The URL can be used to link to this page

Home My WebLink AboutServe You/Amendment (Serve you.) THE HAND-CRAFTED PBM FIRST AMENDMENT TO THE AGREEMENT BY AND BETWEEN SERVE YOU CUSTOM PRESCRIPTION MANAGEMENT,INC. AND CITY OF OSHKOSH Account Number: 3363 Amendment Provisions This Amendment to the Self-Funded Prescription Drug Program Agreement("Agreement")by and between Serve You Custom Prescription Management,Inc. ("Serve You")and City of Oshkosh("Client")that was effective on January 1,2010 is incorporated into and made part of the Agreement effective as of January 1,2013. All remaining terms and conditions of the Agreement shall continue in full force and effect. The following shall replace Exhibit A of the Agreement in its entirety: 1. Serve You Pharmacy Network In the case of a Covered Prescription for a Single-Source Drug or Covered Supply dispensed and submitted by a Pharmacy,the term "Charges" shall mean an amount equal to the lesser of: (i)the Pharmacy's Usual and Customary(U&C)price,as submitted; or(ii)Adjusted Average Wholesale Price (Adjusted AWP)for Affected National Drug Codes(NDCs)minus a discount of 17.0%or Average Wholesale Price(AWP)for Non-Affected NDCs minus a proportional equivalent discount to the Adjusted AWP discount;plus the Dispensing Fee set forth below. In the case of a Covered Prescription for a Multi-Source Drug or Covered Supply dispensed and submitted by a Pharmacy,the term "Charges" shall mean an amount equal to the lesser of(i)the Pharmacy's U&C price, as submitted or(ii)the Maximum Allowable Cost("MAC"); plus the Dispensing Fee set forth below. In the case of a Covered Prescription or Covered Supply designated by Serve You as a Specialty Drug and dispensed and submitted by a Pharmacy,the term"Charges"shall mean an amount equal to the lesser of: (i)the Pharmacy's U&C price,as submitted; or(ii)Adjusted AWP for Affected NDCs minus a discount of 17.0%or AWP for Non-Affected NDCs minus a proportional equivalent discount to the Adjusted AWP discount;or(iii)the MAC;plus the Dispensing Fee set forth below. In the case of a Covered Immunization Service submitted by a Pharmacy,the term"Charges"shall mean an amount equal to the lesser of(i)the Pharmacy's U&C price, as submitted or(ii)the Pharmacy's contracted rate with Serve You. The Charges payable by Client for Covered Prescriptions,Covered Supplies or Covered Immunization Services administered or dispensed and submitted by a Pharmacy shall not include the applicable Copayment/Coinsurance amount. 1.1 Dispensing Fee. The Dispensing Fee per prescription or authorized refill is$1.70 for Single- Source Drugs,$1.70 for Multi-Source Drugs and$1.70 for Specialty Drugs. 1.2 Minimum/U&C Charge.Notwithstanding the pricing set forth above, in order to maintain reasonable access to pharmacies, Serve You may find it necessary during the term of the Agreement to negotiate modifications to the pricing terms above with certain Pharmacies to obtain or maintain their participation in Serve You's pharmacy network. Modifications may include but are not limited to a minimum charge and/or the allowance of U&C for those Claims priced below the applicable Copayment/Coinsurance. 1.3 Sole or Limited Distribution Drugs. The Charges for Sole or Limited Distribution Drugs are subject to the rates set by the Pharmacy and/or the Pharmaceutical Manufacturer. Exhibit A Serve You Custom Prescription Management Client Agreement Page A-1 V17412 1.4 Specialty Drugs are subject to addition,deletion or modification from time to time at the sole discretion of Serve You. 2. Serve You DirectRx Pharmacy In the case of a Covered Prescription for a Single-Source Drug or Covered Supply dispensed by Serve You DirectRx Pharmacy,the term"Charges" shall mean an amount equal to Adjusted AWP for Affected NDCs minus a discount of 24%or AWP for Non-Affected NDCs minus a proportional equivalent discount to the Adjusted AWP discount;plus the Dispensing Fee set forth below. In the case of a Covered Prescription for a Multi-Source Drug or Covered Supply dispensed by Serve You DirectRx Pharmacy,the term "Charges" shall mean an amount equal to the MAC;plus the Dispensing Fee set forth below. In the case of a Covered Prescription or Covered Supply designated by Serve You as a Specialty Drug and dispensed by Serve You DirectRx Pharmacy,the term"Charges"shall mean an amount equal to: (i) the MAC,or(ii)Adjusted AWP for Affected NDCs minus a discount of 18%or AWP for Non-Affected NDCs minus a proportional equivalent discount to the Adjusted AWP discount,or(iii)NDC specific discount, where applicable;plus the Dispensing Fee set forth below. Specialty Drug Charges are contingent upon the specialty network being limited to Serve You DirectRx Pharmacy and limited to a thirty(30)day supply maximum per fill. Specialty Drug Charges shall mean a discount of 17%upon the specialty network not being limited to Serve You DirectRx Pharmacy. The Charges payable by Client for Covered Prescriptions or Covered Supplies dispensed by Serve You DirectRx Pharmacy shall not include the applicable Copayment/Coinsurance. 2.1 Dispensing Fee. The Dispensing Fee per prescription or authorized refill is $0.00 for Single- Source Drugs,$0.00 for Multi-Source Drugs and$1.50 for Specialty Drugs. 2.2 Shipping and Handling. If postage rates(e.g., U.S.mail and/or applicable commercial courier services)increase during the term of this Agreement,additional Charges may be assessed to reflect such increase(s). Covered Services that require special handling may incur additional fees. 2.3 Specialty Drugs are subject to addition,deletion or modification from time to time at the sole discretion of Serve You. 2.4 Limited Availability Drugs may be subject to limited availability from the Pharmaceutical Manufacturer or, because they are in short supply, subject to recall or allocation. As a result of any such limited availability, Serve You reserves the right, at its sole discretion,to modify the pricing until the short supply situation is corrected. 3. Manufacturer Discounts are set forth below: Managed Three-Tier Formulary $15.00 per net paid retail brand Claim $45.00 per net paid mail service brand Claim Payment of Manufacturer Discounts for a managed three-tier Formulary is contingent on Client maintaining a three-tiered Copayment/Coinsurance, as defined below,and adoption of the Serve You Formulary Optimization Program as described below. Three-Tiered Copayment means a Copayment/Coinsurance Benefit Plan whereby the Formulary products are given preferential status through Formulary enforcement mechanisms including but not limited to, lower copayment,placement on the first or second tier of a three-tier copayment Benefit Plan having a minimum $15 Copayment differential or Coinsurance equal to a$15 differential between the second and third tiers. Formulary Optimization Program Serve You encourages use of the drug products found on first or second tier of our three-tier Formulary whenever possible. Promotion of these agents is accomplished through communications with patients and prescribers and prescriber-authorized therapeutic interchange of the preferred agents. Increased mail order utilization is also emphasized in this program as a source of cost savings to Client and Eligible Members. Exhibit A Serve You Custom Prescription Management Client Agreement Page A-2 V17412 4. Right to Adjust Rates The rates set forth in this Exhibit A are based on information provided to Serve You by Client, including, without limitation, information regarding the average number of employees enrolled in the Benefit Plan and Client's selected benefit design. Serve You has relied on that information in developing these rates. Any material modification in this information may result in program pricing term modifications by Serve You. 5. Administrative Fees Client will pay Serve You an Administrative Fee in the amount of$0.00 per Processed Claim. 6. Services Available at Additional Cost Eligibility: Manual Submission $1.25 per entry Claim Adjudication: • Coordination of Benefits&Member-Submitted Paper Claim (secondary COB) $3.50 per Claim • Adjudication of Government Reimbursement Claims $3.50 per Claim Direct Reimbursement: Processing Paper Claims $2.50 per entry Clinical Review $45.00 each Covered Immunization Service $2.00 per immunization Adherence Monitoring Program $0.36 PEPM Controlled Substance Monitoring Program $0.10 PEPM Member Materials: • Targeted Communications or Replacement,Re-issuance,or Customization of any Materials Quoted per request • Reprinting of Entire Group's ID Cards $0.30 per card • Member Mailings Actual postage charges This Amendment contains all revised terms and conditions agreed upon by contracting parties. IN WITNESS WHEREOF,this Amendment is signed and the parties have entered into this Amendment on the date set forth below. SERVE YOU CITY OF OSHKOSH CUSTOM PRESCRIPTION MANAGEMENT, INC. Signed for and in behalf of the City of Oshkosh BY: r'("Z A--—" lc-rZ�!° Collin T.Ray ce President of Finance - "ICI. • • .Rohloff,City ' •.ter; DATE: /'1'13 Pal 1 ;la R.Ubrig,City ..lerk e Ly 7.)4 A. Lorenson, -1 Attorney Peggy Al. S�febno, irector of Finance la DATE: =WI I.5 Exhibit A Serve You Custom Prescription Management Client Agreement Page A-3 V17412