R-09-01-08-8C1 - 1/8/2009RESOLUTION NO. R -09-01-08-8C1
WHEREAS, the City of Round Rock desires to retain professional
services regarding pharmaceutical benefits for eligible individuals,
and
WHEREAS, Wal-Mart Stores, Inc., WMS Division ("WMS") has
submitted an Agreement to provide said services, and
WHEREAS, the City Council desires to enter into said agreement
with WMS, Now Therefore
BE IT RESOLVED BY THE COUNCIL OF THE CITY OF ROUND ROCK,
TEXAS,
That the Mayor is hereby authorized and directed to execute on
behalf of the City an agreement entitled "Wal-Mart Stores, Inc., WMS
Division Agreement to Provide Services: Traditional Copay Plan,"
along with Attachment 1 entitled "HIPAA Business Associate Addendum"
and Attachment 2 entitled "Client Benefit Plan Design (BPD)
Application for Prescription Program Services", a copy of same being
attached hereto as Exhibit "A" and incorporated herein for all
purposes.
The City Council hereby finds and declares that written notice
of the date, hour, place and subject of the meeting at which this
Resolution was adopted was posted and that such meeting was open to
the public as required by law at all times during which this
Resolution and the subject matter hereof were discussed, considered
and formally acted upon, all as required by the Open Meetings Act,
Chapter 551, Texas Government Code, as amended
0:\WDOX\RESOLUTI\R90108C1.DOC/rmc
RESOLVED this 8th day of January, 2009.
ATTEST:
SARA L. WHITE, City Secretary
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ALAN MCGRAW, Mayor
City of Round Rock, Texas
WAL-MART STORES, INC., WMS DIVISION
AGREEMENT TO PROVIDE SERVICES
TRADITIONAL COPAY PLAN
This Agreement made and entered into this day of , 200 , by
and between Wal-Mart Stores, Inc., (hereafter referred to as "WMS"), and the City of Round
Rock, Texas and its affiliates (hereafter referred to as "Sponsor"). This Agreement supersedes
and replaces any existing agreements between the parties related to the same subject matter.
WITNESSETH:
WHEREAS, WMS provides pharmaceutical benefits management, related services
and point-of-sale electronic processing of pharmacy claims, and desires to contract with Sponsor
to provide such management and services; and
WHEREAS, Sponsor offers or directly administers one or more pharmacy benefit
products or plans; and
WHEREAS, Sponsor desires to arrange for the dispensing of pharmaceuticals for
Covered Persons and desires to contract with WMS for Pharmaceutical benefit services that
Sponsor will make available to Covered Persons:
NOW, THEREFORE, premises considered, in consideration of the terms, conditions,
promises, covenants, and agreements set forth herein, WMS and Sponsor covenant and agree as
follows:
DEFINITIONS:
"COPAYMENT or COINSURANCE or DEDUCTIBLE or OTHER CHARGE," collectively
known as "Copayment," means the charge, in addition to the premium, which a Covered Person
is required to pay for certain covered services provided under the pharmacy benefit plan.
Copayment or Coinsurance or Deductible or Other Charge may be either a defined dollar amount
or a percentage of eligible expenses. A Covered Person is responsible for the payment of any
Copayment directly to the pharmacy at the time the prescription is dispensed.
"COVERED PRESCRIPTION DRUG SERVICES" means those covered outpatient prescription
drugs and covered pharmacy products, services and supplies pursuant to a Covered Person's
benefit contract.
"COVERED PERSON" means an individual eligible to receive coverage for outpatient
prescription pharmacy benefits who is currently enrolled under Sponsor's pharmacy plan.
"PARTICIPATING PHARMACY" means a provider of Covered Prescription Drug Services,
including a retail or mail service pharmacy, which has entered into an agreement with WMS
under which pharmacy has agreed to provide Covered Prescription Drug Services to Covered
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Persons and to comply with (i) contractual requirements pursuant to this Agreement; and (ii)
regulatory requirements.
CONTRACTUAL TERMS:
1. Sponsor will provide WMS with appropriate source file so that WMS may create ID cards to
supply Sponsor. It will be Sponsor's responsibility to distribute the cards to Covered
Persons. There will be no cost to Sponsor for printing ID cards.
2. The same file used to print ID cards will be used to check eligibility as claims are filed in the
WMS field locations. The source file may be sent to WMS for updating the eligibility file.
Any claims submitted for Covered Persons per the most current source file will be honored
by Sponsor. It is Sponsor's responsibility to verify that all source files have been received
and loaded. Sponsor is responsible to notify WMS of any additions or terminations of
Covered Persons. If a cardholder is terminated, Sponsor will remain responsible for all
charges incurred by the ineligible cardholder until written notification is provided to WMS.
WMS agrees to administer eligibility of Covered Persons according to eligibility information
provided by Sponsor via tape or telecommunication or such other reasonably practicable
method in a mutually agreeable acceptable format. WMS may rely upon eligibility
information provided by Sponsor for all purposes related to this Agreement.
3. WMS shall deliver, or cause to be delivered to Sponsor a single billing, twice monthly, for the
administrative fee of $0.50 for each new or refilled prescription for its Covered Persons.
Sponsor shall remit payment to WMS for the amount billed in accordance with the following
Prompt Payment Policy:
In accordance with Chapter 2251, V.T.C.A., Texas Government Code, any payment to be
made by City to WMS will be made within thirty (30) days of the date City receives goods
under this Agreement, the date the performance of the services under this Agreement are
completed, or the date City receives a correct invoice for the goods or services, whichever is
later. WMS may charge interest on an overdue payment at the "rate in effect" on September
1 of the fiscal year in which the payment becomes overdue, in accordance with V.T.C.A.,
Texas Government Code, Section 2251.025(b). This Prompt Payment Policy does not apply
to payments made by City in the event:
A. There is a bona fide dispute between City and WMS, a contractor, subcontractor,
or supplier about the goods delivered or the service performed that causes the
payment to be late; or
B. There is a bona fide dispute between WMS and a subcontractor or between a
subcontractor and its supplier about the goods delivered or the service performed
that causes the payment to be late; or
C. The terms of a federal contract, grant, regulation, or statute prevent City from
making a timely payment with federal funds; or
D. The invoice is not mailed to City in strict accordance with any instruction on the
purchase order relating to the payment.
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If Sponsor disputes any amount on any bill, Sponsor shall state the amount in dispute, in
writing, to WMS within thirty (30) days of the date of the bill. No interest shall be imposed
during any period on any amounts Sponsor is disputing in good faith. The "Remit with
Payment" portion of the billing will be returned as directed with the payment check for the
full amount of the billing.
4. Retail Prescriptions will be priced as follows. For Generic Drugs: AWP less 54% plus $1.99
dispensing fee or Participating Pharmacy's usual and customary price, whichever is less.
5. Prescriptions dispensed at WMS's mail order service will be priced as follows. For Generic
Drugs: AWP less 50% plus $1.99 dispensing fee.
6. The Agreement will cover all prescriptions -only medication except those excluded as
detailed in the Client Benefit Plan Design Application.
7. From time to time WMS may receive discounts or rebates from pharmaceutical
manufacturers with respect to certain Covered Drugs dispensed to Covered Persons by
Participating Pharmacies. In addition, WMS may bill Sponsor a rate that may be greater or
less than the actual rate paid to Participating Pharmacies. In negotiating such fees and rates,
WMS acts on its own behalf, and not for the benefit of or as agent for the Sponsor, Covered
Person or any benefit plan in which a Covered Person may participate. Except as may be
expressly provided otherwise in this Agreement, Sponsor acknowledges and agrees that
WMS will retain all such rebate payments from pharmaceutical manufacturers and all such
provider discounts, if any, in addition to any administrative and other fees paid by Sponsor,
as WMS's compensation for administering the services described herein. Sponsor
acknowledges, for itself, Covered Persons and any benefit plan, that, except as may be
expressly provided herein, neither it, nor Covered Person, nor any benefit plan in which a
Covered Person may participate in, has a right to receive, or possesses any beneficial interest
in, any such discounts or payments.
8. WMS agrees that it shall not seek payment (other than Copayment) from any Covered Person
for Covered Prescription Drug Services under any circumstances.
9. Sponsor reserves the right to review or audit WMS's prescription records as to Covered
Prescription Drug Services for Covered Persons during the time this Agreement is in effect
by notifying WMS in writing at least ten (10) days in advance.
10. Each party agrees to indemnify, defend and hold harmless the other, its employees, agents,
officers and directors from and against any and all fines, suits, claims, demands, penalties,
liabilities, costs or expenses, losses, settlements, judgments and awards and actions of
whatever kind or nature, including attorneys' fees and costs (and costs and fees on appeal),
and damages (including, but not limited to, all actual and consequential damages) arising
from (a) the negligence or willful acts or omissions of the indemnifying party in connection
with the representations, duties and obligations of that party under this Agreement; or (b) a
breach by a party of any of its obligations under this Agreement.
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11. Retail Covered Prescription Drug Services will be provided at all Wal-Mart, Sam's Club, and
Wal-Mart Neighborhood Market Pharmacies to Covered Persons. WMS shall provide to
Sponsor and Sponsor shall use WMS's mail service program as its exclusive mail service
program.
12. Notwithstanding anything herein to the contrary, the specific terms, conditions, and details of
this Agreement shall be considered as proprietary to WMS. All pharmacy records of
Covered Persons shall be maintained as confidential in accordance with applicable state and
federal laws. Except as otherwise stated herein, under no circumstances shall any terms,
conditions, or details contained herein be made available in any form to any outside party
aside from those mentioned as either WMS or Sponsor. However, WMS hereby
acknowledges its understanding and acceptance of the fact that the City of Round Rock,
Texas is a home -rule municipality subject to the Texas Freedom of Information Act, and that
its duties and obligations run in accordance with such statutory requirements.
13. WMS shall process Covered Person's Covered Prescription Drug Services claims in
accordance with the benefit contract and WMS's standard operating procedures.
14. This Agreement shall become effective on the 1st day of February, 2009 ("Commencement
Date"). This is a one-year pilot program with a limited renewal option and, as such, the
initial term of this Agreement is one (1) year with Sponsor's option to extend month-to-
month for a period of time not to exceed twelve (12) months.
15. This Agreement may be terminated immediately for Sponsor's delay in payment which
violates contractual provisions hereof, or Sponsor's failure to pay which violates contractual
provisions hereof. It shall terminate automatically and without notice or other action on the
part of either party, if the other party files, or has filed against it, a petition in bankruptcy and
such petition is not dismissed within sixty (60) days of the filing unless the other party elects
to waive such termination prior to the sixty (60) day period. This Agreement may be
terminated by either party, effective thirty (30) days after a not less than 60 -day written
notice and cure period in the event of a material breach other than a payment default of this
Agreement by the other party. Either party may terminate this Agreement, without cause,
upon provision of ninety (90) days' written notice to the other party. Failure to exercise any
of the rights granted herein for any default shall not be a waiver of the right to exercise any
of these rights for subsequent default. In the event this Agreement is terminated by WMS,
Sponsor shall pay WMS the outstanding undisputed balance within thirty (30) days.
16. This Agreement may not be assigned by either party without the prior written consent of the
other party. Subject to the foregoing, this Agreement shall inure to the benefit of and be
binding upon the parties hereto and their respective successors and assigns.
17. The parties mutually acknowledge and agree that this Agreement shall be construed and
enforced in accordance with the laws of the State of Texas, and jurisdiction and venue shall
lie in Williamson County, Texas.
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18. WMS agrees to keep confidential all Covered Person names and social security numbers and
to release and utilize such names and numbers only for purpose of providing services under
the Agreement unless otherwise authorized in writing by Sponsor. However, WMS hereby
acknowledges its understanding and acceptance of the fact that the City of Round Rock,
Texas is a home -rule municipality subject to the Texas Freedom of Information Act, and that
its duties and obligations run in accordance with such statutory requirements.
19. During the term of this Agreement, the parties agree that they shall not use each other's
name, symbol or logo without the prior approval of the other party, which shall not be
unreasonably withheld.
20. To the extent permitted by applicable law, WMS may terminate this Agreement upon the
insolvency of Sponsor, and Sponsor may terminate this Agreement upon the insolvency of
WMS. The "insolvency" of a party shall mean the filing of a petition commencing a
voluntary case against such party under the United States Bankruptcy Code; a general
assignment by such party for the benefit of creditors; the legally -determined inability of such
party to pay its debts as they become due; such party's seeking or consenting to, or
acquiescence in, the appointment of any trustee, receiver or liquidation, insolvency,
dissolution, or like law or statute, which case or proceeding is not dismissed or vacated
within sixty (60) days.
21. In the event of any term of provision of this Agreement, or any portion thereof, or any
application of any term or provision shall be invalid or unenforceable, the remainder of this
Agreement or any other application of such term or provision shall not be affected thereby.
22. All notices or other communications required or permitted hereunder shall be in writing and
shall be delivered personally, by commercial overnight delivery service, by facsimile or sent
by certified, registered or express air mail, and shall be deemed given when so delivered
personally, by overnight delivery or by facsimile, or if mailed, five (5) days after the date of
mailing, addressed as follows:
If to WMS:
Wal-Mart Stores, Inc.
Attn: Prescription Drug Plan Manager
702 S.W. 8th Street, Mail Stop 230
Bentonville, AR 72716-0230
Phone: 479-273-6744
800-972-0943
If to Sponsor:
City of Round Rock
Attn: City Manager
221 East Main Street
Round Rock, TX 78664
Phone: 512-218-5400
23. Sponsor agrees to provide information reasonably needed by WMS to administer its
responsibilities under this Agreement, including (a) benefit contract documents; and (b)
timely eligibility and enrollment data on Covered Persons. Information shall be provided in
a mutually agreeable format.
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24. Each party shall maintain adequate insurance related to the operation of its business and its
obligations under this Agreement.
25. Sponsor shall keep reasonable documentation of all Covered Persons related to this
Agreement. WMS shall have the right to review such data at reasonable times upon
reasonable notice.
26. The parties will maintain the privacy and confidentiality of all individually identifiable
information regarding Covered Persons in accordance with all applicable statutes and
regulations. However, WMS hereby acknowledges its understanding and acceptance of the
fact that the City of Round Rock, Texas is a home -rule municipality subject to the Texas
Freedom of Information Act, and that its duties and obligations run in accordance with such
statutory requirements.
27. Notwithstanding anything contained herein to the contrary, Sponsor agrees that it shall not
enter into a contract, or any other similar arrangement, for pharmacy benefit management
services with a third party other than WMS with respect to services beginning with the
Commencement Date and continuing until the term of this Agreement expires or until the
Agreement is terminated in accordance herewith. However, WMS hereby acknowledges its
understanding and acceptance of the fact that this Agreement is not an exclusive contract in
that Sponsor has and will maintain a contractual relationship with Aetna Insurance Company
whereby Aetna furnishes prescription coverage to City of Round Rock employees; therefore,
carving out the generic prescriptions dealt with in this Agreement is by definition not in
conflict with the referenced Aetna agreement.
28. Sponsor shall be solely responsible for drafting Sponsor's benefit contract.
29. As between WMS and Sponsor, WMS shall own all WMS intellectual property and
intellectual property rights in materials created by WMS.
30. Notwithstanding anything in this Agreement to the contrary, WMS makes no representations
or warranties of any kind whatsoever, directly or indirectly, express or implied, including but
not limited to implied warranties of merchantability and fitness for a particular purpose, with
respect to any goods or services to be provided under this Agreement, other than those
expressly set forth in this Agreement.
31. Nothing in this Agreement is intended to create (nor shall be construed or deemed to create)
any right of WMS or Sponsor to intervene in any manner in the methods or means by which
Participating Pharmacies render Covered Prescription Drug Services or provide prescription
medication to Covered Persons.
32. Non -Appropriation and Fiscal Funding: This Agreement is a commitment of City's current
revenues only. It is understood and agreed that City shall have the right to terminate this
Agreement at the end of any City fiscal year if the governing body of City does not
appropriate funds sufficient to purchase the services as determined by City's budget for the
fiscal year in question. City may effect such termination by giving Vendor a written notice of
termination at the end of its then current fiscal year.
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement in
duplicate originals on the dates specified below:
WAL-MART STORES, INC. CITY OF ROUND ROCK, TEXAS
By: By:
Printed Name: Printed Name:
Title: Title:
Date Signed: Date Signed:
ATTEST:
By:
Sara L. White, City Secretary
FOR CITY, APPROVED AS TO FORM:
By:
Stephan L. Sheets, City Attorney
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Attachment 1
HIPAA BUSINESS ASSOCIATE ADDENDUM
This HIPAA Business Associate Addendum ("Addendum") supplements and is made a
part of the agreement ("Agreement") by and between City of Round Rock (Covered Entity")
and Wal-Mart Stores, Inc., its affiliates, subsidiaries, and assigns ("Business Associate"), and is
effective as of this 1st day of February, 2009 (the "Addendum Effective Date").
RECITALS
A. Covered Entity and Business Associate ("Parties") certify that a pre-existing
written relationship exists that makes Business Associate a "Business
Associate" of Covered Entity under the HIPAA Final Privacy Rule, and
Covered Entity wishes to disclose certain information to Business Associate
pursuant to the terms of the Agreement, some of which may constitute
Protected Health Information (as defined below).
B. Covered Entity and Business Associate intend to protect the privacy and
provide for the security of Protected Health Information disclosed to Business
Associate pursuant to the Agreement in compliance with the Health Insurance
Portability and Accountability Act of 1996, Public Law No. 104-191
("HIPAA"), regulations promulgated thereunder by the U.S. Department of
Health and Human Services (the "HIPAA Regulations"), and other applicable
state and federal laws.
C. The purpose of this Addendum is to satisfy certain standards and requirements
of HIPAA, the Privacy Rule (as defined below), including, but not limited to,
the Business Associate contract requirements of 45 CFR Section 164.504(e),
and the Security Rule (as defined below).
In consideration of the mutual promises below and the exchange of information pursuant to this
Addendum, the parties agree as follows:
1. Definitions.
a. "Designated Record Set" shall have the meaning given to such term under the
Privacy Rule, including, but not limited to, 45 CFR Section 164.501.
b. "Electronic Protected Health Information" (or "Electronic PHP') means Protected
Health Information which is transmitted by Electronic Media (as defined in the Security and
Privacy Rule) or maintained in Electronic Media.
c. "Individual" shall have the meaning given to such term under the Privacy Rule,
including, but not limited to, 45 CFR Section 160.103 and shall include a person who qualifies as
a Personal Representative in accordance with 45 CFR Section 164.502(g).
PCDocs #1867193
Business Associate Agreement
(WM as Business Associate)
Page 1 of 6
d. "Privacy Rule" shall mean the Standards for Privacy of Individually Identifiable
Health Information at 45 CFR Part 160 and Part 164, Subparts A and E.
e. "Protected Health Information" (or "PHI") shall have the meaning given to such
term under the Privacy Rule, including, but not limited to, 45 CFR Section 160.103, as applied to
the information created or received by Business Associate from or on behalf of Covered Entity.
f. "Required by Law" shall have the meaning given to such term under the Privacy
Rule, including, but not limited to, 45 CFR Section 164.103.
g. "Secretary" shall mean the Secretary of the Department of Health and Human
Services or his or her designee.
h. "Security Rule" shall mean the Security Standards for the Protection of Electronic
Protected Health Information at 45 CFR Parts 160 and 162, and Parts 164, Subparts A and C.
2. Permitted Uses and Disclosures of PHI. Except as otherwise limited in this Addendum,
Business Associate may use and disclose PHI solely: (i) to perform functions, activities, or
services for, or on behalf of, Covered Entity as specified in the Agreement, provided that such
use or disclosure would not violate state law or the Privacy Rule if done by Covered Entity; (ii)
for the proper management and administration of Business Associate, or to carry out the legal
responsibilities of Business Associate; and (iii) for purposes of its de -identification or creation
of derivative works, provided that resulting de -identification or derivative works was effected in
accordance and compliance with the provisions of 45 C.F.R. Sections 164.502(d) and 164.514.
PHI may not be used in any other manner, whether individually, collectively, or in any
compilation, statistical summary, or de -identified form, nor may it be disclosed to any third party
without the express written consent of Covered Entity or as required by law.
3. Obligations of Business Associate. Business Associate agrees to use and disclose PHI
only as permitted or required by this Addendum or as otherwise Required by Law. Business
Associate shall obtain reasonable assurances from any person to whom the information is
disclosed that it will remain confidential and will be used or further disclosed only as Required
by Law or for the purpose for which it was disclosed to the person (which purpose must be
consistent with the limitations imposed upon Business Associate pursuant to this Addendum),
and that the person agrees to notify Business Associate of any instances of which it is aware in
which the confidentiality of the information has been breached.
a. Appropriate Safeguards. Business Associate shall use appropriate safeguards to
prevent use or disclosure of PHI other than as provided for by the Agreement and this
Addendum. Business Associate shall maintain a comprehensive written information privacy and
security program appropriate to the size and complexity of Business Associate's operations and
the nature and scope of its activities. Covered Entity shall not request Business Associate to use
or disclose PHI in any manner that would not be permissible under the Privacy Rule, if done by
the Covered Entity.
b. Safeguards of Electronic PHI. Business Associate shall implement and maintain
appropriate administrative, technical and physical safeguards that reasonably and appropriately
protect the authenticity, confidentiality, integrity, and availability of Electronic PHI that it
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creates, receives, maintains, or transmits. Moreover, Business Associate and its agents and
subcontractors shall keep all security measures current and shall documents its security measures
implemented in written policies, procedures or guidelines, which Business Associate shall
provide to Covered Entity upon Covered Entity's request.
c. Reporting of Improper Use or Disclosure. Business Associate shall report to
Covered Entity any use or disclosure of PHI not provided for by the Agreement and this
Addendum within five (5) days of becoming aware of such use or disclosure. Commencing on
the compliance date of the Security Rule, Business Associate shall report to Covered Entity any
Security Incident within five (5) days of becoming aware of such incident. "Security Incident"
means the attempted or successful unauthorized access, use, disclosure, modification, or
destruction of information or interference with system operations in an information system.
d. Business Associate's Agents. Business Associate shall ensure that any agent,
including a subcontractor, to whom it provides PHI or Electronic PHI agrees to the same
restrictions and conditions that apply through this Addendum to Business Associate, and agrees to
implement reasonable and appropriate safeguards to protect such information. If any agents or
subcontractors of the Business Associate are not subject to the jurisdiction or laws of the United
States, or if any use or disclosure of PHI in performing services under the Agreement will be
outside of the jurisdiction of the United States, such entities must agree by written contract with
the Business Associate to be subject to the jurisdiction of the Secretary, the laws, and the courts of
the United States, and waive any available jurisdictional defenses as they pertain to the parties'
obligations under this Agreement, the Privacy Rule, or the Security Rule.
e. Access to PHI. Business Associate shall provide access (at the request of
Covered Entity, and in the time and manner designated by Covered Entity) to PHI in a
Designated Record Set, to Covered Entity or, as directed by Covered Entity, to an Individual in
order to meet the requirements under 45 CFR Section 164.524.
f. Amendment of PHI. Business Associate shall make any amendment(s) to PHI in
a Designated Record Set that Covered Entity directs or agrees to pursuant to 45 CFR Section
164.526, at the request of Covered Entity or an Individual, and in the time and manner
designated by Covered Entity. If an Individual requests an amendment of PHI directly from
Business Associate or its agents or subcontractors, Business Associate must notify Covered
Entity in writing within five (5) days of receiving such request. Any denial of amendment of
PHI maintained by Business Associate or its agents or subcontractors shall be the responsibility
of Covered Entity.
g. Documentation of Disclosures. Business Associate agrees to document such
disclosures of PHI and information related to such disclosures as would be required for Covered
Entity to respond to a request by an Individual for an accounting of disclosures of PHI in
accordance with 45 CFR Section 164.528. At a minimum, such information shall include: (i)
the date of disclosure; (ii) the name of the entity or person who received PHI and, if known, the
address of the entity or person; (iii) a brief description of the PHI disclosed; and (iv) a brief
statement of the purpose of the disclosure that reasonably informs the Individual of the basis for
the disclosure, or a copy of the Individual's authorization, or a copy of the written request for
disclosure.
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h. Accounting of Disclosures. Business Associate agrees to provide to Covered
Entity or an Individual, in the time and manner designated by Covered Entity, information
collected in accordance with Section 3(f) of this Addendum, to permit Covered Entity to respond
to a request by an Individual for an accounting of disclosures of PHI in accordance with 45 CFR
Section 164.528. In the event that the request for an accounting is delivered directly to Business
Associate or its agents or subcontractors, Business Associate shall forward such request to
Covered Entity in writing within five (5) days of receipt of such request. It shall be Covered
Entity's responsibility to prepare and deliver any such accounting requested.
i. Retention of PHI. Notwithstanding Section 4(c) of this Addendum, Business
Associate and its subcontractors or agents shall retain all PHI throughout the term of the
Agreement and shall continue to maintain the information required under Section 3(g) of this
Addendum for a period of six (6) years after termination of the Agreement.
j. Governmental Access to Records. Business Associate shall make its internal
practices, books and records, including policies and procedures relating to (i) the use and
disclosure of PHI received from, or created or received by Business Associate on behalf of,
Covered Entity, and (ii) the implementation of security safeguards, available to the Secretary
and, at the request of the Covered Entity, to the Covered Entity, for purposes of the Secretary
determining Covered Entity's compliance with the Privacy Rule and the Security Rule.
k. Mitigation. Business Associate agrees to mitigate, to the extent practicable, any
harmful effect that is known to Business Associate of a use or disclosure of PHI by Business
Associate in violation of the requirements of this Addendum.
1. Minimum Necessary. Business Associate (or its agents or subcontractors) shall
only request, use and disclose the minimum amount of PHI necessary to accomplish the purpose
of the request, use or disclosure.
4. Term and Termination.
a. Term. The term of this Addendum shall commence as of the Effective Date,
unless the term or condition relates to Electronic PHI only, in which event such term or condition
shall become effective the later of (a) the compliance date applicable to Covered Entity under the
Security Rule, or (b) the date on which the Parties have executed this Addendum. The term of
this Addendum shall terminate when all of the PHI provided by Covered Entity to Business
Associate, or created or received by Business Associate on behalf of Covered Entity, is destroyed
or returned to Covered Entity or, if it is infeasible to return or destroy PHI, protections are
extended to such information, in accordance with the termination provisions in this Section.
b. Termination for Cause. As provided under 45 CFR Section 164.504(e)(2)(iii),
upon Covered Entity's knowledge of a material breach by Business Associate of this Addendum,
Covered Entity shall either (i) provide an opportunity for Business Associate to cure the breach
or end the violation within the time specified by Covered Entity, or (ii) immediately terminate
this Addendum and the Agreement if cure is not possible. If cure or termination are not feasible,
the Covered Entity shall report the violation to the Secretary.
c. Effect of Termination.
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(i) Except as provided in paragraph (ii) of this Section 4(c), upon termination
of this Addendum for any reason, Business Associate shall return or destroy all PHI received
from Covered Entity, or created or received by Business Associate on behalf of Covered Entity,
and shall retain no copies of the PHI. This provision shall apply to PHI that is in the possession
of subcontractors or agents of Business Associate.
(ii) In the event that Business Associate determines that returning or
destroying the PHI is infeasible, Business Associate shall provide to Covered Entity notification
of the conditions that make return or destruction infeasible. Upon mutual agreement of the
parties that return or destruction of PHI is not feasible, Business Associate shall extend the
protections of this Addendum to such PHI and limit further uses and disclosures of such PHI to
those purposes that make the return or destruction infeasible, for so long as Business Associate
maintains such PHI.
5. Regulatory References. A reference in this Addendum to a section in the Privacy Rule or
the Security Rule means the section as in effect or as amended, and for which compliance is
required.
6. Entire Agreement. This Addendum is the entire agreement between the Parties in regard
to the subject matter and supersedes any prior agreements.
7. Amendment. This Addendum may not be amended or modified except by a written
amendment signed by the Parties, or as required by law or due to subsequent revisions to the
Privacy Rule, Security Rule, and HIPAA. Should any provision of HIPAA or its implementing
regulations be amended such that it materially alters the Parties' obligations under this
Agreement, the Parties agree to negotiate in good faith mutually agreeable amendments as are
necessary for Covered Entity to comply with the requirements of the Privacy Rule, the Security
Rule, and HIPAA.
8. Survival. The respective rights and obligations of Business Associate under Section 4(c)
of this Addendum shall survive the termination of the Addendum and the Agreement.
9. No Third Party Beneficiaries. Nothing express or implied in this Agreement is intended
to confer, nor shall anything herein confer, upon any person other than Covered Entity, Business
Associate and their respective successors or assigns, any rights, remedies, obligations or
liabilities whatsoever.
10. Independent Contractors. None of the provisions of this Addendum are intended to
create, or will they be deemed to create, any relationship between the Parties other than that of
independent parties contracting with each other solely for the purposes of effecting the
provisions of this Addendum and any Agreements between the Parties evidencing their business
relationship.
11. Effect on Agreement. Except as specifically required to implement the purposes of this
Addendum, or to the extent inconsistent with this Addendum, all other terms of the Agreement
shall remain in force and effect.
PCdocs # 1867193
Page 5 of 6
12. Interpretation. The provisions of this Addendum shall prevail over any provisions in the
Agreement that may conflict or appear inconsistent with any provision in this Addendum. Any
ambiguity in this Addendum shall be resolved in favor of a meaning that permits Covered Entity
to comply with the Privacy Rule and the Security Rule.
13. State Law. Where any provision of State Law is more stringent or otherwise constitutes a
basis upon which the Privacy and Security Rule is preempted, state law controls and the Parties
agree to comply fully therewith.
14. Definitions. Regulatory citations in this Addendum are to the United States Code of
Federal Regulations Title 45 Parts 160 through 164, as interpreted and amended from time to
time by HHS, for so long as such regulations are in effect. Unless otherwise specified in this
Agreement, all capitalized terms not otherwise defined shall have the meaning established for
purposes of Title 45 Parts 160 through 164, as mended from time to time.
IN WITNESS WHEREOF, the parties hereto have duly executed this Addendum as of the day
and year written above.
COVERED ENTITYBUSINESS ASSOCIATE
City of Round Rock Wal-Mart Stores, Inc.
By: By:
Print Name: Print Name: Ron Chomiuk
Title: Title: Vice President of Pharmacy Operations
Date: Date:
PCdocs # 1867193
Page 6 of 6
Walmart
WMS Prescription
Drug Plans
WELCOME TO WMS!
This document contains the details of the prescription benefit plan design used to set up plan designs in
our system. Place an "X" in the box to indicate your selection. Gray shaded boxes are WMS'
recommended setup. If there are exceptions or notes that you wish to make, please include them in the
`Comments' section. THIS APPLICATION MUST BE COMPLETE BEFORE ANY PROGRAM
SET-UP --UP CAN BEGIN. If you have questions, please contact your WMS Implementation Manager or
sales representative.
Client Benefit Plan Design (BPD)
Application For Prescription
Program Services
PLAN ID:
1. CLIENT ADMINISTRATION INFORMATION:
TPA/Consultant/Broker:
Contact:
Address:
Phone:
Fax:
Email:
Plan Name:
Contact:
Address:
Phone:
Fax:
Email:
City of Round Rock
221 East Main Street
Round Rock, Texas 78664
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GENERAL INFORMATION
Effective Date: 2/1/2009
Business Type:
Est # Employees:
Est# Lives:
Previous Vendor.
512.218.5400
512.341.3301
LOG AND DATE ALL CHANGES BELOW, MOST RECENT LISTED FIRST:
Attachment 2
WHO IS YOUR CURRENT PROCESSOR? Aetna
CARD PRODUCTION PARAMETERS:
Cards Produced By: ❑ TPA Z WMS
Card Delivery: Initial ❑ TPA ® Employer
Replacement ❑ TPA ® Employer
Special Instructions: (logo, etc...)
'Ship To' Address (If different from above):
Phone:
SEND INVOICE TO:
ELIGIBILITY:
Will Eligibility be Provided to:
Will Eligibility be Provided by:
Will Group Update Eligibility Remotely?
Member ID numbers:
2. PLAN ADMINISTRATION INFORMATION:
❑ TPA Z PLAN
❑ FTP
❑ TPA
❑ YES
❑ SS #'s
❑ Fee ❑ Paper ❑ Hard
® WMS(wmselig@wal-mart.com)
® Plan
Z NO
❑ Alternate ID #'s
STANDARD PROGRAM REQUIREMENTS (please 'X' one option - recommended set-up is shaded):
Program Type: ® Retail and Mail ❑ Retail Only ❑ Mail Only
Days Supply: (select the appropriate option)
RETAIL PROGRAM
Z 90 Days Supply
❑ Units
❑ Days Supply or Units, whichever is GREATER
❑ Days Supply or _ Units, whichever is LESS
Refill: (select the appropriate option)
❑ Limit to two (2) - New plus one Refill - at Retail
Dependent Age Limits:
Rev. 07/2004
MAIL PROGRAM
® 90 Days Supply
❑ Units
❑ Days Supply or — Units, whichever is GREATER
❑ Days Supply or Units, whichever is LESS
® No Limitations ❑ Other _
❑ at birth date Non Students
❑ end of month Students
2
N/A
N/A
Max Dollar Paid per Claim:
Retail: ® $1,000 or ❑ Other
Mail: ® $3,000 or ❑ Other:
3. COPAY INFORMATION:
Retail Program: Generic $0.00 Brand(Preferred) $NIA Brand(Non-Preferred) $NIA
Please complete when a percentage is to be combined with a whole dollar copay.
❑ Additional Copay Amount ❑ Whichever is greater 0 Whichever is lower
Mail Program: Generic $ 0.00
%_
OTHER OPTIONS SELECTED:
Coverage for Generic Drugs Only. Brand Drugs Excluded.
Brand(Preferred) $ NIA
Brand(Non-Preferred) $NIA
Note: Copay values that are established on the Plan may be overridden by a Maintenance Copay, a Pharmacy Network, Non -Formulary Copay, Formulary Special Rule, Plan Special Rule, Member
Copay, or Member Special Rule (in that order). Separate Copays can be set for Acute & Maintenance drugs and Compounds at the Plan level and/ or Pharmacy Network level. PERCENTAGE
COPAYS are always based on the total price of the claim that does not include Product Selection Penalty, Front End Deductible, or any amount exceeding the Maximum Benefit.
4. REPORTING:
Quarterly Claim Source by Drug Type ® Yes ❑ No
Prescription Count by Retail, Mail and Member Submit. Included features are Ingredient Cost, Dispensing Fee,
Member Contribution, Plan Cost and Formulary percentages.
**Other Reports available upon Request
5. DAW COMPONENT:
WMS offers several aggressive generic drug dispensing programs for groups interested in optimizing their saving
opportunities.
If a Brand drug has a specific equivalent Generic drug available and the member or doctor chooses the Brand, then the
member must pay the difference between the ingredient cost of the Brand drug and the Generic drug, plus a copay (can be
Brand or Generic, depending on how the group wants it priced).
If a Brand drug does not have a Generic equivalent, then the Brand copay applies.
Do you want to utilize Generic Differentials? (DAW Component) ❑ YES ® NO
If YES, please indicate copay base: ❑ BRAND ❑ GENERIC
What percentage should the member pay when Doctor or patient refuses Generic? (Penalize on both DAW I and DAW II)
0 ZERO ❑ 100% Other
What percentage should the member pay when Patient refuses Generic? (Penalize on DAW II only)
0 ZERO 0 100% Other
Rev. 07/2004
3
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6. DRUG COVERAGE:
ALL GENERIC FEDERAL LEGEND DRUGS ARE COVERED WITH THE EXCEPTION OF THE FOLLOWING BELOW
(Please X' one):
INCL= Include;EXCL=Exclude; P/A= Prior Authorization; S/T= Step Therapy Protocol, N/A=Not applicable
DRUG CATEGORY
INCL
EXCL P/A SIT
Days supply, Quantity, Sex and Age Limits
1
ABORTIFACIENT
Mifetrex
2
AIDS
3
ANTI -FUNGALS, ORAL
4
ATTENTION DEFICIT DISORDER DRUGS
5
COMPOUNDED DRUGS
6
CONTRACEPTIVES
Oral
Depo-Provera
Diaphragm
Nuvaring
Emergency Contraceptives
(Plan B, Prevent)
Transdermal
7
COSMETIC AGENTS
Renova
Rogaine, Propecia
8
DESIDRUGS
9
DIABETES
Insulin
Blood Glucose Monitors
Blood Sugar Testing Supplies
Syringes/Needles (insulin only)
10
DIAGNOSTIC AGENTS
11
DME (Crutches, Walkers, Bandages)
12
FERTILITY (non -injectable)
13
FLUORIDE PREPS
& WASHES
14
IMPOTENCY
DRUGS
Viagra, Cialis, Levitra
Caverject Edex, MUSE
MIGRAINE
MEDICATIONS
Amerge
Frova
Imitrex tablets
Imitrex Spray Inhaler
Imitrex Syringes
Imitrex Vials
Maxalt/Maxalt MLT
Relpax
Zomig/ Zomig ZMT 2.5 mg
Zomig/Zomig ZMT 5 mg
Zomig Nasal Spray
Rev. 07/2004
4
........__.... .
44:Cli+rnt Apptat�n �.
INCL
EXCL
PIA
SIT
DRUG CATEGORY
Days supply, Quantity, Sex and Age
Limits
16
OSTOMY SUPPLIES
17
OVER THE COUNTER (OTC)
Bronchosaline, Codeine-containing preparations
Prilosec OTC and its generic OTC versions
Claritin OTC, Claritin-D, Claritin syrup and generic OTC versions
18
PRESCRIPTION STRENGTH MULTIVITAMINS
Vitamin B-12
Pediatric Fluoride Vitamins
Prescription Prenatal Vitamins
19
PRESCRIPTION STRENGTH NON-SEDATING ANTIHISTAMINE
20
PRESCRIPTION STRENGTH PROTON PUMP INHIBITORS
21
SERUMS 1 TOXOIDS/ VACCINES I ALLERGENS
22
SMOKING DETERRENTS
Nicotine (prescription strength)
Zyban
23
TOPICAL AGENTS
Elidel
Protopic
Retin A, Avita, Differin
Tazorac
24
WEIGHT LOSS MEDICATIONS
25
OTHER SPECIFIC COVERAGES
Celebrex, Bextra
Stadol Nasal Spray
Singulair
Accolate
26
INJECTABLES
Chemotherapy
Epipen, Anakit
Glucagon
Hematinics
27
SPECIALTY DRUGS
Avonex, Copaxone, Betaseron, Rebif
Arava, Enbrel, Humira, Kineret, Remicade, Hyalgan,
Epogen, Procrit, Aranesp
Neupogen, Neulasta, Neumega
Fertility (injectable)
Growth Hormones
Immune Globulins
Anti-Hemophilic Factors
Forteo
Botox
Copegus,Roferon, Intron-A, Infergen, Hepsera, Pegasys,
Peg-Intron, Rebetron
Lupron
Pulmozyme, TOBI
Synagis
Xolair
Provigil, Xyrem
Zelnorm, Lotronex
Raptiva, Amevive
Zyvox
Tracieer, Flolan
Rev. 07/2004
5
SPECIALTY PHARMACY PROGRAM:
WMS offers a Specialty Pharmacy Program integrated with a comprehensive Specialty Pharmacy Network for the
distribution and management of costly specialty pharmaceuticals. This initiative is complemented with a clinical support
program that involves prior authorizations and protocols designed to enhance patient's healthcare as well as to manage costs
incurred by health plans to offer these therapies.
❑ YES (Mail Specialty Contract) ® NO
Other Program Variations: (identify specific drug coverage differentiations between the Retail and Mail Service programs)
COVERAGE FOR GENERIC DRUGS ONLY. BRAND DRUGS EXCLUDED.
7. PROGRAM CONTROL DESIGN PRICING
PLAN MODEL: ❑ Pass Through ® Traditional
RATES:
• RETAIL: Wal-Mart Pharmacies - Generic = AWP -54% + $1.99 Dispensing Fee
• MAIL: Generic = AWP -50% + $1.99 Dispensing Fee
• SPECIALTY N/A
ADMIN FEE: $.50
PAPER CLAIM (DMR) FEE: $N/A
REBATES: N/A
Pharmacy Networks: Pharmacy access is provided to all members for dispensing prescriptions. Select the appropriate
network option from those below (note: Restricted & Custom networks require WMS management approval).
❑ Open — National Pharmacy Network which includes over 55, 000 pharmacies.
® Wal-Mart Pharmacy Only
❑ Custom - Specific participating WMS pharmacies and/or service areas may be accessed.
NABP # Store # City, State
NABP # Store # City, State
NABP # Store # City, State
NABP # Store # City, State
Rev. 07/2004
6
Plan Accumulators: Limits may be placed on the amount of benefits a member may receive, or on the amount the member
is responsible for. Limits may also be placed on each family member individually, or on the family as a whole. The three
types of accumulators available are defined as follows:
A. Deductible: An amount the beneficiary must pay before plan payment of covered services begin.
❑ Plan Year ❑ Calendar Year
❑ Individual $ 0 Family $ N/A
B. Out of Pocket: A limit on total member copays, deductibles, and coinsurance under a benefit contract.
❑ Plan Year ❑ Calendar Year
❑ Individual $ ❑ Family $ N/A
C. Maximum Annual Benefit: A limit on the amount of reimbursed services for a given year.
❑ Plan Year
0 Calendar Year ❑ Individual $
0 Family $ N/A
Combination of Accumulation: If accumulators are used on a plan with both a Retail and Mail plan, the accumulators may
be calculated together or separately. Select the appropriate combination of accumulation:
0 Retail plus Mail Together ❑ Retail Only
0 Mail Only 0 Exclude Generics
Accumulation Period: Accumulators can be accrued for any period of time, after which point they are reset. Select the
appropriate period of accumulation:
Period: 0 Calendar Year ❑ fiscal Year (ending / /
Duration: Months Date: to
Exceed Accumulation Options: If accumulators are used on a plan, specific parameters can be set to determine how
prescriptions should be processed once the member meets the maximum benefit.
0 B — Process only WITH percentage from Extra Copay% ❑ C — Process all claims with set Percentage Copay
❑ R — Reject The Claim ❑ P — Process All Types of Drugs with 100% Co -Pay
0 G — Generic Incentives. Generics Covered. 100% Copay On All Others
❑ M — Mandatory Generics. Generics Covered. Reject All Others
Annual and Lifetime Maximums: Annual or lifetime dollar limits may be placed on the drugs in the table below. These
items are generally classified as not medically necessary. If you do cover these items, it is recommended that the amount of
coverage be limited, especially for smoking cessation and fertility, which are treatments that often times need to be repeated.
Fertility:
$
$
Smoking:
$
$
Growth Hormone:
$
$
Rev. 07/2004
7
I hereby declare that I have read and fully understand all statements and questions on this application, and that the responses
shown on this application are complete and true to the best of my knowledge and belief, and fully represent my intentions. I
hereby authorize WMS to implement this setup according to the parameters outlined in this document. Any changes to the
above information will be submitted to WMS in writing, indicating the effective date of the change.
Client Approval:
Signature
Name
TPA Approval:
Signature
Name
Title Title
Company Name Company Name
Rev. 07/2004
Date Date
8
DATE: December 31, 2008
SUBJECT: City Council Meeting — January 8, 2009
ITEM: 8C1. Consider a resolution authorizing the Mayor to execute the Wal-Mart
Stores, Inc., WMS Division Agreement to Provide Services: Traditional Co -
Pay Plan.
Department:
Staff Person:
Justification:
Human Resources
Teresa Bledsoe, Director of Human Resources
Wal-Mart will provide employees who are covered by the City's health plan prescription drug
service for all generic drugs. Retail covered prescription drug services will be provided at all
Wal-Mart, Sam's Club, and Wal-Mart Neighborhood Market Pharmacies. Employees will have
an opportunity to purchase a prescription at no cost from Wal -Mart's $4 generic program.
Employees must pay the co -pay for any generic drug that is not part of the $4 generic
program.
The intent of the program is to determine if by steering employees to generic medicines we are
able to reduce prescription costs overall.
Funding:
Cost: The cost of this insurance is a function of the number of employees and
dependent units covered.
Source of funds: General Fund, Water/Wastewater Utility Fund
City contribution and employee paid premiums for dependent health
care.
Outside Resources: N/A
Background Information:
The City has experienced an increase in the number of prescriptions for City employees and
their dependents. A brief survey revealed that many of the generic p prescriptions purchased
by city employees are included in Wal -Mart's $4 programs The City will continue to offer the
prescription coverage with Aetna. The Generic Drug Program will be a pilot program and will be
evaluated at the end of the plan year. The goal of the program is to help off -set the rising in
prescription drug cost and to help educate employees in regards to choice of prescription cost
and services.
Public Comment: N/A