HomeMy WebLinkAboutAdden 1 CAG-09-184, Adden #1-09
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MEDICARE RETIREE DRUG SUBSIDY ADDENDUM
This Medicare Retiree Drug Subsidy Addendum ("RDS Addendum") is entered into this 1st day
of October, 2009, by and between Envision Pharmaceutical Services, Inc. ("Envision"), and
City of Renton,Washington ("Plan Sponsor").
RECITALS
WHEREAS, Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services
Agreement dated October 1st, 2009 (the "Agreement") under which Envision provides PBM
Services to and on behalf of Plan Sponsor; and
WHEREAS, Plan Sponsor has established and sponsors a Qualified Retiree Prescription Drug
Plan ("Part D Plan") pursuant to 42 CFR §423.884 under the Medicare Part D Program in order
to apply for and collect retiree drug subsidy ("RDS") payments for covered Part D drugs
provided to Eligible Retirees;
WHEREAS, Envision provides certain services on behalf of Plan Sponsors to assist in the
reporting of information required for the collection of RDS ("RDS Services"); and
WHEREAS, Plan Sponsor desires to engage Envision to provide the RDS Services set forth
herein.
Now, therefore, Envision and Plan Sponsor hereby agree as follows:
1. Definitions: Capitalized terms not otherwise defined herein shall have the meanings
ascribed to them in the Agreement and, as applicable, the Medicare Regulations (as defined
below). The following terms shall have the meanings set forth below:
A. "CMS" means the Center for Medicare and Medicaid Services, the administrator
of the Medicare Part D Program.
B. "Delegation" means the actions and permissions required by CMS for Plan
Sponsor to designate Envision as the entity authorized to report Cost Summary on behalf of Plan
Sponsor.
C. "Eligible Retiree" means a Covered Individual who is eligible for Medicare Part
D and covered by an employment-based retiree health benefits plan sponsored by Plan Sponsor
meeting the requirements for a Part D Plan and who has been identified by Plan Sponsor in the
RDS Eligible Member files
D. "Medicare Regulations" means any and all rules, guidance, interpretations and
operational directives adopted by CMS concerning the Medicare Part D Program.
E. "RDS Payment"means the subsidy amount paid to Plan Sponsor for covered Part
D drugs.
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F. "Cost Reports" means the following reports in a format and with content
consistent with the requirements of the Medicare Regulations:
(i) Initial Eligibility File (list of Plan Sponsor's Eligible Retirees), due no
later than ninety(90) days prior to Plan Sponsor's plan year. Plan Sponsor must complete
the process of Delegation and provide Envision with the list of Eligible Retirees at least
fifteen(15) days prior to Initial Eligibility File due date;
(ii) Eligibility Update File (update of Eligible Retirees), due monthly,
quarterly, or annually as chosen by Plan Sponsor; and
(ii) Cost Data Extract (net covered retiree plan-related prescription drug
costs), due monthly, quarterly, or annually as chosen by Plan Sponsor.
2. RDS Services: In consideration of the fees set forth in Section 3 below, Envision will
provide the following services:
A. Cost Summary: Envision will submit, directly to CMS on behalf of Plan Sponsor,
the Cost Reports in a format and with content consistent with the requirements of Medicare
Regulations in order to enable Plan Sponsor to file for and collect RDS Payments and meet its
Part D Plan reporting obligations under the Medicare Regulations. Plan Sponsor shall provide to
Envision, in a timely manner, any data now and hereafter required under the Medicare
Regulations (e.g., Eligible Retiree Social Security numbers, Health Insurance Claim numbers,
the CMS issued Plan Sponsor ID, Application ID, etc.) in a time frame and format reasonably
required by Envision (i.e. depending on the reporting period chosen by Plan Sponsor and in a
Comma Separated Value (.csv) file containing all required fields).
B. Drug Cost Reporting and Reconciliation: Envision agrees to submit to Plan
Sponsor or, upon Plan Sponsor's request to upload directly to the CMS RDS website, the
aggregate drug costs incurred by Plan Sponsor's Part D Eligible Retirees as required by 42 CFR
423.888(b)(2) and (b)(4). In the case of submissions to the Plan Sponsor, Envision agrees to
provide such data in sufficient time to allow Plan Sponsor to submit such information via the
CMS RDS website within the time periods specified by CMS. In the case of direct uploads to the
CMS RDS website by Envision, Envision agrees to upload the data in sufficient time for Plan
Sponsor to review and formally submit the data to CMS via the CMS RDS website. Envision
also agrees to perform any required reconciliation functions with CMS related to the reject
responses of the drug cost data. Plan Sponsor shall advise Envision, at the time it submits the
RDS application, whether it wishes to receive payments from CMS on a monthly, quarterly or
annual basis in accordance with 42 CFR 423.888(b)(2)(i) so that Envision may prepare and
submit data accordingly to Plan Sponsor or, as directed by Plan Sponsor, to the CMS RDS
website.
C. Appointing Envision as an RDS Designee: Plan Sponsor hereby acknowledges
and agrees that in order for Envision to submit Eligibility and Cost Summary data directly to
CMS, Plan Sponsor must appoint Envision as a designee both for the submission of eligibility
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and costs data. Plan Sponsor is solely responsible for appointing Envision as both an eligibility
and cost reporter designee in the manner prescribed by CMS. Plan Sponsor understands and
agrees that if Plan Sponsor fails to properly appoint Envision as a designee, Envision will be
unable to submit retiree data and Cost Summary Reports directly to CMS. Plan Sponsor shall
indemnify and hold Envision harmless from any claims, damages, liabilities or expenses arising
out of Envision's inability to submit any and all Subsidy, Drug Cost Reporting and Annual
Reports to CMS due to Plan Sponsor's failure to properly appoint Envision as a designee for the
submission of eligibility and/or cost data.
D. Cooperation: Plan Sponsor shall cooperate with Envision as reasonably necessary
for Envision to perform RDS Services hereunder including, without limitation, providing timely
and accurate information as required to complete and reconcile Subsidy Reports, and agrees to
hold harmless Envision from any errors or failures to meet timelines which result from Plan
Sponsor's failure to cooperate or provide timely and accurate information.
E. RDS Applications: Plan Sponsor acknowledges that RDS Services exclude the
completion or filing of the Plan Sponsor's initial or annual renewal CMS application for RDS.
Plan Sponsor shall be solely responsible for the timely and complete filing of RDS applications.
Any assistance requested by Plan Sponsor and provided by Envision shall be solely consultative
and shall not be deemed to be an acceptance by Envision of any responsibility for the completion
or submission of any application.
F. Audit Services: Envision agrees to make available for audit by CMS or its
designee the Claims data and such data in Envision's possession as required to be retained
pursuant to 42 CFR 888(d)(3), for CMS to verify the subsidy payment claimed by Plan Sponsor,
for the six year period specified in 42 CFR423.888(d)(1).
G. Creditable Coverage and Non-Creditable Notices: Upon Plan Sponsor's
independent determination as to whether its Plan qualifies as creditable prescription drug
coverage within the meaning of 42 CFR 423.56(a), Envision agrees to send to Plan Sponsor's
Part D Eligible Retirees notices of creditable or non-creditable coverage, as applicable in
accordance with Part D requirements under 42 CFR 423.56(f) based on creditable coverage
information provided by Plan Sponsor. Plan Sponsor agrees that Envision shall not have any
further responsibility to provide any further services under this Addendum with respect to non-
creditable coverage plan(s). Plan Sponsor will agree to reimburse Envision for the postage cost
incurred in mailing such notices.
I. Reports and Records: Envision shall maintain documentation of all Claims
processed for ten (10) years. In addition, Envision shall maintain, for a period of six (6) years,
books, records, documents and other evidence of accounting procedures and practices directly
related to the financial and other aspects of its administration of the Plan consistent with 42 CFR
423.888(d)(1). Subject to this section, all such records, while maintained by Envision, shall be
accessible by Plan Sponsor for examination and audit during the term of and in accordance with
this Agreement.
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J. Actuarial Equivalence Determination: Envision agrees to provide consultative
assistance to the Plan Sponsor in determining whether its Plan meets the actuarial equivalence
tests specified in 42 CFR 423.884(d)(1). Plan Sponsor acknowledges and agrees that it is
responsible for obtaining the services of an licensed actuary and providing to CMS the actuarial
equivalence attestation required by 42 CFR 423.884(d).
K. Submissions by Envision: Envision shall reimburse Plan Sponsor for any
overpayments, fines, or penalties charged to Plan Sponsor by CMS as a result of a reporting or
submission error made or caused solely by Envision and not, in any manner, made or caused by
Plan Sponsor.
3. Compensation: Plan Sponsor shall reimburse Envision for the provision of RDS Services
as follows: $1.00 per Eligible Retiree per month (with an annual minimum of Two Thousand
($2,000.00) and an annual maximum of Fifteen Thousand ($15,000.00) per Plan Sponsor) which
shall be added to the monthly Administrative Fee charged by Envision under the Agreement.
4. Federal Funds: Envision acknowledges that information and services it provides in
connection with this Addendum will be used by Plan Sponsor for the purpose of obtaining
Federal Funds, as that term is further described in the RDS application.
IN WITNESS WHEREOF, the undersigned have executed this RDS Addendum as of the date
set forth above.
Envision: Plan Sp'nsor:
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