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2025-126
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2025-126
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Last modified
6/23/2025 10:28:09 AM
Creation date
6/23/2025 10:23:56 AM
Metadata
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Template:
Official Documents
Official Document Type
Agreement
Approved Date
06/03/2025
Control Number
2025-126
Agenda Item Number
13.D.1.
Entity Name
RxBenefits, Inc.
Subject
Administrative Services Agreement for the administration of prescription drug benefits
Document Relationships
2025-125
(Agenda)
Path:
\Official Documents\2020's\2025
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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />RYAN L. BUTLER, CLERK <br />Ingredient Cost <br />Pass -Through <br />Lower of submitted <br />amount or pharmacy <br />contracted rate <br />Pass -Through <br />Dispensing Fee <br />RETAIL MAINTENANCE <br />NETWORK (84-90 DAYS' <br />SUPPLY <br />Lower of submitted <br />• PPO <br />$812.00 per Brand Drug claim <br />Pass -Through <br />amount or pharmacy <br />Pass -Through <br />$812.00 per Brand Drug claim <br />SPECIALTY PRODUCTS <br />contracted rate <br />• PPO <br />Vendor Transaction <br />Pass-through at ESI cost for <br />Fee <br />N/A <br />N/A <br />Vendor Transaction Fee <br />(currently $3.75, subject to <br />than e <br />D. REBATES <br />1. Rebate Amounts. Subject to: (i) the conditions set forth in Sections 2 through 4 below and elsewhere in this <br />Agreement; and (ii) Client meeting the Plan Design conditions identified in the table below, the following <br />guaranteed amounts will be payable to Client during the Term of this Agreement: <br />REBATES PER BRAND 1 'PREFERRED <br />PARTICIPATING PHARMACIES <br />1-83 DAYS'SUPPLY) <br />• PPO <br />$293.00 per Brand Drug claim <br />RETAIL MAINTENANCE <br />NETWORK (84-90 DAYS' <br />SUPPLY <br />• PPO <br />$812.00 per Brand Drug claim <br />MAIL SERVICE PHARMACY <br />• PPO <br />$812.00 per Brand Drug claim <br />SPECIALTY PRODUCTS <br />• PPO <br />$3,421.00 per Brand Drug claim <br />(') Specialty Rebates may be impacted if Client changes the days' supply allotment for specialty claims. <br />The Extended Days' Supply pricing set forth in this Agreement shall be subject to certain requirements, as <br />follows. Extended Days' Supply shall mean; (1) for all lines of business other than Medicare or EGWP, any <br />supply of a covered drug of 84 days or greater; and (2) for Medicare or EGWP, if applicable, any supply of a <br />covered drug of 35 days or greater. Certain Participating Pharmacies have agreed to participate in the extended <br />(84 — 90) day supply network ("Maintenance Network") for maintenance drugs. Rebate amounts in the 84 — <br />90 Days' Supply row in the table set forth above are applicable only if Client implements a Plan Design that <br />requires Members to fill such days' supply at a Maintenance Network Participating Pharmacy (i.e., Client <br />must implement a Plan Design whereby Members who fill extended days' supply prescriptions at a <br />Participating Pharmacy other than a Maintenance Network Participating Pharmacy do not receive benefit <br />coverage under the Plan for such prescription). If no such Plan Design is implemented, Rebate amounts for <br />such days' supply will be the same as for Prescription Drug Claims for less than an 84 days' supply, and <br />Rebate amounts for an 84 — 90 days' supply in the table set forth above shall not apply, even if a Maintenance <br />Network Participating Pharmacy is used. <br />Exclusions For Non -Specialty Rebates: Specialty Products, Member Submitted Claims, Subrogation <br />Claims, Exclusive or Limited Distribution Products, COVID test kits, COVID antivirals, Vaccine Claims, <br />OTC products (excluding insulin, diabetic supplies, and test strips), Claims Older than 180 days, Claims filled <br />through In -House Pharmacies that do not utilize PBM for rebates, 340b Claims, COB claims, and claims <br />pursuant to a 100% Member Copayment plan are not eligible for the guaranteed Rebate amounts set forth in <br />Section D.1 above. <br />15 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />
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