Loading...
HomeMy WebLinkAboutContract 46250-A1 (2)CITY SEcRkItAWU CONTRACT, ran Lj! d y c 5F 2 AMENDMENT NO. 1 � jp TO TO Se4 PHARMACY BENEFIT MANAGEMENT SERVICES AGREEMENT \\./ Oc° DI anis Amendment No. 1(this "Amendment"), is entered into by and between Envision Pharmaceutical Services, LLC ("Envision"), and the City of Fort Worth ("Plan Sponsor"). N own ,ftstes, v 1 BACKGROUND Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement, filed as City Secretary Contract No. 46250, dated January 1st, 2015 (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. Exhibit 1 shall be deleted in its entirety and replaced with Exhibit 1 attached hereto and incorporated by this reference. 2. Exhibit 2 shall be deleted in its entirety and replaced with Exhibit 2 attached hereto and incorporated by this reference. 3. This Amendment shall be effective January 1st, 2016 ("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: Matthew A. Gibbs, Pharm D. Chief Commercial Officer OFFICIAL ECORD CITY SECRETARY TO WORTH, TX For PLAN SPONSOR: aVaAA, Alanis tant City Manager APPROVED AS TO PGItM AND LEGALITY: OM City ev J goor Worth mend.-tkri-06;1815 CO Envision Pharmaceutical Services, LLC Page 1 of 7 EXHIBIT 1 FEES, DRUG PRICING, AND FINANCIAL GUARANTEES Administrative Fee (Payable to Envision; not including fees payable to Plan Sponsor's TPAs, consultants, or brokeis, if any) For Contract Year 2016, 2017 & 2018: $4.00 Per Employee, Per Month (PEPM) Fees for Additional Services and Miscellaneous Expenses 1. Replacement by Envision of lost or stolen ID Cards 2. Manual Claims Processing (including DMRs) 3. Claim Adjustment Checks (charged to Plan Sponsor for reimbursements made to Covered Individuals for Claim adjustments requested by Plan Sponsor.) 4. Manually create or update the Eligibility File 5. Ad Hoc Computer or Report Programming 6. Clinical Prior Authorizations (Initial Coverage Determinations) 7. Drug Therapy Care Gap Management 8. Medication Adherence and Persistency (up to three disease states) Drug Pricing and Dispensing Fees(A) Supply/Source BRAND For Contract Year 2016 30 Days' Supply at a Retail Pharmacy 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail Order) Mail Order Pharmacy Specialty Pharmacy Drug Price (B) (Annual Average Effective Rate Guarantee) AWP minus 15.45% AWP minus 20.20% AWP minus 21.06% $1.00 per card plus $0.15 per packet and cost of postage $1.50 per Claim processed $8.50 per check $1.00 per Covered Individual data entry $150.00 per hour $8.00 per authorization $0.55 per Member per month (PMPM) $0.55 PMPM Dispensing Fee (c) (Annual Average Guarantee) $1.20 N/A N/A GENERIC Drug Price (B) (Annual Average Effective Rate Guarantee) AWP minus 77.50% AWP minus 77.50% AWP minus 80% Dispensing Fee (c) (Annual Average Guarantee) $1.20 N/A N/A (Pass -Through of Contract Rate with Dispensing Pharmacy) /Ft. Worth Amend. No. 1 061815 n Envision Pharmaceutical Services, LLC Page 2 of 7 Supply/Source For Contract Year 2017 30 Days' Supply at a Retail Pharmacy 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail Order) Mail Order Phaiivacy Specialty Pharmacy BRAND Drug Price (B) (Annual Average Effective Rate Guarantee) AWP minus 15.55% AWP minus 20.30% AWP minus 21.06% Dispensing Fee tC) (Annual Average Guarantee) $1.20 N/A N/A GENERIC Drug Price (B) (Annual Average Effective Rate Guarantee) AWP minus 78% AWP minus 78% AWP minus 80.50% Dispensing Feet ' (Annual Average Guarantee) $1.20 N/A N/A (Pass -Through of Contract Rate with Dispensing Pharmacy) Supply/Source For Contract Year 2018 30 Days' Supply at a Retail Pharmacy 84 Days' Supply (or greater) at a Retail Pharmacy (non -Mail Order) BRAND Drug Price (B) (Annual Average Effective Rate Guarantee) AWP minus 15.65% AWP minus 20.40% Dispensing Fee (C) (Annual Average Guarantee) $1.20 N/A GENERIC Drug Price (B) (Annual Average Effective Rate Guarantee) AWP minus 78.50% AWP minus 78.50% Dispensing Fee (C) (Annual Average Guarantee) $1.20 N/A Mail Order Pharmacy AWP minus 21.06% N/A AWP minus 81 % N/A 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. (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 /Ft. Worth Amend. No. 1 061815 C). Envision Pharmaceutical Services, LLC Page 3 of 7 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. 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, and (ix) Claims from any Plan Sponsor owned o1 affiliated pharmacy which is not a Participating Pharmacy. (c) 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 Di ugs (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; and (ix) Claims from any Plan Sponsor owned or affiliated pharmacy which is not a Participating Pharmacy. 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 l 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 Envision 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 I 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 Guarantee(EmF),(G) For Contract Year 2016, 2017 & 2018: • For Brand Drugs at a Retail Pharmacy - $23.50 per paid Brand Drug Claim 1 /Ft. Worth Amend. No. 1 061815 c Envision Pharmaceutical Services, LLC Page 4 of 7 • For 90 day supply of Brand Drugs at the Mail Order Pharmacy- $57.10 per paid Brand Paid Claim (E) 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 and other Claims not eligible for Manufacturer Derived Revenue, 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. 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. Nine months after the end of each Contract Year, Envision shall provide Plan Sponsor with a report reconciling Manufacturer Derived Revenue amounts advanced to Plan Sponsor and Manufacturer Derived Revenue amounts earned by Plan Sponsor for eligible Claims (including market share based amounts) during the Contract Year. (a) If the Manufacturer Derived Revenue advanced to Plan Sponsor for the Contract Year is, overall, lower than the overall Manufacturer Derived Revenue eat ned by Plan Sponsor for the Contract Year, Envision shall pay the difference to Plan Sponsor. (b) If the Manufacturer Derived Revenue earned by Plan Sponsor for the Contract Year is, overall, lower than the annual average Manufacturer Derived Revenue guaranteed amounts specified above, Envision shall pay the difference to Plan Sponsor. ;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 or there is a substantial change in drug utilization patterns of Covered Individuals; (v) there is a loss of rebates due to pharmaceutical manufacturer drug patent expirations manufacturer bankruptcy, or removal of a drug from the market; (vi) there are changes in pharmaceutical manufacturer rebate contracting terms or policies; (vii) Plan Sponsor's Benefit Plan does not meet the conditions for rebates of pharmaceutical manufacturer contracts including market share rebates; (viii) if Plan Sponsor has been excluded by a manufacturer; or (ix) there is any governmental regulation, ruling, or guidance that impacts I Envision's ability to maintain current Manufacturer Derived Revenue yields. 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. /Ft. Worth Amend. No. 1 061815 0 Envision Pharmaceutical Services, LLC Page 5 of 7 EXHIBIT 2 PERFORMANCE MEASURES Unless otherwise stated, targets set forth below will be measured on a Contract Year basis. The total amount of penalties payable by Envision in any Contract Year shall not exceed ten percent (10%) of Envision's Administrative Fee paid by Plan Sponsor during applicable Contract Year. Unless otherwise stated, payment of penalties will be credited towards future Administrative Fees. Failure to meet Perfoiutance Measures shall not be deemed to be a breach of this Agreement. canc. Pass -Through Standards GET: 1Vl[EAStIRIh FENAL7 Manufacturer Derived Revenue 100% Pass - (MDR) through Network Discounts Network Dispensing Fees Systems Standards - System Availability 100% Pass - through 100% of MDR earned from pharmaceutical manufacturers is passed through to Plan Sponsor, in accordance with the Agreement. 100% of network discounts and dispensing fees are passed through to Plan Sponsor upon the $40,000 effective date of any negotiated change. Calculated as the amount of time the Claims 99.5% Adjudication System is available to process Claims. System Response time <4 seconds Calculated as the time commencing 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. Rota* and Mail Claims Processing Accuracy Based on PBM s internal quality review. Percent of all claims paid with >99.98% Retail Calculated as all claims audited and found to be no errors >99.98% Mail without error of any form, divided by all claims audited. PBM Customer Service - Calculated per Contract Year Percent of calls that will be answered within 30 seconds 93% answered in an average of 30 seconds or less Percent of calls abandoned <5% $40,000 $15,000 $15,000 $15,000 The amount of time that elapses between when a call is received into the customer service queue and the time the phone is answered by a Customer Service Representative (CSR). Measurement and target determination will be based on an annual average. Percentage of calls that are not answered by a CSR (caller hangs up before call is answered). Calculated as the number of calls that are not answered divided by the number of calls received. Measurement and target determination will be based on an annual average. $15,000 $15,000 /Ft. Worth Amend. No. 1 061815 Envision Pharmaceutical Services, LLC Page 6 of 7 CATEGC)i+;Y''- T RGET' PBM Customer Service cont. Percent of calls with resolution at end of first call (i.e. no further inquiry by caller required to >90% obtain requested information or action) Percent of written inquiries responded to by paper within 10 business days or responded to 99% electronically within 2 business days Pharmacy Network Access Account Management , Account Management Responsiveness Administration Enrollment Processing Ongoing ID card production Calculated per Contract Year Percentage of all calls made to Envision that were resolved by initial CSR. Calculated as the total calls to Envision minus total number of unresolved calls divided by the total number of calls received A7easurement and target determination will be based on an annual average. Response time for all written inquiries will be based on the number of business days subtracting the date received at Envision from the date the response was sent. $15,000 $15,000 Based on network pharmacy access within, >95% 10 miles for Plan Sponsor's Covered $15,000 Individuals. Two (2) business days Two (2) business days Five (5) business days Initial client inquiries will be acknowledged and responded to within two business days. Eligibility information submitted to Envision will become effective within 2 business days following the date of receipt. Assumes complete and accurate information is sent to Envision. Measured as the time from receipt of complete and accurate eligibility information to the time vendor deposits ID Cards into the mail. $15,000 $15,000 $15,000 /Ft. Worth Amend. No. 1 061815 Envision Pharmaceutical Services. LLC Page 7 of 7