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Home My WebLink About2016-09-08 9:00AM WORKSHOPBRAZOS COUNTY BRYANJEXAS PIL..ED 2016 SEP -2 p 131 NOTICE OF MEETING AND AGENDA WORKSHOP SESSION BRAZOS COUNTY COMMISSIONERS COURT BRAZOS COUNTY COMMISSIONERS WILL MEET INA WORKSHOP SESSIONAS FOLLOWS: MEETING DATE: September 8, 2016 MEETING TIME: 9:00 AM MEETING PLACE: Brazos County Administration Building, 200 S. Texas Ave., Suite 339, Bryan, Texas 1. Call to Order 2. Presentation and discussions regarding the County's Pharmacy Benefits. 3. Adjourn The Brazos County Administration Building, 200 S. Twos Ave., Suite 339, Bryan, Texas is wheelchair accessible. Handicap parking spaces are available. Any request for sign Interpretive services must be made two working days before the meeting. To make arrangements, please call (979) 3014102. Vol. MINUTES SEPTEMBER 8, 2016 BRAZOS COUNTY COMMISSIONERS COURT WORKSHOP SESSION Call to Order The Commissioners' Court of Brazos County, Texas met in a Workshop Session in Suite 339 of the Brazos County Administration Building in Bryan, Brazos County, Texas, beginning at 9:00 a.m, on Thursday, September 8, 2016 with the following members of the Court present: Duane Peters, County Judge, Presiding; Lloyd Wassermann, Commissioner of Precinct 1, Absent; Sammy Catalena, Commissioner of Precinct 2; Kenny Mallard, Commissioner of Precinct 3; Irma Cauley, Commissioner of Precinct 4; Karen McQueen, County Clerk, Absent. Attached is a list of the citizens and officials in attendance. 2. Presentation and discussions regarding the County's Pharmacy Benefits. Insurance Consultants Mark Grierson and Brenda Cos with USI gave a presentation regarding the County s health benefits. Mr. Grierson stated that there are currently no excluded drugs, but plans are moving toward excluding some in the future. He gave examples of how price escalation of drugs and coupons for drugs could leave the county paying the total cost of the drug. He said that excluding these drugs would be a way to handle this type of situation. Mr. Grierson went on to say he would recommend certain drug exclusions, prior authorization on certain drugs, and step therapy. He said that this will cause some disruption, but economics make these changes necessary. He also pointed out that on page two (2) of section one (1) in the presentation that Express Scripts Pharmacy offers substantially more rebates on Closed Formulary prescriptions. A copy of the presentation is attached. 3. Adjourn Vol. ^�0Pg - 2- 7 Vol. I � 1 ° c E C o v L n 1 j o I J n°c T� Dc o a ° 0 Vol. I itC J O D � VY o vn P y N a `V N 3 n J G Av Y ° c E C o v L n j o J n°c T� Dc o a ° 0 low itC J O D � VY o vn P y N a `V N 3 n J G vkl 7 r; m I � u Av Y ° c E C o v L n j o J n°c T� Dc o a ° 0 vkl 7 r; m I � u a d 10 1,,CL03 LE �v a d 10 1,,CL03 E E 3 V/ 1 E M 2 E ^0 W Q Zs7 / W I E W N E F M 1 Pricing Comparison Humana Humana IM Optum Retail Brand 30 Discount 16.15% 16.15% 16.50% Retail Generic 30 Discount 75.00% 75.00% 78.10% Retail Brand 30 Dispensing Fee $1.13 $1.13 $1.00 Retail Generic 30 Dispensing Fee $1.19 $1.19 $1.00 Retail Brand 90 Discount 16.15% 16.15% 18.00% Retail Generic 90 Discount 75.00% 75.00% 78.10% Retail Brand 90 Dispensing Fee $1.13 $1.13 $1.00 Retail Generic 90 Dispensing Fee $1.19 $1.19 $1.00 Mail Brand Discount 18.50% 18.50% 23.00% Mail Brand Generic Discount 77.00° 77.00% 82.10% Mail Brand Dispensing Fee $0.00 $0.00 $0.00 Mail Brand Generic Dispensing Fee $0.00 $0.00 $0.00 Retail 30 Rebate Per Brand Claim $41.50 $41.50 $40.00 Retail 90 Rebate Per Brand Claim $41.50 $37.53 $40.00 Mail Rebate Per Brand Claim $121,88 $110.22 $130.00 Specialty Rebate Per Brand Claim $121.88 $150.12 $180.00 Admin Fee Per Claim $0.00 $0.00 $0.00 Commission Per Claim $0.00 $0.00 $0.95 Allowances $0.00 $0.00 $0.00 Open Formulary Vol. g �� pg. �3� I Pricing Comparison Humana Humana ESI ESI Retail Brand 30 Discount 16.15% 16.15% 17.50% 17.50% 17.50% Retail Generic 30 Discount 75.00% 75.00% 79.50% 79.50% 80.00% Retail Brand 30 Dispensing Fee $1.13 $1.13 $0.75 $0.75 $0.80 Retail Generic 30 Dispensing Fee $1.19 $1.19 $0.75 $0.75 $0.80 Retail Brand 90 Discount 16.15% 16.15% N/A 20.75% 21.50% Retail Generic 90 Discount 75.00% 75.00% N/A 79,50% 80.00% Retail Brand 90 Dispensing Fee $1.13 $1.13 N/A $0.45 50.00 Retail Generic 90 Dispensing Fee $1.19 $1.19 N/A $0.45 $0.00 Mail Brand Discount 18.50% 18.50% 24.00% 24.00% 23.50% Mail Brand Generic Discount 77.00% 77.00% 83.00% 83.00% 82.00% Mail Brand Dispensing Fee $0.00 $0.00 $0.00 $0.00 $0.00 Mail Brand Generic Dispensing Fee $0.00 $0.00 $0.00 $0.00 $0.001 Retail 30 Rebate Per Brand Claim $52.49 $47.41 $80.00 $80m $38.72 Retail 90 Rebate Per Brand Claim $52.49 $47.41 N/A $210.00 $38.72 Mail Rebate Per Brand Claim $151.17 $136.54 $210.00 $210.00 $105.60, Specialty Rebate Per Brand Claim $151.17 $189.64 $650.00 $650.00 $100.00 Admin Fee Per Claim $0.00 $0.00 $0.00 $0.00 $0.95 Commission Per Claim $0.00 $0.00 $0.00 $0.00 $0.00, Allowances $0.00 $0.00 $21,500.00 $21,500.00 $0.00 Closed Formulary Vol. -� pg, County Pharmacy Pricing—Guaranteed Discounts and Dispensing Fees Soludol Discounts 9 . . Year 2 Pae: Year a Fee' Guwenued am 01/OJ/s0Men IA Yu Rete $015 PERM I Man Pdm Authorbaelon Brand Dhceunt( ort -rollback) - 18.15% ennd Oheeunt pmt•roIIWc . 185016 Brand DNpeming Fee- $1.19 Brand Ds an Fee- $O10 Specialty Discount (post -rollback)• 1550% Specialty Discount (PoatmDo c - AWN 5 alty Dlspenring Fee- $1.13 Specialty Dispensing Fee- Solid ENaclus Generic Discount- 7510% EffacIN.Genetic Dlrcount- 771n% Efeetlye Generic Db end,Fee- $1.19 ENeefWe Gananc Dlr enalns Fee- $0.00 Plan AdminNta n(PEPM): Services Included' W"(PERM): Yavl YNr2 vara Included Included Included Included Included Included Bundled Seryl Included In "Is pravmal Year S Fan Year 2 Pae: Year a Fee' Sup Therapy Yu $019 PEPM $015 PERM $0.09 PFM Pdm Authorbaelon Yee; BONd Saparaw, $45.00 per revlew $45.00 per mi. $45.00 per ryYlew an0analservim: Included In Th% PraeaW fig fm [gy. Datafeeds(per feed) Manthll' No SW.WPer Feed $50.00 Perrone $50.00 Pm Feed W..Wy Nn $90.00 par Feed $50.WPar Feb 550.00 Per Fuad Daily No SWOOPerWed $50.01OPer Feed $501(1 Far Feed Annual Maintanahm No $500.00 Par Feed $SW10 Per Feed $500.00 For Fead Custam Drug List No $1.94 PERM $1.34 PEPM $134 REM Custom ores rer Placementor Cllnlnitirt No $0.80 PEPM SON PEPM $050 PEPM Adhoc Reporbns No $150 ",hour $150 per hour $150perhaur Audit Racovedm Vol 20% Billed Separately 20% Billed Separately 20% Billed Separately R Rebem Barb Yeerl Ye°rf YearB Per Paid Brand Claim Ratio; $47A1 $52.95 $56.60 M.11: $19654 $132.43 $181.99 Specialty: Slag'" $211.79 $216.18 Vol. r i/C) pg ,_2✓ate PCL XL error Warning: ILLegaNediaSize Brazos County. Underwriting Stipulations and Caveats HUMANk PHAPkIACY Solutions o Humana'; offer Is based on the Information proalded during the bidding process. My material meddiczdon of the plan design or program spedfusomes will ,sun In Priclag medmatla. by Humane, demollmant dMates by 15% or mora upon [depletion of the 02/01/21117 .,an enrollment, Humana Pharmacy Solutlbm revenues the right to revaluate a0 quoted edminiswatin and eptlorlalseMa/ees and make any neasaryatljwtmend effmMhackw 01/01/201]. , o Ouotaassumes MedBpnbMe AWPwumoforakuWingdi ound. o Humena's generic discount list Includes all generic drugs as dented by Madison's "y' Indicator and Includes both Single Source generic (SSG) aed Multiple Source generic (MM) protium. Bond drug Include Mow Drefctlpdons end mnsklered a genrtk percher gemrkdeRnklan. a The orders understand that pricing Indices historically used, (and that an the bask In this quotel, for detemining the financial components./ pharmacy billing nations outside the mrlwl of gams County and Humana Pharmacy Solutions. The some, also understand them anaetomarket Indwtry, legal, goomment and regulatory ectirides which may lead to chane, modest m, or elimination of these pricing Indices that rnutd after the BwMal Ammons of the times se Intended under this quote. The pamm aped that, upon entMng Into an agreement and thereafter, their mutuafint nt has been and Is W maintain pricing mbility as Intended and net toatlnntye either paMtothe debhent of theoriser. Meerdigly, be immerse this mutual Imam, if Humana Pharmacy Solutions undertakes any of the following. al sharps Me AWP wurce ecrou IYs book of bwlnes0 or b) Maintains AWP .,the pddr, Ind,, In the event %. AWP methodology and /err lye cskulatlon Is changed,whenher by the axistlnE or a.mmhnourceg or c) troothons the pricing Index from AWP to another Index orbenchmark (e. C., to Whol,ale AcquMtlen rash, ANINpdng Pharmacy, Specialty, and Mall Servlet Pharmacy rales, rebate, and gumma,, u.mulable, will be modified as reasonably and equitably h,asury to maintain the pricing Intent under this quote and subsequent Allotment. Humana Pharmacy Solutions shall pmvWe B.I, County with, lest slaty, (0) days notice of the Merge lord such notice Is not praNkalke, u much notice, Is reasonable under the NmummncesL and written Nustath n Of the flnanNal Imply of the pricing dura or Intl, change (e;, specific drug examples). H Bas, Cauntydls smother Illwtradon oft. fina,lal Irepactof the pricing wurce, the omen agree in cooperate, In good faith W moble such disputes. o Brame County acknowledges that it maybe eligible for rebates as proposed only so long es gran, County or any parent subsidiary, or afBlhb of BramsCounty does net wnVaddirectlywith anyone she far desoun% utllhation IIMb, rebates, or other financial Incommme on pharmamud ed prodded orfam.1my program, kr pmcHpdon drug [biros proceed by Humana Ph..W g lW.ns, without W pdarwrimn wment of Humana Phamaw Solu.,. a Rehabs an ba afdcted by varbu+awn4 wdide the PameY wntrol. Foreeemple, motes an be affected by Induse"arganmment actlen, legal proceedings, the I,eor expiration of prier, or pharmawurkabbemmingganade(94.N,lum,ed.). When any swans mum that lmpm the waits;"Wel by Humana Pharmacy SolWons, Humana Primmer Solutions ma.,wo Me right to adjust the robate acmrtlinglyw aceouM for the char®e. Adjustments for patent loom will be done annuallyand arm take In, amount the net Impact of naw rebate madam and rebate loses. Otherennd Met hose rebates will to Mountatl ferw.n they occur. no talent shall retake me net Imply olm,e updates but not mon than thelrguanMeed robin level, Dappliabla, e Humana Phamary Serbians' quaaad rated dlsmund,e for all amsedptimm filed at small phamam, regardless offhand", supply. e All .onto, saduda DBC procdpdons. e no quota students Humana Phamwcy SclWons is awarded the pharmacy adminhbatlon an a full replacement buts. o Pmmsal assumes Humana PharwwS l,lonY Sfaedard Pormulery WM clinial ed. end managed dbpansing Ilmid. Humana updates id doused Ilmftm ce an annual bmla Thea plan provisions and admlabdathe functions coke effed on January I aeach year and app" this proposal. o Humane Pharmacy dWutiens h offering guaranteed discounts and dispensing fem thatwni amain feed during themus, of the contact period. Humana PharmacyS mfam"retainantmaminnhle.d abowmsgumnteed leveis and will absorb my lora, rcaliud bebw Ne Hameed loris. Gefltld and surpluses foreech gmonteewpl cross apply lade an apapte aaitlemmC e Dismumand tllmend„g He Nsameu de end apph In those rat, when regula0.ns Inspect the PBM', ablldy'to runplote to wish retail phamad, o The quote includes standard data feed for HCR maximum out of packet. o This document represents Humana Pharmacy Soluticne propaaL Flealtams, and conditions will he documented In Ne mmnNwl,annnard between Humana and the client. o Client .01 ...1. a Plan Management Agreement (PMA), PMA amendment or a droner agreement when mutually agreed upon by both the Client and Humana ('Agreement'). The Agreement b the legal contract that defines Ne business relationship between Client and Humana. Client su aa+ to sealed and proaido NPir algmmrs arms Agreement within 90 days of receiving itfmm Humana. A'peramployee per year' (PEP9i fee will has Named he the Cllemafrer 90 day. Fad.. m send round eftemW,lan of Plan edmlnistrad...ithln 30 days of this proposal will be mnshlood assent to the addwon.1 PE" late m,ulbn fee dewribed heroin. Vol. 6 � Pg. �� r i t� Brazos County I• I, 1- - -- --=--- -- - -- -- — - - - - - - - ------- -- Pharmacy Pricing -Guaranteed Discounts and Dispensing Fees 4ACY Solutions - r— ------- -- --- ---- — Discounts — - ---- --- and Dispensing -- -: Yearl Fee: Geeronteod m 01/01/]0100. 11/9l/101A Y.3Fee; Rerad I Mai Ym Brand Discednt(pd-rollback)- 16.15% Brand Discount dw-miONckl- 1830% Brand DB nsl Fee- $1.19 Braid Db ndn Fee- Onor SWI.Ity DNcount(,.A.Ilberkl- 1530% 5 NhY Dismuntgp0d-rellhec • 15.0m S,ed.It, Dls enen Fee• $1.13 5 a Dls nsin Foo• 040 E&dive GenerNDlscount- ]SAO% 1 nIndere Generic Discount- ]1.001{ ENecIMGeneNCDBpomi,Fea- $1.19 1 ENedNe Generic Depending Fee- $OA3 i- Bundled Services: Induded Innis Prooesei Yearl Fee: YearlFee: Y.3Fee; Administrative Fees and Ciptional Services Ym $axe PEW i $0.119 PEW l PdprRdhoduNon Yes; Billed Se,.nnev Se.5A0 per mol. $69AO perrevi. Gue=Wd ,, 0l/M%IU70 tl/31/M9 Dellen ISeMces: Induded In nb Pnop t58i Y..re Yr..2 rwe - P)eeAlmlntamedon PEFM): Included Induded IneWdod Servlcee loduded' Balom(PEPM): Included Induded Inducted $50.00 For Food CsonmNclons PE➢Mp $O.00hMudod $0.001nduded $O.Oelnduded Teter Re AdminbtraOon FoB(PEPM): SO.DO $am $OAO wy No $SO.00 Per reed $50.00 For Food $30.ODPer Feed — 1 I ; 1 _i Ol. pg. Bundled Services: Induded Innis Prooesei Yearl Fee: YearlFee: Y.3Fee; l - stepnenpy Ym $axe PEW $OA9 PEW $0.119 PEW l PdprRdhoduNon Yes; Billed Se,.nnev Se.5A0 per mol. $69AO perrevi. SOAOPerrevim Dellen ISeMces: Induded In nb Pnop t58i IM 111th O:embode 1perlead) Monthly No $AXPer Fud $50.00 Per Feed $50.00 For Food 1 Weekly Na $30.00 Per Feed $SOHO Per Feed $51100 For Food wy No $SO.00 Per reed $50.00 For Food $30.ODPer Feed — Annual Mdntenana No S500AOPerreed $SOOAO For Food $500.00 For Feed Eustam OraBllst No $ub PEW $130 PEW $1.96 PEW CustmnO gM.r I Placement or Etlnical Wt No $0.90 PEPM S030 FEW $030 PEW Adhoe Report" No $150 per hour $130perhour $150 per hour AudNRecpvedee Yes 2095 Billed Separately 10% Billed Separately 10% Billed Separately 1 I ; 1 _i Ol. pg. Brazos County Underwriting Stipulations and Caveats ITUMANA PHA .tVMCY Solutions - a Numana'.offar8 based on the Information provided daringthe bWding proms. My mabrbl mMmmtlun At me plan design orprpgram specifications will mesa In pddng mMakanoo by Humana. Hanroulnent daWtas by 15%orseam upon mmplatlon MthaGS/01/]A1] open enrollment Humane Pharmacy Solmlom.1 the rseheb rPemluahall quoted adminWr and option) urvlce hes and masa any necessary adjustments eHecthe beck to 01/01/2017. n guests assumes MMI[pan Ntha AWP [aurta for nhmWne dlscouotr. A Human's gemark discount IIn bolus. W genedc drugs as defined by MadfaW,' ' Indlubr and Includes loom ShMno Spurts gmork (SSG) and Il Soumgenadc IMSGI products. annd drug Includes coma pnwlpdom nm mmidertd a genedc partha generic definition. e no Win, understand that Pell., Indlm. historicallyused,(and mat am the basis In this puou), for detaminingthe Gnanclal components of pharmacy Will, rases on omtge the control Bruns County and Humana Pharmacy5olutiom. The gonia also wdernand move an Mraanrkat indotry, Irpl, ewemmnt and mdbbryactivlmawNN mW lad b change. mlanng W. fir .limn atlon of, then pdclog Indlms that could alter the financial podnaa fir the persons as Intended under this quote. no puna a,mthat; upon entering Into an sgrcemnt and mercalbr,melr mmuel lnbnt haz bean and s lo malnbin prsdn[ sbWliry a lobndM and notb sdyanbp alther W M b me detrlmem of the athas. AccmdlnLly, b prwemwa mutual Intens M Numma Pharmry Solu[tem undersakes anYofthekllawin{: a) clan{ n me A W P mune across Me book Poen Nm; fir b) Maintains AWP as the priding index, In the wmetM1e AWP methMobeyand /ax's wlmrlaW n schanLed, whether bythe mbtlne araaematlm mums; or c) transitions the pricing Index fmm AWP W another lodes orbenchmarkle4., to Whale ale AcquNllon Cat), Nutdpatin¢ Phamary, Specialty, and Men Service Phamacy rete+, Whores and guarantees, as appllmble, will be modified as memorably and equ'abty, necessary to maintain the Pricing intent under this quote and subsequent aLmement. Humane Pharol Solutions hall promds Bnasos County with at Iron ably (W) days notlm of the champ )fir It such notlm N set pratlmble, a much notlm as Is reasonable undxtha dramusa ms), and written Inns radon of me financial Impastof the pricing source orindox change (e.g.. spulBc drug mampbaL N Brum County disputes the illustration of the financial Impact of the prsdng mum, the path.1 eareeb cooperate In good him to nambisuch disputes. A BMWs county aiknowledpes that It may, be sigINe tarmbab+as proposed ontym long a Bruns County or any parent subsidiary, oralRlate of Boom County does not contract dbanlywith anyone else far dbmunb, mllNatlon n.m..bates, w nthsfinanolal Inm."S on pharmawutkal products or formulary pmgramsforpre crlMlan drug claims proposed by Humana Phamacysaludons, without me prior written consent of Humana Pharmacy.Solutlam. o Rehabs can be affected bymriom enema outside me ParWf control. Fpr sample, robmesmn M etuchd by Industry or¢oyemment Mian, legal pmesdings, the bursar expeagm of pater, or pharmawutlw4 bemmingpnerk le.¢. Nealum. etc). When aryemnt occurs that impacts the rebates wwlsed by Humane PhamucySiMlons. Humana Pharmacy Solutions rnarva the right badjust me wbate.m.Amglyb accpmt fmthechenge. Adjustments Mrpatmt losses will be don annu.11Yand W U take Nm accountthe net Impact of new rebate cmtsactseed nabob losses. Ulnereverm thatImpact rebate[will loo acwunted krwhenmayacclir. no client shall recce the net armed a men updates but not mon man their guaranteed slab Irl, ff applicable. o Humana Pharmary5olutlons quoted rataB dlttounts ana brag prexmptions &clad at mull Dhamaclu rcpNlas otma days mpPN a All 1.1masauIud. U&C pmprlptlone. o The quote mumee Humana Pharmacy SWutlons Is awarded the pharmacy administration Ana NII laPlacamem huh. o Protons! assumes Humana Plurmacy Solutions Traditional Formulary with clinical MIN and managed ds,mul limits. Huron update Its lists and limb on an annual has. These plan pmW lona and edminLLttatM Nncdom bks affect an January l of each year and apply to this proposal, o Humana Pharmacy Solution$is offerng{mrmteed discounts and d4penslng bo that will remain fixed owing the course of the contract period. Humana PhimaH Solution. will ratam any nu In uWamd above the guaranteed Iw!s and will absorb any house realized below the c.mked 1.11. Defllb eat 1.15,0.1 for mach ■uarenhe wlu ova ePPfY tem an segregate aettleal a OlamumeM d4pamb{tea{uasmteasdonmapphmmom stekswhenreeulaHna Impactme PBMY abiBty to ne{otlme oto wish redo phamacin. o The quote Includes standard data feed for MCP maximum out of pocket. P W. detoured rapresents Humana Pharmacy Solutlore propoml. Final tome and conditions will be dommenbd In the contactual arrangement batwmn Humana and the client. e Cbnl will repNme Plan Management Agreement IPMA4 PMA amendment ma slmilereereemant when mmualthl upon by both th67lant and Humana (•Apeem mel. no Agrwmem Is me Iasi contract that definer the buNnss nlamonshlp between Client end Humes. CUM agora bmlew and prwldr their slpaturs on the Agmmmwlthln 90 days W nwNing Rfmm Humana. A "ser amplowea per knot (PUY)he will be charged to the Client after 90 days. Failun b send notlm 0 termlnadon of Plan MminstnUon within SO door of this proposal will be c..,Rlmad Instant the Mdmoml PEPY Into wecutlon M described hereon. TABLE OF CONTENTS FOR BRAZOS COUNTY Executive Summary Proposal Pricing Supplement Specialty List Exhibits: I Sample Reporting Portfolio * EXPRESS SCRIPTS• 1 Vol. Brazos County August 12, 2016 ,_. r• ' Our commitment to Brazos County J A partnership to solve your most pressing challenges Express Scripts appreciates this opportunity to serve Brazos County and your 2,146 members. We understand that you are looking for a pharmacy partner who delivers innovative solutions to your greatest healthcare challenges: Preparing for today's challenges and tomorrow's unknowns r• As with any organization today, you're also trying to mitigate exploding healthcare costs and effectively manage patient care in the face of these challenges. Rex 50% of patients have a U.S. drug spending increased Specialty Preventable u chronic or complex 5.2% in 2015 —half the medications hospital condition, which drives rate seen in 2014. Solutions accounted for 37% of readmissions in 95% of drug spend and that encouraged the use of drug spend in 2015 the U.S. cost more affordable medications and are expected to $25B each year 75% of medical spend helped to hold down costs. reach 50% by 2018. Meanwhile, the next. decade promises to be the most volatile in the history of healthcare, with an aging population healthcare's continued evolution from a.fee-for-service to value -based model; and advances in personalized medicine driving ongoing change. In this environment, it's not enough to plan for today's challenges alone. You 1 need a partner that can help you predict and prepare for changes on the horizon and act thoughtfully and nimbly to address whatever comes your way. } ` ® EXPRESS SCRIPTS' 0 20M Express Scripts Hddingcompsny. NI Rights RmNed. -."----- F LVO i. pg. �ill� Bold Action Doing what's right on behalf of you andyour members to keep healthcare sustainable — even wh.e.n.others won't. Po Data Insights Pharmacy Smarter.M Practicing pharrnacy.d:ifferently. Express Scripts has an'uhwaveringfocus'on"providing access to medication at aoaffordable price, delivered with patient centered care. We practice pharmacy:diffe,rently than anyone else in our Industry. , Mining data across 80 million members and pairing this with high -touch consulting to uncover opportunities for action. ® 2016 Express ScrlpM Rolding Company. All Rights Reserved. Specialized Care Reinventing pharmacy care for patients with chronic and complex conditions to improve adherence and health outcomes. Innovative Solutions Thinking and working differently and continually innovating to solve your toughest healthcare challenges. ®� EXPRESS SCRIPTS' i FVO l. -.-- i O Pg. S L.. f - ® Bold Action Doing what's right on behalf of Brazos County and your members A true partner takes action to protect you and your members. Express Scripts has a history of doing what's right to keep medications affordable and accessible — even when others won't Over the past two years alone, we took market -changing action to address unsustainable costs and ensure optimal care for Brazos County and your members. o The Hepatitis Cure Value Program® saved our clients more than $1 billion — and the U.S. healthcare system more than $4 billion — in 2015. a We. launched our Cholesterol Care Valuesm Program the day PCSK9 inhibitors entered the market, helping clients avoid up to 90% of plan cost increases for these cholesterol drugs. 1 . ® Our National Preferred Formulary exclusions will deliver $1.3 billion in savings for our clients in 2016 with minimal patient disruption. o The Oncology Care Valuesm Program ties the cost of a drug to its efficacy for specific types of cancer, helping ensure patients get the treatment they need at the right price. a Our Compound Management program eliminates about 95% of compound spend and is much more effective for addressing compounds than prior authorization programs or per -prescription price limits. And we aren't stopping there. Express Scripts is proud to offer Brazos County Express Scripts SafeGuardRxsm for your commercial -population. This suite of unprecedented solutions is designed to protect your interests while ensuring important therapies and specialized care are available to your members. The suite includes enhanced versions of our Hepatitis Cure Value Program® and Cholesterol Care Value Programsm, along with two new solutions that provide unique protection for your plan: our Oncology Care Value ProgramsM, designed to align a drug's cost with the clinical value it provides; and our Inflation Protection Program, which_ helps control brand drug inflation for your plan. Our upcoming solutions target three of the most significant challenges for payers: diabetes, the costliest traditional therapy class; inflammatory conditions, the costliest specialty therapy class; and unforeseen market events that that require payers to react rapidly or be faced with significant amounts of wasteful drug spending. s-� "When the Price Is Wrong: Express Scripts Battles Ultra -Expensive Drugs" L; -CNBC 4EXPRESS SCRIPTS' � i 02016 express Scripts Holding Company. All Rights Reserved. Vol. Pg. Specialized Care Reinventing pharmacy care for patients with chronic conditions Today, the 50% of Americans who take daily medications for chronic conditions, such as diabetes, drive 95% of U.S. drug spend. The disparity is even more staggering for specialty conditions, with just 1% of patients accounting for almost 31% of pharmacy costs. These rising costs will continue, in part because patients aren't getting the specialized care they need to understand their treatments and stay adherent. At Express Scripts, we have the right solutions to help you deliver better health and cost outcomes for patients today and into the future. Our philosophy is simple: The expertise a specialist pharmacist delivers lowers costs for Brazos County and provides better care for your patients. If you had cancer, you'd consult an oncologist. Pharmacy is no different. Our condition -specific Therapeutic Resource Centers® (T:RCs) are key to this philosophy. Each TRC is staffed with specially trained pharmacists, nurses, and other clinicians who collaborate and focus their care for patients with chronic and complex conditions like cancer, hepatitis C, and diabetes. Unlike the brief conversations patients have with a generalist pharmacist at a busy retail counter, lasting an average of only two minutes, discussions with our pharmacists are private and last as long as a patient needs— an average of 12 minutes across all TRCs —to ensure optimal clinical care and outcomes. For traditional medications, patients who use Express Scripts Pharmacysm are more satisfied, more adherent, and spend less money on their medications than those who fill their prescriptions at retail. This channel also has significant benefits for Brazos County, including reduced drug trend, increased formulary compliance and generic fill rate, improved adherence and persistence with essential therapies, and a decrease in preventable adverse drug events. We continue to invest in capabilities to put our home delivery. experience on par with best -in -class home delivery experiences in other industries. These initiatives are simplifying the process of signing up for and continuing to use home delivery. ER Q ® c I o 19 � 2311 89 Patients with diabetes, high Specialized bare through Patients using blood pressure, or high our Therapeutic Resource Accredo specialty j cholesterol who use the Centers for patients with pharmacy are 89% '-_! Express Scripts Pharmacy chronic conditions can more likely to stay are up to 19% more likely to reduce hospitalizations on therapy vs. adhere to drug therapy and lower medical costs by those using retail 23% — r ® 2016 Express Senors Holding Company. All RIgms Rese"d. VA SCRIPTS'.: 3 Vol.— pg.Y;,� i r Data Insights Uncovering opportunities for action We know that you don't just need more data. You need a pharmacy partner to put the power of data to work for you. We continually mine vast amounts of information for our 80 million members using proprietary models y designed to pinpoint actionable insights for Brazos County's plan. Our approach results in superior data -driven solutions, including the ExpressAlliances, ScreenRx® and Fraud, Waste, and Abuse programs we recommend for you. ExpressAlliance Our advanced care coordination program, ExpressAlliance®, puts actionable prescription data at Brazos County's fingertips to improve adherence, reduce drug errors, expose clinical waste, and facilitate an integrated health conversation for your patients with chronic and complex conditions — enabl'ingyou to achieve optimal clinical and �_• financial outcomes from your healthcare programs and partners. 1- ScreenRx Three years ago, Express Scripts launched ScreenRx®, the industry's first solution to leverage predictive modeling to identify patients with the highest risk for medication nonadherence and use behavioral science to promote healthier choices — helping solve for nonadherence before it even occurs. ScreenRx® focuses on the conditions IJ with the biggest Impact and patients most likely to respond to outreach to yield maximum results, closing up to 45% of targeted adherence gaps. To date, ScreenRx has closed 375,000 gaps in care, allowing plan sponsors to realize total healthcare savings of $92 million. Fraud, Waste, and Abuse 'I Express Scripts leads the industry in helping clients like Brazos County reduce the costs associated with prescription drug fraud and abuse. Our Fraud, Waste, and Abuse programs rely on intensive data analytics to T detect fraudulent behavior, proactively identify unusual 'utilization patterns, and provide actionable evidence for I plan sponsors. In 2015 alone, Express Scripts referred approximately 2,200 cases to authorities, resulting In $2,3 billion of inferred savings in healthcare costs. i - ti I �I 'titll'l'I'l'�lt® 'll' fi fi 9 ® s41 5.ym gaps In care it identified and closed, Proprietary predictive Every $1 in fraud with annual savings of models resulted in prevented drives $344 per gap, when $1.56 in avoided cost out $41 of wasteful _ Advanced Clinical for plan sponsors spend in the Solutions are in place medical benefit i ¢ ' EXPRESS SCRIPTS' 4 I ` '® 2016 Erprne Scripts Holding Company. All Rigits Reserved._� // �) ._• ___.__.._ Vol.— pg. 5�Y Innovative Solutions .,. Thinking and working differently to solve your healthcare challenges Only one thing fuels our innovation pipeline: solving your greatest healthcare challenges. That's why we put Brazos County in the front seat of product development at the Express' Scripts Lab, where scientists, pharmacists; data analysts, and market experts work together with you to generate ideas and test new approaches that drive value and improve care. We invite Brazos County to tour the Lab, collaborate to create new approaches to better manage your clinical and financial outcomes, and participate im upcoming pilots. Nothing energizes us more than when our clients bring us their biggest challenges and work shoulder to shoulder with us to design and test solutions. Recent examples of our work include: • Diabetes Remote Monitoring Solution: High-tech, high -touch solutions for diabetes care via smart devices and our Therapeutic Resource: Centers®. _ • 'Onsite Physician Dispensing: Safe, convenient option at point of care for initial fills of long-term medications, helping reduce primary nonadherence. • Tailored Laser Messaging,Customized, etching on pill bottle caps at Express Scripts Pharmacysm to encourage adherence and positive health behaviors. • Proactive.Opioid Dependency Pilot: Early identification and interventions for members with predicted likelihood to develop opioid dependence. 6M+ nation 61% MREII II II �I $5;2!M+ Hundreds of pilots Involving In the early stages of innovative use of clinical over 6 million members to testing this solution, 61% protocols helped one plan create better solutions and of patients lowered their sponsor avoid more than . healthier outcomes for A1c levels. $5.27M in medical _. patients and plans expenses I Express Scripts Is*the only Independeht pharmacy services company named to the Forbes Most Innovative.Companies list m,both 2014 and 2015 } I -- �Al-E-(PRE S SCRIPTS' 5 0 2016 Express Scripts Hold ft Company. All Rights Reser d. Vol. � G Pg. 1 r Smarter together: Brazos County and Express Scripts You have high expectations for your pharmacy partner, and we're confident that Express Scripts will deliver the highest quality care and most cost-effective benefit for Brazos County and your 2,146 members. As you review our proposal, please don't hesitate to contact Bill Pearce at 770.753.0048 or bpearce@express-scripts.com with any questions. EXPRESS SCRIPTS' 6 ® 2016 Express Scripts Holding Company. All Rights Resenreo. '--"-""'-'— Vol. � Pg.,�-n= r- �� A Proposal to Provide Pharmacy Benefit Management Services I Brazos County August 12, 2016 r: All of the materials in this proposal and any materials subsequently disclosed in any media form that relate to this proposal ('Proposal Materials") are confidential and the sole and exclusive proprietary property of Express Scripts Holding Company, and all rights, titles and interests are vested in Express Scripts. The Proposal Materials are provided to Brazos County for your exclusive use, and for the sole purpose, to evaluate Express Scripts prescription -drug program. The Proposal Materials may not be distributed, copied or made available for review or use to any other parry. If you use any consultant or other parry to review the Proposal Materials, you may divulge the Proposal Materials to them on the condition that each recipient agrees to be bound by the restrictions Express Scripts has placed on the use and disclosure of the Proposal Materials. This disclaimer Is applicable to any recipient assisting or participating In the evaluation of these Proposal Materials on behalf of Brazos County. Vol. jyc) Pg WHY EXPRESS SCRIPTS We are uniquely positioned to help Brazos County achieve optimal clinical and cost outcomes now and into the future. Nearly three decades ago, Express Scripts was founded on the belief that the pharmacy benefit would be best served by an organization focused on singular alignment with clients and their members. This continues as the guiding principle of our business model today, and we are committed to bringing our philosophy to bear for Brazos County and your members to ensure the excellent outcomes and service you deserve. We achieve these results through four key differentiators: Bold Action — Express Scripts has a long history of doing what's right for our clients and their members — even when it isn't easy. Most recently, we took bold market -changing action to improve health and lower costs for unethically priced compound drugs and exorbitantly priced therapies for hepatitis C, high cholesterol, and cancer. As healthcare evolves, we will continue to partner with our clients to ensure patients have access to the medications they need at a reasonable cost. Specialized Care — We've reinvented the practice of pharmacy via our Therapeutic Resource Centers®. Our specialist pharmacists in these 20 specialized practices provide Brazos County's sickest members with expert counseling in chronic and complex diseases like diabetes, depression, oncology, hepatitis C, and multiple sclerosis. This . specialized care is fundamental to how we practice pharmacy and will be a part of your. core pharmacy benefit at no additional charge. Data Insights — As the largest pharmacy benefit manager in the United States, Express Scripts has access to a vast amount of actionable data, enabling us to analyze a third of the nation's prescription information at a granular level. This results in superior data - driven services — such as the industry's most advanced solutions to improve adherence and manage fraud, waste, and abuse — and gives us the insight to close millions of gaps in care each year. Innovation — Express Scripts is proud to be the only pharmacy benefit manager named to Forbes' list of most innovative companies for two years running. Innovation begins at the Express Scripts Lab, where we partner with our clients to design and test pilots that address key pain points in healthcare and drive greater clinical and financial value. Today, we are running pilots with more than 300 clients and 5 million members to identify new solutions to solve healthcare's greatest challenges. Brazos County EXPRESS SCRIPTS® August12,2016 Vol. —a pg. S� Why Express Scripts r Company Overview Based in St. Louis, with offices throughout the U.S. and in Canada, we provide pharmacy Express Scripts has never been owned by a drug manufacturer. Our independence and j integrated services enable us to work in the best interests of our plan sponsors and their members. Express Scripts has made strategic acquisitions and mergers to expand our T capabilities in important market segments. We have incorporated the best practices of ? each acquired organization to reinforce our position as an industry leader. Recent acquisitions include: r Date Express Scripts' Acquisitions J September 2013 Smart!) Medicare Prescription Drug Plan — Express Scripts acquired Smartl) Rx, further strengthening our Medicare PDP offering. Medco Health Solutions — Express Scripts and Medco merged -to form a April 2012 healthcare leader that discovers, develops, and implements solutions for T the healthcare challenges faring plan sponsors. j Nex[Rx — NextRx subsidiaries provide pharmacy benefit management and specialty' pharmacy services to millions of members. The acquisltIon December 2009 provided operational efficiencies and enhanced out Industry-leading 1 health -Information technologies, clinical capabilities, and thought leadership. I Brazos County EXPRESS SCRIPTS- August 12, 2016 L LVol. Pg.� benefit management services to 78 million members. We deliver fully integrated pharmacy benefit management services, including network claims processing, benefit .. design optimization, drug utilization review, formulary management, and clinical programs. Since our founding in -1986, Express Scripts has served as a thought leader in pharmacy benefit management. Our.emphasis on evidence -based research has driven us to establish F the fust in-house Research department, produce the fust annual Drug Trend Report, and at times, take positions unpopular with companies in the supply chain in order to sustain a meaningful pharmacy benefit. Our research -backed model for using markef forces to control costs and maintain the benefit for all members has been hailed by independent market analysts and patient rights groups as a game changer. We continue this legacy of - innovation to enable better decisions that ultimately lead to better health and financial outcomes.. t _.- History Express Scripts has never been owned by a drug manufacturer. Our independence and j integrated services enable us to work in the best interests of our plan sponsors and their members. Express Scripts has made strategic acquisitions and mergers to expand our T capabilities in important market segments. We have incorporated the best practices of ? each acquired organization to reinforce our position as an industry leader. Recent acquisitions include: r Date Express Scripts' Acquisitions J September 2013 Smart!) Medicare Prescription Drug Plan — Express Scripts acquired Smartl) Rx, further strengthening our Medicare PDP offering. Medco Health Solutions — Express Scripts and Medco merged -to form a April 2012 healthcare leader that discovers, develops, and implements solutions for T the healthcare challenges faring plan sponsors. j Nex[Rx — NextRx subsidiaries provide pharmacy benefit management and specialty' pharmacy services to millions of members. The acquisltIon December 2009 provided operational efficiencies and enhanced out Industry-leading 1 health -Information technologies, clinical capabilities, and thought leadership. I Brazos County EXPRESS SCRIPTS- August 12, 2016 L LVol. Pg.� Why Express Scripts Challenging the Status Quo: Express Scripts SafeGuardRx Over the past three years, the pharmacy landscape underwent seismic change, and the budgetary impact to healthcare payers has been significant. Express Scripts' exclusive Prescription Price Index shows that the average price of brand drugs increased 16.2% in 2015, with one-third of brand products experiencing price increases greater than 20%. Meanwhile, the cost of specialty medications continued to climb, accounting for 37.7% of total drug spend in 2015. To address these rising costs, Express Scripts is committed to doing what is best for our clients and their members — even when others won't. Our Hepatitis Cure Value Program (HCV) transformed the financial and clinical landscape for treating hepatitis C, saving clients more than $I billion in 2015 alone, while saving the U.S. healthcare system more than $4 billion. Our Cholesterol Care Value ProgramsM (CCV) helps clients avoid up to 90% of plan cost increases in the cholesterol therapy class while ensuring patients who meet rigorous clinical standards for use of PCSK9 inhibitors receive them. Our Oncology Care Value ProgramsM (OCV) ties the cost of a drug to its efficacy for specific types of cancer, helping ensure members get the medications they need at the right price. Our Inflation Protection Program, another industry first, helps minimize the impact of rising drug trend on participating plan. These programs are components of Express Scripts SafeGuardRxm, a suite of innovative solutions that we are offering Brazos County, designed to safeguard your interests while ensuring important therapies and specialized care are available to your members. And we're not stopping there: We're enhancing our current programs to further reduce costs and improve care, and we're introducing additional unprecedented solutions that will provide unique protection to your plan: the Diabetes Care Value Programsm, the Inflammatory Conditions Care Value ProgramsM, and the Market Events Protection Program', a program to minimize the financial impact of major market events, such as dramatic price increases or generic launches with price points similar to brands. All existing and new SafeGuardRx programs will be available to Brazos County at no charge. WRI EXPRESS SCRIPTS* Brazos County August 12, 2016 3 Vol. _a /6 _ Pg. i I r 1 PHARMACY BENEFIT EXPERTISE With an unwavering commitment to pharmacy benefit management strategies backed by evidence -based research, Express Scripts recommends a comprehensive pharmacy benefit solution, that involves the following components: • National Preferred Formulary • Clinical Solution • Medicare Services Below you will find more information about each of these components: Express Scripts' Formulary As the pharmacy benefit landscape continues to evolve, Express Scripts is working hard for our clients to manage pharmacy cost while preserving client and member choice through formulary management. Our clinically sound, cost-effectiveformulary options help decrease prescription -drug expenses when combined with a well-designed benefit plan. To ensure the clinical appropriateness of our formularies, Express Scripts' physicians and pharmacists carefully evaluate pharmaceuticals and prepare recommendations for the National Pharmacy & Therapeutics (P&T) Committee. This independent body, consisting of physicians and a pharmacist located throughout the U.S., reviews and approves our formularies. National Preferred For.. The National Preferred Formulary, Express Scripts' standard formulary, enables Brazos County to achieve optimum trend management while preserving individual choice and access to clinically effective generic and brand-name drugs. The formulary includes nearly 100616 of generics and more than 4,000 unique products. If provides brand-name pharmaceutical selection, is typically used with a three-tier benefit design or an open formulary benefit design, and provides rebates tied to formulary products that give increased savings back to the plan sponsor. In 2016 alone, we anticipate the National Preferred Formulary's exclusions to deliver $1.3 billion in client savings. More than 25 million Americans obtain their pharmacy benefit coverage through the Express Scripts National Preferred Formulary-- more people use this formulary than any other formulary in the U.S. .Brazos County EXPRESS SCRIPTS* August 12, 2016 Ll [VOL Pharmacy Benefit Expertise To provide added value to our clients in an increasingly complex pharmaceutical landscape, the National Preferred Formulary excludes 80 products that represent a mere 2% of all available drugs in the marketplace, including formulary and nonformulary. These drugs, most of which have copayment cards that push members toward expensive non -preferred brands, also offer no added clinical value over other drugs that remain in the therapy class. Any members impacted by formulary exclusions will have access to multiple product alternatives, including preferred brands and generics. These safe, proven medication alternatives in each therapy class are based upon guidance from an independent national panel of expert health professionals. Express Scripts manages the National Preferred Formulary and updates it regularly to optimize management of traditional and specialty drugs. We perform deletions twice annually, on July 1 and January 1. As part of the update process, we conduct reviews of therapy classes currently subject to exclusions. Any new -to -market drugs in these therapy classes are evaluated for possible exclusion prior to their market. availability. We also proactively monitor for potential additional exclusions in novel therapeutic categories and will monitor new drugs that may drastically change market dynamics. Brazos County WEXPRESS SCRIPTS° August 12, 2016 6 Pharmacy Benefit Expertise Express Scripts' Clinical Solution Express Scripts provides the most comprehensive set of base solutions in the industry, with advanced options for even greater care and cost control. Our practical solutions make three types of decisions easier: drug choices, pharmacy choices, and health choices. Drug Choices Better drug choices increase safety and savings. Our Drug Choices solutions facilitate the proper use of the safest, most cost-effective medications. Anomer imporonr program racxies rraua, wasoe, & Abuse to control costs and reduce inappropriate drug use and prescribing practices. Our standard offering includes: • Standard network -wide pharmacy monitoring and audit • Identification and discipline of potentially fraudulent pharmacies Fraud Tip Line: External tips received from retail ' pharmacies, prescribers and law enforcement are Formulary Management enables patients and physicians to rimose safe and cost-effective drugs for a given condition. Our Enhanced Fraud; Waste, & Abuse offering Includes: • Client-spedfic claims review Identification of potential member and . prescriber fraud • Compilation of evidence to confirm or dismiss allegations • Integration of medical claims with prescription Investigations when possible . Various packages of Advanced Utilisation Management (LIM) tools (including different levels of Step Therapy, Prior Authorization, and Drug Quantity Management) support Brazos County's cost -control goals. There are four levels 'of, Advanced LIM available to best meet Brazos County's needs. For clients who want to better manage Increasingly expensive specialty drugs, nearly half of which are billed through the medical benefit, Express Scripts offers Medical Benefit Management and Medical Channel Management programs. \ Brazos County i EXPRESS SCRIPTS - August 12, 2016 6 pg. a�� - Pharmacy Benefit Expertise Pharmacy Choices Our Pharmacy Choices solutions help patients and their providers choose the most cost- effective, highest -quality pharmacies for their conditions. Our National Network of retail pharmacies includes 60,229 locations. Our National Plus Network includes 69,002 locations. For patients with chronic conditions, Express Scripts Pharmacy offers the most reliable path between member and medication, delivering greater safety, lower costs, and optimal clinical care. For patients with complex conditions, Express Scripts Specialty Benefit Services offers the most comprehensive range of specialty health solutions, improving care while adding value for Brazos County. aEXPRESS SCRIPTS* For acute and general pharmacy pre, our network management programs advantage better decisions, making It easy for patients to choose high-quality pharmacies at affordable prices. For maximum savings without compromising access, we offer the Express Advantage Network®, a tiered pharmacy network featuring preferred network providers for even better pricing and service. For patients with chronic conditions, Exclusive Home Delivery Is the best solution for clients who want to maximize member savings, plan savings, and member adherence to medications. For clients who are not able to Implement an exclusive program, we offer a powerful choke - based program called Select Home Delivery that preserves member choice while delivering a greater conversion rate than education -only For clients seeking maximum plan performance, our Exclusive Specialty Pharmacy care program enables greater control, deeper discounts, higher adherence, and better patient satisfaction rates through personalized clinical services and Flexible specialty network management programs, along with IV o!. _ �`� Pg. �%� Brazos County August 12, 2016 Y I Pharmacy Benefit Expertise Health Choices Solutions in this area are designed to prevent drug-related adverse events, detect potential issues, address gaps in care, identify savings opportunities, and improve adherence. Concurrent Drug Utilization Review is a clinically based program that automatically alerts pharmacists — In real-time at the point of service—to potential. safety concerns, Identifying medication conflicts before the member obtains a prescription. This prevents drug-related adverse events, reducing emergency room utilization, hospitalizations, and urgent care visits. Retrospective Drug Utilization Review analyzes prescription data to address patient health and safety Issues across Brazos County's population. The goal of this clinical safety program Is to Identify and help prevent adverse drug events Our Physician Connectivity solution facilitates smarter electronic prescribing with real-time Insight for physicians, leading to better home delivery utilization, higher generic dispensing rates, greater formulary compliance, fewer adverse drug events, and higher first -fill adherence rates. Therapeutic Resource Centers are designed to optimize the safe and appropriate dispensing of therapeutic agents, minimize waste, and Improve clinical and financial outcomes, Access to specialist pharmacists and nurses is part of our core PBM pharmacy solution and is free of charge to all members whether they get their medications through an Express Scripts home delivery pharmacy or at a retail pharmacy (certain state -sensitive -drug -list clients and standalone -mail clients excluded). ExpressAAiancea enhances ore-, Improves adherence, and increases savings for patients with chronic and complex conditions through a flexible portfolio of ore coordination services, leveraging client -authorized healthcare professionals who can analyze prescription data and generate clinical and member savings opportunities. ScreenRx® is the industry's first adherence screening tool.that provides significant savings for clients and improved health outcomes for members. Screen Rx detects patients at risk for future nonadherence and then proactively addresses the problem through patient -specific, tailored Interventions. ' Our Personal Medication Coach program, designed -by pharmacists, improves the way members manage their medications and reduces wasteful healthcare spending. Through member -specific consultations, we help members make the best possible healthcare choices that optimize medication therapy outcomes. To enhance these solutions, we provide member -specific information about savings opportunities through My Rx Choices , a free, multimedia member education program that helps guide informed drug, pharmacy, and health choices. EXPRESS SCRIPTS` Brazos County August12,2016 Pharmacy Benefit Expertise Medicare Services EGWP Plus is Express Scripts' standard offering — it comprises a Part D plan with secondary commercial wrap for other health insurance. EGWP Plus provides Brazos County with the greatest potential savings by taking advantage of pharmaceutical manufacturer discounts available in the coverage gap, while providing plan design flexibility and the ability to maintain the current retiree benefit. The Express Scripts Difference • We offer EGWP Plus solutions for retiree populations of all sizes and industries. • Leading the market since 2006, and currently serving 46% of EGWP lives, Express Scripts is the largest provider of services in this arena. • We currently support and administer 2.2 million EGWP lives — that's two times more lives than our closest competitor. • The leader in innovation, Express Scripts has made significant investments in personnel and infrastructure, including hundreds of millions in technology investments specific to government programs, to deliver a better experience for employers and their retirees. t" • A 4 -star rating for 2015 demonstrates our commitment to continuous quality enhancements and validates our adherence to CMS guidelines. • We were one of just six providers invited to share insights for ensuring a quality and compliant plan at last year's inaugural CMS Best Practices Workshop. • Express Sczipts' EGWP plan offers unmatched savings: – A 103% increase in subsidy – Plan design options to meet Brazos County's savings goals – The ability to fully insure your plan • Our signature service model directly correlates to our 96% EGWP client retention rate. Through our Medicare expertise and services, we make it easier for you to implement and manage the Part D benefit. • EGWP Client Forums are available regularly to share insights to CMS information and industry changes • Various strategies and programs are presented for reducing plan costs through benefit design changes, new product development, and member experience enhancements. ®® Brazos County Ali EXPRESS SCRIPTS` August 12, 2016 I. THE SUPPORT To SUCCEED In order to successfully execute recommended solutions, we must deliver exceptional support to Brazos County. Express Scripts excels in the following fundamental areas: M• Implementation • Account Management I Reporting I Below, you will find more information about how Express Scripts will support Brazos ? County's goals in each of these areas: Implementation Express Scripts recognizes that a smooth implementation is crucial to a new pharmacy benefit program's success. We focus on implementation as a core competency and have gained years of experience in transitioning new members with minimal disruption. Our implementation process is structured, yet flexible to ensure a successful and quality - oriented implementation for each client, regardless of size. Our current client �- implementation satisfaction rate attests to this fact: In June 2015, Express Scripts achieved our target client satisfaction rating of 98%. Our success in implementing new pharmacy benefit programs depends on cooperation and timely interaction with Brazos County and the many Express Scripts functional areas involved. Your implementation project manager is key to coordinating this effort. 7 Brazos County's implementation project manager has extensive experience establishing managed pharmacy benefit accounts. The implementation project manager plays a vital role early in the implementation process — beginning with the sales process through T - transition to the account management team. i The implementation project manager represents your needs to all operational areas within Express Scripts. During the implementation process, the members of both the implementation team and the account team will assist Brazos County to educate your staff on the specifics of working with our company. Your account team also participates in the implementation process to ensure smooth, ongoing management of your account after implementation. Subsequently, your account team will provide additional support on an ongoing basis to keep Brazos County's staff informed of new developments and programs. Brazos County y EXPRESS SCRIPTS• August 12, 2016 t . 1)0 �[ The Support to Succeed Account Management Overview To demonstrate Express Scripts' commitment to our clients, we will provide you with a highly professional, experienced account management team, committed to meeting your specific needs through expert consultative services, strategic planning, and issue resolution. Express Scripts manages your account using a multidisciplinary, client - centered service approach. This sophisticated model applies the talents of cross - functional teams organized to serve your unique business needs. Our account management teams comprise key professionals supported by vast internal resources to ensure Brazos County and your stakeholders have access to the information you need when you need it. In partnership with the extended service team, Express Scripts' account management provides you with consistent, accessible, informed services at every level. This model of service excellence allows your account team to focus on a core set of responsibilities, while directing tasks beyond this core to experts on the extended service team. The extended service team has a deep understanding of Express Scripts' systems, operations, and processes and will work closely with Brazos County's account team on tasks such as plan design changes, program implementations, billing, eligibility, reporting, and communications. Centralizing these key, repeatable tasks allows your account team to execute on Brazos County's needs. 1% EXPRESS SCRIPTS* 11 Vol. � Pg.__,�_ Brazos County August 12, 2016 1 Y t" The Support to Succeed �VI O Brazos County _ EXPRESS SCRIPTS• August12,2016 �I 12 Reporting TJ Express Scripts understands that each client has unique reporting and consultative needs. Our reporting and analytics offering ranges from full-service benefit support to self- service reporting via our cutting-edge, industry-leading online tools. With proactive plan management and ongoing data reporting, our clients are able to stay on top of developing trends and make informed decisions about their pharmacy benefit. Our data warehouse strategy aligns with the needs of the pharmacy benefit management business and our clients' requirements. We maintain all client data in one central M location, providing a single source for all information used in the continuum of reporting. This strategy gives Express Scripts the information edge when compared to our competitors. r , �VI O Brazos County _ EXPRESS SCRIPTS• August12,2016 �I 12 MEMBER SERVICE AND ENGAGEMENT The services we provide directly impact the lives of millions of people. We strive to provide high-quality service to our members at every interaction Below, you will find more information about the following member features: • Express Scripts Pharmacy • Contact Center • Express-Scripts.com for Members • Member Communications Express Scripts Pharmacy When members use the Express Scripts Pharmacy for medications taken on an ongoing basis, they enjoy greater convenience as demonstrated by the following: • Free shipping directly to the member's home or office. • The 90 -day supply available from home delivery decreases the number of refills required and eliminates extra trips to a retail pharmacy. • Members can easily order medications via the phone, mail, mobile app, member website, or a fax from their physician. • Members with Internet capability can submit refill prescriptions online and access leading-edge, health-related content and applications, including an automated email refill reminder program, all from the convenience of their home or office. Also, in the near future, we will be rolling out a broad based text messaging capability for home delivery that builds off of recent successful pilots. • Members can also use Express-Scripts.com to compare differences in drug coverage and pricing between home delivery and retail, obtain order status, and set up refill reminder notifications. • Members who have Express Scripts' mobile app have access to the Refills and Renewals feature, which allows quick and easy management of their delivery prescriptions by refilling and renewing them right from their phone. • Members benefit from the unique, high level of care provided by our specialist pharmacists. This service, combined with certain DUR alerts that are unique to Express Scripts pharmacies (including clinical review for certain drugs that have inherent safety risks, such as chemotherapy and HIV medications), bring a specialized focus to DUR and your members' safety. • Members enjoy fast turnaround times from home delivery. Upon receipt, prescriptions are electronically routed to the pharmacy best equipped to expedite a member's order. • Members complete less paperwork and do not have to file claim forms. Brazos County EXPRESS SCRIPTS° August 12,2016 13 Pg VoEl. •.�5� I i C r I Member Service and Engagement EXPRESS SCRIPTS' _i 14 Vol - Kz� . Pg. ��5 Brazos County August 12, 2016 • Conversations with Express Scripts' specialist pharmacists and patient care advocates can be held in the privacy of the member's home, an important aspect in maintaining patient satisfaction. As demonstrated by the J.D. Power 2015 U.S. Pharmacy r Surveyor survey, patient satisfaction improves 9.9% when pharmacy consultations are handled privately, away from other patients or shoppers. Approximately 98% of those who received counseling from an Express Scripts specialist pharmacist were r extremely satisfied or very satisfied with the interaction • Pharmacist interactions last longer at the Express Scripts Pharmacy —12 minutes on average, versus less than two minutes for retail patients. Because home delivery patients engage with specialist pharmacists in private, at the members' convenience, they don't have the distraction of long lines at retail or someone overhearing. This is - a level of privacy retail pharmacists cannot provide. Furthermore, through Express Scripts' advanced pharmacy practice model, each specialist pharmacist works continuously to better understand the needs of the members under their care. They may engage members to discuss medication issues and explore new approaches to improving care. The focus of this work is on those members with _ important gaps in their pharmacy care or who are at -risk for complications. Members are eligible for inclusion, regardless of whether they use retail or home delivery. When specialist pharmacists evaluate prescriptions, they look for cost and safety concerns, identify and address issues with members and their physicians, and counsel those who have questions and special needs. After prescriptions are evaluated and all issues are r- resolved, the prescriptions are routed to one of our fully automated dispensing pharmacies for fulfillment. Members benefit from the expertise of the specialist pharmacists, and they and their physicians are better engaged in making treatment decisions based on both health and cost. 'I had many concerns about my recent medication change. I was fortunate to reach Eric, who spent an hour counseling me about my new insulin. He was m friendly and attentive, answered ali my questions, and provided so much additional helpful information. My experience with Eric was great — no i- comparison to my retail pharmacist. I appreciated the excellent service. • t — Eric L .is a specialist pharmacist in Express Scripts' Diabetes Therapeutic Resource Center EXPRESS SCRIPTS' _i 14 Vol - Kz� . Pg. ��5 Brazos County August 12, 2016 Member Service and Engagement Member Savings Members save money and time through the use of home delivery as demonstrated by the following: • Members can receive up to a 90 -day supply of medication for only one copayment, which is often less than the cost of three 30 -day retail copayments, depending on plan design. • Members save time by eliminating trips to a retail pharmacy. Contact Center Express Scripts' Contact Center network, which is available 24 hours a day, seven days a week, combines advanced technology with skilled and courteous staff to provide the highest levels of care and service to your members. Equipped with state-of-the-art technology, our advanced facilities are the key to handling member inquiries in a timely manner and ensuring satisfaction. In alignment with our model of engagement, our staff of more than 3,200 highly trained patient care advocates optimizes all interactions to address members' most immediate needs while also informing them of actionable opportunities to improve care and reduce healthcare costs. Express-Scripts.com for Members Our member website is a powerful tool that focuses on opportunities to influence patients' behavior so higher quality, more affordable prescription drug care can be delivered, thereby achieving greater patient satisfaction and clear client savings. Because we view members as patients and not just consumers, we provide an online safety net of information that connects patients with online resources, desktop tools, and mobile apps to proactively maintain their prescription drug therapies at home and on the go. This empowers members to protect themselves against certain unnecessary health risks and helps them close their own gaps in care. By delivering a wealth of functionality, information, and resources, our website is designed to help members become better informed about, and take a more active role in, their own healthcare. The member website supports members' choices and encourages thoughtful decisions around the pharmacy benefit. By providing members with all the tools and information they need to manage their pharmacy benefit online, we stress compliance, continuation of therapy, and other related behaviors that ultimately help clients avoid rising health care costs. EXPRESS SCRIPTS' Brazos County August 12, 2016 15 V Ji. :? /d _ pg. 6, zz r- Member Service and Engagement Our member website also strives to offer easy accessibility to Express Scripts. Our member service representatives and specialist pharmacists are available when questions arise. Our feedback link encourages members to tell us about their online experience so we know what we arc doing well and where we could provide future enhancements. Express-Scripts.com delivers easy access to personalized prescription benefit information, as well as easy -to -order prescription refills and renewals. Express- Scripts.com not only delivers all the core functionality typically associated with an online pharmacy, but it also offers unique features that create exceptional convenience and ease of use while educating members on the most effective use of their benefit, thus helping members understand critical gaps in care and enabling them to take appropriate health action. By applying the same strict quality and clinical appropriateness principles that we practice in our traditional pharmacy benefit management business to our Internet initiative, we assure high quality, cost-effective pharmacy benefit services for our members and clients. Member Communications Our research has shown that the vast majority of members want exactly what plan sponsors want: lower costs and optimal health. The disparity is not between the goals of plan sponsors and members. It is between what members want and what they do. Championed by the Member Communications Council, our preferred communications process streamlines communications while leveraging insights from the behavioral sciences. Brazos County WEXPRESS SCRIPTS- August 12, 2016 16 / T ! )) A Proposal to Provide . Pharmacy Benefit Management Services i I Brazos County P August 29, 2016 All of the materials in this proposal and any materials subsequently disclosed in any media form that relate to this proposal ("Proposal Materials") are confidential and the sole and exclusive proprietary property of Express Scripts Holding Company, and all rights, titles and interests are vested in Express Scripts. The Proposal Materials are provided to Brazos County for your exclusive use, and for the sole purpose, to evaluate Express Scripts prescription -drug program. The Proposal Materials may not be distributed, copied or made available for review or use to any other party. If you use any consultant or other parry to. review the Proposal Materials, you may divulge the Proposal Materials to them on the condition that each recipient agrees to be bound by the restrictions Express Scripts has placed on the use and disclosure of the Proposal Materials. This disclaimer Is applicable to any recipient assisting or participating In the evaluation of these Proposal Materials on behalf of Brazos County. RETAIL PHARMACY NETWORK AND HOME DELIVERY PRICING Average Annual AWP- AWP -20.75% AWP - Discount Guarantee 17.50% 24.00% Brands $0.75 $0.45 $0.00 Dispensing Fee Guarantee/ Rx Year 1: AWP - 83.00% Average Annual Year 1: AWP -79.50% Year 2: Discount Guarantee Year 2: AWP -80.00% AWP - Generics Year 3: AWP -80.50% 83.50% 3.50 Year 3: AWP - 84.00% Dispensing Fee $0.75 $0.45 $0.00 Guarantee/ Rx Compounds Lesser of U&C or combined Not AWP plus service fee Applicable Administrative Fee/Rx $0.00 Year 1: Year 1: $80.00 Year 1:$210.00 $210'00 Rebates/Brand Rx All Plan Designs Year 2. $95.00 Year 2: $250.00 Year 2: $250.00 Year 3: Year 3: $290.00 Year 3: $110.00 $290.00 Claims will be processed at the lower of the applicable AWP discount, MRA (if applicable), or U&C (retail only).Certain participating pharmacies have agreed to participate In the extended (84 -90) day supply network (`maintenance network`) for maintenance drugs. The 84-90 Days' Supply pricing column in the table set forth above is applicable only if Brazos County implements a plan design that requires members to fill such days' supply at a maintenance network participating pharmacy (i.e., Brazos County must implement a plan design whereby members who fill 84-90 days' supply prescriptions at a participating pharmacy other than a maintenance network participating pharmacy db not receive benefit coverage under the plan for such prescription). If no such plan design is implemented, the pricing for such days' supply will be the same as the 1- 83 Days' Supply pricing column set forth above, and pricing for an 8490 days' supply in the table set forth above shall not apply, even if a maintenance network particlpating pharmacy is used. Brazos County EXPRESS SCRIPTS • August 29, 2016 Fvoi. ,;750 — Pg �—Y- Pricing Supplement Express Scripts' Inflation Protection Program Express. Scripts is pleased to offer our Inflation Protection Program to your organization. Under the program, Express Scripts will pay to Brazos County $2.00 per formulary brand drug claim (the "Brazos County Inflation Payment'), Subject to the conditions set forth herein, Express Scripts shall pay Brazos County the Brazos County Inflation Payment within approximately one hundred and eighty (180) days following the end of each calendar quarter for utilization occurring during such quarter. Non -formulary claims will be excluded. Terms and Conditions of the Inflation Protection Program, The following claims will be excluded from all calculations related to the Inflation Protection Program: Medicare claims, Medicaid claims, any other government health care program claims, OTCs, member submitted claims, subrogation claims, compounds, generic drugs, claims submitted by Brazos County owned, in-house, or on-site' pharmacies, 340B claims, claims submitted through a 100% member cost -share program, biosimilars, drugs where the'quantity or packaging has been changed by the manufacturer from the past year, and drugs for which there was no utilization in the calendar year prior to the calendar year for which the Inflation Guarantee payment is being determined. If Brazos County makes material changes to its formulary or benefit design that negatively impact Express Scripts' ability to control inflation relative to Brazos County's formulary drug mix, then Express Scripts reserves the right to make an equitable adjustment to the Inflation Guarantee. Express Scripts' Inflation Protection Program, and the underlying economics, is separate and apart from, rebates and manufacturer administrative fees and the amounts described above will be paid to Brazos County in addition to any rebate payments to which Bmzos County is entitled. Brazos County will not be entitled to receive any amounts related to drug price inflation or a related guarantee other than as set forth above. No payments will be made to Brazos County unless Brazos County has an executed PBM agreement with Express Scripts. Other terns and conditions apply, and will be,laid out in more detail in the PBM Agreement. Brazos County EXPRESS SCRIPTS' AugustN,2016 vol. �� _. pge ---4 Pricing Supplement Express Scripts' Specialty Offering n:.....r rsa.mnw. Express Scripts guarantees that the overall annual Net Effective Discount for the products listed on the Specialty Price List that were dispensed through the mail order channel : excluding Limited Distribution and Exclusive products will be at least AWP (-) minus 17.00% for Brazos County. Within one hundred eighty days (180) following the end of each contract year Express Scripts will calculate the actual net effective discount for the products listed on the Specialty Price List that were dispensed through the mail order channel to determine if the guarantee has been met. If the actual overall Net Effective Discount is less than the guaranteed Net Effective Discount Express Scripts will reimburse Brazos County the full dollar amount of the difference between the actual and guaranteed Net Effective Discounts. Brazos County will retain any amount that the actual . Net Effective Discount exceeds the guaranteed Net Effective Discount. The calculation for the actual Net Effective Discount will be as follows: ((Total Ingredient Cost for the products listed on the Specialty Price List) divided by (Total AWP for the products listed on the Specialty Price List)) minus 1. This guarantee is contingent on Brazos County's participation in an exclusive specialty arrangement: Rebates/Brand All plan Year : $ 2 Rx Designs Year 2: $770000 Year 3: $750 Brazos County Ir AOL& EXPRESS SCRIPTS' August 29, 2016 VOA._ Fg � I f— Pricing_ Supplement Exclusive jExpress Scripts' Exclusive specialty offer, with Select Specialty for HIV medications, is designed to provide clients maximum cost savings and superior patient care. Under this offer, patients obtain all specialty medications through the Express Scripts Specialty I. Pharmacy at the reimbursement rates set forth in Appendix A. Specialty products will T not be available through the Express Scripts home delivery pharmacy and will not be available through other pharmacies except for: • . Limited distribution products not available.at the Express ScriptPharmacy s Specialty Phaacy Up to two (2) initial courtesy fills for STAT (immediate need or medical necessity) medications . HIV medications, wherethe member opts to fill the prescriptions at retail under the Select Specialty HIV program, and • Overrides for urgent situations. --Nv� Brazos County EXPRESS SCRIPTS - August 29, 2016 Vol. _ � Pg. � 7,��- The current specialty drug list with pricing is provided in AppendlirA. Note that this list is current as of the date of this proposal. This list will change continually as new specialty drugs enter the market or as the Express Scripts Specialty Pharmacy gains access to additional limited distribution products. On a monthly basis, Express Scripts will communicate new drug additions that occurred throughout the previous month as well as their applicable discount rates, r Pricing does not include home infusion supplies and services unless otherwise noted. -. Limited Distribution Drugs -' Distribution of a small number of all specialty drugs is limited by the manufacturer to specific pharmacy,providers. The drugs, listed in Appendix A, are not available through the Express Scripts Specialty Pharmacy. If the Express Scripts Specialty Pharmacy receives a prescription for one of these limited distribution medications, the Express Scripts Specialty Pharmacy will: Determine dispense the pharmacy that is able to the medication. • Validate that the pharmacy is contracted to provide the medication based on the patient's insurance information, and: r - Work with the patient and prescribing physician to initiate the transfer of the script to the appropriate pharmacy for fulfillment, or - Provide the patient and physician with information regarding possible patient assistance programs. The cost of the medication will be billed through your regular invoice if the medication is a covered product. --Nv� Brazos County EXPRESS SCRIPTS - August 29, 2016 Vol. _ � Pg. � 7,��- Pricing Supplement Updates Express Scripts updates the specialty drug lists as new products are introduced to the . market or as the Express Scripts Specialty Pharmacy gains access to additional limited distribution drugs. Express Scripts provides a monthly notice of added drugs. Pricing for these new products will be determined by Express Scripts, and Brazos County will have. the option of covering the medication. The full current list is always available on request from your account team. Pharmacy Management. Fund (PMF) Up to $10.00 per member implemented as of the effective date, not to exceed $21,500, to reimburse Brazos County for the actual, fair market value of expense items and services related to managing the pharmacy benefit, such as ID Cards, IT programming, formulary letters, member communications, and benefit set-up quality assurance. V Brazos County must submit adequate documentation of any applicable implementation expenses within 180 days of implementation, at which time a final reimbursement of eligible expenses will be made. Adequate documentation of any expenses not related to implementation must be submitted prior to contract - termination for reimbursement. Expenses for reimbursable items or services must be incurred by Brazos County and submitted along with adequate documentation supporting the item or service performed in order to be considered for reimbursement in accordance with Express Scripts' standard PMF policies. All reimbursement under the PMF is subject to Express Scripts' standard PMF business practices for all clients. • If the agreement terminates for any reason other than breach of the agreement by Express Scripts, Brazos County shall reimburse Express Scripts any amounts paid that have not been amortized by the effective date of termination. Assumptions • Quoted fees and services are valid for 90 days from the date of the proposal. • Quoted fees are guaranteed for the term of the three-year contract, subject to -terms and conditions stated herein and in the PBM Agreement. • No more than 25% of the membership is enrolled in a 100% copayment benefit plan or high deductible health plan. • Rates may be modified if more than 5% of claims are incurred in Massachusetts, Hawaii, Alaska, or Puerto Rico. _ u • This offering is subject to implementation of the Express Scripts Specialty Pharmacy Exclusive. Removal of this program will result in the applicable administrative. fee. Brazos County EXPRESS SCRIPTS° August 29, 2018 r 7-� i` Pricing. Supplement • The guarantee will be calculated as: [1-(total discounted AWP ingredient cost ? (excluding dispensing fees and claims with ancillary charges, and prior to application of copayments) of applicable prescription drug claims for the annual period divided ' . _. by total undiscounted AWP ingredient cost (both amounts will be calculated as of the date of adjudication) for the annual period)]. OTC, compounds, member submitted claims, subrogation claims, vaccines, specialty products, biosimilar products, long term care pharmacy claims, and products filled through in-house or 340b pharmacies (if applicable) are excluded from the guarantee. • Express Scripts reserves the right to amend the price quotation set forth herein if there is a material change in the number of persons included in the prescription dru program or any material change.in the benefit plan from that which was presented to Express Scripts and upon which this price quotation is based. 1 Brand average annual aggregate discount guarantees will include those prescription fdrug claims that processed to Brazos County for payment where the underlying prescription drug product was identified by Medi-Span as having a Multi-Source Indicator code identifier of "M", "N', or "O" on'the 'date dispensed, unless otherwise noted as an exclusion. Generic average.annual aggregate discount guarantees will include those prescription drug claims that processed to Brazos County for payment where the underlying prescription drug product was identified by Medi-Span as having a Multi-Source Indicator code identifier of "Y" on the date dispensed, unless otherwise noted as an exclusion. For all other purposes (e.g„ rebates, claims adjudication, member cost share; reporting, etc.), Brand Drugs and Generic Drugs will be identified as such in Express Scripts' master drug file using indicators from First Databank (or other. source nationally recognized in the prescription drug industry) on the basis of a standard Bmnd/Generic Algorithm.- i Mail order pricing includes handling and postage expense of mail-order prescriptions. If postage rates (i.e., U.S. mail and/or applicable commercial courier services) . increase during the term of this Agreement, the Dispensing Fee will be increased to reflect such increase(s). • Brazos County agrees to adopt Express Scripts' National Preferred Formulary in . order to be eligible for rebates, whether rebates are paid or applied. Drugs and supplies Included on the selected formulary may be modified by Express Scripts from time to time as a result of factors, including, but not limited to, medical appropriateness, manufacturer rebate arrangements, and patent expirations. Claims submitted to the Express.Sciipts home delivery pharmacy for less than a 46- day supply will be subject to retail discounts, fees, rebates and guarantees. !i Rebate guarantees assume that the current benefit plan design or the new benefit'plan !J; design as disclosed by Brazos County will be implemented afthe time these guarantees gointo effect. Rebate guarantees are subject to adjustment if any clinical or trend programs intended to drive higher generic or OTC utilization are currently in place without Express Scripts' knowledge of both the program and the drugs within the program. Rebate guarantees are also subject to,adjustment if Brazos County chooses to implement any clinical or trend management programs intended to drive y ^! higher generic or OTC utilization during the course of the contract. Rebates are paid only upon receipt of a signed contract. Brazos County EXPRESS SCRIPTS' August 29, 2016 6 FVol.77eEq pg„ �sl�� Pricing. Supplement • Under its rebate program, Express Scripts may implement Express Scripts' formulary - management programs and controls, which may include, among other things, cost- containment initiatives and communications with members, participating pharmacies, and/or physicians. Express Scripts reserves the right to modify or replace such ? programs from time to time. Guaranteed rebate amounts, if any, are conditioned on adherence to various formulary management controls, benefit design requirements, claims volume, and other factors stated in the applicable pharmaceutical manufacturer agreements, as communicated by Express Scripts to Brazos County from time to time. I£ any government action, change in law or regulation, change in the interpretation of any law or regulation, or any action by a pharmaceutical manufacturer has an adverse effect on the availability of rebates, then Express Scripts may make an adjustment to the rebate terms and guaranteed rebate amounts, if any, hereunder. • Express Scripts' retail, home delivery, and rebate pricing excludes `specialty drugs. Please see the specialty offering for details. • Rebate allocations will be made quarterly within approximately, 150 days from the - end of the quarter. • The rebate guarantee does not apply to claims processed through staff nmodelthospital pharmacies where such pharmacy is subject to its own manufacturer contracts (rebate or purchase discounts), or through pharmacies that participate in the federal government pharmaceutical purchasing program • In addition, m -submitted claims, subrogation claims, biosimilar products, OTC products, claims older than 180 days, and claims pursuant to.a 100% member copayment plan are also excluded for the purposes of rebate payments. Unless specifically disclosed in the rebate section of this pricing proposal, Manufacturer Administrative Fees are retained by Express Scripts. • The Specialty Pricing offered assumes a.days' supply consistent with the Express Scripts Specialty Pharmacy Clinical Days' Supply Program. • If the Pricing Source discontinues the reporting of AWP or materially changes the manner in which AWP is calculated, then Express Scripts reserves the right to make r an equitable adjustment as necessary to maintain the parties' relative economics and the pricing intent of this Agreement. • For each eligible Brand Drug prescription -drug claim, ingredient cost will be calculated at the lesser of the applicable U&C or AWP discount price in determining the discount achieved for purposes of the guarantee, including 100% member copayment (claims where full cost is paid by member). is • For each eligible Generic Drug prescription -drug claim, ingredient cost will be calculated at the lesser of the applicable U&C, MRA (if applicable), or AWP discount price in determining the discount achieved for purposes of the guarantee, ? including 100% member copayment (claims where full cost is paid by member). • The application of brand or generic/MRA pricing may be subject to certain "dispensed as written" (DAW) protocols and Brazos County -defined plan design and r^ coverage policies for adjudication and member copayment purposes. Brazos County EXPRESS SCRIPTS* August 29, 2016 - 7 vel. hyo �7�, Pricing Supplement • Express Scripts will pay Brazos County the difference attributable to any shortfall between the actual result and the guaranteed result. Any excess achieved in any other guarantee offered pursuant to this Agreement will be used to.make up for, and.offset, a shortfall in the other guarantees. Rebate guarantees are measured in the aggregate and reconciled annually. • , Brazos County will be responsible for any unpaid member copayment or coinsurance amounts, in accordance with Express Scripts' standard credit policy, if payment has not been received from the member within 120 days of dispensing. • To the extent the assumptions are incorrect as of the implementation date of this Agreement, or Brazos County changes its benefit design or formulary during the term of the Agreement, the guarantee will be equitably adjusted if there is a material impact on the generic discount achieved. Brazos County EXPRESS SCRIPTS' August 29, 2016 8 F l. Pg, %(P I Pricing Supplement r Included Services Express Scripts' financial proposal includes.the following services: Customer service for members Electronic/online eligibility submission — Standard coordination of benefits (COB) (reject for primary carrier) Electronic claims processing Plan set-up Software training for access to our online system(s) FSA eligibility needs Electronic Prescribing — Core Services. Pharmacy help desk Pharmacy network management Pharmacy reimbursement Benefit education Prescription delivery — standard 2ennrtinc Web -based client reporting — produced by Express Scripts Web -based client reporting — produced by client Ad hoc desktop parametric reports Claims detail extract file electronic (NCPDP) Load 12 months claims history for clinical reports and reporting _ Annual Strategic Account Plan report Billing reports Inquiry access to claims processing system Client Website — eServlce Delivery (Eligibility, Claims, and Benefit Administration), Coverage Management and Appeals, Eligibility File Transfer, Reporting Solutions and Resources Area. My Rx Choices — Helps members make informed medication choices based on cost, health, and safety. Member website portion only. Express-Scdpts.com for Members — Access to benefit, drug, health, and wellness information; prescription ordering capability; and customer service. Online Benefit Management — eServlce web -based application with Claims History, Eligibility Maintenance, and Prior Authorization Add. Mobile App for Members — Includes My RxChoices, My Medicine Cabinet, Pharmacy Care Alerts, Refills and Renewals, and virtual prescription ID mrd. Brazos CountyMAPA — EXPRESS SCRIPTS°VW August29,2016 9 � - p 'f_ D_pg % i Pricing Supplement Member replacement cards printed via web {t Implementation support New member packets (Includes two standard resin ID Concurrent Drug Utilization Review (DUR) Prior Authorization — Adminisbrative Non -clinical Prior Authorization i • Lost/stolen overrides .; Vacation supplies Brazos County EXPRESS SCRIPTS:• August 29, 2016 10 Vol. _ D pg. Pricing Supplement i Optional PBM Services PBM Services Digital Engagement Program Fees Express Scripts shall provide Brazos County credit per new $4.00 credit per new Member website registration per Member website registration measured as of the effective year. The Credit will be a reduction in the amount date. Brazos County is charged by Express Scripts for prescription drug claims dispensed to Brazos County's Manual Submissions Members. Manual/hardcopy eligibility submission $10.00/update (includes initial entry) Member Submit Fee $3.00/clalm Medicaid Subrogation Claims $3.00/claim Communication with physicians and/or members (e.g., program descriptions, notifications, formulary compliance, non -Medicare EOBs, etc.) $1.35/letter plus postage Medicare Explanation of Benefits (EOB) $1.75/letter plus postage Electronic Medicare Part D E013 Electronic Medicare EOB is an e-mail notification to the $0.95/EOB member informing them at the time of EOB production that their Medicare Part D Explanation of Benefits is available for viewing. Members can opt in/opt out at any time. Electronic ECB includes: • Email notification to the member • Solicitation e-mail sent to registered members • Prominent Web messaging Reporting Custom ad hoc reporting — applies for reporting outside of $150/hour, with a minimum of $500 self services reporting tool Replacement,- Member -requested replacement packets $1.50 + postage per packet Client -requested re -carding $1.50 + postage per packet Communication Fee Smart90 and Mail (EHD, SHD & HDE) Programs $2.50 per employee upon implementation of program (one-time charge) I Cost Exceeds Maximum Express Scripts -Managed Cost Exceeds Maximum (CEM) edit $10,000 CEM limit— included in pricing (For non -compound drugs) Custom CEM limit less than $10,000 - $0.01PMPM fee Express Scripts -Managed Cost Exceeds Maximum (CEM) Included in pricing edit (For compound drugs) Brains County EXPRESS SCRIPTS' August 29, 2016 Pricing Supplement P13M Services Fees Brazos County -Managed Cost Exceeds Maximum (CEM) edit Included in pricing (For non -compound and compound drugs) AppealsReviews and .- Initial Determinations and Level./ Non -urgent UM PMPM charge Appeals under the UM Program. Examples: prior authorization, step therapy, quantity reviews OR $55 per initial determination UM charge Initial Determinations and Level 1 Ndin-urgent $55 per inldal determination* Appeals for benefit reviews. Examples: copay review, plan excluded drug coverage review, administrative plan design review Level 2 and Urgent Appeal Service for UM, formulary, and $10 par Initial determination* benefit reviews - final internal appeals External Reviews - facilitated by'UM company, reviewed by $800 pu review independent review organizations - Initial determination —this Is the first rem" of drug coverage based onthe plan's conditions of coverage. Initial determinations are also referred togas initial reviews, coverage reviews, prior authadzation revlews, UM reviews, or benefit reviews. The Level 2 and Urgent Appeal Service is an optional service for clients to enroll in and there is an Incremental fee of $10perinitial determination, Level 2 and Urgent Appeals are not included In the UM packagefees. The Level 2 and Urgent Appeal Service fee is not charged per appeal. It Is chargedfor each Initial review. This allows the client to better estimate their appeal costs since It Is based on the number of InitialAeterninations. The fees cover the legal and operational costs involved with handling final and binding appeal.reMews, which includes, but is not limited to: staffing of clinical professionals and supportive personnel, notlBcallons to patients and prescribers, and maintaining a process aligned with state and Federal regulations, Charges for the Level 2 and Urgent Appeal Service are billed on the:monthly admin invoice for completed initial determination for UM, formulary, and benefit reviews. No subsequent charges are incurred when cases are appealed. Appeals can be deemed urgent at Level 1 or Level 2. Urgent appeal decisions are ficial and binding. If a Level 1 . Appeal is processed as urgent, there is no Level 2 appeal. initial aetermma ion i his is me determination made In ms nrst review or drug coverage based on me plana conditions of coverage. The initial review decision Is based oft of the information provided by the prescriber (clinical) or the patient (administrative) and me criteria that Is in place. If the Initial review gets denied (adverse benefit determination), then the patient/representative may appeal the decision. Initial determinations are also referred. to as initial reviews, coverage reviews, prior authorization reviews, UM reviews, benefit reviews. Level 1 Appeal Review of an initial denial, and any additional information provided and/or available, to determine if the patient's use of the drug meats the plan's Intent for coverage. When an Initial determination Is a denial (adverse beneflt determinallon); a request for appeal maybe submitted by the member or authorized representative within 180 days from recelot of notice of the Initial adverse benefit determination. available, to, determine if the patients use of the drug meets the plan's Intent for coverage. Whana level 1 appeal has been denied, a request for a level appeal may be submitted by the member or authorized representative within so days from receipt of notice of the level 1 appeal.advarse benefit determination. Brazos County EXPRESS SCRIPTS' August 29, P016 12 t -, .Urgent Appeal External Review Pricing Supplement An urgent appeal may be SODnrlttec It, in, me opinion or me aaerramg prowner, me appllcation.of the time periods for making non -urgent care determinations could seriously jeopardize the We or health of the patient or the patient's ability to regain maximum function, or would subject the patient tosevere pain that cannot be adequately managed without the care or treatment that is the subject of the clalm. Urgent appeals must be submitted by phone or fax. Claims and appeals submitted by mail will not be considered for urgent processing unless.a subsequent phone call or .. .. fax identifies the appeal as urgent. The decision made on an urgent appeal Is final and binding. In the urgent care situation for a level 1 appeal, there is only one level of appeal. :In 2010, Healthcare Reform (also referred to as ACA or PPACA) mandated an 'external review process for non•grandfathered plans. Plans may satisfy that requirement by contracting with at least three Independent review organizations (IROS) accredited by the Utilization Review Accreditation Commission (URAC) for external reviews. External reviews must be rotated at random among the.IROs. To support clients that need to conform to ACA requirements, Express Scripts provides clients with access to external review services through an independent contractor. The independent contractor provides coordination and rotation of external reviews among the required number of URAC-a=edited IROs. Alternatively, clients .may contract directly with IROS or use the Office of Personnel Management (OPM) or: state process if one is available to them. Includes: (1) researching grievances related to the Part D benefit, (Il) mmmunicabng resolution back to'the member, (III) providing oversight reporting servlces to Brazos County, and (iv) providing data required for CMS reporting. RDS enhanced service (Express Scripts sends reports to $1.12 PMPM for Medicare-qualifled members with a CMS on behalf of client) minimum annual fee of $7,500 'RDS standard service (Express Scripts sends reports to $0.62 PMPM:for Medicare -qualified members with a client) minimum annual fee of $5,000 Notice of Creditable Coverage $1.35/letter +. postage Calculation of member months is:determined by Express Scripts by reference to the eligibility files. Brazos County EXPRESS SCRIPTS:' August 28; 2016 13 Vol 1• o 61 I 4_ M Y r Pricing Supplement Comprehensive Consumer Directed Health (CDH) Solution . Services • Technical Bi-directional data exchange; dedicated operations; 24 -hour -a -day, seven -day -a -week monitoring and quality control; performance reporting; and analytics • Decision Support Dedicated CDH member services, Prescription Benefit Review Statements, Retail Pricing Transparency • Member Adherence ScreenRx Preventive Medications • Member Education Proactive, personalized member communicators open enrollment tools and member communications library, robust online features, and preventive care proactive, personalized member communications Advanced Data Integration, Member Decision Support, Member Adherence and Member Education $0.48 PMPM Combined Benefit Management $0.10 PMPM per combined accumulator up to maximum Services to manage combined medical -pharmacy of $0.20 PMPM for existing connection with medical benefits that are not a consumer -directed health (CDH) carrier or TPA. plan. Services Include ongoing management of the data Fees to establish connection with new medical carrier or exchange platform with the medical vendor/TPA, TPA are quoted upon request. production monitoring and quality control, and designated operations team. Combined benefit types :may Include deductible, out of pocket, spending account, and lifetime maximum. These charges would be in addition to any pricing adjustments It greater than 10 percent or erazos Ciountys total utilization for all Plans is attributable to a CDHC..: Additional services will be quoted upon request, Postage charges are not Included and will be billed to Brazos County. Brazos County EXPRESS SCRIPTS' August 29, 2016 14 Pricing Supplement Optional Clinical Programs 2016 Health Choices and Drug Choices Express Scripts offers a comprehensive suite of health solutions. These offerings may change or be discontinued from time to time as our offering is updated to meet the clinical needs of our clients and the changing marketplace. Guided by the insights of Health Decision SciencesM, our proprietary platform for delivering better decisions that drive healthier outcomes, Express Scripts provides the most comprehensive set of base solutions in the industry, with advanced options for even greater care and cost control. Medicare and Medicaid clients may not be eligible for all programs listed based on state and federal guidelines. Health Choices Fees Concurrent DUR . No charge (included in base offering) Screen Rx $0.25 PMPM ExpressApiance Web Access, Priced on request (Less than 8,000 lives) Web Access: 10.04 PMPM (8.000 lives minimum Secure, online access to real-time, patient eligibility, medication history, clinical gaps in care, and potential savings opportunities Advantage: $0,10 PMPM (15.000 life minimum) Same as Web Access, plus high-value, flexible targeting options at population level with prioritized recommendations based on clinical severity, and continuous program monitoring and reporting Advantage Plus: 50.15 PMPM (15.000 life minimum) All of the above, plus enhanced specialist pharmacist services for nurses, including weekly case screenings, educational services, and grand round case reviews Just Diagnosed (New to theraov) data feed: 15.000 set up and $500 per month Single sign on: Client specific priced upon request RationalMed Client specific, priced upon request (5,000 life minimum) Personal Medication Coach Client specific, priced upon request Brazos County 10 EXPRESS SCRIPTS* August 29, 2016 16 Fc), oS o PCS Pricing Supplement Health Choices Fees Pharmacogenomics 2C9/ VKORC1 Warfarin Testing: $450 per completed test 2019 Clopidogrel (Plavix) Testing: $480 per completed test HLA-B*5701 AbacavlrTesting: $625 per completed test CCR5 Maraviroc (Selzentry) Testing: $2,800 per completed test BCR -ABL Gleevec, Sprycel, Tasigna Testing: $660 per completed test Entire Pharmacogenomic Portfolio: $0.04 PMPM Basic Retrospective OUR $0.05 PMPM Advanced Retrospective DUR: Includes all $0.10 PMPM rule categories within the Basic Module plus expanded rule sets. Seniors Retrospective DUR: Health and $0.04 PMPM safety drug Issues for members 65+ years of age. Retrospective Bundle: Advanced and Senior $0.11 PMPM Modules Physician Report Card— Mailed Profiles Fixed Quarterly Fee: $1,350 per quarter Only Cost per package mailed -enrolled: 1-4 pages: $3.00 per package 5-8 pages: $4.00 per package 9-12 pages: $5.00 per package 12-14 pages: $5.50 per package Physician Consultation Phone based consultation: $100 per consulted physician/provider Face-to-face consultation: Client specific upon request Blood Glucose Meter No charge Formulary Notification No charge for standard Drug Conversion Program at Home Delivery No charge (included in base offering) My RxChoices No charge (Included In base offering) My RxChoices Plus $0.01 PMPM .Copay Waiver for.Generics $1,000 set up or $1:25/letter AND client funds waiver �feGuerdRx Cholesterol Care Value (CCV)Program: No charge Hepatitis Cure Value (HCV) Program: No charge Oncology Care Value (OCV)Program: No charge Brazos County.EXPRESS SCRIPTS' August 29, 2016 16 1!�� 1177O Pricing Supplement Commercial 30,000499,999 lives: $0.05 PMPM 12,000 - 29,999 lives: $0.07 PMPM :512,000 lives: $10,000 annual fee :512,000 lives: $4,000 annual fee (no quarterly' consultations/reports; otherwise the same as $10,000 option) >_500,000 lives: custom pricing applies Fraud, Waste, & Abuse Medicaid 30,000-499,999 lives: $0.05 PMPM 12,000 - 29,999 lives: $0.07 PMPM :512,000 lives: $10,000 annual fee :512,000 lives: $4,000 annual fee (no quarterly consultations/reports; otherwise the same as $10,000 option) Medicare Part D $0.04 per claim Enhanced Pharmacy Audit Program Value Based Insurance Design (VBID) 0 EXPRESS SCRIPTS' r Option 1: $0.03/claim If the amount of recoveries for Client made through the Enhanced Pharmacy Audit Services, measured on an annual aggregate basis ("Total Recoveries), are less than the total amount of fees paid by the Client for the Enhanced Pharmacy Audit Services (measured on an annual aggregate basis) ("Total Fees"), Express Scripts will reimburse Client in an amount equal to.the difference between the Total Fees and the Total r Recoveries. Option 2: $0.04/claim For the clients that are not eligible for the ROI guarantee, but that have greater than 500,000 lives Option 3: $0.06/clalm For the clients that are not eligible for the ROI guarantee and have under 500,000 lives — Members enrolled using automated file Standard file layout/clinical rules Install set up: $15,000 per vendor or vendor change Maintenance: $500 per month ($760/month If quarterly eligibility reporting is requested) Standard file layout/custom rules: Client specific, priced upon request Eligibility Reporting: $1,000 per adhoc report Manual set up Standard Clinical Rules Install set up: $5,000 per vendor or vendor change Maintenance: $500 per month ($750/month If quarterly. eligibility reporting is requested) Custom Rules: Client specific, priced upon request Eligibility Reporting: $1,000 per adhoc report _ Brazos County August 29, 2016 17 r EXPRESS SCRIPTS• Pricing Supplement Brazos County 4gust 29, 2016 18 Vol. Pricing Supplement ProgramsDrug Choice I Drug Choice Programs - UM Packages Our UM Package building-block approach aggregates medications Into lists and packages L/mlted UM Package- delivers plan savings with minimal member Impact : Advantage UM Package- same as Limited, adding chronic disease states and a broad specialty offering Advantage Plus UM Package- same as Advantage, adding undermanaged medication classes for select chronic diseases UnUmited UM Option- allows Implementation of any current and/or futureUM program Lists can be purchased individually and packages can be tallored to meet client needs. Some modules are available on an ala carte basis. specificClient .. . Limited UM Package $0.32 PMPM $1.28 PMPM Prior Authorization Limited Prior Authorization List $0.06 PMPM $0.18 PMPM ! Proactive Prior Authorization List $0.05 PMPM N/A Dru99uantity Management Limited, Drug Quantity Management List $0.10 PMPM $0.30 PMPM Step Therapv Limited Step Therapy List $0.20 PMPM $0.60 PMPM Expendable List $0.02 PMPM N/A 7 Advantage UM Package $0.80 PMPM $3.20 PMPM Everything in the Limited UM Package Plus: Prior Authorization r Advantage Prior Authorization List $0.20 PMPM $0.60 PMPM Nonessential Therapy Prior Authorizatior ist $0.10 PMPM $0.30 PMPM Drug Ouantlty Management Advantage Drug Quantity Management List $0.10 PMPM $0.30 PMPM Step Theraov . Preferred Specialty Management $0.12 PMPM N/A Advantage Step Therapy List $0.06 PMPM $0.18 PMPM , Advantage Plus UM Package $1.20 PMPM $4.80 PMPM Everything In the Advantage UM Package Plus: Prior Authorization _ +` Advantage Plus Prior Authorization List $0.06 PMPM $0.18 PMPM Pharmacogenomics Prior Authorization List $0.10 PMPM N/A j Oncology Package . $0.15 PMPM N/A 4 Drug Quantity Management Advantage Plus Drug Quantity Management $0.03 PMPM $0.09 PMPM List Step Theraov - .Advantage Plus Step Therapy List $0.06 PMPM $0.18 PMPM i Brews County EXPRESS SCRIPTS° August 29, 2016 r 19 I V_ 'n Pg.. Pricing Supplement Unlimited UM Option $1.45 PMPM N/A Everything inthe Advantage Plus UM Package .Plus: Prior Authorization Adjunctive Sperlalty PA List $0.05 PMPM N/A Optional Prior Authorization $0.04 PMPM N/A Step Theraov Optional Step. Therapy Modules Varies by individual module N/A Guarantees (packages only): <1,000 lives — no guarantee, 1,0017 2,500 —1:1 guarantee, 2,501 —*5,000 — 2:1 guarantee, >5,000 lives 4:1 guarantee. Note: Closed formulary or 100% tier 3 mpay clients do not qualify for guarantees Guarantees (lists) apply to clients with 10,000+ lives. Unlimited option fee allows clients to Implement any available UM program over the life of their contract Individual list guarantees still apply for clients with 10,000+ lives. If client chooses Unlimited option and Implements all elements of the Advantage Plus Package, The Advantage Plus guarantee applies. Please note: Prior Authorization must be implemented without Grandfathering to receive guarantee. Some programs may Impact rebates. Brazos County EXPRESS SCRIPTS:° August 29, 2016 �•� 20 ' / Pricing Supplement Optional Pharmacy Vaccination Program Q In an effort to broaden the reach of vaccinations for flu and other. diseases, Express = Scripts offers a retail pharmacy vaccination program for our plan sponsors. Through this program, vaccines are more convenient and less expensive than physician office visits. Vaccinations are important to the maintenance of a healthy workforce and can lead to lower medical costs and less absenteeism due to illness. Each state has different regulations regarding what vaccines a pharmacist can administer, age restrictions, etc., but certified pharmacists can now administer influenza vaccines in all 50 states. Members are encouraged to contact their local pharmacy to verify the current vaccination schedule, availability, and any age restrictions. r The vaccinations shall adjudicate at the lower of - (i) according to the billing frequency set forth in the Agreement. This Vaccine Program Fee will apply to any vaccine claims, whether at contracted rates or UBC, and is in addition to any per prescription drug claim administrative fee set forth in the Agreement. No vaccine claims will be included in any guarantees set forth in the Agreement and/or amendments thereto. or (ii) the combined ingredient cost, dispensing fee (if any) and professional service fee (if any) that the participating pharmacy generally charges an. individual paying cash, without coverage for prescription drug benefits, plus the .Vaccine Program Fee set forth above. Brazos County EXPRESS SCRIPTS- i August 29, 2016 Participating Pharmacy Participating Pharmacy INFLUENZA Participating Pharmacy Ingredient Cost as set OTHER Participating Pharmacy Ingredient Ingredient Cost + forth in the Agreement Cost as set forth in the Agreement Dispensing Fee Participating Pharmacy Dispensing Fee as set Participating Pharmacy Dispensing + forth In the Agreement Fee as set forth in the Agreement Professional Service Fee Pass-through Passthrough (PSF); cost for (capped at $15 per . (capped at $20 per vaccine claim) pharmacist to vaccine claim) administer the vaccine Vaccine Program Fee* 11 $2.50 $2.50 per vaccine claim per vaccine claim ' The Vaccine Prooram Fee wlil be billed separately to Brazos Countv as Dart of the administrative Involoe according to the billing frequency set forth in the Agreement. This Vaccine Program Fee will apply to any vaccine claims, whether at contracted rates or UBC, and is in addition to any per prescription drug claim administrative fee set forth in the Agreement. No vaccine claims will be included in any guarantees set forth in the Agreement and/or amendments thereto. or (ii) the combined ingredient cost, dispensing fee (if any) and professional service fee (if any) that the participating pharmacy generally charges an. individual paying cash, without coverage for prescription drug benefits, plus the .Vaccine Program Fee set forth above. Brazos County EXPRESS SCRIPTS- i August 29, 2016 T Pricing Supplement Billing and Payment Wire Transfer Payments must be transferred within two days of receipt of Express Scripts' invoice/billing statement. Automated Clearing Payments must be made within two days of receipt of Express Scripts' House (ACH) invoicelbilling statement. Pre4uthorized Debit Funds must be available In Brazos County's bank account within 48 Transaction hours of receipt of Express Scripts' Involoe/billing statement. Each client is subject to a standard credit evaluation — Brazos County EXPRESS SCRIPTS:• - —/wgust-�S; 20� 22 P9.- .r I Pricing. Supplement Financial Disclosure to Express Scripts PBM.Clients This disclosure provides an overview of the principal revenue sources of Express Scripts, Inc. and Medco Health. Solutions, Inc. (individually and collectively referred to herein as r- "ESr'), as well as ESI's affiliates. In addition to administrative and dispensing fees paid to ESI by our clients for pharmaceutical benefit management ("PBM'J services, ESI and its affiliates derive revenue from other sources, including arrangements with pharmaceutical manufacturers, wholesale distributors, and retail phartriacies. Some of Us revenue relates to utilization of prescription drugs :by members of the clients receiving PBM services. ESI may pass through certain manufacturer payments to its clients or may retain those payments for itself, depending on the contract terms between ESI and the client. Network Pharmacies — ESI contracts for its own account with retail pharmacies to dispense prescription drugs to client members. Rates paid by ESI to these pharmacies may differ among networks (e.g., Medicare, Worker's Comp, open and limited), and ! among pharmacies within a network, and by client arrangements. PBM agreements generally provide that a client pays ESI an ingredient cost, plus dispensing fee, for drug claims. If the rate paid by a client exceeds the rate contracted with a particular pharmacy, ESI will realize a positive margin on the applicable claim. The reverse also may be true, resulting in negative margin for ESI. ESI also enters into pass-through arrangements where the client pays ESI the actual ingredient cost and dispensing fee amount paid by ESI for the particular claim when the claim is adjudicated to the pharmacy. In addition, when ESI receives payment from a client before payment to a pharmacy, ESI retains the r benefit of the use of the funds between these payments. ESI may maintain non -client specific aggregate guarantees with pharmacies and may realize positive margin. ESI may charge pharmacies standard transaction fees to access ESI's pharmacy claims systems _ and for other related administrative purposes. Brand/Generic Classifications — Prescription drugs may be classified as either a "brand" or "generic;" however, the reference to a drug by its chemical name does not necessarily mean that the product is recognized as a generic for adjudication, pricing or copay purposes. For the purposes of pharmacy reimbursement; ESI distinguishes brands and generics through a proprietary algorithm ("BGA") that uses certain published elements provided by First DataBank (FDB) including price indicators, Generic Indicator, Generic Manufacturer Indicator, Generic Name Drug Indicator; Innovator, Drug Class and ANDA. The BGA uses these data elements in a hierarchical process to categorize the products as brand or generic. The BGA also has processes to resolve discrepancies and prevent "flipping" between brand and generic status due to price fluctuations and marketplace availability changes. The elements listed above and sources are subject to change based on the availability of the specific fields. Updated summaries of the BGA are available upon request. Brand or generic classification for client reimbursement purposes is either based on the BGA or specific code indicators from Medi -Span or a combination of the two as reflected in the client's specific contract terms. Application of an alternative methodology based on specific client contract terms does not affect ESI's application of its BGA for ESI's other contracts. Brazos County EXPRESS SCRIPTS® August 29, 2016 23 � . Voi. 02 0. Pg� a, L -- �i Pricing. Supplement EXPRESS SCRIPTS' Brazos County August 29, 2016 24 q_ of _. lug,_ ��. Maximum Allowable Cost ("MAC'1/Maximum Reimbursement Amount ("MRA")— As part of the administration of the PBM services, ESI maintains a MAC List of drug products identified as requiring pricing management due to the number of manufacturers, utilization and/or pricing volatility. The criteria for inclusion on the MAC List are based on whether the drug has readily available generic product(s), is generally equivalent to a — brand drug, is cleared of any negative clinical implications, and has a cost basis that will allow for pricing below brand rates. ESI also maintains MRA price lists for drug �. products on the MAC List based on current price reference data provided by Medi -Span _ or other nationally recognized pricing source, market pricing and availability information from generic manufacturers and on-line research of national wholesale drug company files, and client arrangements. Similar to the BGA, the elements listed above and sources are subject to change based on the availability of the specific fields. Updated summaries of the MAC methodology are available upon request. C Manufacturer Programs Formulary Rebates: Associated Administrative Fees. and PBM Service Fees — ESI contracts for its own account to obtain formulary rebates attributable to the utilization of certain brand drugs and supplies (and possibly certain authorized l generics marketed under a brand manufacturer's new drug application). Formulary rebate amounts received vary based on client specific utilization, the volume of utilization as well as formulary position applicable to the drug or supplies, and -adherence to various formulary management controls, benefit design requirements, claims volume, and other similar factors, and in certain instances also may vary based on the product's market -share. ESI often pays an amount equal to all or a portion of the formulary rebates it receives to a client based on the client's PBM agreement terms. ESI or its affiliates may maintain non -client specific aggregate guarantees and may realize positive margin. In addition, ESI provides administrative services to contracted manufacturers, which include, for example, maintenance and operation of systems and other infrastructure necessary for invoicing and processing rebates, pharmacy discount programs, access to ' dmg'utilization data, as allowed by law, for purposes of verifying and evaluating ; applicable payments, and for other purposes related to the manufacturer's products.. ESI receives administrative fees from the participating manufacturers for these services. These administrative fees are calculated based on the price of the drug or supplies along with the volume of utilization and do not exceed the greater of (i) 4.58% of the average ! wholesale price, or (ii) 5.5% of the wholesale acquisition cost of the products.. In its capacity as a PBM company, ESI also may receive other compensation from manufacturers for the performance of various programs or services, including, for example, formulary compliance initiatives,clinical services, therapy }management services, education services, inflation protection programs, medical benefit management services, cost containment programs, discount programs, and the sale of noir-patient r .. identifiable claim information. This compensation is not part of the formulary rebates or associated administrative fees, and ESI may realize positive margin between amounts paid to clients and amounts received from pharmaceutical manufacturers. ESI retains the financial benefit of the use of any funds held until payment is made to the client. Copies of ESL's standard formularies may be reviewed at www.express- scripts.com/wpslportaU. In addition to formulary considerations, other plan design elements are described in ESI's Plan Design Review Guide, which may be reviewed at ` www.express-smpts.com/wps/portal/. EXPRESS SCRIPTS' Brazos County August 29, 2016 24 q_ of _. lug,_ ��. Pricing Supplement ESI Subsidiary Pharmacies — ESI has several licensed pharmacy subsidiaries, including our specialty pharmacies. These entities may maintain product purchase discount arrangements and/or fee-for-service arrangements with pharmaceutical manufacturers, . wholesale distributors, and other health care providers. These subsidiary pharmacies contract for these arrangements on their own account in support of their various pharmacy operations. Many of these subsidiary arrangements relate to services provided outside of PBM arrangements, and may be entered into irrespective of whether the particular drug is on one of ESI's national formularies. Discounts and fee-for-service I payments received by ESI's subsidiary pharmacies are not part of the PBM formulary rebates or associated administrative fees paid to ESI in connection with ESI's PBM formulary rebate programs. However, certain purchase discounts received by ESI's subsidiary pharmacies, whether directly or through ESI, may be considered for formulary purposes if the value of such purchase discounts is used by ESI to supplement the discount on the ingredient cost of the drug to the client based on the client's PBM agreement terms. From time to time, ESI and its affiliates also may pursue.and maintain for its own account other supply chain sourcing relationships not described below as beneficial to maximize ESI's drug purchasing capabilities and efficiencies, and ESI or r affiliates may realize an overall positive margin with regard to these initiatives. The following provides additional information regarding examples of ESI subsidiary discount arrangements and fee-for-service arrangements with pharmaceutical manufacturers, and wholesale distributors: ESI Subsidiary Pharmacy Discount Arrangements = ESI subsidiary pharmacies purchase prescription drug inventories, either from manufacturers or wholesalers, for dispensing to patients. Often, purchase discounts off the acquisition cost of these products are made available by manufacturers and wholesalers in the form of either up -front discounts or retrospective discounts. These purchase discounts, j obtained through separatepurchase contracts, are not formulary rebates paid in connection with our PBM formulary rebate programs. Drug purchase discounts are based on a pharmacy's inventory needs and, at times, the performance of related patient care services and other performance requirements. When a subsidiary pharmacy dispenses a product from its inventory, the.purchase price paid for the dispensed product, including applicable dispensing fees, may be greater or less than that pharmacy's acquisition cost for the product net of purchase discounts. In general, our pharmacies realize an'overall positive margin between the net acquisition cost and the amounts paid for the dispensed drugs. iJ Brazos County EXPRESS SCRIPTS' August 29, 2016 -' Pricing Supplement ESI Subsidiary Fee -For -Service Arrangements — One or more of ESI's subsidiaries, including, but not limited to, its subsidiary pharmacies also may receive fee-for-service.payments from manufacturers, wholesalers, or other health care providers in conjunction with various programs or services, including, for example, patient assistance programs for indigent patients, dispensing prescription medications to patients enrolled in clinical trials, various therapy adherence and fertility programs, administering FDA compliance requirements related to the drug, 340B contract pharmacy services, product reimbursement support services, and various other clinical or pharmacy programs or services. As a condition to having access to certain products, and sometimes related to certain therapy adherence criteria or FDA requirements, a pharmaceutical manufacturer may require a pharmacy to report selected information to the manufacturer regarding the pharmacy's service levels and other dispensing -related data with respect to patients who receive that manufacturer's product. A portion of the discounts or other fee-for-service payments made available to our pharmacies may represent compensation for such reporting. t Other Manufacturer Arrangements — ESI also maintains other lines of business that may involve discount and service fee relationships with pharmaceutical manufacturers and wholesale distributors. Examples of these businesses include a r wholesale distribution business, group purchasing organizations (and related group purchasing organization fees), a medical benefit management company, and United BioSouroe Corporation ("UBC'. Compensation derived through these business - arrangements is not considered for PBM formulary placement, and is in addition to other amounts described herein. Of particular note, UBC partners with life sciences and pharmaceutical companies to develop, commercialize, and support safe, effective use and access to pharmaceutical products. UBC maintains a team of research scientists, biomedical experts, research operations professionals, technologists and clinicians who work with clients to conduct and support clinical trials, create, and validate and administer pre and post product safety and risk management programs. UBC also works on behalf of pharmaceutical manufacturers to provide product and disease state education programs, reimbursement assistance, and other support services to the public at large. These r service fees are not part of the formulary rebates or associated administrative fees. Third Parry Data Sales — Consistent with any client contract limitations, ESI or its affiliates may sell HIPAA compliant information maintained in their capacity as a PBM,.pharmacy, or otherwise to data aggregators, manufacturers, or other third parties on a fee-for-service basis or as a condition of discount eligibility. All such activities are conducted in compliance with applicable patient and pharmacy privacy laws and client contract restrictions. r� i ,i Brazos County EXPRESS SCRIPTS° August 29, 2016 26 Pricing Supplement October 1, 2015 EXPRESS SCRIPTS' Brazos County August 29, 2016 V F�—fo I - T p 9 �-� - 5— L� �! Pricing Supplement Express Scripts Manufacturer Payment Disctosure For the last publicly reported fiscal year (2015), Express Scripts Total Product Revenue I— exceeded $101,751,800,000 (rounded to the nearest million).. For the same reporting period, Express Scripts Total Manufacturer Payments equaled $13,593,003,742. Of that total, approximately 83% was attributable to Manufacturer Formulary Payments and approximately 17% was attributable to Manufacturer Additional Payments. Express Scripts reports this information on a quarterly and annual basis to clients that receive amounts through their contracted PBM arrangement with Express Scripts attributable to formulary rebates earned by Express Scripts. Express Scripts'tptal net revenue, which consists principally of sales of prescription drugs to clients, either through Express Scripts' network of contracted retail pharmacies or through Express Scripts' mail order pharmacies. All compensation or remuneration earned by'Express Scripts from 1' pharmaceutical manufacturers, Including, but not limited to, rebates, IJ regardless of how characterized, and administrative or management fees. Manufacturer payments earned by Express Scripts that are in return for or part of formulary placement, or that are characterized as "formulary" or "base" rebates, divided by Express Scripts Total Manufacturer Payments. i Percentage , All manufacturer payments earned other than "formulary" or "base" rebates, _Manufacturer divided by Express Scripts Total Manufacturer Payments. Paymentsthat arer Manufacturer i T 1. r 1. Brazos County EXPRESS SCRIPTS* August 29, 2016 Pricing Supplement Appendix A Please find our Specialty Ustattached "Per Diem" The Specialty Drugs designated above incur an:additional charge to cover costs of all supplies, equipment (e.g., pumps), and clinical monitoring required to administer the Specialty Drugs. TherapeuticBilling All .- Code S9338 $65.00 / Infusion Immun Immune Deficiency Metabolic Disorder All S9357 $65.00 / Infusion PAH Flolan, Veletrl and Remodulin S9347 $65.00 / Day PAH Epoprostenol Sodium (Generic S9347 $65.00 / Day Flolan) PAH Ventavis 59379 $65.00 / Day PAH Tyvaso 59061 $30.00/ Day Pulmonary All 59346 $55.00 / Infusion $150.00 per initial visit up Nursing Rates All drugs/therapies requiring 99601 to two(2) hours/$75.00 nursing 99602 per additional hour or a fraction thereof EXPRESS SCRIPTS' Brazos County August 29, 2016 29 E01 — i The foregoing minutes of the Commissioners Court Workshop Session held September 8, 2016, have, _b_een_ examined and are approved in open Court this the 1�' day of Vh�jY , 2016, in Bryan, Brazos County, Texas. Duane Peters Lloyd W sermann County Judge Commissioner, Precinct 1 S�kimy Caul ria Kenny Mallard Commissioner, Precinct 2 Commissioner, Precinct 3 Commissioner, Precinct 4 Attest: Karen'McQueen— County Clerk Vol, :Ii�—O- Pg. '12 J� r COMMISSIONERS COURT MEETING Date and Time Name Ll kle, QCs XAA zT r Ni not Mem n --s weMa _ ... /�, /,//)/z/cq Leo q1,00 awl Organization / Department -&)tvw. ecaa— lu,ectl. & Wz )Vel 67yel. L d<G/ILjt �727/vy 6M M. �S� M5 -T- / -- --__« a _P ge vol. ,— _ `7�. �-) Pct. 7 �y I of