1st Amendment 07/01/2018 (Null & Void) ocuSlgn Envelope 1U E 3A9 -DE -4 F -5A ® FCD 7
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 January 1',2018(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. Any capitalized term used and not identified in this Amendment shall have the same meaning
as defined in the Agreement.
2. Section 1.7"Contract Year"shall be deleted in its entirety and replaced as follows:
"The term"Contract Year(s)"shall mean the complete twelve(12)month period beginning
on the Effective Date of this Agreement(subject to Section 3.3)and all subsequent twelve
month periods thereafter."
3. SSggion 3.3 shall be added to the Agreement as follows:
"3.3 Reconciliation for the 2016-2018 Contract Year. Plan Sponsor agrees that it shall adopt
the terms of the then existing agreement(as amended) for the dates October 1, 2016 through
June 30, 2018. This includes, but is not limited to, Exhibit 1, all financial and performance
guarantees,reconciliations,reporting obligations,and Administrative Fees.For the 2016-2018
Contract Year, Plan Sponsor will maintain the ability to audit annually; however, the audit
scope for the 2016-2018 Contract Year will extend through June 30, 2018. Beginning July 1,
2018, as described below, Plan Sponsor will maintain Contract Years that begin on July 1, of
the applicable year and end June 30 of the applicable year. Chart 1 is provided below for
clan
Extended 2016-2018 Following Contract
Prior Contract Year Period Contract Year Period Year
October 1,2016- October 12016-June 30 July 1,2018-June 30,
December 31 2017 1 2018 1 2019
Li
4. "Drug Pricing and Dispensing Fees,""Annual Average Effective Rate and Annual Average
Dispensing Fee Guarantee"and"Annual Average Manufacturer Derived Revenue
Guarantee"sections of Exhibit 1 shall be deleted in their entireties and replaced with
Attachment I attached hereto and incorporated into the Agreement by this reference.
Amendment No.1070919 0 Envision Pharmaceutical Savices,t.1.0 Page l of 7
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5. This Amendment shall be effective July 1",2018 ("Effective Date").
6. To the extent there is a conflict between this Amendment and the Agreement,the terns of this
Amendment shall control. All other terms or provisions of the Agreement not modified by this
Amendment or any other amendments or addenda shall remain unchanged and are incorporated
herein by reference.
IN WITNESS WHEREOF,Envision and Plan Sponsor have executed this Amendment as of the
Effective Date above.
For ENVISION: For PLAN SPONSOR:
DwuftmW by-
BY:P Byi I v'
h4l
Jane Lyons Natalie M.Mgoddox
General Manager,Commercial Interim Employee Benefits Administrator
Amendment No.1070918 0 Envision Phamweuticall Savim.LLC Page I of 7
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ATTACHMENT 1
Drag Pricing and Dispensing Fees(A)
Supply/Source BRAND GENERIC
Drag Price(UXC Dispensing Drug Price(8XQ DisPensing
For Contract Year l (Annual Average Fee(c) (Anne>Ial Average Fee
(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) 77.00%
Retail Pharmacy(84
Days' Supply or AWP minus 22.00% NIA AWP minus NIA
greater)(non-Mail 83.00%
Order)roe'
Mail Order Pharmacy AWP minus
(84 Days' Supply or AWP minus 24.00% NIA 85 00% NIA
greater)
Specialty Pharmacy(E) Priced per Envision Specialty Drug List.
Supply/Source BRAND GENERIC
Drug Priee(lxl) Dispensing Drng PriceMQ 'Dispensing
For Contract Year 2 (Annual Average Fee tQ (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% AWP minus
Days' Supply) $1.� 77.50% $1.00
Retail Pharmacy(84
Days' Supply or AWP minus 22.25% NIA AWP minus NIA
greater)(non-Mail 83.25%
Order)(°)
Mail Order Pharmacy AWP minus
(84 Days' Supply or AWP minus 24.25% N/A o N/A
greater)� 85.25/o
Specialty Pharmacym Priced per Envision Specialty Drug List.
Amendment No.1070918 0 Envision Phmmaoeutical services,LLC Page 3 of 7
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Supply/Source BRAND GENERIC
Drug Price(BxQ Dispensing Drug Price d Dispenain9'
For Contract Year 3 (Annr3al Average Fee(cl (Annual Average Fee tot
(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 $1.00
Days' Supply) 78.00%
Retail Pharmacy(84
Days' Supply or AWP minus 22.50% N/A AWP minus N/A
greater)(non-Mail 83.50%
Order)(D)
Mail Order Pharmacy
(84 Days' Supply or AWP minus 24.50% NIA A5. N/A
greater)[� 85.50/a
Specialty Pharmacy(E) Priced per Envision Specialty Drug List.
(A) For purposes of this Agreement the "Average Wholesale Price" or "AWP" means the average
wholesale price of a Covered Drug indicated on the most current pricing file provided to Envision
by Medi-Span® (or other applicable industry standard reference on which pricing hereunder is
based)for the actual drug dispensed using the 11 digit National Drug Code(NDC)number provided
by the dispensing pharmacy. Envision uses a single source for determining AWP and updates the
AWP source file at least once weekly.
($)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.
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;
Amendment No.1070918 O Envision P6amnaceutical Services,LLC Page 4 of 7
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(xi) manually processed Claims; (xii) coordination of benefits Claims; and (xiii) Medicaid
subrogation Claims.
(°)84 Days' supply or greater at retail pharmacy guarantees apply only if Plan Sponsoes Benefit
Plan includes a 90 days' supply at retail benefit for the entire Contract Year.
In no event will the Retail Pharmacy or Mail Order Pharmacy pricing terms specified in the Agreement,
including, but not limited to, the Annual Average Effective Rate and Annual Average Dispensing Fee
guarantees, apply to Specialty Drugs dispensed at a Specialty Pharmacy. Specialty Drugs dispensed at the
Specialty Pharmacy will be included in the Annual Average Aggregate Effective Rate Guarantee for Specialty
Drugs dispensed at the Specialty Pharmacy. For all other purposes, Specialty Drugs are excluded from all
Effective Rate Guarantees.
'(n The calculation is inclusive of the postage expense of Mail Order Claims.Should any United States Postal
Service (LISPS)or commercial carrier postage rate increase during the contract term, such increase will be
passed through to Plan Sponsor via an equal increase to the Mail Order dispensing fee.
Annual Average'Effective Mute 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. 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 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 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.
Annual Average Manufacturer Derived Revenue Guarant,ee(G�Mm cn
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 Mail Order Pharmacy- $96.92 per paid Brand
Amend mnt No.1070918 0 Envision MwnaceudicW Services,LLC Page 5 of 7
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Drug Claim
• For 46+days' supply of Brand Drugs at the Mail Order Pharmacy- $407.53 per paid Brand Drug
Claim
• For Specialty Brand Thugs-$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- S285.20 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-$315.99 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
• For Specialty Brand Drugs-$647.03 per paid Specialty Brand Drug Claim
(c) Manufacturer Derived Revenue guarantees are stated as annual average amounts per Contract
Year.
(H) 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.
m 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 I 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
Amendment No.107091B 0 Envision Pharmaceutical Services,L LC Page 6 of 7
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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 change+/-20% 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.
Amcndmcnt No.1 07O918 0 Envision Phmaemdcal Serviecs,LLC Page 7 of 7