on-line computerized claims processing system (hereinafter "Claims Adjudication System"). 1.24 "Specialty Drug" means those high -cost injectable, infused, oral, inhaled, or biotech drugs which require special ordering, handling and/or patient intervention. Specialty Drugs will be priced based on where the drug is dispensed (i.e. retail, mail order, or specialty pharmacy). 2. PBM SERVICES Q Envision shall perform the following pharmacy benefit management services ("PBM Services-): 11 Identification Card: Envision shall provide Plan Sponsor with Envision approved identification cards ("ID Cards"), up to two per family, for distribution to Members by Plan Sponsor. If requested by Plan Sponsor, Envision shall provide ID Cards directly to Members at no additional cost, except for the cost of postage and handling. Additional ID Cor Zards LU replacement ID Cards (i.e. for lost or stolen ID Cards) will be provided at a cost as specified in Exhibit I . 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 acceptprocess PK9�i� , , Z 0 and adjudicate Claims for Covered Medications (i) submitted electronically by Participating F5 5; Pharmacies in National Council for Prescription Drug Programs (NCPDP) formats; (ii) Z submitted by Members 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 C which Claims are successfully processed, ended for prior authorization, or rejected for E 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). 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 fors TBMSA ( frmO607 I I t{ fina12) 0 Envision Pharrnaccutica Services, Inc, Page 4 of I ' Packet Pg. 235 1 ineligible payments, will incur a fee as set forth in Exhibit 1. After termination of this Agreement, Envision shall process Claims 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 timely payment of invoices as provided herein. 2.3 Direct Member Reimbursement (DMR): Envision shall provide, via its website, a DMR form, for use by Members to obtain reimbursement for amounts paid out-of-pocket (other than Cost Share) for Covered Medications (e.g. Covered Medications dispensed at a non -Participating Pharmacy). 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 Member until Plan Sponsor provides funds for such purpose. 2.4 Fuss -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 charged to Plan Sponsor shall be determined as follows and as specified in Exhibit 1: 14,1 For Brand Drugs: Envision shall charge Plan Sponsor the calculated negotiated amount payable to the Participating Pharmacy based on the drug pricing fields (i.e. AWP, MON Y code, etc.) for the 11 digit NDC of the drug dispensed, less any applicable Manufacturer Derived Revenue (plus applicable dispensing fees); or, if lower, the Participating Pharmacy's reported usual and customary price (except for mail order and specialty pharmacies). For purposes of this Agreement, the usual and customary price ("U&C Price") is the retail amount the pharmacy charges its cash paying customers for the drug dispensed, as reported to Envision by the dispensing pharmacy. 2.4.2 For Generic Drugs: For Generic Drugs included on the then current Envision MAC List, Envision shall charge Plan Sponsor the MAC Price for the drug dispensed; for Generic Drugs not on the MAC List (i.e. Excluded Generics), Envision shall charge Plan Sponsor the calculated negotiated amount payable to the Participating Pharmacy based on the drug pricing fields (i.e. AWP, MONY code, etc.) for the I I digit NDC of the drug dispensed (Plus applicable dispensing fees); or, if lower, the Participating Phan-Tiacy's reported U&C Price (except for mail order and specialty pharmacies). 14.3 Modifications by Plan Sponsor: Plan Sponsor's Benefit Plan may contain certain programs (e.g. mandatory generic program) and/or rules which determine the way in which Claims are adjudicated (i.e. what portion of a Claim is payable by Plan Sponsor and what portion is payable by Members). The rules by which Plan Sponsor's Claims arc adjudicated are detailed by Plan Sponsor as set forth in the Benefit Specification Form. To the extent Plan Sponsor's Benefit Plan modifies the standard Claims adjudication process, the Claims Adjudication System will be configured accordingly. However, such modifications shall not result in the reclassification of a Claim. \1113MSA (finP00071 1)(fina]2) (), Envision Pharmaceutical Services, Inc. Page 5 of 24 2.4.4 For Dispensing Fees: Envision shall charge Plan Sponsor the actual dispensing fee amount payable to the Participating Pharmacy for both Brand Drugs and Generic Drugs as applicable. 2.4.5 Drug, Pricing and Dispensing Fees: Unless otherwise stated herein, the Annual Average Effective Rates and Annual Average Dispensing Fees set forth in Exhibit I shall be deemed to have been achieved if, overall, the amounts paid by Plan Sponsor for all Claims during the Contract Year are equal to or more favorable than the amounts paid for each drug type or category individually. 2.5 Manufacturer Derived Revenue 2.5.1 Pass -Through of Manufacturer Derived Revenue: Envision has negotiated contracts with pharmaceutical manufacturers to obtain Manufacturer Derived Revenue for eligible Brand 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 such eligible Brand Drugs. Envision shall include such eligible Brand Drugs on the Formulary, subject to approval by Envision's Pharmacy & Therapeutics Committee. Plan Sponsor acknowledges that its yield of Manufacturer Derived Revenue is dependent on certain factors including, without limitation, the following: (i) whether the terms and conditions of Plan Sponsor's Benefit Plan are consistent with the application of Envision's Formulary; (ii) the structure of Plan Sponsor's Benefit Plan; and (iii) the drug utilization patterns of Members. 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 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. Manufacturer Derived Revenue for Claims paid entirely by Members (e.g. a Claim occurring while the Member has not yet met his or her deductible) and 340B Claims are ineligible for Manufacturer Derived Revenue, and no Manufacturer Derived Revenue shall be payable to Plan Sponsor for such Claims. 2.5.2 Pass -Through Methodology: Manufacturer Derived Revenue shall be advanced to Plan Sponsor by adjusting the Claim for an eligible Brand Drug by the estimated Manufacturer Derived Revenue using Envision's patent pending 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 expected earned Manufacturer Derived Revenue. (Plan Sponsor acknowledges that, unless otherwise indicated by Plan Sponsor on the Benefit Specification Form, if a Member 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 Member at the Point -of -Sale). Any earned Manufacturer Derived Revenue (including market share rebates) not applied to Claims at the Point -of -Sale shall be paid to Plan Sponsor when collected by Envision. 2.5.4 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 Manufacturer Derived Q1 \PB',,ISA (frinO6011 ()(finaQ) Envision Phannaccutical Services, Inc. Page 6 of I Packet Pg. 237 Revenue 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 Manufacturer Derived Revenue or create a situation which would cause a 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 advanced to Plan Sponsor by Envision which is connected with any Claims for which Plan Sponsor received Manufacturer Derived Revenue from any other source or for amounts advanced to Plan Sponsor by Envision which have been withheld by a manufacturer due to the ineligibility of such Claims for Manufacturer Derived Revenue (i.e. 340B Claims) or breach of these provisions by Plan Sponsor, 2 4-5.5 Early Termination: Notwithstanding anything herein to the contrary, if this Agreement is terminated for any reason by Plan Sponsor prior to the end of the Initial Term (other than for a material breach by Envision), Plan Sponsor agrees (i) to reimburse Envision for any Manufacturer Derived Revenue advanced to Plan Sponsor that Envision has not collected from pharmaceutical manufacturers within nine months from the effective date of termination; and (n) all market share rebates payable as of the date of delivery by Plan Sponsor of the notice of termination shall be forfeited by Plan Sponsor. 2.6 Pharmacy Network: Envision shall arrange for the dispensing of Covered Medications to Members pursuant to contracts with a network of Participating Pharmacies. Plan Sponsor understands and agrees that the network of Participating Pharmacies may change from time to time, including the designated mail order provider and/or specialty pharmaceuticals 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 Medications shall not be dispensed to Members without a prescription order by a Licensed Prescriber; and (iii) the availability of drugs are subject to market conditions and that Envision cannot, and does not, assure the availability of any drug from any Participating Phan-nacy. 2.7 Formulary: Envision shall maintain a list of commonly prescribed drugs and supplies ("Formulary") which has been reviewed by Envision's Pharmacy & Therapeutics Committee (using evidence -based evaluation criteria for safety and efficacy in accordance with URAC standards and. when applicable, CMS guidelines) to be used by Plan Sponsor, Licensed Prescribers, Participating Pharmacies, and Members to guide the selection of cost effective Covered Medications. "The Formulary may be modified from time to time as new medications and/or new clinical information become available, is constantly updated to reflect any changes, and is accessible via Envision's website. Plan Sponsor acknowledges that adherence to the Formular-N, is necessary to maximize cost savings and yields in Manufacturer Derived Revenue, however, the determination of which Formulary and non -Formulary drugs are covered, limited, or excluded are governed by Plan Sponsor's Benefit Plan. Any customization of the Formulary desired by Plan Sponsor for its use must be approved, in writing, by Envision, and Plan Sponsor acknowledges that such modifications may affect yields in Manufacturer Derived Revenue. \PIMSA PrmO6071 1)(fina12) '(, Envision Pharmaceutical Services, Inc. Page 7 of 24 2.8 Generic Substitution: Unless other -wise specified by Plan Sponsor in the Benefit Specification Form, the Claims Adjudication System will permit Participating Pharmacies to dispense a Generic Drug when a prescription is written for a Brand Drug. The decision to substitute a Generic Drug for a Brand Drug and the choice of drug is at the discretion of the dispensing pharmacy and subject to the law of the state in which the pharmacy is located. 2.9 Prior Authorizations; Drug Utilization Review• and Drug Therapy Management 2.9. 1 System Generated Prior Authorizations: Envision shall configure the Claims Adjudication System to require prior authorization before Covered Medications are dispensed in certain circumstances which have been specified by Plan Sponsor in the Benefit Specification Form. Examples of system generated prior authorizations include requests for lost or stolen drugs, vacation supplies, certain package sizes, dosage changes, and invalid days' supply. System generated prior authorizations are included in the Administrative Fee. 2.9.2 Clinical Prior Authorizations: If Plan Sponsor has elected to receive Clinical Prior Authorization services from Envision, for those Covered Medications 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, 2-93 Concurrent Drug Utilization Review: Envision shall program edits into the Claims Adjudication System which are applied to Claims during the adjudication process to identify the following: duplicate prescriptions; over-utilization/refill too soon; under -utilization; drug interactions; pediatric warnings; geriatric warnings; acute/maintenance dosing; formulary compliance, therapeutic duplication; drug inferred health state; drugs exceeding maximum dose; drugs below minimum daily dosage, and other financial and cost limitations which are specified by Plan Sponsor in the Benefit Specification Form. The Claims Adjudication System will provide the dispensing pharmacy with the appropriate messaging to advise the pharmacy of Concurrent Drug Utilization Review issues. W 2.9.4 Retrospective Drug Utilization Review: Envision may review Claims retrospectively, as specified in the Benefit Specification Form, to determine the drug utilization Z patterns of Members, and report the results of retrospective reviews to Plan Sponsor. 0 Retrospective Drug Utilization Review reports may include, but are not limited to: high cost/high utilization of a particular drug class, or therapeutic appropriateness of drug for a particular Z disease state, and other agreed upon reports. 2.9.5 Drug Therapy Management (DTM) and other Clinical Programs: Envision provides certain clinical programs such as Drug Therapy Management, Drug Therapy Care Gap E Management, and Formulary Adherence. Plan Sponsor may elect to receive some or all of these 0 services at an additional charge by indicating so in the Benefit Specification Form. A description and cost of these programs will be provided upon request. N \111IMSA Jnn06071 1)(fina]12) c?j Envision Pharmaceutical Services, Inc. Page 8 oll"M I Packet Pg. 239 110 Business Associate Agreement: Envision shall execute a HIPAA Business Associate Agreement, attached as Exhibit 2. Ill 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, Members, Licensed Prescribers, and Participating Pharmacies. 2.12 '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 Medications and the provision of services by Envision under this Agreement. 2.13 Re -ports: Envision shall provide Plan Sponsor with access to 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 111PAA 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. 2.14 Distribution of Materials: Envision shall bulk ship printed materials produced by Envision as agreed hereunder to Plan Sponsor at no additional charge. If` Plan Sponsor requests ID Cards or other printed materials to be mailed directly to Members, Plan Sponsor shall reimburse Envision its costs of postage and handling. 215 Retiree Drug Subsidy (RDS) Reports: For Plan Sponsors which submit requests for drug subsidies tinder 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 Z Members who Plan Sponsor has identified on the appropriate form as Medicare eligible retirees. ILU ME Plan Sponsor acknowledges that any estimated Manufacturer Derived Revenue which has been W ILU passed -through to Plan Sponsor will have been deducted from the Claim amounts reported. W 0 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 Z 0 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 Z completion or submission of any RDS application or request for subsidies under Medicare Part W D. 116 Additional Services: Any services to be rendered under this Agreement which are not C 0 included in the Administrative Fee shall be itemized in the Exhibits and Addendums hereto along E with any associated costs or charges. \1113MSA ffrrn0007I 10=12) 0 Envision Pharmaceutical Smices, Inc. Page 9 of 24 117 Performance Guarantees: Envision shall provide PBM Services in accordance with the till Performance Guarantees specified in Exhibit 3. Failure to meet targets will be determined by means of reports produced by Envision. If Envision fails to meet any of the Performance Guarantees, and Plan Sponsor desires to assess penalties, payment to Plan Sponsor is payable by Envision within thirty (30) business days. 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. Upon approval from Plan Sponsor, payment of penalties may be credited towards future Administration Fees. Failure to meet Performance Guarantees shall not be deemed to be a breach of this Agreement. 3. PLAN SPONSOR RESPONSIBILITIES 3.1 Eli ibilitv 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 Members. 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 41 or update eligibility by manually entering Member 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. 3.2 Benefit Plan: Plan Sponsor shall provide Envision with complete information concerning LU ME the Benefit Plan. Plan Sponsor understands and agrees that Envision shall rely on the terms and LU LU conditions provided by Plan Sponsor on the Benefit Specification Form. The Benefit Specification Form may be changed from time to time by Plan Sponsor; provided, however, that < the form must be signed by Plan Sponsor and any changes to the Benefit Plan must be Z 0 communicated to Envision, in writing, at least thirty (30) days before any such change shall be implemented. The most recent executed Benefit Specification Form shall supersede any prior Z dated form. Plan Sponsor shall have sole authority to determine the terms of the Benefit Plan LU and the coverage of benefits thereunder, however, Plan Sponsor understands and agrees that any change in the Benefit Plan (e.g. mandatory generic program, coverage of over-the-counter drugs or medications, etc,) may affect yields in Manufacturer Derived Revenue and average drug C pricing, and that Envision will not be liable to Plan Sponsor for a reduction of such yields or E increase in pricing which result from any change in the Benefit Plan. H \1113\1SA (frnft(171 [)(finaQ) V Envision Pharmaceutical Services, Inc. Page 10 of 24 1for Payment: Plan Sponsor shall timely pay, or cause its designee to timely pay, Envision o services rendered hereunder in accordance with Section 4 below and Exhibit 1. 3.4 Cooperation: Plan Sponsor shall provide such cooperation and support as reasonably necessary to ensure that Envision can provide all services described hereunder in a timely, responsible, and professional manner. 4. TERMS OF PAYMENT 4.1 Fees and Drug Pricing,: Envision and Plan Sponsor agree that fees for PBM Services and drug pricing payable by Plan Sponsor hereunder are as set forth in Exhibit I hereto, as may be amended in writing from time to time. Plan Sponsor acknowledges that (i) Exhibit I has been reviewed and approved by Plan Sponsor; (ii) the rates specified in Exhibit I are conditioned upon Plan Sponsor's adherence to certain conditions under this Agreement; and (iii) the rates specified in Exhibit I are subject to adjustment for Contract Years after the Initial Term due to, among other factors, changes to administrative costs, changes in the negotiated discounts with Participating Pharmacies, and/or changes in Manufacturer Derived Revenue amounts with pharmaceutical manufacturers. 4,2 Payments for Claims: Envision shall provide Plan Sponsor with an invoice of payable Claims once each week and Plan Sponsor shall pay Envision's invoices no later than 12:00 pm. on the thirtieth (3 01h) calendar day from receipt of said invoices and backup containing a breakdown of the claims paid. 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. 43 Financial Responsibility: Plan Sponsor understands and agrees that Envision cannot obligate Participating Pharmacies to continue to dispense Covered Medications without receiving payment for past Claims and Envision shall not be obligated to pay Participating Pharmacies if Plan Sponsor fails to timely pay Envision as required under this Agreement. Plan Sponsor understands that, if Plan Sponsor has not paid within seven (7) calendar days of written notice by Envision of a past due Claims invoice. Envision may notify Participating Pharmacies that Plan Sponsor has not timely paid amounts due for Claims. Further, Envision may suspend the provision of services until any unpaid balance is received and, as a condition of continuing to perform set -vices under this Agreement, require Plan Sponsor to deposit with Envision a reasonable amount to ensure the timely payment of future invoices and/or discontinue advancing Manufacturer Derived Revenue to Plan Sponsor using Envision's Point -of -Sale Technology. Plan Sponsor further agrees that Envision shall not be liable for any consequences resulting from the untimely payment of Participating Pharmacies, including, without limitation, failure to meet any applicable prompt payment laws, due to the failure of Plan Sponsor to timely pay Envision as required under this Agreement. Notwithstanding anything herein to the contrary, Plan Sponsor shall be and remain responsible for the payment of all invoices for Covered Medications dispensed to Members, along with any associated Cost Share not timely paid by Members, and dispensing fees and taxes. If Plan Sponsor should fail to pay any amounts due Envision hereunder due to insolvency, bankruptcy, termination of business, sale, or rebuff, Envision reserves the right to pursue payment from Members to the extent permitted by law. TRNISA (fraiO6071 0(final2) S(,) Envision Pharmaceutical Services, Inc. Page 1 1 of 24 4.4 Payment of Administrative Fee: Envision shall provide Plan Sponsor with an invoice of Administrative Fees on or about the first day of each month following delivery of services. Administrative Fees are due within thirty (30) calendar days of receipt of Envision's invoice. The monthly Administrative Fee is calculated by multiplying the number of 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 forth in Exhibit 1. 4.5 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 I hereunder, within thirty (30) calendar days of receipt of an invoice and supporting documentation. 4.6 Retroactive Disenrollment: Retroactive termination or disenrollment of a group, Employee, or Member shall not release Plan Sponsor of its obligation to pay Claims incurred, at any time, on behalf of such Member, or Administrative Fees due to Envision for such Member during any period for which services were renderable hereunder based on the then current eligibility. 4.7 Taxes. Any sales or use taxes for Covered Medications sold to Members shall be charged, collected, and paid to state and local taxing authorities by the dispensing pharmacy. Plan Sponsor shall reimburse Envision or the dispensing pharmacy for taxes paid as part of the reimbursement for Claims. Other than as stated herein, the Plan Sponsor is not liable under Florida law for sales or use taxes. Q 4,8 Financial Audit by Plan Sponsor: Plan Sponsor, at its sole expense, may audit Envision's 50 (n records of Claims adjudicated under this Agreement. Envision shall make available to Plan 4- 0 Sponsor's auditor, any and all financial records containing Plan Sponsor's information and such — AD other records as reasonably necessary for auditor to confirm that the amounts paid by Plan > 2 Sponsor are the cost to Envision on the day the Covered Medication 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 Z person or entity which has a conflict of interest with Envision. Plan Sponsor understands that LU ME Envision's contracts with pharmaceutical manufacturers, Participating Pharmacies, and other LU Ui third parties may contain non -disclosure provisions, and hereby agrees to comply with such non- disclosure provisions, subject to requirements of Florida public records law in the Florida < Constitution and Chapter 119 of the Florida Statutes. If Plan Sponsor utilizes an independent Z auditor, such auditor shall execute a conflicts of interest disclosure and confidentiality agreement 0 with Envision prior to the audit. Audits shall only be made during normal business hours 5; following ten (10) days written notice, be conducted without undue interference to Envision's Z W 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 or by a secure website, and no copies of such contracts may be removed C from Envision's offices. Plan Sponsor agrees to disclose the findings and methodologies of a E completed audit, and provide Envision with a reasonable period of time to respond to such 0 findings and methodologies, before a demand is made by Plan Sponsor for amounts it believes M are due from Envision. If an auditor employed by the County or Clerk determines that monies TBMSA Jrm0607I 0(finaQ) 0 Envision Pharmaceutical Services, Inc. Page 12 of 24 paid to Envision pursuant to this Agreement were spent for purposes not authorized by this Agreement, Envision shall repay the monies together with interest calculated pursuant to Sec. 55.03, FS, running from the date the monies were paid to Envision. 5. TERM AND TERMINATION 5.1 Teriti: The term of this Agreement shall commence on the Effective Date and shall remain in full force and effect for an initial term of three (3) 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; unless, at least sixty (60) days prior to the end of such term, either party hereto notifies the other, in writing, of its intent that the Agreement terminate at the end of the current term. 5.2 Termination: This Agreement may be terminated as follows: 5,2.1 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; 5 . 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, (6) 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; 5.23 Failure to Pay: By Envision, upon reasonable notice, in the event Plan Sponsor fails to pay Envision according to terms of this Agreement. 5.2.4 'Fermi - nation Without Cause. By either party, effective no sooner than the end of the second Contract Year, by providing the other party with at least sixty (60) days written notice. 53 Notices: All notices required in this Section 5 shall be reasonably specific concerning the cause for termination and shall specify the effective date and time of termination. 54 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. All services required to be performed under the terms of this Agreement shall be provided \11[IMSA (frrn0607 I 1)(final2) (0 Envision Pharmaceutical Services, Inc, Page 13 of 24 through the effective date of termination. Except as otherwise agreed, in writing, no services shall be provided by Envision after the effective date of termination. All payments required to be paid under the terms of this Agreement shall be paid in full. 6. CONFIDENTIAL INFORMATION 6,1 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 Linder 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. 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. 6.2 Protected Health Information: Plan Sponsor will have access to Protected Health Information (PI 11) (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 PIll 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. Ell, 7. INDEMNIFICATION 7.1 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. 7.2 Limited Indemnification by Plan Sponsor: Subject to the limitations of Section 768.28, Florida Statutes, 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 erroneous information; or (ii) Plan Sponsor's failure to comply with state or federal law in the operation of its Benefit Plan. T3 Limitation of Liability: Except for the indemnification obligations set forth above, 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. In no event will either party or any of their is z LU 2 LU LU z 0 z UJ c: 0 E 4414NISA (frm060'7I 1)(final21 k, Envision Pharmaceutical Services. Inc. Page 14 of 24 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. T4 Survival: This Section 7 shall survive the expiration or termination of this Agreement for 8. RELATIONSHIP WITH CONTRACTED PHARMACIES 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 Members. 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 Members. Plan Sponsor releases Envision from any liability arising from the dispensing of drugs or medical supplies by any pharmacy to Members. 9. GENERAL 9.1 L If Status: Nothing in this Agreement shall be deemed to confer upon Envision the status of a fiduciary (as defined in the Employee Retirement Income Security Act of 1974, as amended ("ERISA"), the Americans with Disabilities Act, as amended ("ADA"), or by any other definition), except to extent, in the performance of its obligations under this Agreement, Envision exercises actual discretionary control over the property of Plan Sponsor, or as required tinder applicable law. Further, Plan Sponsor retains the sole responsibility for the terms and/or validity of the Benefit Plan; the interpretation and determinations of coverage under the Benefit Plan, and for the disclosing or reporting of information regarding the Benefit Plan or changes in the Benefit Plan (e.g., calculation of Cost Share or creditable coverage) as may be required by law to be disclosed to governmental agencies or Members. 92 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. 93 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. 9.4 Assiatiment: Except as follows, this Agreement may not be assigned by either party hereto without the prior express written consent of the other party, which may not be unreasonably withheld. C 4) E 9,5 Binding Fffect: 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. TRMSA (frm060'71 I)if=12) [--'nvision Pharmaceutical Services, Inc. Page 15 of 24 11 9.6 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. 9,7 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. 9.8 Severability: The invalidity or non -enforceability of any term or provision of this Agreement shall in no way affect the validity or enforceability of any other term or provision. 9.9 Chans-)e 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 the Agreement), either now existing or subsequently occurring, affects the ability of either patty 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 the 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. 9.10 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. 9.11 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. 9.12 Acceptance of Offer: Notwithstanding anything herein to the contrary, this Agreement shall not be binding upon the parties hereto unless and until the 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. 1-- Z LU ME UJ LU Z 0 Z LU E TFINISA (fnn0601 I I }(finaQ) 0 Envision Pharmaceutical Services, Inc. Page 16 of 24 9.13 Mediation: If either party to this Agreement should declare a breach of this Agreement, or if any dispute arises from this Agreement or the subject of this Agreement, the parties shall first submit the matter to non -binding mediation (not arbitration) and attempt to resolve the matter, in good faith, prior to the institution of any arbitration or any other legal action. Any statements made at such mediation shall be for settlement purposes only and shall not be construed to be an admission. A party demanding mediation shall be entitled to obtain a court order mandating mediation if the other party does not agree to commence mediation within thirty (30) days after written demand. The fees and costs incurred by the party seeking such court order shall be reimbursed by the other party; otherwise, each party shall pay its own costs of mediation. All such mediation proceedings shall be conducted on a confidential basis. The mediation shall be conducted in Key West, Florida. 9.14 Choice of Law: This Agreement shall be construed, interpreted, and governed according to the laws of the State of Florida, except to the extent such laws are preempted by applicable Federal law, 9.15 Force Maieure: 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 or 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 cause preventing performance ceases, the party affected thereby shall fulfill its obligations as set forth under this Agreement. This Section 9.15 shall not be considered to be a waiver of any continuing obligations under this Agreement, including, without limitation, the obligation to make payments. 9. 16 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. 9. 17 Rep -esentationZs: Each signatory named below represents and warrants that he or she (i) LU 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 C which are the subject matter of this Agreement; and (iv) has the full power and authority to E execute this Agreement. Envision further represents that there are no organizational arrangements that could potentially create a conflict of interest that affects clinical or financial decisions. plan Sponsor further represents and warrants that (i) the entering into this Agreement \1113MSA (firm()6071 I )(finaQ) 0 Envision Pharmaceutical Services, Inc. Page 17 of for PBM Services is not in violation of any other agreement; (ii) has no undisclosed conflicts of �. interest; and (iii) 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. 9,18 Contlict of Interest: Envision warrants that, with respect to itself, it has neither employed nor retained any company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person, company, corporation, individual. or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision, Envision agrees that the Plan Sponsor shall have the right to terminate this Agreement without liability and, at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration. Envision also warrants that it has not employed, retrained or otherwise had act on its behalf any former Monroe County officer or employee in violation of Section 2 of Ordinance No. 10-1990 or any Monroe County otTiicer or employee in violation of Section 3 of Ordinance No. 10-1990. For breach or violation of this provision Monroe County may, in its discretion, terminate this contract without liability and may also, in its discretion, deduct from the contract or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former Monroe County officer or employee. 65 IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Agreement as of the Effective Date above. For ENVISION: For PLAN SPONSOR: .lose h R. Schauer COO Print Name & Title .address: Envision Pharmaceutical Services, Inc 2181 East Aurora Road Twinsburg, OH 44087 PH: 330-405-8080 FX. 330-405-8081 MON E COUNTY ATTORNEY AP QV AS O VNTH ASSISTANT p TY tT aRNEY Date ,11B1ASA (trmO6071 1 yi final2l By: CCi Y _ Print Name & Title MCr1fOe- c-J.c.�- rnuyt:>r- C�XL'\ Address: MCBO CC 1100 Simonton Street Key West, FL 33040 PH: 305-292-4452 P P X: E-MAIL: 1~EIN: Dn CJ ' 4 i''flEAQ T T. DANNY L. KOLHAGE r �. 1 i f� (7EP!]TY CLERK i. Envision Ph .Services, Inc. Page 18 of 24 a Packet Pg. 249 EXHIBIT I DRUG PRICING AND FEES I Drug Pricing and Dispensing FeeSIAI i Supply/Source BRAND GENERIC' Based On 3 Year Drug Price(u) Dispensing Drug Price(C) Dispensing Contract Fee (D) Fee (D) Annual Average Effective Rate of Annual Annual Average Annual 30 Days' Supply at a AWP minus 13.55% Average Effective Rate of Average I Retail Pharmacy (Equivalent to Pre- $1.40 AWP minus 73% $1.50 Settlement discount of 17%) Annual Average 90 Days' Supply at a Effective Rate of Annual Average Retail Pharmacy AWP minus 19.75% None Effective Rate of None (non -Mail Order) (Equivalent to Pre- AWP minus 74% Settlement discount of 22%) Annual Average Mail Order (at Orchard Effective Rate of AWP minus 19.8% Annual Average Pharmaceutical $9.50 Effective Rate of $9.50 Services) (Equivalent to Pre- Settlement discount of AWP minus 86% 23%) Specialty (at Walgreens Specialty (Pass -through of negotiated price with dispensing pharmacy) Pharmacy) IAI Calculated price using the applicable negotiated contract rate (i.e. AWP or MAC rate, or U&C Price). In order to illustrate economic neutrality to the 2009 McKesson/First Data Bank Settlement, the pre - settlement AWP values noted in this exhibit have been adjusted to restore the relationship between WAC and AWP as it was prior to September 26'h, 2009. Only the post -settlement AWP values are used to calculate the Average Annual Effective Rates as set forth in Exhibit 1. If the calculated price is lower than the allowable amount under any state Medicaid -Favored Nations" rule, Frivision shall pass -through, and Plan Sponsor shall pay, the Medicaid allowable amount. (14 ) Annual Average Effective Rate for Brand Drugs is calculated using actual price paid to pharmacies by Envision (betbre deducting Manufacturer Derived Revenue) for all Brand Drug Claims (including Claims paid at the U'&C Price) during a Contract Year, excluding (i) Compound Drugs, (ii) Specialty Drugs, (iii) Claims from non -Participating Pharmacies, (iv) Claims paid at the Medicaid allowable amount, (v) 340B Claims. (( 'v Annual Average Effective Rate for Generic Drugs is calculated using actual price paid to pharmacies by F rivision for all Generic Drug Claims (including Claims paid at the U&C Price) during a Contract Year, excluding (i) Excluded Generics, (ii) Compound Drugs, (iii) Specialty Drugs. (iv) Claims from non- \Pt3MSA (firm06071 1)(fina12) 0 Envision Pharmaccuticai Services, Inc. Page 19 of 24 Participating Pharmacies, (v) Claims paid at the Medicaid allowable amount, (vi) 340B Claims. to) Annual Average Dispensing Fee is the average per Claim fee for all Claims (including Claims paid at the U&C Price) during a Contract Year, excluding (i) Compound Drugs, (ii) Specialty Drugs, (iii) Claims from non -Participating Pharmacies, (iv) Claims paid at the Medicaid allowable amount. Administrative Fee (Payable to Envision; not including fees payable to Plan Sponsor's TPAs, consultants, or brokers, if any) For Contract Year 1: $3.75 Per Employee, Per Month (PEPM) For Contract Year 2: $3.75 PEPM For Contract Year 3: $3.75 PEPM [Fees for Additional Services and Miscellaneous Expenses 1. Replacement by Envision of lost or stolen ID Cards $1.00 per card plus cost of postage 2. Manual Claims Processing and Direct Member Reimbursements (DMRs) $1.50 per Claim processed 3. Manually create or update the Eligibility File $ 1. 00 per Member data entry 4. Ad Hoc Computer or Report Programming $150.00 per hour 5. Clinical Prior Authorizations $8.00 per authorization I fgr g 0 M 0 CL I Z Ui ME Uj Uj Z 0 Z Ui c: 0 E \PBMSA jnnO6071 I)(finaQ) ',0 Envision Pharmaceutical Services, Inc. Page 20 of 24 EXHIBIT, 3 Minimum Performance Standards *TOTAL DOLLAR CATEGORV/ AMOUNT MEASURE TARGET DEFINITION AT RISK System Availability 99.5% Calculated as the amount of time the $1,000 POS system is available to process claims. System Response time/ <4 seconds Calculated as the time commencing $1,000 measured annually immediately after receipt of the last character of a transaction submitted by a pharmacy until the first character of the response is sent to the pharmacy. Retail Paper Claims Processing Time Percent of direct member 95% Calculated as the number of claims $1,000 submitted prescription reimbursed or responded to within 10 drugs claims reimbursed business days, divided by the total or responded to within number of prescription drugs for a 10 business days specified time period Mail Order Claims Processing Time Turnaround time for 95% within 2 Measured in business days from the $1,0001 prescription drugs business days date a prescription drug claim is requiring no intervention received by the PBM (either via paper, phone, fax, or Internet) to the date it is mailed I'Llmaround time for 98% within 5 Measured in business days from the $1,000 prescription drugs business days date a prescription drug claim is requiring administrative or less received by the PBM (either via paper, /clinical intervention phone, fax, or Internet) to the date it is mailed I E 4) co cc C: M E c: E L. c: .2 An c: LU o c: 0 M 0 CL Q. Q z LU ME LU LU z 0 z LU c: 0 E AIBMSA (tran)6071 1)(final2) 0 Envision Pharmaceutical Services, Inc. Page 22 of 24 Retail and Mail Claims Processing Accuracy Percent of all claims paid >99.98% with no errors I Retail >99.98% Mail Customer Service Based on PBM's internal quality review. Calculated as all claims audited and found to be without error of any form, divided by all claims audited $1.000 Percent n-t o- f- calls that will 95% The amount of time that elapses $1,000 be answered within 30 answered in between the time a call is received seconds an average of into a customer service queue to the 30 seconds or time the phone is answered by a less Customer Service Representative (CSR) Percent of calls <4% Percentage of calls that are not $1.000 abandoned answered by PBM (caller hangs up before call is answered). Calculated as the number of calls that are not answered divided by the number of calls received Percent of calls blocked <2% Percentage of all calls made to PBM $1,0001 vendor that were not answered because the calls did not enter phone system due to excess volume Percent of calls with >90% Percentage of all calls made to PBM $1,000 resolution at end of first that were resolved by initial CSR. call (i.e. no turther Calculated as the total calls to PBM inquiry by caller required minus total number of unresolved to obtain requested calls divided by the total number of information or action) calls received. Percent of written 99% Response time for all written inquiries 1$1,000 inquiries responded to by will be based on the number of paper within 10 business business days subtracting the date days or responded to received at PBM from the date the electronically within 2 response was sent business days Pharmacy Network >95% Based on network pharmacy access $1,000 Access within, 10 miles for Plan Sponsor's participants. \1113MSA (firnftff? I I )(F=12) 'G, Envision Pharmaceutical Services, Inc. Page 23 of 24 Account Management Account Sponsor satisfaction Results will Plan Sponsor satisfaction results will $1,000 with Account be based on be measured by the response to the Management overall results following question: Overall, how of all Plan satisfied are you with the Account Sponsor Team Service level? "Overall Plan contacts with Sponsor Satisfaction" for the purpose direct contact of this guarantee includes the with Account following responses: Satisfied and Team Very Satisfied. Administration Enrollment Processing Two (2) Eligibility information submitted to $1.000 business days vendor will become effective within 2 business days. Assumes complete and accurate information is sent to vendor. --1000 Ongoing ID card Five (5) Measured as the time from receipt of $I, production business days complete and accurate eligibility information to the time vendor deposits ID cards into the mail. Standard reporting cycle Mutually Measured as the time from the last day $1,000 agreed upon of the end of a reporting cycle to the timeline day standard reports are sent to Plan Sponsor. NOTE: Failure to meet targets will be determined by means of reports produced by Envision. For purposes of calculating time with the respect to these Performance Guarantees, the day of receipt shall be excluded and the day of delivery will be included in the calculation as long as delivery occurs prior to 4:00 PM local time. If Envision fails to meet the above listed Performance Guarantees and Plan Sponsor desires to assess penalties, payment to Plan Sponsor is payable within thirty (30) business days. 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. Upon approval from Plan Sponsor, payment of penalties may be credited towards future Administration Fees. Failure to meet Performance Guarantees shall not be deemed to be a breach of this Agreement. I I TUNSA (frm0607I 1)(finaQ) ,,C) Envision Pharmaceutical Services, Inc, Page 24 of 24 i. A AMENDMENT NO. 1 TO PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT This Amendment No. 1 (this "Amendment"), is entered into by and between Envision Pharmaceutical Services, LLC ("Envision"), and Monroe County Board of County Commissioners ("Plan Sponsor"). BACKGROUND Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement dated October 1", 2011 (the "Agreement"), under which Envision provides PBM Services to Plan Sponsor; and The parties desire to amend the Agreement, and therefore Envision and Plan Sponsor agree as follows: 1. The term of the Agreement shall extend to September 30t', 2017. 2. Section 2.4.5 shall be deleted in its entirety. 3. Exhibit 1 shall be deleted in its entirety and replaced with the following: EXHIBIT 1 DRUG PRICING AND FEES Administrative Fee (Payable to Envision; not including fees payable to Plan Sponsor's TPAs, consultants, or brokers, if any) For Contract Year 2014: $3.50 Per Employee, Per Month (PEPM) For Contract Year 2015: $3.65 PEPM For Contract Year 2016: $3.65 PEPM Fees for Additional Services and Miscellaneous Expenses l . Replacement by Envision of lost or stolen ID Cards $1.00 per card plus 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 /Monroe County 130C Am. 1 073114 k) Envision Pharmaceutical Services, LLC Pa Packet Pg. 256 C nical Prior Authorizations (Initial Coverage erminations) P $8.00 per authorization ricing and Dispensing Fees Supply/Source BRAND GENERIC For Contract Year Drug Price (A) Dispensing Drug Price (A) Dispensing 2014 (Annual Average Fee (B) (Annual' Average Fee (B) (based on 3 year Effective Rate Annual Effective Rate (Annual Agreement) Guarantee) Average g Guarantee ) Average Guarantee) Guarantee) 30 Days' Supply at a Retail Pharmacy AWP minus 15.35% $1.30 AWP minus 75% $1.30 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail AWP minus 20% N/A AWP minus 76% N/A Order) Mail Order Pharmacy Acquisition Cost $9.50 Acquisition Cost $9.50 Specialty Pharmacy (Pass -Through of Contract Rate BRAND with Dispensing Pharmacy) GENERIC Supply/Source Drug Price (A) Dispensing Drug Price (A) Dispensing For Contract Year (Annual Average Fee (B) (Annual Average Fee (B) 2015 Effective Rate Guarantee) (Annual Effective Rate (Annual Average Guarantee) Average g Guarantee ) Guarantee) 30 Days' Supply at a Retail Pharmacy AWP minus 15.45% $1.30 AWP $1.30 75.50 /o 0% 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail AWP minus 20.10% N/A AWP minus N/A Order) Acquisition Cost $9.50 76.50% Acquisition Cost $9.50 Mail Order Pharmacy Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) Supply/Source BRAND GENERIC Drug Price (A) Dispensing Drug Price (A) Dispensing For Contract Year (Annual Average Fee (B) (Annual Average Fee (B) 2016 Effective Rate Guarantee) (Annual Effective Rate (Annual Average Guarantee) Average g Guarantee ) Guarantee) /Monroe County BOC Am. 1 073114 © Envision Pharmaceutical Services, LLC Pal Packet',Pg. 256 jr 30 Days' Supply at a Retail Pharmacy AWP minus 15.55% $1.25 AWP minus 76% $1.25 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail AWP minus 20.20% N/A AWP minus 77% N/A Order) Mail Order Pharmacy Acquisition Cost $9.50 Acquisition Cost $9.50 Specialty Pharmacy (Pass -Through of Contract Rate with Dispensing Pharmacy) (A) Annual Average Effective Rate is calculated using actual price paid by Envision to Participating Pharmacies in the designated Network, plus any Cost Share, (the Ingredient Cost) for all Claims for the applicable category (including Claims paid at the U&C Price) during a Contract Year, excluding (i) Compound Drugs; (ii) Limited Distribution Drugs; (iii) drugs dispensed at a Specialty Pharmacy; (iv) Claims from non -Participating Pharmacies, LTC pharmacies, or government owned or operated pharmacies (e.g. Veterans Administration); (v) Claims paid at government required amounts (e.g. Medicaid); (vi) 340B Claims; (vii) vaccines; (viii) non -Prescription Drugs; (ix) Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy; and (x) Excluded Generics. (B) 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) Limited Distribution Drugs; (iii) drugs dispensed at a Specialty Pharmacy; (iv) Claims from non -Participating Pharmacies, LTC pharmacies, or government owned or operated pharmacies (e.g. Veterans Administration); (v) Claims paid at government required amounts (e.g. Medicaid); (vi) 340B Claims; (vii) vaccines; (viii) non -Prescription Drugs; (ix) Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy; and (x) Excluded Generics. Annual Average Effective Rate and Annual Average Dispensing Fee Guarantee Plan Sponsor acknowledges that the Annual Average Effective Rates and Annual Average Dispensing Fees specified in this Exhibit 1 are conditioned upon Plan Sponsor's adherence to certain conditions under this Agreement and that the actual Annual Average Effective Rates and Annual Average Dispensing Fees will also depend on Plan Sponsor's drug utilization and mix of Participating Pharmacies. Within four months after the end of each Contract Year, Envision shall provide Plan Sponsor, upon request, with a report showing the actual Annual Average Effective Rates and Annual Average Dispensing Fees paid by Plan Sponsor for the Contract Year. The Annual Average Effective Rates and Annual Average Dispensing Fees guarantees set forth in Exhibit I shall be deemed to have been satisfied if the discounts passed through to Plan Sponsor for all Claims during the Contract Year are equal to or more favorable, in the aggregate, than the drug pricing and dispensing fee guarantees stated for each drug type or category individually. If the amounts paid by Plan Sponsor for all Claims during the Contract Year are less favorable, in the aggregate, than the combined Annual Average Effective Rates and Annual Average Dispensing Fees stated in Exhibit 1, Envision shall credit Plan Sponsor with the difference. Envision shall not be liable to Plan Sponsor for shortfalls in guaranteed Annual Average Effective Rates or Annual Average Dispensing Fees if (i) Plan Sponsor makes a change to the Benefit Plan at any time (regardless of whether or not such change is required by law); (ii) the configuration of System edits is modified by Plan Sponsor; (iii) Plan Sponsor does not adhere to the Formulary; or (iv) the utilization data provided by Plan Sponsor (or Plan Sponsor's agent) upon which the calculation of guarantees were based is inaccurate, incomplete, or there is a substantial change in drug utilization patterns of Covered Individuals. Plan Sponsor agrees that Envision's liability to Plan Sponsor for shortfalls in financial guarantees, in the aggregate, for any Contract Year shall be limited /Monroe County 130C Am. 1 073114 U Envision Pharmaceutical Services, LLC Pa Packet Pg. 257 t aa. Ir 11 L to amounts paid by Plan Sponsor to Envision for Administrative Fees during the applicable Contract Year, and Plan Sponsor has no right of offset to withhold any payment due Envision under this Agreement for any amounts Plan Sponsor believes are owed by Envision for financial guarantees. 4. This Amendment shall be effective October lst, 2014 ("Effective Date"). 5. All other terms or provisions of the Agreement not modified by this Amendment or any other amendments or addenda shall remain unchanged. IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Amendment as of the Effective Date above. For ENVISION: By: Frank J. heehy Chief Executive O 7icer For PLAN SPONSOR: By: s Z���i urpk7y, �r Print Ttle MONROE COUNTY ATTORNEY �4RYNTHIA � � T� FO M: L. HALL ASSISTANT COUNTY AT, Date /Monroe County 130C Am. 1 073114 6) Envision Pharmaceutical Services, LLC Pa Packet Pg. 258 AMENDMENT NO.2 TO PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT This Amendment No. 2 (this "Amendment"), is entered into by and between Envision Pharmaceutical Services, LLC ('Envision"), and Monroe County Board of County Commissioners ("Plan Sponsor"). Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement dated October 1st, 2011 (the "Agreement"), under which Envision provides PBM Services to Plan Sponsor; and The parties desire to amend the Agreement, and therefore Envision and Plan Sponsor agree as follows: 1. The term of the Agreement shall extend to December 31St, 2017. 2. Financial performance guarantees for Contract Year 2016 will include all Claims from October 1st, 2016 through December 31 st, 2017. 3. This Amendment shall be effective January 111, 2017 ("Effective Date"). 4. All other terms or provisions of the Agreement not modified by this Amendment or any other amendments or addenda shall remain unchanged. IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Amendment as of the Effective Date above. For ENVISION: By: L— atthew A. Gibbs, Pharm D. �ent, Commercial & Managed Markets KEVIN MADOK, CLERK b YPq a� Deputy C erk , j 11 7 For PLAN SPONSOR: By: Mayor George Neugent Print Name & Title BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA ATTORNEY AP (--,i%E.€-) 6S 0 F ?"TALL ASSISTA` 4 ;,),ij T"� ATT0RN� y /Monroe County BOC Am. 2 113016 C Envision Pharmaceutical Services, LLC Page 1 of I