240028-CONTRACT- UNITED HEALTHCARE SERVICES.PDF
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CONTRACT ADMIN SERVICES FOR SELF-INSURED
MEDICAL & RX BENEFITS 240028-ITN
This contract is entered into this 26th day of June, 2024 by and between Maricopa County (“County”), a
political subdivision of the State of Arizona, and United HealthCare Services, Inc., a Connecticut corporation
(“Contractor”), for the purchase of administrative services for the Maricopa County Self-Insured Benefits
Plan that offer medical, prescription, and behavioral health benefits up to approximately 13,000 employees
and their eligible dependents. Services under this contract will include, but not be limited to claims
processing, provider network access services, chronic disease management, cost management strategies,
screening and preventive care, clinical care programs, member services, point solutions, strategic planning
and consultative services, and reporting and analytics.
1.0
CONTRACT TERM
This contract is for a term of five years, beginning on the 1st day of January 2025 and ending the
31st day of December 2029.
2.0
OPTION TO RENEW
The County may, at its option and with the concurrence of the Contractor, renew the term of this
contract up to a maximum of five additional years, (or at the County’s sole discretion, extend the
contract on a month-to-month basis for a maximum of six months after expiration). The Contractor
shall be notified in writing by the Office of Procurement Services of the County’s intention to renew
the contract term at least 60 calendar days prior to the expiration of the original contract term.
3.0
CONTRACT COMPLETION
In preparation for contract completion, the Contractor shall make all reasonable efforts for an
orderly transition of its duties and responsibilities to another provider and/or to the County. This
may include, but is not limited to, preparation of a transition plan and cooperation with the County
or other providers in the transition. The transition includes the transfer of all records and other data
in the possession, custody, or control of the Contractor that are required to be provided to the
County either by the terms of this agreement or as a matter of law. The provisions of this clause
shall survive the expiration or termination of this agreement.
4.0
PRICE ADJUSTMENTS
Any requests for reasonable price adjustments must be submitted 180 calendar days prior to
contract expiration for subsequent agreement periods for which the County elects to renew beyond
the initial term of five years. The reasonableness of the request will be determined by comparing
the request with the Consumer Price Index or by performing a market survey. Any such service fee
change will become effective the first day of the new term. Contractor will provide the County with
a new Exhibit A that will replace the existing Exhibit A for the successor term. If County agrees to
the adjusted price terms, County shall issue written approval of the change and provide an updated
version of the contract. The new change shall not be in effect until the date stipulated on the
updated version of the contract.
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Contractor may also request for a change to services fees with 60 days’ notice (i) any time there
are changes made to this Contract or the Plan, which affect the fees, (ii) when there are changes
in laws or regulations which affect the services Contractor is providing, or will be required to provide,
under this Contract, (iii) if the number of employees covered by the Plan or any Plan option changes
by 15% or more, or (iv) if the average contract size, defined as the total number of enrolled
Participants divided by the total number of enrolled employees, varies by 15% or more from the
assumed average contract size of 2.28. Any new service fee required by such change will be
effective as of the date the changes occur.
5.0
PAYMENTS
5.1
As consideration for performance of the duties described herein, County shall pay
Contractor the sums stated in Exhibit A.
5.2
Monthly enrollment for billing purposes will be measured based on the enrolled population
on the first day of the month.
5.3
Payment shall be made within 30 days of the County’s receipt of a properly completed
invoice or 30 days from the first day of the month for which it is due, whichever is later.
5.4
INVOICES
5.4.1
The Contractor shall submit one legible copy of their detailed invoice before
payment(s) will be made. Incomplete invoices will not be processed. At a minimum,
the invoice must provide the following information:
•
Company name, address, and contact information
•
Remittance name, address, Tax ID and contact information if different from
the Company name and information
•
County bill-to name and contact information
•
Contract serial number
•
County purchase order number
•
Project name and/or number
•
Invoice number and date
•
Payment terms
•
Date of service or delivery
•
Quantity
•
Contract item number(s)
•
Description of purchase (product or services)
•
Pricing per unit of purchase
•
Total amount due
5.4.2
Payments for claims should be made via the contractor’s Imprest or clearing bank
account which initially covers the payment of the claim to the provider, and then
through ACH pull that replenishes the Imprest or clearing account daily with a
sweep from the County’s bank account. Electronic claims details that match the
ACH pull will be available to the County on a daily and monthly basis. This is more
fully defined in Exhibit B-Scope of Work (Administrative Services Agreement),
Section 7
5.4.3
Problems regarding billing or invoicing shall be directed to the department as listed
on the purchase order.
5.4.4
Payment for administrative service fees or non-claim invoices shall only be made
to the Contractor by Accounts Payable through the Maricopa County Vendor
Express Payment Program. This is an Electronic Funds Transfer (EFT) process.
After Contract Award the Contractor shall complete the Vendor Registration Form
located on the County Department of Finance Vendor Registration Web Site
(https://www.maricopa.gov/5169/Vendor-Information).
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5.4.5
Discounts offered in the contract shall be calculated based on the date a properly
completed invoice is received by the County.
5.4.6
EFT payments to the routing and account numbers designated by the Contractor
shall include the details on the specific invoices that the payment covers. The
Contractor is required to discuss remittance delivery capabilities with their
designated financial institution for access to those details.
6.0
APPLICABLE TAXES
6.1
It is the responsibility of the Contractor to determine any and all applicable taxes and
include those taxes in their proposal. The legal liability to remit the tax is on the entity
conducting business in Arizona. Tax is not a determining factor in contract award.
6.2
The County will look at the price or offer submitted and will not deduct, add, or alter pricing
based on speculation or application of any taxes, nor will the County provide Contractor
any advice or guidance regarding taxes. If you have questions regarding your tax liability,
seek advice from a tax professional prior to submitting your bid. You may also find
information at https://www.azdor.gov/Business.aspx. Once your bid is submitted, the offer
is valid for the time specified in this solicitation, regardless of mistake or omission of tax
liability. If the County finds overpayment of a project due to tax consideration that was not
due, the Contractor will be liable to the County for that amount, and by contracting with the
County agrees to remit any overpayments back to the County for miscalculations on taxes
included in a bid price.
6.3
Tax Indemnification: Contractor and all subcontractors shall pay all Federal, State, and
local taxes applicable to their operation and any persons employed by the Contractor.
Contractor shall, and require all subcontractors to, hold Maricopa County harmless from
any responsibility for taxes, damages, and interest, if applicable, contributions required
under Federal and/or State and local laws and regulations, and any other costs including:
transaction privilege taxes, unemployment compensation insurance, Social Security, and
workers’ compensation. Contractor may be required to establish, to the satisfaction of
County, that any and all fees and taxes due to municipality or the State of Arizona for any
license or transaction privilege taxes, use taxes, or similar excise taxes are currently paid
(except for matters under legal protest).
7.0
AVAILABILITY OF FUNDS
7.1
The provisions of this contract relating to payment for services shall become effective when
funds assigned for the purpose of compensating the Contractor as herein provided are
available to County for disbursement. The County shall be the sole judge and authority in
determining the availability of funds under this contract. County shall keep the Contractor
fully informed as to the availability of funds.
7.2
If any action is taken by, any State agency, Federal department, or any other agency or
instrumentality to suspend, decrease, or terminate its fiscal obligations under, or in
connection with, this contract, County may amend, suspend, decrease, or terminate its
obligations under, or in connection with, this contract. In the event of termination, County
shall be liable for payment only for services rendered prior to the effective date of the
termination, provided that such services are performed in accordance with the provisions
of this contract. County shall give written notice of the effective date of any suspension,
amendment, or termination under this section, at least 10 days in advance.
8.0
POST AWARD MEETING
The contractor may be required to attend a post-award meeting with the department to discuss the
terms and conditions of this contract. This meeting will be coordinated by the procurement officer of
the contract.
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9.0
DUTIES
9.1
The Contractor shall perform all duties stated in the contract, including Exhibit B – Scope
of Work, Exhibit B-1 Services, B-2 Health Savings Account Enrollment and Contribution,
or as otherwise directed in writing by the procurement officer.
9.2
REQUIRED SERVICES
9.1.1
General Services
9.1.1.1
Contractor shall provide administrative services only (ASO) for medical,
behavioral health, pharmacy benefit manager (PBM), and health
savings account (HSA) services. Such services shall include, but not be
limited to strategic planning and consultative services, claims
processing, network access services, chronic disease management,
cost management strategies, screening and preventive care, clinical
care programs, wellness programs (integrated with County’s existing
employee wellness program), member services including advocacy and
navigation, and reporting and analytics, point solutions and coordination
with other county vendors (e.g., benefits consultant, employee wellness
program).
9.1.1.2
Contractor shall coordinate case management and care navigation
services as needed so that the right resources are available to treat
participants holistically, including those with a mental health and/or
substance use diagnosis.
9.1.1.3
Contractor shall provide 24/7, HIPAA and ADA compliant, secure
access to an online participant portal for activities such as benefits
overview, claims review and submission, account monitoring,
searchable provider directory, pricing tool for procedures and
medications, access to print and/or request physical ID cards (mailed to
the participant at no charge).
9.1.1.3.1
Contractor’s participant portal shall be accessible and
usable for mobile access.
9.1.1.4
Contractor shall provide a plan sponsor portal to monitor eligibility,
claims, reporting, etc.
9.1.1.5
Contractor shall coordinate with the County’s third-party Wellness
contractor that provides tools, activities, and support to employees to
help them maintain healthy behaviors. To integrate with the County’s
wellness plan, contractor shall:
9.1.1.5.1
Provide monthly claims files to wellness vendor to assist
with tracking participant preventive screenings.
9.1.1.5.2
Establish single sign on functionality with the County’s
contracted Wellness provider or include access to the
Wellness site from the contractor’s participant portal.
9.1.1.5.3
Provide 24/7 unlimited participant access to telephonic
coaching for healthy living, suicide prevention, chronic
conditions, and preventive activities through the third-party
wellness contractor.
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9.1.1.5.4
Provide consultation and annual recommendations of
activities that encourage healthy behaviors and that can be
tracked and incentivized through the third-party Wellness
contractor.
9.1.2
Plan Design and Strategic Planning
9.1.2.1
In collaboration and/or consultation with the County’s benefit consulting
firm, contractor shall provide ongoing strategic planning and consultative
services to the County’s benefits management staff at various times
during the year, including upon implementation, during the annual
renewal, and periodically to address various topics.
9.1.2.2
Topics include, but are not limited to, plan design, implementation,
network management, formulary management, claims processing,
reporting, rebate management, marketing and communication,
customer service, industry trends, new or emerging initiatives, best
practices, improvement of health outcomes, cost saving measures,
compliance requirements, benchmarking data, point solutions, and
wellness initiatives.
9.1.2.3
Final plan design decisions shall be at the sole discretion of the County
with the contractor advising the County of its ability to administer the
plan design effectively and efficiently.
9.1.3
Implementation
9.1.3.1
Contractor shall develop a comprehensive implementation plan with the
objective of achieving an effective benefit start date of January 1, 2025.
9.1.3.2
All implementation/open enrollment activities shall begin no later than
July 1, 2024 and be completed in time for the County’s open enrollment
period for the 2025 benefit year.
9.1.3.3
Contractor
shall
designate
an
implementation
manager
and
implementation team to include persons with expertise in plan design,
benefits and exclusions, account structure, systems, networks,
transition of care, formulary, pharmacy benefits, eligibility, enrollment
services, claims processing, compliance, best practices, banking and
finances, file integrations, and drafting of plan materials including
Summaries of Benefits and Coverage (SBCs), Summary Plan
Descriptions (SPDs), and enrollment/transition communications.
9.1.4
Annual Enrollment Planning and Responsibilities
9.1.4.1
Annual enrollment planning begins in February, and the employee open
enrollment period begins in October and ends in November with a
January 1 effective date.
9.1.4.2
Contractor shall support annual enrollment by developing a
comprehensive plan to implement any changes to the County’s benefits
program. Such plan shall include a list of all deliverables including
plan/system set-up, system testing, portal updates, pricing tools,
formulary changes, program onboarding/off-boarding, physical ID card
issuance, participant communications, and pre-enrollment customer
service line staffed with representatives ready to answer questions from
prospective participants.
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9.1.4.3
After the annual enrollment period, contractor shall load current year
changes and annual enrollment eligibility files by the agreed-upon due
dates.
9.1.5
Annual Market Check
9.1.5.1
On an annual basis, the Contractor agrees to review the pharmacy
financial terms and other contract provisions as compared to financial
offerings presented to similar collectives, coalitions and/or employers in
the marketplace. Contractor agrees that such comparisons shall be
based upon, among other things, the mail and retail pricing for brand
and generic drugs, pricing for Specialty Drugs, administrative fees and
rebates and other contract provisions. The County agrees to provide
sufficient information relating to such financial offerings to allow the
contractor to conduct a fair and adequate review of the marketplace
pricing. In the event that the marketplace pricing, as measured in the
aggregate, would result in at least a two percent savings, in addition to
all of the existing pricing and contract improvements contained in the
contract for the County, the Contractor shall renegotiate pricing terms
and contract provisions in good faith.
9.1.5.1.1
Contractor shall provide to the County most favored
customer pricing. Prices and provisions provided to the
County shall be as good or better than prices offered to
other employers, coalitions, collectives, of similar size and
scope.
9.1.6
Account Management
9.1.6.1
Contractor shall provide account management services to the County,
including but not limited to, the following:
9.1.6.1.1
An account management team that includes:
9.1.6.1.1.1 The person responsible for the successful
management of the account and who serves as
the everyday point of contact for the County.
9.1.6.1.1.2 A customer service person who is familiar with
the County’s plan design and who can quickly
handle the day-to-day inquiries that come up
(e.g., participant questions, requests for haste
enrollments, handling of escalations).
9.1.6.1.1.3 Applicable and sufficient clinical experts (i.e.,
Doctor of Medicine (MD), pharmacist, licensed
mental health professional) to provide clinical
information pertaining to drug performance,
trends,
population
health,
cost-controlling
recommendations, and disease and clinical
programs.
9.1.6.1.1.4 A strategic account executive and executive
sponsor assigned to the County to assist with
overall strategy, oversight of administrator
resources, and as needed for escalation
situations.
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9.1.6.1.1.5 Contractor shall ensure that all account
management team members are preapproved
by the County, in writing, throughout the term of
the contract. The County reserves the right to
remove any team member the contractor
assigns to the account.
9.1.6.1.2
Response to inquiries and service requests and completion
of haste enrollments within 24 hours of contact/notification.
9.1.6.2
Daily maintenance of the County’s account and weekly account team
meetings.
9.1.6.2.1
Development
of
custom
participant
communication
materials in accordance with the County’s branding
standards.
9.1.6.2.2
Account structure set-up to include actives, COBRA,
surviving spouses, and any other group structure needed
for purposes of claims processing and reporting.
9.1.6.2.3
Electronic invoice submission and payment remittance, with
as much detail as required by the County for ease in
payment processing and reconciliation.
9.1.6.2.4
Access to an employer portal for viewing of coverage
eligibility, claims status, ID card requests, and utilization
reporting.
9.1.6.2.5
Preparation of a customized Summary of Benefits and
Coverage (SBC) for each benefit plan, highlighting the most
utilized services and detailing what the plan pays and what
a participant’s out-of-pocket cost share is expected to be.
The County shall have final approval on the SBCs.
9.1.6.2.6
Contractor shall ensure that SBCs be completed within ten
business days following the date of benefit decisions by the
County.
9.1.6.2.7
Preparation of a customized Summary Plan Description
(SPD) for each benefit plan detailing plan design, covered
services, limitations and exclusions, information on how the
plan works, drug tiering and participant costs, utilization
management requirements, clinical programs, claims
procedures, coordination of benefits, the appeals process,
and other coverage details. The County shall have final
approval on the SPDs.
9.1.6.2.7.1 Contractor
shall
ensure
that
SPDs
be
completed within ten business days following
the date of benefit decisions by the County.
9.1.6.2.8
Participation in weekly and semi-annual strategic meetings
with the County benefits staff for purposes of discussing
operational business, problem resolution, customer service
issues, and plan direction.
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9.1.6.2.9
Participation in no more than six benefits and wellness fairs,
and educational meetings at different locations and times of
the year as requested by the County with a 30-day notice.
9.1.7
Eligibility and Enrollment Services
9.1.7.1
The County controls eligibility and enrollment. The County uses
Workday for benefit enrollment. Contractor shall integrate with Workday
and shall ensure timely and accurate enrollments in the County’s
medical plan, process eligibility and demographic changes, and manage
disenrollment from the plan.
9.1.7.2
Contractor must use Electronic Data Interchange (EDI) 834 or another
equally HIPAA-compliant file format, and shall use secure file
transmission methods (e.g., EDI, API, SFTP).
9.1.7.3
Contractor agrees to accept eligibility files at whatever frequency
desired by the County, including accepting daily and weekly files.
Eligibility files will include records of subscribers, spouses, and
dependents in simple structure groups.
9.1.7.3.1
Contractor must be able to accept and process eligibility
files and generate an electronic exception report within
24 hours of receipt of the eligibility file.
9.1.7.3.2
The County shall have final approval on questions regarding
correction of eligibility errors.
9.1.7.3.3
Contractor shall work with the County or its designee to fully
resolve errors within 24 hours.
9.1.7.4
Identification (ID) cards shall be produced by contractor and mailed to
the subscriber’s home address within seven calendar days from
submission of enrollment information.
9.1.7.5
Contractor shall grant the County’s benefits staff access to make haste
eligibility updates using the employer portal.
9.1.8
Underwriting Services
Contractor shall provide periodic claims projections and estimated cost impacts of
plan design or related changes. Such services shall include recommended reserve
estimates and year-end claims accounting and reconciliation.
9.1.9
Claims Processing
9.1.9.1
Contractor shall process claims, both in-network and out-of-network, in
accordance with the SPDs and all applicable plan documents and
pricing terms. No subcontracting or use of another’s network shall be
allowed for purposes of claims processing without the express written
consent of the County. Claims processing services shall also include the
following:
9.1.9.1.1
Set up of the contractor’s claims system to facilitate the
automatic and accurate adjudication of claims submitted by
health care providers. Contractor shall, at a minimum,
include claims system edits that trigger review for the
following:
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Total billed charges less than total allowable payment
Potential duplicates
Work-related, auto, and other accidents identified for
potential subrogation
Provider licensing and credentialing matches the type
of services billed
Cross references for providers with multiple locations
to include national provider identifier (NPI) and tax
identification number (TIN)
Potential third-party payor
Under/over payment
Manual claim processing
Pended claims
Unbundled procedure coding
Billing for inappropriate care for stated diagnosis,
age, or gender
Billing for excluded drugs
Over-utilization
Billing for inappropriate site of care
Participant eligibility
Missing prior authorization
9.1.9.1.2
Accurate manual processing of claims submitted via paper
or electronic claims forms within 10 business days of receipt
of request from participants.
9.1.9.1.3
Coordination of benefits with Medicare and other third-party
payers.
9.1.9.1.4
Production and issuance of electronic and hard copy
(Explanation of Benefits (EOB) for each claim processed.
9.1.9.1.5
Claims payment services/run-out processing services for 18
months upon termination of the contract at no additional
cost to the County.
9.1.9.1.6
Claims audits shall be performed by the Contractor as
requested by the County to confirm whether claims are
processing in accordance with plan design. Reports of
these claim audits shall be provided to the County within 30
days from completion of audit. Any findings requiring
potential correction or re-processing of claims shall be
reviewed with the County and implemented within 30 days.
9.1.9.1.7
Hospital claims and claims greater than $100,000 must
undergo a second level review before payment is issued to
providers.
9.1.9.1.8
A $100,000 allowance shall be furnished to the County by
the contractor once every two years to be used to fund an
independent claims and billing audit performed by an
independent third-party company designated by the
County. Contractor shall immediately correct any claims
processing discrepancies identified through the audit
process and shall refund the County any fees or claims
dollars paid in error, such as those resulting from claims
processing errors.
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9.1.10 Other Claims Management Services
9.1.10.1 Contractor shall provide claims management services to include
recovery services for overpayments, fraud and abuse, third-party
liability, and subrogation matters.
9.1.10.1.1 Overpayments are payments made to a provider that are
more than what is due based on set plan design, pricing,
and other contractual agreements.
9.1.10.1.2 Third-party liability and subrogation matters refer to
instances where claims for plan benefits were paid but are
recoverable by the plan because a claim was or should have
been paid by a third party (including in instances of
coordination of benefits with other plans, including
Medicare). The County has unique statutory subrogation
and reimbursement rights under the Arizona Revised
Statute section 12-962, which entitles the County, among
other things, to recover the cost of medical treatment from
the injured party’s net recovery of any third-party recovery.
9.1.10.1.2.1 Contractor shall be responsible for the
negotiation of reimbursement on subrogation
matters, with the contractor obtaining the
County’s written approval on all settlements in
accordance with the Declaration of Trust for
Maricopa
County,
Arizona
Self-Insured
Benefits Trust Fund and revised and restated
from time to time.
9.1.10.1.2.2 Contractor shall prepare a written summary of
each case detailing pertinent facts of the
accident or injury, parties involved, continuing
treatment needs, third-party insurance bodily
injury limits, underinsured motorist coverage,
other liens, and all potential sources of
recovery.
9.1.10.1.2.3 Contractor shall be available to discuss written
report.
9.1.10.1.2.4 Both the County and contractor shall engage in
discussions regarding strategy and next steps
in the recovery process.
9.1.10.2 Contractor shall handle all first and second level claim denials and
appeals including but not limited to those involving prior authorizations,
transition of care, step therapy, formulary exceptions, limitation or
exclusion, or direct participant reimbursements by conducting a
thorough review of information submitted by an appellant or on behalf of
an appellant, along with plan information and in consultation with health
care professionals with the knowledge and expertise to assist with
making a determination to uphold or reverse a denial or appeal.
9.1.10.3 Contractor shall help facilitate an external review process when an
appellant has exhausted the first and second levels of appeals and
remains dissatisfied with the outcome of the first and second level
appeals. Any external review organization with whom the contractor has
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a contract must meet the Patient Protection and Affordable Care Act
(PPACA) requirements to conduct such reviews. Contractor shall
document the claim denials and appeals process, along with timelines
that must be met both by the appellant and the contractor. All responses
to claims, denials and appeals must be in writing, and quarterly reports
indicating number of appeals, reasons for the appeals, and disposition
of the appeals shall be provided to the County on a quarterly basis.
9.1.10.4 Contractor shall provide the County quarterly reporting of all appeal
metrics and identify areas of opportunity to address common themes
noted in appeal volume.
9.1.11 Utilization Management Services
Contractor shall provide robust utilization management services with a focus on
delivering high quality care and cost/risk management. Such services shall include
decision-making/steerage
tools,
prior
authorizations,
medical
necessity
determinations, case management, step therapy, quantity limits, appropriate site
of care, high-cost claimant care, appropriate level of care education, transition of
care, inpatient admission, skilled nursing facility admission, duration reviews,
home health visits, and overall cost and risk management. Contractor shall identify
all services that require pre-authorization or pre-certification and manage those
consistently and correctly. Procedures for all utilization management services must
be well-documented and communicated.
9.1.12 Network Access Services
9.1.12.1 Contractor shall provide sufficient access to a network of contracted
providers, as relevant to the medical, behavioral health, and/or PBM
services provided, to address the health needs of County participants,
and such providers shall include primary care, specialty care, ancillary
services, labs and radiology, urgent care, emergency care, out-patient
and in-patient facilities, mental, behavioral and substance abuse
counseling, participating in-network pharmacies, specialty drug
pharmacy, infusion services providers, and other health care and
prescription services.
9.1.12.2 Network providers shall provide care in a variety of sites/modalities,
including but not limited to in-patient, outpatient, in-person in office,
telephonic, videoconference, chat, and text. The adequacy of the size
and range of a contractor’s network, and thus its ability to provide
expansive coverage, will be determined at the start of the contract, and
throughout the term of the contract as requested by the County, in part
by utilizing the County’s employee census whereby the contractor shall
indicate the number of each contracted provider type and specialty type
including behavioral health providers and participating pharmacies and
prescription services providers operating within a 10-mile radius of each
zip code in which County participants work and reside. The network shall
include a transplant network utilizing centers of excellence and services
necessary to support participants receiving transplants.
9.1.12.3 The network of contracted providers shall be credentialed by the
contractor upon application to participate in the contractor’s network,
and current physicians and providers shall be re-credentialed on a
rotating schedule set forth by the contractor. While it is understood that
the make-up of the network can change at any time, the contractor shall
provide notice of any such changes to the County’s participants no less
than 30 days in advance of any changes. Contractor should identify to
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the County hospital contracts within the County that are up for renewal
in the next three years.
9.1.12.4 Contractor shall exercise oversight of network providers to ensure they
are compliant with administering the County’s plan design and services,
and that they are otherwise compliant with local, state, and federal
regulations. Network providers shall direct and/or refer participants to
other network providers when additional services are required. The
County is not liable or responsible for any care, pharmacy, or health
services rendered to participants by network providers.
9.1.12.5 Contractor shall provide access to its electronic provider directory for
purposes of enabling participants to locate participating pharmacies and
in-network providers of their choosing. The provider directory shall be
searchable and clearly designate which providers are high quality
designated, premium, preferred, or those whom the contractor has
identified as being providers whose care and treatment yields better
health outcomes. The provider directory should include all provider
types, including those outlined in paragraph one of this section, and
must include a listing of inpatient and outpatient facilities. The provider
directory shall be updated in real time so as to remain accurate and up
to date.
9.1.12.6 Contractor
shall
make
membership
eligibility/enrollment,
copayment/coinsurance, and benefit coverage information, supplied by
the County or its designated agent in mutually agreed upon format,
available to network pharmacies at the time of dispensing through the
online electronic transmission link maintained between contractor and
pharmacies. Subject to contractor’s responsibility to load all such data
received from County in a timely manner (within 24 hours of receipt),
County is solely responsible for the accuracy, completeness, reliability,
and timeliness of all information provided to contractor and
acknowledges contractor’s reliance thereupon.
9.1.13 Member Services
9.1.13.1 Contractor shall provide the County with a dedicated toll-free number for
participants to seek assistance with questions or to receive support with
service-related issues. Contractor shall indicate in their response their
commitment to a wide span of days/hours of operation in Mountain
Standard Time (MST) so as to be available to County employees and
their dependents, with the preference being that the service line be
staffed 24 hours per day/7 days per week (24/7), including holidays.
Representatives
shall
be
trained
to
assist
participants
with
understanding plan coverage and exclusions, address claims questions,
advocate for the participant with providers, locate in-network providers,
resolve problems, explain wellness and other health programs, and
provide exceptional customer service.
9.1.13.2 Contactor shall provide navigation assistance and natively connect
participants to other County benefits and point solutions (e.g., disability,
Employee Assistance Program (EAP), telehealth, group legal,
wellness).
9.1.13.3 Contractor shall also provide access to registered nurses 24/7, including
holidays, to answer health care questions and direct participants to
appropriate level of care.
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9.1.13.4 Acceptable service levels per the performance guarantees shall always
be maintained to ensure participant satisfaction.
9.1.13.5 Contractor shall not outsource participant services to a third-party
without the expressed written consent of the County.
9.1.13.6 Contractor shall provide other methods for communicating with the
County’s participants including a secure portal (secure portal shall also
be accessible as a mobile application) where participants may view plan
information, claims, request a new ID card (receipt options to include
downloadable or mailed hard copy ID card), and search for in-network
providers. Other methods of communication shall include an online app,
chat option, or other similar technology, along with updated marketing
and informational materials.
9.1.13.7 Contractor shall provide introductory materials for issuance to
participants, via paper and electronic media. This includes prescription
mail service order forms, program brochures, newsletters, mail service
promotional materials, generic usage educational pieces and retail
pharmacy prescription labels. Contractor shall be responsible for all
costs associated with its development, printing, and mailing of standard
marketing and educational materials that contractor provides to County
participants, unless contractor obtains written agreement from the
County directing it to develop, print, and mail custom material. This does
not include the standard materials that the contractor shall develop for
posting on the County’s benefits website during the annual enrollment
period. The County shall have final approval on all implementation and
annual enrollment communication being provided to its participants.
9.1.13.8 Contractor shall provide County participants with medical procedure and
drug transparency pricing tools for their use to determine the cost of a
procedure or drug. Pricing shall be based on the County’s medical and
prescription plan design, procedure or drug name, site of care, drug
dosage, the delivery method, and fill amount (i.e., 30 day or 90 day).
9.1.13.8.1 Information about lower cost alternatives and comparison of
costs across pharmacy options covered under the County’s
plan shall be available through the pricing tool. Pricing tool
shall include the plan cost share of any procedure or drug
and the participant’s cost share as this will serve as
educational information for participants with the potential to
drive better consumer decisions.
9.1.13.8.2 A similar tool shall be made available during newly eligible
and annual enrollment for prospective enrollees in the plan
to make informed decision when selecting their benefits.
9.1.14 Health Care Management Programs
9.1.14.1 Contractor shall provide programs intended to support participants with
managing care associated with complex, chronic, and/or high-cost
medical conditions including diabetes, cardiac care, cancer, kidney and
other transplants, musculoskeletal and back pain, arthritis and other
inflammatory or pain management care, blood disorders, mental health,
asthma, and COPD. Such programs shall include participant outreach,
engagement strategies, proven steps that lead to better health
outcomes, and measurable improvement results. Most appropriate/least
expensive site of care strategies shall be implemented for specialty
and/or infusion services where evidence exists that driving participants
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to such sites is financially advantageous, convenient, and yields the
same or better health outcomes.
9.1.14.2 Contractor shall agree to work cooperatively with other vendors to
provide a holistic approach to managing participants’ health.
9.1.15 Data and Reports
9.1.15.1 Monthly, the contractor shall securely transmit to the County, or the
County’s third-party data warehouse vendor, de-identified claims
utilization data. On a monthly or as-needed basis, contractor shall
provide a variety of routine and ad hoc reports to the County to include,
but not be limited to the following:
9.1.15.1.1 Medical and PBM services utilization by participant and by
place/method of service
9.1.15.1.2 Demographic data
9.1.15.1.3 Top diagnostic/disease categories
9.1.15.1.4 Spend per member per month (PMPM)
9.1.15.1.5 Catastrophic/large dollar claims
9.1.15.1.6 In-network versus out-of-network utilization
9.1.15.1.7 Drug utilization review
9.1.15.1.8 Top drugs by spend/volume/condition.
9.1.15.1.9 Drug rebates
9.1.15.1.10 Program performance
9.1.15.1.11 Health care trends and drivers
9.1.15.1.12 Number of appeals and their disposition
9.1.15.1.13 Participant engagement
9.1.15.2 Reports must be provided electronically and be accessible to the County
through access to the contractor’s secure portal.
9.1.15.3 On an annual basis, contractor shall provide Service Organization
Control Reports (SOC 1 and SOC 2) that represent that the contractor
has been audited during the year and has been deemed to have the
appropriate controls in place for its claims payment and financial system
and other related technology housing County data. Contractor shall also
provide additional reports necessary to assist the County with any
internal or external audit it undergoes.
9.1.16 HIPAA Privacy and Security
Contractor shall provide, upon request a comprehensive HIPAA Privacy and
Security Policy complete with protocols and procedures for handling breaches or
unauthorized disclosures of varying degrees of seriousness.
9.1.17 Compliance
Contractor shall comply with IRS regulations, Health Information Technology for
Economic and Clinical Health Act (HITECH) and Health Insurance Portability And
Accountability Act (HIPAA), Patient Protections and Affordable Care Act (PPACA),
Genetic
Information
Non-Discrimination
Act
(GINA),
the
Consolidated
Appropriations Act (CAA) and its Transparency in Coverage (TIC) rule, and other
Federal, state, and local laws and regulations that govern the administration of a
Self-Insured Government Employee Group Health Plan. This includes advising the
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County on actions needed to remain in compliance as legislative changes at all
levels of government are approved and whereas adherence is required. Contractor
shall assist the County in complying with the Mental Health Parity and Addiction
Equity Act (MHPAEA).
9.1.18 Formulary Management
9.1.18.1 Contractor shall perform formulary management, rebate sharing, and
other clinical services, including self-reporting of adherence to all
guarantees, pricing, discounts, and services. These services shall
include, but are not limited to, prior authorization, step-therapy,
systematic prospective, concurrent, and retrospective drug utilization
review, a pharmacy and therapeutics (P&T) committee or an equivalent
entity, and other measures that are deemed appropriate to effectively
manage a closed, multi-tiered formulary or prescription drug list. While
the contractor is responsible for managing formulary changes, the
County reserves the right to authorize any and all such changes.
9.1.18.1.1 At a minimum, contractor shall provide the County with self-
reporting, including all reporting on guarantees, pricing,
discounts, and services outlined in contractor’s response in
attachments/questionnaires/pricing sheets and that are
subsequently included in a contract.
9.1.18.2 As part of the plan design process, the County will determine the
frequency of formulary changes. Contractor shall provide advance
written notice to the County of any planned formulary changes at least
90 days prior to any such change. Additionally, contractor shall provide
60-day advance written notice to County participants adversely
impacted by any formulary change, including changes in tier and
exclusions. Additionally, contractor shall notify participants no later than
60 days in advance, in writing to their home address, of the expiration
date of a prior authorization and for industry changes (e.g., black box
warnings, drug withdrawals when significant impact is expected, etc.).
9.1.19 Mail-Order Pharmacy
Contractor shall offer access to a mail-order pharmacy where participants may
purchase prescription drugs conveniently, with secure and timely delivery, and at
competitively low pricing. Mail-order prescriptions for a 90-day supply of
maintenance medication shall be sent to a participant’s home address, work
address, or to a local network-participating pharmacy (provided the pharmacy is
willing to accept the delivery) via the United States Postal Service, an express
delivery service (e.g., UPS, DHL, FedEx), or any other method that achieves the
goal of secure delivery within 48 hours. Limiting the risk of loss or damage to
covered drugs is the responsibility of the mail-order pharmacy until such drugs
have been delivered to a participant. Contractor shall guarantee that certain
products which require cold-pack shipping methods as recommended by the
manufacturer will be handled appropriately. The mail-order pharmacy is
responsible for the cost of shipping. When placing a new or refill order through the
mail-order pharmacy, participants must pay for their share of the cost (copayment,
coinsurance, or deductible). Additionally, participant will be responsible for paying
or reimbursing the mail-order pharmacy, as applicable, for all additional expenses
due to expedited delivery (e.g., next day) requested by a participant unless such a
request is the result of an error on the part of the pharmacy to ensure a participant
has received a new or re-fill order within 48 hours of being sent. To the extent
contractor’s shipping costs significantly increase due to rate increases by the
United States Postal Service or any other mail delivery handler after the effective
date of the rates set forth in this agreement, the parties will negotiate in good faith
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to reach agreement on an adjustment to the rates to compensate contractor for its
increased costs.
9.1.20 Specialty Drug Program
9.1.20.1 Contractor shall provide a cost-effective Specialty Drug Program with
either centralized distribution or multi-channel distribution that is
national, convenient, consistent, and flexible. Specialty pharmaceuticals
are generally high-cost medications that are usually prescribed for
people with complex or chronic medical conditions (i.e., multiple
sclerosis, hemophilia, hepatitis, and rheumatoid arthritis) and/or that
require special handling/administration. Medications typically exhibit
one or more of the following characteristics: are injected or infused,
however some may be taken orally; have unique monitoring, storage, or
shipment requirements; require additional education and support from a
health care professional; and are usually not readily available at retail
pharmacies.
9.1.20.2 Contractor must have fully developed Specialty Drug Program services
that meet the unique challenges of dispensing and monitoring specialty
pharmaceuticals. The program must provide cost-effective care and
positive patient outcomes through increased adherence, as well as
provide an enhanced patient experience through the convenience of
scheduled delivery, disease management programs, and compliance
monitoring employing a care-coordination model. In care coordination,
licensed clinicians (nurses, pharmacists, and physicians) provide
comprehensive clinical management services. Clinical professionals
support patients through education, training, and mental health support
(e.g., behavioral health, case management or disease management
referral). The care plan shall address education, interventions,
compliance, monitoring parameters, and goals and outcomes of
therapy. Non-adherence or non-compliance and the rationale must be
communicated to the prescribing physician.
9.1.20.3 The Specialty Drug Program must contain provisions addressing and
controlling the high cost of preferred specialty medications and
biosimilars, biologics, and gene therapies.
9.1.21 Pharmacy Member Services
9.1.21.1 Contractor and its providers shall dispense prescription products and
services as follows:
9.1.21.1.1 Dispensed upon presentation by a participant of his/her
identification card, authorized prescription order, and
remittance of any required participant cost share (i.e., co-
insurance, deductible). A pharmacy shall compound and
dispense all qualified prescriptions and covered drugs
pursuant to the pharmacy benefit plan design and eligibility
information provided by the County to the contractor and
communicated by the contractor to such pharmacy via the
Online Eligibility and Claim System at the time of dispensing
and subject to legal restrictions and professional ethics and
professional judgment.
9.1.21.1.2 Pharmacy shall collect any applicable co-payment,
coinsurance
and/or
deductible
amount
from
each
participant for each covered prescription, as indicated by
the Online Eligibility and Claims System at the time of
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dispensing. When the participating pharmacy’s usual and
customary charge or retail cash price for the prescription is
less than the coinsurance, the participating pharmacy will
collect the lowest amount in lieu of the minimum
coinsurance indicated by the Online Eligibility and Claims
system.
9.1.21.1.3 Pharmacy may withhold prescription services to a
participant for good cause, including, but not necessarily
limited to: 1) the County’s nonpayment for prescription
services provided to participants; 2) the participant’s failure
to pay for products or services (i.e. coinsurance, and/or
deductible); 3) requests by participant for drug quantities in
excess of prescribed amounts or refill limitations pursuant
to the pharmacy benefit information; or 4) where, in the
professional judgment of the dispensing pharmacist, the
prescription should not be filled.
9.1.21.1.4 Pharmacy shall attempt to dispense lowest net cost or tier
drugs in lieu of prescribed non-preferred brand name drugs
if commercially available, meet quality rating standards, and
if consistent with the prescriber’s orders and the dispensing
pharmacist’s professional judgment and state and federal
law.
9.1.22 Transition
9.1.22.1 At no cost to the County, the contractor shall comply with the following
provisions upon receipt of a notice of termination or upon the expiration
of the contract, and at no additional cost to the County:
9.1.22.1.1 The contractor shall transfer title and deliver to the County
or its designee any and all completed or partially completed
reports, materials, information, data, other work product of
the contractor that were made under the contract or as part
of the contractor’s performance of the contract, and all work-
in-progress, including any work covered under the contract
but scheduled for delivery at a future date.
9.1.22.1.2 Provide
claims
payment
services/runout
processing
services for 18 months upon termination of contract.
9.1.22.1.3 Provide a minimum of 18 months of historical data upon
termination of contract.
9.1.22.1.4 Make available for a period of 18 months any reports or
other materials pertaining to the administration and
performance of the County’s plans.
9.1.22.1.5 As directed by the County, the contractor shall terminate or
assign to the County or its designee any outstanding orders
or contracts that relate to the contractor’s performance
under the contract.
9.1.22.1.6 As directed by the County, the contractor shall destroy
and/or deliver to the County or its designee all confidential
or proprietary documents, information, and data that the
contractor has received under the contract and all copies
thereof.
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9.1.22.1.7 Upon written request from the County, the contractor shall
provide to the County or its designee all records,
documents, information, and data reasonably necessary to
allow the County or its designee to continue to provide
and/or administer, without interruption, all health and other
benefit plans to County beneficiaries, and to comply with
Federal, state, and other legal requirements to which the
County is subject. Such records, documents, information,
and data shall include, but not be limited to, eligibility
information and data, claims experience or history data, and
administrative records. For prescription drug plans, this
shall include, but not be limited to:
9.1.22.1.7.1
All claim files for the entire contract period
9.1.22.1.7.2
Prior authorization files
9.1.22.1.7.3
Exceptions to formulary approvals
9.1.22.1.7.4
True out-of-pocket balances
9.1.22.1.7.5
Medical necessity review files
9.1.22.1.7.6
Quantity limit information by participants
and exceptions
9.1.23 Additional Contractual Requirements
Contractor shall not require minimum participation requirements, and rates in the
proposal shall be guaranteed.
10.0
TERMS AND CONDITIONS
10.1
INDEMNIFICATION
10.1.1 To the fullest extent permitted by law, and to the extent that claims, damages,
losses, or expenses are not covered and paid by insurance purchased by the
contractor, the contractor shall defend, indemnify, and hold harmless the County
(as Owner), its agents, representatives, officers, directors, officials, and employees
from and against all claims, damages, losses, and expenses (including, but not
limited to attorneys' fees, court costs, expert witness fees, and the costs and
attorneys' fees for appellate proceedings) arising out of, or alleged to have resulted
from, the negligent acts, errors, omissions, or mistakes of the contractor, a
subcontractor, anyone directly or indirectly employed by them, or anyone for
whose acts they may be liable relating to the performance of this contract.
10.1.2 Contractor's duty to defend, indemnify, and hold harmless the County, its agents,
representatives, officers, directors, officials, and employees shall arise in
connection with any claim, damage, loss, or expense that is attributable to bodily
injury, sickness, disease, death, or injury to, impairment of, or destruction of
tangible property, including loss of use resulting therefrom, caused by negligent
acts, errors, omissions, or mistakes in the performance of this contract, but only to
the extent caused by the negligent acts or omissions of the contractor, a
subcontractor, anyone directly or indirectly employed by them, or anyone for
whose acts they may be liable, regardless of whether or not such claim, damage,
loss, or expense is caused in part by a party indemnified hereunder.
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10.1.3 The amount and type of insurance coverage requirements set forth herein will in
no way be construed as limiting the scope of the indemnity in this section.
10.1.4 The scope of this indemnification does not extend to the sole negligence of County.
10.2
INSURANCE
10.2.1 Contractor, at Contractor’s own expense, shall purchase and maintain, at a
minimum, the herein stipulated insurance from a company or companies duly
licensed by the State of Arizona and possessing an AM Best, Inc. category rating
of B++. In lieu of State of Arizona licensing, the stipulated insurance may be
purchased from a company or companies, which are authorized to do business in
the State of Arizona, provided that said insurance companies meet the approval of
County. The form of any insurance policies and forms must be acceptable to
County.
10.2.2 All insurance required herein shall be maintained in full force and effect until all
work or service required to be performed under the terms of the contract is
satisfactorily completed and formally accepted. Failure to do so may, at the sole
discretion of County, constitute a material breach of this contract.
10.2.3 In the event that the insurance required is written on a claims-made basis,
Contractor warrants that any retroactive date under the policy shall precede the
effective date of this contract and either continuous coverage will be maintained,
or an extended discovery period will be exercised for a period of two years
beginning at the time work under this contract is completed.
10.2.4 Contractor’s insurance shall be primary insurance as respects County, and any
insurance or self-insurance maintained by County shall not contribute to it.
10.2.5 Any failure to comply with the claim reporting provisions of the insurance policies
or any breach of an insurance policy warranty shall not affect the County’s right to
coverage afforded under the insurance policies.
10.2.6 The insurance policies may provide coverage that contains deductibles or self-
insured retentions. Such deductible and/or self-insured retentions shall not be
applicable with respect to the coverage provided to County under such policies.
Contractor shall be solely responsible for the deductible and/or self-insured
retention and County, at its option, may require Contractor to secure payment of
such deductibles or self-insured retentions by a surety bond or an irrevocable and
unconditional letter of credit.
10.2.7 The insurance policies required by this contract, except Workers’ Compensation
and Errors and Omissions, shall name County, its agents, representatives, officers,
directors, officials, and employees as additional insureds.
10.2.8 The policies required hereunder, except Workers’ Compensation and Errors and
Omissions, shall contain a waiver of transfer of rights of recovery (subrogation)
against County, its agents, representatives, officers, directors, officials, and
employees for any claims arising out of Contractor’s work or service.
10.2.9 If available, the insurance policies required by this contract may be combined with
Commercial Umbrella Insurance policies to meet the minimum limit requirements.
If a Commercial Umbrella insurance policy is utilized to meet insurance
requirements, the Certificate of Insurance shall indicate which lines the
Commercial Umbrella Insurance covers.
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10.2.9.1 Commercial General Liability
Commercial General Liability (CGL) insurance and, if necessary,
Commercial Umbrella insurance with a limit of not less than $2,000,000
for each occurrence, $4,000,000 Products/Completed Operations
Aggregate, and $4,000,000 General Aggregate Limit. The policy shall
include coverage for premises liability, bodily injury, broad form property
damage, personal injury, products and completed operations and
blanket contractual coverage, and shall not contain any provisions which
would serve to limit third party action over claims. There shall be no
endorsement or modifications of the CGL limiting the scope of coverage
for liability arising from explosion, collapse, or underground property
damage.
10.2.9.2 Workers’ Compensation
10.2.9.2.1 Workers’ compensation insurance to cover obligations
imposed by Federal and State statutes having jurisdiction of
Contractor’s employees engaged in the performance of the
work or services under this contract; and Employer’s
Liability insurance of not less than $1,000,000 for each
accident, $1,000,000 disease for each employee, and
$1,000,000 disease policy limit.
10.2.9.2.2 Contractor, its subcontractors, and sub-subcontractors
waive all rights against this contract and its agents, officers,
directors, and employees for recovery of damages to the
extent these damages are covered by the workers’
compensation and Employer’s Liability or Commercial
Umbrella Liability insurance obtained by Contractor, its
subcontractors, and its sub-subcontractors pursuant to this
contract.
10.2.9.3 Errors and Omissions/Professional Liability Insurance
Contractor shall maintain Professional Liability insurance which will
provide coverage for any and all acts arising out of the work or services
performed by the contractor under the terms of this contract, with a limit
of not less than $2,000,000 for each claim, and $4,000,000 aggregate
claims.
10.2.10 Certificates of Insurance
10.2.10.1 Prior to contract award, Contractor shall furnish the County with valid
and complete Certificates of Insurance, or formal endorsements as
required by the contract in the form provided by the County, issued by
Contractor’s insurer(s), as evidence that policies providing the required
coverage, conditions and limits required by this contract are in full force
and effect. Such certificates shall identify this contract number and title.
10.2.10.2 In the event any insurance policy(ies) required by this contract is (are)
written on a claims-made basis, coverage shall extend for two years past
completion and acceptance of Contractor’s work or services and as
evidenced by annual certificates of insurance.
10.2.10.3 If a policy does expire during the life of the Contract, a renewal certificate
must be sent to County 15 calendar days prior to the expiration date.
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10.2.10.4 Certificates of Insurance shall identify Maricopa County as the certificate
holder as follows:
Maricopa County
c/o Risk Management
301 W Jefferson St, Suite 910
Phoenix, AZ 85003
10.2.11 Cancellation and Expiration Notice
Applicable to all insurance policies required within the insurance requirements of
this contract, Contractor’s insurance shall not be permitted to expire, be
suspended, be canceled, or be materially changed for any reason without 30 days
prior written notice to Maricopa County. Contractor must provide to Maricopa
County, within two business days of receipt, if they receive notice of a policy that
has been or will be suspended, canceled, materially changed for any reason, has
expired, or will be expiring. Such notice shall be sent directly to Maricopa County
Office of Procurement Services and shall be mailed, or hand delivered to 301 W.
Jefferson, Suite 700, Phoenix, AZ 85003, or emailed to the procurement officer
noted in the solicitation.
10.3
FORCE MAJEURE
10.3.1 Neither party shall be liable for failure of performance, nor incur any liability to the
other party on account of any loss or damage resulting from any delay or failure to
perform all or any part of this contract, if such delay or failure is caused by events,
occurrences, or causes beyond the reasonable control and without negligence of
the parties. Such events, occurrences, or causes include, but are not limited to,
acts of God/nature (including fire, flood, earthquake, storm, hurricane, or other
natural disaster), war, invasion, act of foreign enemies, hostilities (whether war is
declared or not), civil war, riots, rebellion, revolution, insurrection, military or
usurped power or confiscation, terrorist activities, nationalization, government
sanction, lockout, blockage, embargo, labor dispute, strike, and interruption or
failure of electricity or telecommunication service, and pandemic.
10.3.2 Each party, as applicable, shall give the other party notice of its inability to perform
and particulars in reasonable detail of the cause of the inability. Each party must
use best efforts to remedy the situation and remove, as soon as practicable, the
cause of its inability to perform or comply.
10.3.3 The party asserting Force Majeure as a cause for non-performance shall have the
burden of proving that reasonable steps were taken to minimize delay or damages
caused by foreseeable events, that all non-excused obligations were substantially
fulfilled, and that the other party was timely notified of the likelihood or actual
occurrence which would justify such an assertion, so that other prudent
precautions could be contemplated.
10.4
NO MINIMUM OR MAXIMUM PURCHASE OBLIGATION
This contract does not guarantee any minimum or maximum purchases will be made.
Orders will only be placed under this contract when the County identifies a need and proper
authorization and documentation have been approved.
10.5
BACKGROUND CHECK
Respondents may be required to pass multiple background checks (e.g. Sheriff’s Office,
County Attorney's Office, Courts, as well as Maricopa County general government) to
determine if the respondent is acceptable to do business with the County. This applies to,
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but is not limited to, the company, subcontractors, and employees, and the failure to pass
these checks shall deem the respondent non-responsible.
10.6
SUSPENSION OF WORK
The procurement officer may order the Contractor, in writing, to suspend, delay, or interrupt
all or any part of the work of this contract for the period of time that the procurement officer
determines appropriate for the convenience of the County. No adjustment shall be made
under this clause for any suspension, delay, or interruption to the extent that performance
would have been so suspended, delayed, or interrupted by any other cause, including the
fault or negligence of the Contractor. No request for adjustment under this clause shall be
granted unless the claim, in an amount stated, is asserted in writing as soon as practicable
after the termination of the suspension, delay, or interruption, but not later than the date of
final payment under the contract.
10.7
STOP WORK ORDER
10.7.1 The procurement officer may, at any time, by written order to the Contractor,
require the Contractor to stop all, or any part, of the work called for by this contract
for a period of 90 calendar days after the order is delivered to the Contractor, and
for any further period to which the parties may agree. The order shall be specifically
identified as a stop work order issued under this clause. Upon receipt of the order,
the Contractor shall immediately comply with its terms and take all reasonable
steps to minimize the incurrence of costs allocable to the work covered by the order
during the period of work stoppage. Within a period of 90 calendar days after a
stop work order is delivered to the Contractor, or within any extension of that period
to which the parties shall have agreed, the procurement officer shall either:
10.10.1.1 cancel the stop work order; or
10.10.1.2 terminate the work covered by the order as provided in the Termination
for Default or the Termination for Convenience clause of this contract.
10.10.1.3 The procurement officer may make an equitable adjustment in the
delivery schedule and/or contract price, and the contract shall be
modified, in writing, accordingly, if the Contractor demonstrates that the
stop work order resulted in an increase in costs to the Contractor.
10.8
TERMINATION FOR CONVENIENCE
The County may terminate the contract for convenience by providing 60 calendar days
advance notice to the Contractor.
10.9
TERMINATION FOR DEFAULT
10.9.1 The County may, by written Notice of Default to the Contractor, terminate this
contract in whole or in part if the Contractor fails to:
10.12.1.1 deliver the supplies or to perform the services within the time specified
in this contract or any extension;
10.12.1.2 make progress, so as to endanger performance of this contract; or
10.12.1.3 perform any of the other provisions of this contract.
10.9.2 The County’s right to terminate this contract under these subparagraphs may be
exercised if the Contractor does not cure such failure within 10 business days (or
more if authorized in writing by the County) after receipt of a Notice to Cure from
the procurement officer specifying the failure.
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10.10
PERFORMANCE
It shall be the Contractor’s responsibility to meet the proposed performance requirements.
Maricopa County reserves the right to obtain services on the open market in the event the
Contractor fails to perform, and any price differential will be charged against the Contractor.
10.11
CONTRACTOR EMPLOYEE MANAGEMENT
10.11.1 Contractor shall not reassign any key personnel identified in their proposal without
the express consent of the County. Contractor shall provide a minimum of two
weeks’ notice to the County of any changes to key personnel on the County’s
account.
10.11.2 County reserves the right to request the replacement of any Contractor personnel
at any time, for any reason.
10.12
TRAINING
Contractor shall provide training services to completely train County personnel in the use
of employer and participant portal. All training shall take place on-site in Maricopa County,
unless otherwise negotiated with County.
10.13
WARRANTY OF SERVICES
10.13.1 The Contractor warrants that all services provided hereunder will conform to the
requirements of the contract, including all descriptions, specifications, exhibits, and
attachments made a part of this contract. County’s acceptance of services or
goods provided by the Contractor shall not relieve the Contractor from its
obligations under this warranty.
10.13.2 In addition to its other remedies, County may, at the Contractor's expense, require
prompt correction of any services failing to meet the Contractor's warranty herein.
Services corrected by the Contractor shall be subject to all the provisions of this
contract in the manner and to the same extent as services originally furnished
hereunder.
10.14
USAGE REPORT
The Contractor shall furnish the County a usage report upon request, delineating the
acquisition activity governed by the contract. The format of the report shall be approved by
the County and shall disclose the quantity and dollar value of each contract item by
individual unit of measure at no cost to the County.
10.15
STATUTORY RIGHT OF CANCELLATION FOR CONFLICT OF INTEREST
Notice is given that, pursuant to A.R.S. § 38-511, the County may cancel any contract
without penalty or further obligation within three years after execution of the contract, if any
person significantly involved in initiating, negotiating, securing, drafting, or creating the
contract on behalf of the County is at any time, while the contract or any extension of the
contract is in effect, an employee or agent of any other party to the contract in any capacity
or consultant to any other party of the contract with respect to the subject matter of the
contract. Additionally, pursuant to A.R.S. § 38-511, the County may recoup any fee or
commission paid or due to any person significantly involved in initiating, negotiating,
securing, drafting, or creating the contract on behalf of the County from any other party to
the contract arising as the result of the contract.
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10.16
OFFSET FOR DAMAGES
In addition to all other remedies at Law or Equity, the County may offset from any money
due to the Contractor any amounts Contractor owes to the County for damages resulting
from breach or deficiencies in performance of the contract.
10.17
SUBCONTRACTING
10.17.1 The Contractor may not assign to another Contractor or subcontract to another
party for performance of the terms and conditions hereof without the written
consent of the County. All correspondence authorizing subcontracting must
reference the bid serial number and identify the job or project.
10.17.2 The subcontractor’s rate for the job shall not exceed that of the prime Contractor’s
rate, as bid in the pricing section, unless the prime Contractor is willing to absorb
any higher rates. The subcontractor’s invoice shall be invoiced directly to the prime
Contractor, who in turn shall pass-through the costs to the County, without mark-
up. A copy of the subcontractor’s invoice must accompany the prime Contractor’s
invoice.
10.18
AMENDMENTS
All amendments to this contract shall be in writing and approved/signed by both parties.
Maricopa County Office of Procurement Services shall be responsible for approving all
amendments for Maricopa County.
10.19
ADDITIONS/DELETIONS OF REQUIREMENTS
The County reserves the right to add and/or delete materials and services to a contract. If
a service requirement is deleted, payment to the Contractor will be reduced proportionately
to the amount of service reduced in accordance with the bid price. If additional materials
or services are required from a contract, prices for such additions will be negotiated
between the Contractor and the County.
10.20
RIGHTS IN DATA
10.20.1 The County shall have the use of data and reports resulting from a contract without
additional cost or other restriction except as may be established by law or
applicable regulation. Each party shall supply to the other party, upon request, any
available information that is relevant to a contract and to the performance
thereunder.
10.20.2 Data, records, reports, and all other information generated for the County by a third
party as the result of a contract are the property of the County and shall be provided
in a format designated by the County or shall be and remain accessible to the
County into perpetuity.
10.21
ACCESS TO AND RETENTION OF RECORDS FOR THE PURPOSE OF AUDIT AND/OR
OTHER REVIEW
10.21.1 In accordance with Section MC1-372 of the Maricopa County Procurement Code,
the Contractor agrees to retain (physical or digital copies of) all books, records,
accounts, statements, reports, files, and other records and back-up documentation
relevant to this contract for six years after final payment or until after the resolution
of any audit questions, which could be more than six years, whichever is longest.
The County, Federal or State auditors and any other persons duly authorized by
the department shall have full access to and the right to examine, copy, and make
use of, any and all said materials.
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10.21.2 If the Contractor’s books, records, accounts, statements, reports, files, and other
records and back-up documentation relevant to this contract are not sufficient to
support and document that requested services were provided, the Contractor shall
reimburse Maricopa County for the services not so adequately supported and
documented.
10.22
AUDIT DISALLOWANCES
If at any time it is determined by the County that a cost for which payment has been made
is a disallowed cost, the County shall notify the Contractor in writing of the disallowance.
The course of action to address the disallowance shall be at sole discretion of the County,
and may include either an adjustment to future invoices, request for credit, request for a
check, or a deduction from current invoices submitted by the Contractor equal to the
amount of the disallowance, or to require reimbursement forthwith of the disallowed amount
by the Contractor by issuing a check payable to Maricopa County.
10.23
STRICT COMPLIANCE
Acceptance by County of a performance that is not in strict compliance with the terms of
the contract shall not be deemed to be a waiver of strict compliance with respect to all other
terms of the contract.
10.24
VALIDITY
The invalidity, in whole or in part, of any provision of this contract shall not void or affect
the validity of any other provision of the contract.
10.25
SEVERABILITY
The removal, in whole or in part, of any provision of this contract shall not void or affect the
validity of any other provision of this contract.
10.26
RELATIONSHIPS
In the performance of the services described herein, the Contractor shall act solely as an
independent Contractor, and nothing herein or implied herein shall at any time be
construed as to create the relationship of employer and employee, co-employee,
partnership, principal and agent, or joint venture between the County and the Contractor.
10.27
NON-DISCRIMINATION
Contractor agrees to comply with all provisions and requirements of Arizona Executive
Order 2009-09, including flow down of all provisions and requirements to any
subcontractors. Executive Order 2009-09 supersedes Executive Order 99-4 and amends
Executive Order 75-5 and is hereby incorporated into this contract as if set forth in full
herein. During the performance of this contract, contractor shall not discriminate against
any employee, client, or any other individual in any way because of that person’s age, race,
creed, color, religion, sex, disability, or national origin. (Arizona Executive Order 2009-09
can be viewed at https://apps.azsos.gov/public_services/register/2009/46/governor.pdf)
10.28
WRITTEN CERTIFICATION PURSUANT to A.R.S. § 35-393.01
If Contractor engages in for-profit activity and has 10 or more employees, and if this
agreement has a value of $100,000 or more, vendor certifies it is not currently engaged in,
and agrees for the duration of this agreement to not engage in, a boycott of goods or
services from Israel. This certification does not apply to a boycott prohibited by 50 U.S.C.
§ 4842 or a regulation issued pursuant to 50 U.S.C. § 4842.
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10.29
CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
10.29.1 The undersigned (authorized official signing on behalf of the Contractor) certifies
to the best of his or her knowledge and belief that the Contractor, its current
officers, and directors:
10.33.1.1 are not presently debarred, suspended, proposed for debarment,
declared ineligible, or voluntarily excluded from being awarded any
contract or grant by any United States department or agency or any
state, or local jurisdiction;
10.33.1.2 have not within a three-year period preceding this contract:
10.33.1.2.1 been convicted of fraud or any criminal offense in
connection with obtaining, attempting to obtain, or as the
result of performing a government entity (Federal, State or
local) transaction or contract; or
10.33.1.2.2 been convicted of violation of any Federal or State antitrust
statutes or conviction for embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false
statements, or receiving stolen property regarding a
government entity transaction or contract;
10.33.1.3 are not presently indicted or criminally charged by a government entity
(Federal, State or local) with commission of any criminal offenses in
connection with obtaining, attempting to obtain, or as the result of
performing a government entity public (Federal, State or local)
transaction or contract;
10.33.1.4 are not presently facing any civil charges from any governmental entity
regarding obtaining, attempting to obtain, or from performing any
governmental entity contract or other transaction; and
10.33.1.5 have not within a three-year period preceding this contract had any
public transaction (Federal, State or local) terminated for cause or
default.
10.29.2 If any of the above circumstances described in the paragraph are applicable to the
entity submitting a bid for this requirement, include with your bid an explanation of
the matter including any final resolution.
10.29.3 The Contractor shall include, without modification, this clause in all lower tier
covered transactions (i.e. transactions with subcontractors or sub-subcontractors)
and in all solicitations for lower tier covered transactions related to this contract. If
this clause is applicable to a subcontractor or sub-subcontractor, the Contractor
shall include the information required by this clause with their bid.
10.30
VERIFICATION REGARDING COMPLIANCE WITH A.R.S. § 41-4401 AND FEDERAL
IMMIGRATION LAWS AND REGULATIONS
10.30.1 By entering into the contract, the Contractor warrants compliance with the
Immigration and Nationality Act (INA using E-Verify) and all other Federal
immigration laws and regulations related to the immigration status of its employees
and A.R.S. § 23-214(A). The Contractor shall obtain statements from its
subcontractors certifying compliance and shall furnish the statements to the
procurement officer upon request. These warranties shall remain in effect through
the term of the contract. The Contractor and its subcontractors shall also maintain
Employment Eligibility Verification forms (I-9) as required by the Immigration Reform
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and Control Act of 1986, as amended from time to time, for all employees performing
work under the contract and verify employee compliance using the E-Verify system
and shall keep a record of the verification for the duration of the employee’s
employment or at least three years, whichever is longer. I-9 forms are available for
download at www.uscis.gov.
10.30.2 The County retains the legal right to inspect documents of Contractor and
subcontractor employees performing work under this contract to verify compliance
with paragraph 10.30.1 of this section. Contractor and subcontractor shall be given
reasonable notice of the County’s intent to inspect and shall make the documents
available at the time and date specified. Should the County suspect or find that the
Contractor or any of its subcontractors are not in compliance, the County will
consider this a material breach of the contract and may pursue any and all remedies
allowed by law, including, but not limited to: suspension of work, termination of the
contract for default, and suspension and/or debarment of the Contractor. All costs
necessary to verify compliance are the responsibility of the Contractor.
10.31
CONTRACTOR LICENSE REQUIREMENT
The Contractor shall procure all permits, insurance, and licenses, and pay the charges and
fees necessary and incidental to the lawful conduct of his/her business, and as necessary
complete any requirements, by any and all governmental or non-governmental entities as
mandated to maintain compliance with and remain in good standing. The Contractor shall
keep fully informed of existing and future trade or industry requirements, and Federal,
State, and local laws, ordinances, and regulations which in any manner affect the fulfillment
of a contract and shall comply with the same. Contractor shall immediately notify both the
Office of Procurement Services and the department of any and all changes concerning
permits, insurance, or licenses.
10.32
INFLUENCE
10.32.1 As prescribed in MC1-1203 of the Maricopa County Procurement Code, any effort
to influence an employee or agent to breach the Maricopa County Ethical Code of
Conduct or any ethical conduct, may be grounds for disbarment or suspension
under MC1-902.
10.32.2 An attempt to influence includes, but is not limited to:
10.36.2.1 A person offering or providing a gratuity, gift, tip, present, donation,
money, entertainment or educational passes or tickets, or any type of
valuable contribution or subsidy that is offered or given with the intent to
influence a decision, obtain a contract, garner favorable treatment, or
gain favorable consideration of any kind.
10.32.3 If a person attempts to influence any employee or agent of Maricopa County, the
chief procurement officer, or his designee, reserves the right to seek any remedy
provided by the Maricopa County Procurement Code, any remedy in equity or in
the law, or any remedy provided by this contract.
10.33
CONFIDENTIAL INFORMATION
10.33.1 Any information obtained in the course of performing this contract may include
information that is proprietary or confidential to the County. This provision
establishes the Contractor’s obligation regarding such information.
10.33.2 The Contractor shall establish and maintain procedures and controls that are
adequate to assure that no information contained in its records and/or obtained
from the County or from others in carrying out its functions (services) under the
contract shall be used by or disclosed by it, its agents, officers, or employees,
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except as required to efficiently perform duties under the contract. The Contractor’s
procedures and controls, at a minimum, must be the same procedures and controls
it uses to protect its own proprietary or confidential information. If, at any time
during the duration of the contract, the County determines that the procedures and
controls in place are not adequate, the Contractor shall institute any new and/or
additional measures requested by the County within 15 business days of the
written request to do so.
10.33.3 Any requests to the Contractor for County proprietary or confidential information
shall be referred to the County for review and approval, prior to any dissemination.
10.34
PUBLIC RECORDS
Under Arizona law, all offers submitted and opened are public records and must be
retained by the County at the Maricopa County Office of Procurement Services. Offers shall
be open to public inspection and copying after contract award and execution, except for
such offers or sections thereof determined to contain proprietary or confidential information
by the Office of Procurement Services. If an offeror believes that information in its offer or
any resulting contract should not be released in response to a public record request, under
Arizona law, the offeror shall indicate the specific information deemed confidential or
proprietary and submit a statement with its offer detailing the reasons that the information
should not be disclosed. Such reasons shall include the specific harm or prejudice which
may arise from disclosure. The records manager of the Office of Procurement Services
shall determine whether the identified information is confidential pursuant to the Maricopa
County Procurement Code.
10.35
INTEGRATION
This contract represents the entire and integrated agreement between the parties and
supersedes
all
prior
negotiations,
proposals,
communications,
understandings,
representations, or agreements, whether oral or written, expressed, or implied.
10.36
UNIFORM ADMINISTRATIVE REQUIREMENTS
By entering into this contract, the Contractor agrees to comply with all applicable provisions
of
Title
2,
Subtitle
A,
Chapter
II,
Part
200—UNIFORM
ADMINISTRATIVE
REQUIREMENTS, COST PRINCIPLES, AND AUDIT REQUIREMENTS FOR FEDERAL
AWARDS contained in Title 2 C.F.R. § 200 et seq.
10.37
GOVERNING LAW
This contract shall be governed by the laws of the State of Arizona. Venue for any actions
or lawsuits involving this contract will be in Maricopa County Superior Court, Phoenix,
Arizona.
10.38
FORCED LABOR
10.38.1 By submitting a bid for this solicitation and/or entering into a contract as a result of
this solicitation, contractor agrees to comply with all applicable portions of Arizona
Revised Statutes Section 35-394. Contracting; procurement; prohibition; written
certification; remedy; termination; exception; definitions.
10.38.2 Contractor certifies that it does not currently, and agrees for the duration of the
contract, that it will not use:
10.42.2.1 The forced labor of ethnic Uyghurs in the People’s Republic of China.
10.42.2.2 Any goods or services produced by the forced labor of ethnic Uyghurs
in the People’s Republic of China.
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10.42.2.3 Any contractors, subcontractors or suppliers that use the forced labor or
any good or services produced by the forced labor of ethnic Uyghurs in
the People’s Republic of China.
10.38.3 If contractor becomes aware during the term of the agreement that contractor is
not in compliance with this paragraph, the contractor shall notify the County within
five business days after becoming aware of the noncompliance. If the contractor
fails to provide a written certification to the County that the contractor has remedied
the noncompliance within 180 days after notifying the County of its noncompliance,
then the agreement terminates, except that if the agreement termination date
occurs before the end the 180-day period, the agreement terminates on the
agreement termination date.
10.39
PRICES
Contractor warrants that prices extended to County under this contract are no higher than
those paid by any other customer for these or similar services.
10.40
ORDER OF PRECEDENCE
In the event of a conflict in the provisions of this contract and Contractor’s ASO agreement,
if applicable, the terms of this contract shall prevail.
10.41
UNIQUE ENTITY IDENTIFIER (UEI) AND SYSTEM FOR AWARD MANAGEMENT
REGISTRATION
All
contractors
that
receive
funding
must
have
a
UEI
number
through
https://sam.gov/content/entity-registration. Contractor must also remain current with the
System for Award Management www.sam.gov throughout the term of the contract.
10.42
INCORPORATION OF DOCUMENTS
10.42.1 The following are to be attached to and made part of this Contract:
10.46.1.1 Exhibit A – Vendor Information and Pricing
10.46.1.2 Exhibit A-1
10.46.1.3 Exhibit B – Scope of Work (Administrative Services Agreement)
10.46.1.3.1 Exhibit B-1 - Services
10.46.1.3.2 Exhibit B-2 - Health Savings Account Enrollment and
Contribution
10.46.1.4 Exhibit C – Business Associates Agreement
10.46.1.5 Exhibit D – Performance Service Level Agreements (Medical and PBM)
10.46.1.6 Exhibit E – Claims Guarantee
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10.43
NOTICES
All notices given pursuant to the terms of this contract shall be addressed to:
For County:
Maricopa County
Office of Procurement Services
301 W. Jefferson St. Suite 700
Phoenix, Arizona 85003-1647
For Contractor:
Attn: Senior Strategic Account Executive
United HealthCare Services Inc
1 East Washington Street Suite 1700
Phoenix, AZ 85004
10.44
INQUIRIES
10.44.1 Administrative telephone/email inquiries shall be addressed to:
ELIZABETH KUTTNER, PROCUREMENT OFFICER
TELEPHONE: (602) 506-0099
elizabeth.kuttner@maricopa.gov
10.44.2 Inquiries may be submitted by telephone but must be followed up in writing. No
oral communication is binding on Maricopa County.
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IN WITNESS WHEREOF, this contract is executed on the date set forth above.
CONTRACTOR
AUTHORIZED SIGNATURE
PRINTED NAME AND TITLE
ADDRESS
DATE
MARICOPA COUNTY
CHAIRMAN, BOARD OF SUPERVISORS
DATE
ATTESTED:
CLERK OF THE BOARD
DATE
APPROVED AS TO FORM:
DEPUTY COUNTY ATTORNEY
DATE
By: ______________________________________
Holly Durinick, Regional Contract Manager
185 Asylum Street, Hartford, CT 06103-3408
06/03/2024
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EXHIBIT A: VENDOR INFORMATION AND PRICING
COMPANY NAME:
United HealthCare Services, Inc.
DOING BUSINESS AS (dba):
UnitedHealthcare
MAILING ADDRESS:
9900 Bren Road East, Minnetonka, MN 55343
REMIT TO ADDRESS:
9900 Bren Road East, Minnetonka, MN 55343
TELEPHONE NUMBER:
952-936-1300
FAX NUMBER:
952-939-7430
WWW ADDRESS:
www.unitedhealthcare.com
REPRESENTATIVE NAME:
Elizabeth Kirschner
REPRESENTATIVE TELEPHONE NUMBER:
602-255-8030
REPRESENTATIVE EMAIL ADDRESS
elizabeth.kirschner@uhc.com
UNIQUE ENTITY ID (UEI) FROM SAM.GOV
ZBYAMU8W9UJ1
YES
NO
REBATE
WILL ALLOW OTHER GOVERNMENTAL ENTITIES TO PURCHASE
FROM THIS CONTRACT:
WILL ACCEPT PROCUREMENT CARD FOR PAYMENT:
NET 30 DAYS
ADMINISTRATIVE SERVICE FEES
ASO MEDICAL FEES
Year 1
ASO Fees
(PEPM)
Year 3
Year 4
Year 5
Plan Year
1/1/2025
through
12/31/2025
1/1/2026
through
12/31/2026
1/1/2027
through
12/31/2027
1/1/2028
through
12/31/2028
1/1/2029
through
12/31/2029
Choice +
$20.59
$20.59
$20.59
$20.59
$20.59
Choice+ HSA
$20.59
$20.59
$20.59
$20.59
$20.59
Credits
Audit Credit
N/A
$100,000.00
N/A
$100,000.00
N/A
Administrative
Credit
$275,000.00
$275,000.00
$275,000.00
$275,000.00
$275,000.00
Communication
Credit
N/A
N/A
N/A
N/A
N/A
Wellness Credit
N/A
N/A
N/A
N/A
N/A
Ad Hoc custom
reporting hours
20 hours
20 hours
20 hours
20 hours
20 hours
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The following services may require an additional cost as noted below:
Additional Disease Management, Specialty and Wellness
Programs (Fees are on a PEPM basis unless specifically
noted)
Current
Year 1
Year 2
Year 3
Year 4
1/1/2024
1/1/2025
1/1/2026
1/1/2027
1/1/2028
through
through
through
through
through
12/31/2024
12/31/2025
12/31/2026
12/31/2027
12/31/2028
Disease Management Programs:
Congestive Heart Failure (VOM)
Included in
Personal Health
Support
Included in Personal
Health Support
Included in
Personal Health
Support
Included in
Personal Health
Support
Included in
Personal Health
Support
Chronic Obstructive Pulmonary Disease (VOM)
Coronary Artery Disease (VOM)
Diabetes Program (VOM)
Asthma Program (VOM)
Medical Management Programs
Core Medical Necessity
Included
Included
Included
Included
Included
Physical Health Solutions:
Chiropractic Network
Included
Included
Included
Included
Included
Physical Therapy/Occupational Therapy/Speech Therapy Network
Included
Included
Included
Included
Included
Complementary Alternative Medicine (CAM) Network
Management
Included
Included
Included
Included
Included
Other Programs/Services:
PHS 3.0 Tier 3
Included
Included
Included
Included
Included
Behavioral Health Solutions
$3.34
$3.34
$3.34
$3.34
$3.34
Claim Fiduciary
Included
Included
Included
Included
Included
Designated PS Call Team in San Antonio
Included
Included
Included
Included
Included
Dedicated 800 Number
Included
Included
Included
Included
Included
Onsite Customer Service Representative
Included
Included
Included
Included
Included
MH/SA Feed w Magellan
Included
Included
Included
Included
Included
Customer Specific Provider Networks
Included
Included
Included
Included
Included
Claims Run Out - 18 Months
Included
Included
Included
Included
Included
Hinge Health Acute
$250 Per Case,
Chronic $995,
Surgery $995
$250 Per Case,
Chronic $995,
Surgery $995
$250 Per Case,
Chronic $995,
Surgery $995
$250 Per Case,
Chronic $995,
Surgery $995
$250 Per Case,
Chronic $995,
Surgery $995
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The following are not included in the above ASO Fees:
Additional Services
Fee
Naviguard
$11.00 PEPM, not to exceed $750,000 per year for both plans
combined
Flex Share Rewards
34.7% of network savings achieved between 61.9 and 65%
Transplant Resource Services Transplant Cost Negotiation Program
$8,333 per negotiation
Payment Integrity (Fees collected through Bank Account):
Enhanced Abuse and Fraud Management Program
30% of recoveries
Prospective Abuse and Fraud Management Program
30% of recoveries
Advanced Analytics and Recovery Services (AARS)
30% of recoveries
Credit Balance Recovery Program
not to exceed 30% of recoveries
Hospital Bill Audit Program
not to exceed 30% of savings
Subrogation Services
25% of recoveries
Focused Claim Review
30% of savings
Coordination of Benefits
25% of savings
Health Savings Account Maintenance fee
$1.00 per month per account, . (if the account holder’s average
daily balance is more than $3,000 as calculated on the last day of
the month, the monthly maintenance fee is waived).
The following are included in the ASO Fees (applies to Active and Pre-65 Retiree population only):
eServices Select Reporting - (interactive fully Web-based reporting)
Federal External Review Program (third level appeals) - our Medical ASO fee includes a maximum of 10 reviews. Reviews in excess of this limit will be
charged at $500 per review.
Advocate4Me Customer Service Model that provides participants with access to a one-stop advocacy resource for an unprecedented range of
needs, including support and access to services across medical benefits, claims, pharmacy, clinical, incentives, and more.
team organized around the account providing in-depth, actionable insights based on real-time data.
Customer Service, our quoted customer service model offers participants a high-touch, personal guide who provides support in navigating benefits,
understanding payment options, resolving claim issues and working through the health care system. In addition to acting as a one-stop shop
where participants can be directed to the most appropriate existing services, representatives can provide additional information relevant to
personal needs and take ownership of inquires end-to-end. For those not resolved during the initial call, customer service representatives
take ownership until resolution including call back to the participant.
Employer Internet Solution – www.employereservices.com
Our quote includes the management of over 100 disease states/conditions, as part of our Personal Health Support (PHS) program. We believe this
approach will adequately address the clinical conditions present within the population - though we are open to discussing and proposing
alternative programs, should clinical prevalence indicate an appropriate ROI.
Consumer Activation, including basic navigation guide, health statements with individualized messaging, advanced concierge call services,
and access to participant portal with consumer activation messaging
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UnitedHealthcare will duplicate requested plan of benefits in principle and in a manner compatible with our understanding of the basic plan
designs. Our quotation may be adjusted contingent upon review of all Medical plan design specifics. Our fees may be adjusted, or changes
to the plans may be required to enable us to administer claim payments.
Pricing Assumptions
Our quote includes the Flex Share Rewards program which includes a variable fee equal to 34.7% of network savings achieved above 61.9% to a cap of
65% on claims up to $1M. The Flex Share Rewards program fee will be based on the Overall UHC Network Savings discount amount associated with your
claims. With the County’s approval, UnitedHealthcare may adjust rates, by amendment to the contract, in the event there are changes to these
assumptions. UnitedHealthcare will provide annual reporting 60 days following the end of the plan year that illustrates how the fee is calculated and what
savings were attained.
The Plan or its sponsor is responsible for state or federal surcharges, assessments, or similar taxes or fees imposed by governmental entities or agencies on
the Plan, Plan Sponsor or us, including but not limited to those imposed pursuant to the Patient Protection and Affordable Care Act of 2010 (PPACA), as
amended from time to time. This includes responsibility for determining the amount due, funding, and remitting the PPACA Transitional Reinsurance fee and
the PCORI fee which are remitted to the government (federal and/or state).
The fees quoted do not include state or federal surcharges, assessments, or similar taxes/fees imposed by governmental entities or agencies on the Plan,
Plan Sponsor or UnitedHealthcare. We reserve the right to adjust the rates (i) in the event of any changes in federal, state or other applicable legislation or
regulation; (ii) in the event of any changes in plan design or procedures required by the applicable regulatory authority or by the sponsor; and (iii) as
otherwise permitted in the Administrative Services Agreement.
The administrative fees set forth herein do not include fees related to the requirements set forth in the Consolidated Appropriations Act, 2021, including the
No Surprises Act. Additional fees for these new regulatory requirements will be provided at a future date once regulatory guidance is received and final
compliance requirements are determined.
UnitedHealthcare reserves the right to revise this quotation under the following circumstances:
The total number of enrolled medical employees varies by more than 15 percent from the assumed medical enrollment of 7,618
The average contract size, defined as the total number of enrolled employees plus dependents divided by the total number of enrolled
employees, varies by 15 percent or more from the assumed average contract size of 2.28.
The benefits or service requirements requested and/or quoted change prior to or after the effective date.
In the event of any changes in federal, state or other applicable legislation or regulation that require changes to this quotation.
In the event of any changes in plan design required by the applicable regulatory authority or by the Plan sponsor.
In the event that any taxes, surcharges, assessments, or similar charges are imposed by governmental entities or agencies on the Plan or
UnitedHealthcare, in its role as administrator or insurer.
As otherwise permitted in our Administrative Services Agreement
Our mature quotation includes the processing of runout claims for 18 months following the termination of our contract.
MARICOPA COUNTY will receive 100.0% of rebates on prescription drug products dispensed under the medical benefit plan.
Commissions are excluded.
No Stop Loss carrier with a competing network or affiliated with an entity with a competing network may write Stop Loss coverage (individual or aggregate)
on top of a UnitedHealthcare network
This quotation assumes UnitedHealthcare will retain claim fiduciary responsibility
UnitedHealthCare will provide an Audit Credit and Administrative Credit (General Purpose) to help MARICOPA COUNTY mitigate costs associated with
communication to Participants, additional wellness services from United, and external Audit services.
These credits are available as follows:
The parties must have an executed Agreement.
The first month of service fees under the Agreement has been received by United.
SERIAL 240028-ITN
Credits must be used between 01/01/2025 and 12/31/2029. Any Credits not used during this time period are forfeit.
Upon request from MARICOPA COUNTY, a credit will be issued in UnitedHealthCare’s fee billing system.
If MARICOPA COUNTY terminates the Agreement prior to 12/31/2027, MARICOPA COUNTY will repay UnitedHealthCare a prorated portion
of the credit paid in the year of termination based on the termination date. Credits in prior years are not subject to repayment. All unpaid
credits are forfeit.
United will provide 20 hours of custom Ad Hoc reporting hours annually. Unused hours shall be rolled over for use in the subsequent year(s)
and capped at 60 hours.
SERIAL 240028-ITN
EXHIBIT A-1
The Standard Medical Service Fees (excluding Optional and Non-Standard Fees) and that portion of the Standard Medical Service Fees attributable
to Commission Funds, if applicable, (hereinafter referred to as “Fees”) payable by the County under this Agreement will be adjusted through a credit
to the County's Service Fees in accordance with the arrangements set forth below unless otherwise noted.
Unless otherwise specified, these arrangements apply to pharmacy benefits and are effective for the period beginning 01/01/2025 and ending on
12/31/2029 (each twelve month period is a "Guarantee Period"). With respect to the aspects of UnitedHealthCare’s performance and in this exhibit,
these fee adjustments are the County's exclusive financial remedies.
The arrangements will become effective upon the later of (1) the effective date of the Guarantee Period; or (2) the date the Agreement is signed by
both parties. In the event these arrangements become effective later than the effective date of the Guarantee Period the arrangements will
commence with the Agreement Period during which the Agreement is signed by both parties.
UnitedHealthCare shall not be required to meet any of the guarantees provided for in this Agreement or amendments thereto to the extent
UnitedHealthCare’s failure is due to the County's actions or inactions or if UnitedHealthCare fails to meet these standards due to fire, embargo,
strike, war, accident, pandemic, act of God, acts of terrorism or UnitedHealthCare’s required compliance with any law, regulation, or governmental
agency mandate or anything beyond UnitedHealthCare’s reasonable control.
Prior to the end of the Guarantee Period, and provided that this Agreement remains in force, UnitedHealthCare may specify to the County in writing
new arrangements for the subsequent Guarantee Period. If UnitedHealthCare specifies new arrangements, UnitedHealthCare will also provide the
County with a new Exhibit that will replace this Exhibit for that subsequent Guarantee Period.
Pharmacy Financials
Definition
Pharmacy rate guarantees.
Measurement
2025
2026
2027-2029
and Criteria
Combined Discount Guarantee - Broad Network
Retail Brand, Average Wholesale Price (AWP) less
19.30%
19.40%
19.50%
Retail Brand -- 90 Day Supply, AWP less
22.50%
22.60%
22.70%
Retail Generic - 30 and 90 Day Supply, AWP less
85.00%
85.10%
85.20%
Mail Order Brand, AWP less
25.50%
25.60%
25.70%
Mail Order Generic, AWP less
87.00%
87.10%
87.20%
The Guaranteed Discount amount will be determined by multiplying the AWP by the guaranteed discount off AWP by each component
and adding the amounts together.
Dispensing Fees - Broad Network
Retail Brand - 30 Day
$0.55
$0.55
$0.55
Retail Brand -- 90 Day Supply
$0.25
$0.25
$0.25
Retail Generic - 30 Day
$0.55
$0.55
$0.55
Retail Generic -- 90 Day Supply
$0.25
$0.25
$0.25
Home Delivery – any supply
$0.00
$0.00
$0.00
SERIAL 240028-ITN
Dispensing fee totals are calculated by multiplying the actual scripts for each type by the contracted rate for that script type.
Minimum Rebate Guarantee (Traditional PDL)
Rebate Sharing Percentage
100.0%
100.0%
100.0%
Basis, per script
Brand
Brand
Brand
Retail - 30 Day
$368.95
$437.00
$487.05
Retail - 90 Day Supply
$1,152.83
$1,398.44
$1,627.80
Mail Order
$1,152.83
$1,398.44
$1,627.80
Specialty
$3,877.85
$4,281.02
$4,678.39
Credits and Allowances
Pharmacy Management Allowance (once per enrolled
participant)
$3.00
$3.00
$3.00
Fees
Variable Copay program (monthly, per eligible participant)
$0.45
$0.45
$0.45
Level
County Specific
Period
Annually
Payment Period
Annually
Payment
Amount
--
Discounts
The amount the actual discounts are less than the combined guaranteed Retail, Mail, and Specialty discount amount.
Payment
Amount
--
Dispensing Fees
The amount the combined actual dispensing fee exceeds the combined contracted dispensing fee.
Payment
Amount
--
Rebates
The amount the combined actual Rebate amount is less than the combined guaranteed Rebate amount.
Conditions
Discount & Dispense Fee Specific Conditions
• Discounts are based on actual Network Pharmacy brand and generic usage of retail and mail order drugs. The guaranteed discount
amount will be determined by multiplying the AWP by the contracted discount rate off AWP by component.
• Does not apply to items covered under the Plan for which no AWP measure exists.
• Discounts calculated based on AWP less the ingredient cost; discount percentages are the discounts divided by the AWP. Discounts
for retail and mail order generic prescriptions represent the average AWP based on savings off Maximum Allowable Cost (MAC) pricing
for MAC generics and percentage discount savings off AWP for non-MAC generics. All other discounts represent the percentage
discount savings off of AWP.
• The arrangement excludes generic medications launched as an 'at-risk' product, generic medication with pending litigation, retail out of
network claims, mail order drugs (for dispensing fee arrangement) and Indian Health Service Claims.
• The Arrangement excludes usual & customary claims, vaccines, long term care facility claims.
• The Arrangement includes veterans’ affairs facility claims, over-the-counter claims.
• The 90-day supply Retail guarantee includes drugs dispensed for 84 days or greater.
• The Mail Order guarantee includes drugs dispensed for 46 days or greater; claims with less than 46 days’ supply are reconciled at
retail.
SERIAL 240028-ITN
• When a drug is identified as a brand name drug, it will be considered a brand name drug for the calculation of discount guarantees.
When a drug is identified as a generic drug, it will be considered a generic drug for the calculation of discount guarantees.
• Specialty drugs dispensed outside UnitedHealthCare’s specialty Pharmacy Network are included in the retail guarantees. Specialty
drugs dispensed through UnitedHealthCare’s specialty Pharmacy Network are excluded from the Retail and Mail guarantees.
Rebate Specific Conditions
• Assumes implementation of UnitedHealthCare's Traditional PDL
• County directed deviations from the PDL may result in changes to pricing and guarantees, which will be communicated to the County at
the time the deviation is made and factored in at the time of rebate payment and/or reconciliation.
• Calculation of the guaranteed rebate amount will exclude ineligible claims including:
- claims where the plan is not the primary payer (e.g., coordination of benefits and subrogation claims)
- claims approved by formulary exception
- claims not covered by County's benefit design or PDL
- claims receiving 340B pricing
- long term care pharmacy claims
- federal government pharmacy claims
- claims for non-FDA approved products
- compound drug claims with no rebates
- direct participant reimbursement claims
• Over-the-counter and repackaged drugs are excluded from the claim counts.
• Devices are excluded from the claim counts; Test Strips are not excluded.
• Claims for insulin products are excluded from the claim counts
• Vaccines are excluded from the claim counts.
• Rebate guarantee payments or reconciliations may be adjusted in the event of a change impacting the level of Rebates due to the
introduction of therapeutically equivalent, lower Rebate drugs (e.g. biosimilar, authorized brand alternative, lower cost non-Generic Drug
alternative) or the reduction of Wholesale Acquisition Cost on a Brand Drug subject to Rebates. In the event a payment or reconciliation
adjustment is required, such adjustment will be based on the difference between a) pharmaceutical manufacturer revenue prior to the
introduction of the lower Rebate drugs and b) the actual pharmaceutical manufacturer revenue received after the introduction of the
lower Rebate drugs. Such adjustment does not apply to Generic Drugs that launch after the Brand Drug no longer has patent protection.
• The Rebate guarantees set forth herein account for projected Rebate reductions in the following classes of Prescription Drugs in
connection with the elimination of the Average Manufacturer’s Price (AMP) Cap pursuant to the American Rescue Plan Act of 2021:
Insulin products and Respiratory Medications. UnitedHealthCare reserves the right to modify or eliminate any Rebate guarantees if there
are any additional changes to Rebates received from pharmaceutical manufacturers.
SERIAL 240028-ITN
UnitedHealthCare reserves the right to modify or eliminate this arrangement as follows based upon changes in Rebates:
• if changes made to UnitedHealthCare’s PDL, for the purpose of achieving a lower net drug cost for the County and UnitedHealthCare’s
other ASO customers, result in significant reductions to the Rebate level
• in the event that there are material deviations to the anticipated timing of drugs that will come off patent and no longer generate
Rebates
• if there is a change impacting the availability or amount of Rebates offered by drug manufacturer(s), including changes related to the
elimination or material modification of a drug manufacturer(s) historic models or practices related to the provision of Rebates
• UnitedHealthCare will pay Rebates consistent with the Agreement. A reconciliation of the Rebate amounts will occur after the end of
each annual contract period and when Rebate payments are substantially complete. The reconciliation calculates the minimum rebate
amount by multiplying the actual number of scripts filled by the applicable rebate amount for that script type.
• Manufacturer Administrative Fees are the administrative fees paid by drug manufacturers to UnitedHealthCare’s PBM affiliate as
consideration for maintaining systems and processes necessary for managing and administering Rebate programs. Manufacturer
Administrative Fees are included in the guaranteed rebate arrangement.
• If the County terminates pharmacy benefit services with UnitedHealthCare prior to the end of the Pharmacy Pricing Term, United will
retain any and all pending or future Rebates payable under the Agreement as of the effective date of the termination of pharmacy benefit
services and no reconciliation of minimum rebate guarantees will apply.no reconciliation of minimum rebate guarantees will apply.
Credits and Allowances
• Pharmacy Management Allowance: UnitedHealthCare will provide a credit allowance to help the County mitigate costs appropriately
associated with the administration of the pharmacy program. This credit allowance is available once the parties have an executed
Agreement and the first month of service fees under the Agreement has been received by United. Upon request from the County, a
credit will be issued in UnitedHealthCare’s fee billing system
• If Customer terminates pharmacy benefit services with UnitedHealthcare prior to the end of the Pharmacy Pricing Term, The County
will repay UnitedHealthCare a prorated portion of the amount of the Pharmacy Management Allowance that has been paid as of the
termination date. All unpaid credits are forfeit.
General Conditions
• All pricing guarantees shall remain in effect for the entire contract period of 01/01/2025 through 12/31/2029 ("Pharmacy Pricing Term").
Each twelve month period is a Guarantee Period.
• Drugs, products, supplies approved, covered and/or prescribed for the diagnosis, treatment or prevention of COVID-19 are excluded
from all guarantees.
• On mail order drugs, specialty drugs, and retail pharmacy drugs and services including dispensing fees, UnitedHealthCare will retain
the difference between what UnitedHealthCare reimburses the Network Pharmacy and The County's payment for a prescription drug
product or service.
SERIAL 240028-ITN
• Pricing and guarantees assume enrollment of ,7,618 Employees and 17,369 Participants; pricing and guarantees may be revised or
withdrawn if actual enrollment varies by 15% or more from assumptions.
• The lesser of three logic (non- zero balance logic) will apply to Participant payments. Participants pay the lesser of the discounted
price, the usual and customary charge or the cost share amount.
• All pricing guarantees require the selection of UnitedHealthcare as exclusive provider of pharmacy benefit services, including but not
limited to retail, mail order, and specialty networks for County Plans administrated by UnitedHealthcare.
UnitedHealthCare will have no financial guarantee obligation under the Agreement for any partial Guarantee Period if The County
terminates with an effective date prior to the end of the Pharmacy Pricing Term.
• In the event any of the terms herein is inconsistent with the requirements of any federal, state or other applicable law or regulation, then
the inconsistent term(s) will be null and void and UnitedHealthCare will have the right to revise, reprice or revoke this arrangement.
• UnitedHealthCare reserves the right to revise or revoke this arrangement if: a) changes in federal, state or other applicable law or
regulation require modifications; b) there are material changes to the AWP as published by the pricing agency that establishes the AWP
as used in these arrangements; c) The County makes benefit changes that impact the arrangements; d) there is a material industry
change in pricing methodologies resulting in a new source or benchmark; e) it is not accepted within ninety (90) days of the issuance of
our quote; f) if The County changes their mail service benefit; g) The County utilizes a vendor, that facilitates steering participants to
different drugs or pharmacies to the extent these services impact the financial guarantees under this Agreement.
Brand / Generic Reconciliation Definition
• Brand Drug: An FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy Study Implementation) drug, or
product, which is manufactured and distributed by an innovator drug company, or its licensee , set forth in Medi-Span’s National Drug
Data File as a brand drug identified by all of the products meeting at least one of the following criteria:
- Medi-Span Multi-Source Code ("MSC") is equal to M, O, or N.
• Generic Drug: An FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy Study Implementation) drug, or
product, that is therapeutically equivalent to other pharmaceutically equivalent products, as set forth in Medi-Span’s National Drug Data
File as a generic drug identified by all products meeting at least one of the following criteria:
- Medi-Span Multi-Source Code ("MSC") is equal to Y.
Market Check
The County may request one market check annually to confirm its financial terms are competitive with those currently available in the
market for substantially similar customers. Such analysis shall:
ꞏ be initiated in the second quarter after the first anniversary of the Effective Date of the Agreement
ꞏ be conducted by a mutually agreed upon third party
ꞏ include no fewer than five substantially similar customers under active contracts as determined by the following criteria which must be
included in the market check report:
ꞏ Within 10% of total membership count
ꞏ Same customer type (carve-in, coalition, etc.)
ꞏ Same line of business (commercial, Medicare, Medicaid, etc.)
ꞏ Same types of services (retail, home delivery, specialty, etc.)
SERIAL 240028-ITN
ꞏ Comparison of pricing for same contract year
ꞏ Pricing quoted within past six-month period
ꞏ The County’s average participant age must be within, plus or minus, 5 years
ꞏ A majority of membership located in a comparable geographic region
ꞏ The market check will compare the aggregate value of pricing terms including the combined net value of:
ꞏ Ingredient cost discounts and dispensing fees from retail pharmacies, home delivery pharmacies, and specialty pharmacies
ꞏ Rebates, including manufacturer derived administrative fees
ꞏ Administrative fees
ꞏ County Credits
If the market check report validates an annualized savings of greater than three (3) percent between the median of the financial terms for
such substantially similar customers and the County’s financial terms for time period that is the subject of the market check, the parties
will negotiate in good faith to revise the financial terms. UnitedHealthCare responds to the County within 30 days of receipt of the
complete market check report containing sufficient information for UnitedHealthCare to validate that the analysis was conducted in
accordance with the above criteria. Any revisions to financial terms resulting from the parties’ negotiations are effective the first day of
the following contract year, subject to the parties having executed an amendment to the Agreement at least 60 days prior to the effective
date.
SERIAL 240028-ITN
Specialty Pharmacy
Specialty Pharmacy Discount Guarantee
Definition
Specialty drug discount level based on actual specialty drug utilization for the specialty drugs dispensed through UnitedHealthCare’s specialty Pharmacy
Network. UnitedHealthCare reserves the right to change the designation of a drug from specialty to non-specialty based on market conditions.
Measurement
Listed
2025
2026
2027-2029
All Include LDD
22.00%
22.10%
22.20%
Unlisted
2025
2026
2027-2029
All Include LDD
14.00%
14.00%
14.00%
Criteria
Actual utilization, using Average Wholesale Price (AWP) in dollars, using our data, of listed specialty drugs through Our specialty Pharmacy Network will
be multiplied against the discount target to determine the overall discount target dollars.
The overall discount target dollars may be adjusted based on utilization of unlisted drugs to which the separate unlisted discount applies. This total will be
compared to actual discounts achieved for these drugs during the Guarantee Period.
Level
Customer Specific
Period
Annual
Payment
Period
Annual
Payment
Amount
The amount the actual discounts are less than the combined guaranteed Retail, Mail, and Specialty discount amount.
Conditions
• Discounts calculated based on the AWP less the ingredient cost; discount percentages are the discounts divided
by the AWP. Discounts for generic
prescriptions represent the average savings off AWP based on Maximum Allowable Cost (MAC) pricing for MAC
generics and percentage discount savings
off AWP for non-MAC generics. All other discounts represent the percentage discount savings off of AWP.
• Specialty drugs dispensed outside UnitedHealthCare’s specialty Pharmacy Network and drugs for which no AWP measure exists are excluded.
• Listed drugs which cease to be defined as specialty drugs during the Guarantee Period will be reconciled outside of the Specialty Pharmacy guarantee in
the channel in which they are dispensed (retail or mail order).
• Limited Distribution (LDD) status is subject to change based on manufacturer decision.
• Specialty drugs typically covered under the medical benefit (administered / handled by a provider, administered in a physician's office, ambulatory or
home infusion), and/or transitioned to the pharmacy benefit, are excluded from all guarantees.
• UnitedHealthCare reserves the right to revise or revoke this guarantee if:
a) material changes in federal, state or other applicable law or regulation require modifications;
b) there are material changes to the AWP as published by the pricing agency that establishes the AWP as used in this guarantee;
c) The County makes benefit changes that impact the guarantee;
d) there is a material industry change in pricing methodologies resulting in a new source or benchmark;
• On specialty drugs, UnitedHealthCare will retain the difference between what UnitedHealthcare reimburses the Network Pharmacy and the County’s
payment for a prescription drug product or service y.
SERIAL 240028-ITN
SPECIALTY DRUG LIST
(County will not amend the contract to reflect updates to the Specialty Drug List; County will save approved updates to file)
Specialty Drug
Category
Drug Name
LDD
Indicator
Included/Excluded
From Guarantee
Specialty Drug
Category
Drug Name
LDD
Indicator
Included/Excluded
From Guarantee
ANEMIA
ARANESP
No
Included
INFLAMMATORY
CONDITIONS
HUMIRA
No
Included
ANEMIA
EPOGEN
No
Included
INFLAMMATORY
CONDITIONS
ILUMYA
No
Included
ANEMIA
PROCRIT
No
Included
INFLAMMATORY
CONDITIONS
KEVZARA
No
Included
ANEMIA
RETACRIT
No
Included
INFLAMMATORY
CONDITIONS
KINERET
Yes
Included
ANTICONVULSANT
DIACOMIT
Yes
Included
INFLAMMATORY
CONDITIONS
OLUMIANT
Yes
Included
ANTICONVULSANT
EPIDIOLEX
Yes
Included
INFLAMMATORY
CONDITIONS
OPZELURA
No
Included
ANTICONVULSANT
FINTEPLA
Yes
Included
INFLAMMATORY
CONDITIONS
ORENCIA
No
Included
ANTICONVULSANT
ZTALMY
Yes
Included
INFLAMMATORY
CONDITIONS
OTEZLA
No
Included
ANTIHYPERLIPIDEMIC
JUXTAPID
Yes
Included
INFLAMMATORY
CONDITIONS
RIDAURA
No
Included
ANTI-INFECTIVE
ARIKAYCE
Yes
Included
INFLAMMATORY
CONDITIONS
RINVOQ
No
Included
ANTI-INFECTIVE
DARAPRIM
Yes
Included
INFLAMMATORY
CONDITIONS
SILIQ
Yes
Included
ANTI-INFECTIVE
PYRIMETHAMINE
No
Included
INFLAMMATORY
CONDITIONS
SIMPONI
No
Included
ANTIVIRAL
LIVTENCITY
Yes
Included
INFLAMMATORY
CONDITIONS
SKYRIZI
No
Included
ASTHMA
FASENRA
Yes
Included
INFLAMMATORY
CONDITIONS
SOTYKTU
No
Included
ASTHMA
NUCALA
Yes
Included
INFLAMMATORY
CONDITIONS
STELARA
No
Included
ASTHMA
XOLAIR
Yes
Included
INFLAMMATORY
CONDITIONS
TALTZ
No
Included
CARDIOVASCULAR
CAMZYOS
Yes
Included
INFLAMMATORY
CONDITIONS
TREMFYA
No
Included
CARDIOVASCULAR
DROXIDOPA
Yes
Included
INFLAMMATORY
CONDITIONS
XELJANZ
No
Included
CARDIOVASCULAR
NORTHERA
Yes
Included
INFLAMMATORY
CONDITIONS
XELJANZ XR
No
Included
CARDIOVASCULAR
VYNDAMAX
Yes
Included
IRON OVERLOAD
DEFERASIROX
Yes
Included
CARDIOVASCULAR
VYNDAQEL
Yes
Included
IRON OVERLOAD
DEFERIPRONE
Yes
Included
CNS AGENTS
AUSTEDO
No
Included
IRON OVERLOAD
EXJADE
Yes
Included
CNS AGENTS
ENSPRYNG
Yes
Included
IRON OVERLOAD
FERRIPROX
Yes
Included
SERIAL 240028-ITN
CNS AGENTS
EXSERVAN
Yes
Included
IRON OVERLOAD
JADENU
No
Included
CNS AGENTS
FIRDAPSE
Yes
Included
KIDNEY DISEASE
TARPEYO
Yes
Included
CNS AGENTS
HETLIOZ
Yes
Included
LIVER DISEASE
OCALIVA
Yes
Included
CNS AGENTS
INGREZZA
Yes
Included
MONOCLONAL
ANTIBODY
MISCELLANEOUS
BENLYSTA
Yes
Included
CNS AGENTS
RADICAVA
Yes
Included
MOOD DISORDER
DRUGS
SPRAVATO
No
Included
CNS AGENTS
RELYVRIO
Yes
Included
MULTIPLE
SCLEROSIS
AMPYRA
Yes
Included
CNS AGENTS
RILUTEK
No
Included
MULTIPLE
SCLEROSIS
AUBAGIO
No
Included
CNS AGENTS
RILUZOLE
No
Included
MULTIPLE
SCLEROSIS
AVONEX
No
Included
CNS AGENTS
RUZURGI
Yes
Included
MULTIPLE
SCLEROSIS
BAFIERTAM
Yes
Included
CNS AGENTS
SABRIL
Yes
Included
MULTIPLE
SCLEROSIS
BETASERON
No
Included
CNS AGENTS
SODIUM OXYBATE
Yes
Included
MULTIPLE
SCLEROSIS
COPAXONE
No
Included
CNS AGENTS
TASIMELTEON
Yes
Included
MULTIPLE
SCLEROSIS
DALFAMPRIDIN
Yes
Included
CNS AGENTS
TETRABENAZINE
No
Included
MULTIPLE
SCLEROSIS
DIMETHYL
FUMARATE
Yes
Included
CNS AGENTS
TIGLUTIK
Yes
Included
MULTIPLE
SCLEROSIS
EXTAVIA
No
Included
CNS AGENTS
VIGABATRIN
No
Included
MULTIPLE
SCLEROSIS
FINGOLIMOD
No
Included
CNS AGENTS
VIGADRONE
Yes
Included
MULTIPLE
SCLEROSIS
GILENYA
No
Included
CNS AGENTS
XENAZINE
Yes
Included
MULTIPLE
SCLEROSIS
GLATIRAMER
No
Included
CNS AGENTS
XYREM
Yes
Included
MULTIPLE
SCLEROSIS
GLATOPA
No
Included
CNS AGENTS
XYWAV
Yes
Included
MULTIPLE
SCLEROSIS
KESIMPTA
No
Included
CYSTIC FIBROSIS
BETHKIS
No
Included
MULTIPLE
SCLEROSIS
MAVENCLAD
Yes
Included
CYSTIC FIBROSIS
BRONCHITOL
Yes
Included
MULTIPLE
SCLEROSIS
MAYZENT
No
Included
CYSTIC FIBROSIS
CAYSTON
Yes
Included
MULTIPLE
SCLEROSIS
PLEGRIDY
Yes
Included
CYSTIC FIBROSIS
KALYDECO
Yes
Included
MULTIPLE
SCLEROSIS
PONVORY
Yes
Included
CYSTIC FIBROSIS
KITABIS PAK
No
Included
MULTIPLE
SCLEROSIS
REBIF
No
Included
CYSTIC FIBROSIS
ORKAMBI
Yes
Included
MULTIPLE
SCLEROSIS
REBIF REBIDOSE
No
Included
CYSTIC FIBROSIS
PULMOZYME
No
Included
MULTIPLE
SCLEROSIS
TECFIDERA
Yes
Included
SERIAL 240028-ITN
CYSTIC FIBROSIS
SYMDEKO
Yes
Included
MULTIPLE
SCLEROSIS
VUMERITY
Yes
Included
CYSTIC FIBROSIS
TOBI
No
Included
MULTIPLE
SCLEROSIS
ZEPOSIA
Yes
Included
CYSTIC FIBROSIS
TOBI PODHALER
No
Included
MUSCULOSKELETAL
AGENTS
EVRYSDI
Yes
Included
CYSTIC FIBROSIS
TOBRAMYCIN
No
Included
MUSCULOSKELETAL
AGENTS
VOXZOGO
Yes
Included
CYSTIC FIBROSIS
TRIKAFTA
Yes
Included
NARCOLEPSY
WAKIX
Yes
Included
ENDOCRINE
BETAINE
Yes
Included
NEUTROPENIA
FULPHILA
No
Included
ENDOCRINE
BUPHENYL
No
Included
NEUTROPENIA
GRANIX
No
Included
ENDOCRINE
BYNFEZIA
No
Included
NEUTROPENIA
LEUKINE
No
Included
ENDOCRINE
CARBAGLU
Yes
Included
NEUTROPENIA
NEULASTA
No
Included
ENDOCRINE
CARGLUMIC
Yes
Included
NEUTROPENIA
NEUPOGEN
No
Included
ENDOCRINE
CHENODAL
Yes
Included
NEUTROPENIA
NIVESTYM
No
Included
ENDOCRINE
CLOVIQUE
No
Included
NEUTROPENIA
NYVEPRIA
No
Included
ENDOCRINE
CORTROPHIN
Yes
Included
NEUTROPENIA
UDENYCA
No
Included
ENDOCRINE
CUPRIMINE
No
Included
NEUTROPENIA
ZARXIO
No
Included
ENDOCRINE
CYSTADANE
Yes
Included
NEUTROPENIA
ZIEXTENZO
No
Included
ENDOCRINE
CYSTADROPS
Yes
Included
ONCOLOGY -
INJECTABLE
ELIGARD
No
Included
ENDOCRINE
CYSTARAN
Yes
Included
ONCOLOGY -
INJECTABLE
INTRON A
Yes
Included
ENDOCRINE
DEPEN TITRATABS
No
Included
ONCOLOGY -
INJECTABLE
LEUPROLIDE
No
Included
ENDOCRINE
DICHLORPHENAMIDE
Yes
Included
ONCOLOGY -
INJECTABLE
SYNRIBO
Yes
Included
ENDOCRINE
D-PENAMINE
No
Included
ONCOLOGY - ORAL
ABIRATERONE
No
Included
ENDOCRINE
EGRIFTA
Yes
Included
ONCOLOGY - ORAL
AFINITOR
No
Included
ENDOCRINE
FIRMAGON
No
Included
ONCOLOGY - ORAL
AFINITOR
DISPERZ
No
Included
ENDOCRINE
GATTEX
Yes
Included
ONCOLOGY - ORAL
ALECENSA
Yes
Included
ENDOCRINE
H.P. ACTHAR
Yes
Included
ONCOLOGY - ORAL
ALKERAN
No
Included
ENDOCRINE
IMCIVREE
Yes
Included
ONCOLOGY - ORAL
ALUNBRIG
Yes
Included
ENDOCRINE
ISTURISA
Yes
Included
ONCOLOGY - ORAL
AYVAKIT
Yes
Included
ENDOCRINE
JAVYGTOR
Yes
Included
ONCOLOGY - ORAL
BALVERSA
Yes
Included
ENDOCRINE
JYNARQUE
Yes
Included
ONCOLOGY - ORAL
BEXAROTENE
No
Included
ENDOCRINE
KEVEYIS
Yes
Included
ONCOLOGY - ORAL
BOSULIF
Yes
Included
ENDOCRINE
KORLYM
Yes
Included
ONCOLOGY - ORAL
BRAFTOVI
Yes
Included
ENDOCRINE
KUVAN
Yes
Included
ONCOLOGY - ORAL
BRUKINSA
Yes
Included
ENDOCRINE
LANREOTIDE
No
Included
ONCOLOGY - ORAL
CABOMETYX
Yes
Included
ENDOCRINE
MYALEPT
Yes
Included
ONCOLOGY - ORAL
CALQUENCE
Yes
Included
SERIAL 240028-ITN
ENDOCRINE
MYCAPSSA
Yes
Included
ONCOLOGY - ORAL
CAPECITABINE
No
Included
ENDOCRINE
NATPARA
Yes
Included
ONCOLOGY - ORAL
CAPRELSA
Yes
Included
ENDOCRINE
NITYR
Yes
Included
ONCOLOGY - ORAL
COMETRIQ
Yes
Included
ENDOCRINE
OCTREOTIDE ACETATE
No
Included
ONCOLOGY - ORAL
COPIKTRA
Yes
Included
ENDOCRINE
PENICILLAMINE
No
Included
ONCOLOGY - ORAL
COTELLIC
Yes
Included
ENDOCRINE
PROCYSBI
Yes
Included
ONCOLOGY - ORAL
DAURISMO
Yes
Included
ENDOCRINE
RAVICTI
Yes
Included
ONCOLOGY - ORAL
ERIVEDGE
Yes
Included
ENDOCRINE
RECORLEV
Yes
Included
ONCOLOGY - ORAL
ERLEADA
No
Included
ENDOCRINE
SAMSCA
Yes
Included
ONCOLOGY - ORAL
ERLOTINIB
Yes
Included
ENDOCRINE
SANDOSTATIN
No
Included
ONCOLOGY - ORAL
ETOPOSIDE
No
Included
ENDOCRINE
SAPROPTERIN
Yes
Included
ONCOLOGY - ORAL
EVEROLIMUS
No
Included
ENDOCRINE
SIGNIFOR
Yes
Included
ONCOLOGY - ORAL
EXKIVITY
Yes
Included
ENDOCRINE
SODIUM PHENYLBUTYRATE
No
Included
ONCOLOGY - ORAL
FARYDAK
Yes
Included
ENDOCRINE
SOMATULINE DEPOT
No
Included
ONCOLOGY - ORAL
FOTIVDA
Yes
Included
ENDOCRINE
SOMAVERT
Yes
Included
ONCOLOGY - ORAL
GAVRETO
Yes
Included
ENDOCRINE
SYPRINE
No
Included
ONCOLOGY - ORAL
GILOTRIF
Yes
Included
ENDOCRINE
THIOLA
Yes
Included
ONCOLOGY - ORAL
GLEEVEC
No
Included
ENDOCRINE
TIOPRONIN
No
Included
ONCOLOGY - ORAL
GLEOSTINE
No
Included
ENDOCRINE
TOLVAPTAN
No
Included
ONCOLOGY - ORAL
HYCAMTIN
No
Included
ENDOCRINE
TRIENTINE
No
Included
ONCOLOGY - ORAL
IBRANCE
Yes
Included
ENDOCRINE
XERMELO
Yes
Included
ONCOLOGY - ORAL
ICLUSIG
Yes
Included
ENDOCRINE
XURIDEN
Yes
Included
ONCOLOGY - ORAL
IDHIFA
No
Included
ENZYME DEFICIENCY
CHOLBAM
Yes
Included
ONCOLOGY - ORAL
IMATINIB
MESYLATE
No
Included
ENZYME DEFICIENCY
CYSTAGON
Yes
Included
ONCOLOGY - ORAL
IMBRUVICA
Yes
Included
ENZYME DEFICIENCY
GALAFOLD
Yes
Included
ONCOLOGY - ORAL
INLYTA
Yes
Included
ENZYME DEFICIENCY
MIGLUSTAT
No
Included
ONCOLOGY - ORAL
INQOVI
Yes
Included
ENZYME DEFICIENCY
NITISINONE
No
Included
ONCOLOGY - ORAL
INREBIC
Yes
Included
ENZYME DEFICIENCY
ORFADIN
No
Included
ONCOLOGY - ORAL
IRESSA
Yes
Included
ENZYME DEFICIENCY
PALYNZIQ
Yes
Included
ONCOLOGY - ORAL
JAKAFI
Yes
Included
ENZYME DEFICIENCY
STRENSIQ
Yes
Included
ONCOLOGY - ORAL
KISQALI
No
Included
ENZYME DEFICIENCY
SUCRAID
Yes
Included
ONCOLOGY - ORAL
KISQALI FEMARA
No
Included
ENZYME DEFICIENCY
TEGSEDI
Yes
Included
ONCOLOGY - ORAL
KOSELUGO
Yes
Included
ENZYME DEFICIENCY
ZAVESCA
Yes
Included
ONCOLOGY - ORAL
LAPATINIB
No
Included
GAUCHERS DISEASE
CERDELGA
Yes
Included
ONCOLOGY - ORAL
LENALIDOMIDE
Yes
Included
GENETIC DISORDER
DOJOLVI
Yes
Included
ONCOLOGY - ORAL
LENVIMA
Yes
Included
GENETIC DISORDER
VIJOICE
No
Included
ONCOLOGY - ORAL
LONSURF
Yes
Included
SERIAL 240028-ITN
GENETIC DISORDER
ZOKINVY
Yes
Included
ONCOLOGY - ORAL
LORBRENA
Yes
Included
GROWTH HORMONE
DEFICIENCY
GENOTROPIN
No
Included
ONCOLOGY - ORAL
LUMAKRAS
Yes
Included
GROWTH HORMONE
DEFICIENCY
HUMATROPE
No
Included
ONCOLOGY - ORAL
LYNPARZA
Yes
Included
GROWTH HORMONE
DEFICIENCY
INCRELEX
Yes
Included
ONCOLOGY - ORAL
MATULANE
Yes
Included
GROWTH HORMONE
DEFICIENCY
NORDITROPIN
No
Included
ONCOLOGY - ORAL
MEKINIST
Yes
Included
GROWTH HORMONE
DEFICIENCY
NUTROPIN AQ
No
Included
ONCOLOGY - ORAL
MEKTOVI
Yes
Included
GROWTH HORMONE
DEFICIENCY
OMNITROPE
No
Included
ONCOLOGY - ORAL
MELPHALAN
No
Included
GROWTH HORMONE
DEFICIENCY
SAIZEN
No
Included
ONCOLOGY - ORAL
MESNEX
No
Included
GROWTH HORMONE
DEFICIENCY
SEROSTIM
Yes
Included
ONCOLOGY - ORAL
NERLYNX
Yes
Included
GROWTH HORMONE
DEFICIENCY
SKYTROFA
No
Included
ONCOLOGY - ORAL
NEXAVAR
Yes
Included
GROWTH HORMONE
DEFICIENCY
ZOMACTON
No
Included
ONCOLOGY - ORAL
NILANDRON
No
Included
GROWTH HORMONE
DEFICIENCY
ZORBTIVE
Yes
Included
ONCOLOGY - ORAL
NILUTAMIDE
No
Included
HEMATOLOGIC
BERINERT
Yes
Included
ONCOLOGY - ORAL
NINLARO
No
Included
HEMATOLOGIC
CABLIVI
Yes
Included
ONCOLOGY - ORAL
NUBEQA
Yes
Included
HEMATOLOGIC
CINRYZE
Yes
Included
ONCOLOGY - ORAL
ODOMZO
No
Included
HEMATOLOGIC
DOPTELET
Yes
Included
ONCOLOGY - ORAL
ONUREG
No
Included
HEMATOLOGIC
FIRAZYR
Yes
Included
ONCOLOGY - ORAL
ORGOVYX
Yes
Included
HEMATOLOGIC
HAEGARDA
Yes
Included
ONCOLOGY - ORAL
PEMAZYRE
Yes
Included
HEMATOLOGIC
ICATIBANT
Yes
Included
ONCOLOGY - ORAL
PIQRAY
No
Included
HEMATOLOGIC
MOZOBIL
No
Included
ONCOLOGY - ORAL
POMALYST
Yes
Included
HEMATOLOGIC
MULPLETA
No
Included
ONCOLOGY - ORAL
PURIXAN
No
Included
HEMATOLOGIC
OXBRYTA
Yes
Included
ONCOLOGY - ORAL
PYRUKYND
Yes
Included
HEMATOLOGIC
PROMACTA
Yes
Included
ONCOLOGY - ORAL
QINLOCK
Yes
Included
HEMATOLOGIC
REZUROCK
Yes
Included
ONCOLOGY - ORAL
RETEVMO
Yes
Included
HEMATOLOGIC
RUCONEST
Yes
Included
ONCOLOGY - ORAL
REVLIMID
Yes
Included
HEMATOLOGIC
SAJAZIR
Yes
Included
ONCOLOGY - ORAL
ROZLYTREK
No
Included
HEMATOLOGIC
TAKHZYRO
Yes
Included
ONCOLOGY - ORAL
RUBRACA
Yes
Included
HEMATOLOGIC
TAVALISSE
Yes
Included
ONCOLOGY - ORAL
RYDAPT
No
Included
HEMOPHILIA - INFUSED
ADVATE
No
Included
ONCOLOGY - ORAL
SCEMBLIX
No
Included
HEMOPHILIA - INFUSED
ADYNOVATE
No
Included
ONCOLOGY - ORAL
SORAFENIB
Yes
Included
HEMOPHILIA - INFUSED
AFSTYLA
No
Included
ONCOLOGY - ORAL
SPRYCEL
No
Included
HEMOPHILIA - INFUSED
ALPHANATE/VON WILLEBRAND
No
Included
ONCOLOGY - ORAL
STIVARGA
Yes
Included
SERIAL 240028-ITN
HEMOPHILIA - INFUSED
ALPHANINE SD
No
Included
ONCOLOGY - ORAL
SUNITINIB
Yes
Included
HEMOPHILIA - INFUSED
ALPROLIX
No
Included
ONCOLOGY - ORAL
SUTENT
Yes
Included
HEMOPHILIA - INFUSED
BENEFIX
No
Included
ONCOLOGY - ORAL
TABLOID
No
Included
HEMOPHILIA - INFUSED
COAGADEX
Yes
Included
ONCOLOGY - ORAL
TABRECTA
No
Included
HEMOPHILIA - INFUSED
CORIFACT
No
Included
ONCOLOGY - ORAL
TAFINLAR
Yes
Included
HEMOPHILIA - INFUSED
ELOCTATE
No
Included
ONCOLOGY - ORAL
TAGRISSO
Yes
Included
HEMOPHILIA - INFUSED
ESPEROCT
No
Included
ONCOLOGY - ORAL
TALZENNA
Yes
Included
HEMOPHILIA - INFUSED
FEIBA
No
Included
ONCOLOGY - ORAL
TARCEVA
Yes
Included
HEMOPHILIA - INFUSED
HEMOFIL M
No
Included
ONCOLOGY - ORAL
TARGRETIN
No
Included
HEMOPHILIA - INFUSED
HUMATE-P
No
Included
ONCOLOGY - ORAL
TASIGNA
Yes
Included
HEMOPHILIA - INFUSED
IDELVION
No
Included
ONCOLOGY - ORAL
TAZVERIK
Yes
Included
HEMOPHILIA - INFUSED
IXINITY
No
Included
ONCOLOGY - ORAL
TEMODAR
No
Included
HEMOPHILIA - INFUSED
JIVI
No
Included
ONCOLOGY - ORAL
TEMOZOLOMIDE
No
Included
HEMOPHILIA - INFUSED
KOATE
No
Included
ONCOLOGY - ORAL
TEPMETKO
Yes
Included
HEMOPHILIA - INFUSED
KOATE-DVI
No
Included
ONCOLOGY - ORAL
THALOMID
Yes
Included
HEMOPHILIA - INFUSED
KOGENATE FS
No
Included
ONCOLOGY - ORAL
TIBSOVO
Yes
Included
HEMOPHILIA - INFUSED
KOVALTRY
No
Included
ONCOLOGY - ORAL
TRETINOIN
No
Included
HEMOPHILIA - INFUSED
MONONINE
No
Included
ONCOLOGY - ORAL
TRUSELTIQ
Yes
Included
HEMOPHILIA - INFUSED
NOVOEIGHT
No
Included
ONCOLOGY - ORAL
TUKYSA
Yes
Included
HEMOPHILIA - INFUSED
NOVOSEVEN RT
No
Included
ONCOLOGY - ORAL
TURALIO
Yes
Included
HEMOPHILIA - INFUSED
NUWIQ
No
Included
ONCOLOGY - ORAL
TYKERB
No
Included
HEMOPHILIA - INFUSED
PROFILNINE
No
Included
ONCOLOGY - ORAL
UKONIQ
Yes
Included
HEMOPHILIA - INFUSED
REBINYN
No
Included
ONCOLOGY - ORAL
VENCLEXTA
Yes
Included
HEMOPHILIA - INFUSED
RECOMBINATE
No
Included
ONCOLOGY - ORAL
VERZENIO
Yes
Included
HEMOPHILIA - INFUSED
RIXUBIS
No
Included
ONCOLOGY - ORAL
VITRAKVI
Yes
Included
HEMOPHILIA - INFUSED
SEVENFACT
No
Included
ONCOLOGY - ORAL
VIZIMPRO
Yes
Included
HEMOPHILIA - INFUSED
TRETTEN
Yes
Included
ONCOLOGY - ORAL
VONJO
Yes
Included
HEMOPHILIA - INFUSED
VONVENDI
Yes
Included
ONCOLOGY - ORAL
VOTRIENT
Yes
Included
HEMOPHILIA - INFUSED
WILATE
No
Included
ONCOLOGY - ORAL
WELIREG
Yes
Included
HEMOPHILIA - INFUSED
XYNTHA
No
Included
ONCOLOGY - ORAL
XALKORI
Yes
Included
HEMOPHILIA -
INJECTABLE
HEMLIBRA
Yes
Included
ONCOLOGY - ORAL
XELODA
No
Included
HEPATITIS C
EPCLUSA
No
Included
ONCOLOGY - ORAL
XOSPATA
Yes
Included
HEPATITIS C
HARVONI
No
Included
ONCOLOGY - ORAL
XPOVIO
Yes
Included
HEPATITIS C
LEDIPASVIR/SOFOSBUVIR
No
Included
ONCOLOGY - ORAL
XTANDI
Yes
Included
HEPATITIS C
MAVYRET
No
Included
ONCOLOGY - ORAL
YONSA
No
Included
HEPATITIS C
PEGASYS
No
Included
ONCOLOGY - ORAL
ZEJULA
Yes
Included
SERIAL 240028-ITN
HEPATITIS C
PEGINTRON
No
Included
ONCOLOGY - ORAL
ZELBORAF
Yes
Included
HEPATITIS C
SOFOSBUVIR/VELPATASVIR
No
Included
ONCOLOGY - ORAL
ZOLINZA
No
Included
HEPATITIS C
SOVALDI
No
Included
ONCOLOGY - ORAL
ZYDELIG
Yes
Included
HEPATITIS C
VIEKIRA PAK
No
Included
ONCOLOGY - ORAL
ZYKADIA
Yes
Included
HEPATITIS C
VOSEVI
No
Included
ONCOLOGY - ORAL
ZYTIGA
No
Included
HEPATITIS C
ZEPATIER
No
Included
ONCOLOGY -
TOPICAL
TARGRETIN
No
Included
HEPATOLOGY
BYLVAY
Yes
Included
ONCOLOGY -
TOPICAL
VALCHLOR
Yes
Included
HEPATOLOGY
LIVMARLI
Yes
Included
OPHTHALMIC
OXERVATE
Yes
Included
HEREDITARY
ANGIODEMA
ORLADEYO
Yes
Included
OSTEOPOROSIS
FORTEO
No
Included
IMMUNE MODULATOR
ACTIMMUNE
Yes
Included
OSTEOPOROSIS
TERIPARATIDE
No
Included
IMMUNE MODULATOR
ARCALYST
Yes
Included
OSTEOPOROSIS
TYMLOS
No
Included
IMMUNOLOGICAL
AGENTS
LUPKYNIS
Yes
Included
PARKINSONS
DISEASE
APOKYN
Yes
Included
IMMUNOLOGICAL
AGENTS
PALFORZIA
Yes
Included
PARKINSONS
DISEASE
APOMORPHINE
Yes
Included
IMMUNOLOGICAL
AGENTS
TAVNEOS
Yes
Included
PARKINSONS
DISEASE
INBRIJA
Yes
Included
INFERTILITY
CETRORELIX
No
Included
PARKINSONS
DISEASE
KYNMOBI
Yes
Included
INFERTILITY
CETROTIDE
No
Included
PULMONARY
DISEASE
ESBRIET
Yes
Included
INFERTILITY
CHORIONIC GONADOTROPIN
No
Included
PULMONARY
DISEASE
OFEV
Yes
Included
INFERTILITY
FOLLISTIM AQ
No
Included
PULMONARY
DISEASE
PIRFENIDONE
Yes
Included
INFERTILITY
FYREMADEL
No
Included
PULMONARY
HYPERTENSION
ADCIRCA
No
Included
INFERTILITY
GANIRELIX ACETATE
No
Included
PULMONARY
HYPERTENSION
ADEMPAS
Yes
Included
INFERTILITY
GONAL-F
No
Included
PULMONARY
HYPERTENSION
ALYQ
No
Included
INFERTILITY
GONAL-F RFF
No
Included
PULMONARY
HYPERTENSION
AMBRISENTAN
Yes
Included
INFERTILITY
MENOPUR
No
Included
PULMONARY
HYPERTENSION
BOSENTAN
No
Included
INFERTILITY
NOVAREL
No
Included
PULMONARY
HYPERTENSION
LETAIRIS
Yes
Included
INFERTILITY
OVIDREL
No
Included
PULMONARY
HYPERTENSION
OPSUMIT
Yes
Included
INFERTILITY
PREGNYL
No
Included
PULMONARY
HYPERTENSION
ORENITRAM
Yes
Included
INFLAMMATORY
CONDITIONS
ACTEMRA
No
Included
PULMONARY
HYPERTENSION
REVATIO
No
Included
INFLAMMATORY
CONDITIONS
ADBRY
Yes
Included
PULMONARY
HYPERTENSION
SILDENAFIL
No
Included
SERIAL 240028-ITN
INFLAMMATORY
CONDITIONS
AMJEVITA
No
Included
PULMONARY
HYPERTENSION
TADALAFIL
No
Included
INFLAMMATORY
CONDITIONS
CIBINQO
No
Included
PULMONARY
HYPERTENSION
TADLIQ
Yes
Included
INFLAMMATORY
CONDITIONS
CIMZIA
No
Included
PULMONARY
HYPERTENSION
TRACLEER
Yes
Included
INFLAMMATORY
CONDITIONS
COSENTYX
No
Included
PULMONARY
HYPERTENSION
TYVASO
Yes
Included
INFLAMMATORY
CONDITIONS
DUPIXENT
No
Included
PULMONARY
HYPERTENSION
UPTRAVI
Yes
Included
INFLAMMATORY
CONDITIONS
EMFLAZA
Yes
Included
PULMONARY
HYPERTENSION
VENTAVIS*
Yes
Included
INFLAMMATORY
CONDITIONS
ENBREL
No
Included
*Includes Nebulizer
2Q 2023 v2
SERIAL 240028-ITN
EXHIBIT B: SCOPE OF WORK
Administrative Services Agreement
Table of Contents
Section 1 – Definitions
Section 2 – Employee Benefit Plan: County Responsibilities
Section 3 – County Other Responsibilities
Section 4 – Services Provisions
Section 5 – Benefit Determinations and Appeals
Section 6 – Service Fees
Section 7 – Process For Providing Funds For Benefits
Section 8 – Services Begin and End
Section 9 – Records, Information, Audits
Section 10 – System Access
Section 11 – Taxes And Assessments
Section 12 – Plan Benefits Litigation
Section 13 – Miscellaneous
EXHIBIT B-1 – Services
EXHIBIT B-2 – Health Savings Account Enrollment and Contributions
SERIAL 240028-ITN
Section 1 – Definitions
When these terms are capitalized in this Scope of Work – Administrative Services Agreement (“Agreement”), they
have the meanings set forth below or defined elsewhere in the Contract Pursuant to Invitation to Negotiate (ITN) No.
240028 (the “Contract”) between Maricopa County (“County”) and United HealthCare Services, Inc. (“Contractor”).
The words may be singular or plural.
Agreement Period: The initial contract term of five years commencing on the Services Effective Date (as defined in
the Contract) and continuing as indicated in Section 2.0 Option to Renew the Agreement is terminated.
Bank: JPMorgan Chase Bank, New York, New York.
Bank Account: Benefits Demand Deposit Bank Account maintained for the payment of Plan benefits, expenses, and
fees.
Employee: A current or former employee of County or its affiliated employer as described in Section 2.4.
HSA or Health Savings Account: A tax-advantaged account established by County’s Employees principally to fund
certain qualified medical expenses. This account is maintained in accordance with applicable provisions of the IRC
and associated guidance issued by the IRS/Treasury Department, as well as under various agreements and documents
maintained between an enrolling Employee and the HSA trustee or custodian.
IRC: The United States Internal Revenue Code of 1986, as amended from time to time.
IRS: The United States Internal Revenue Service.
Network: The group of Network Providers Contractor makes available to the Plan who have entered into or are
governed by contractual arrangements under which they agree to provide health care services to Participants and
accept negotiated fees for these services.
Medicare Part D Retiree Drug Subsidy Program (“RDS”): The program as set forth in Section 1860D-22 of Title
XVIII of the Social Security Act, as amended by the Medicare Prescription Drug, Improvement and Modernization
Act of 2003 (“MMA”), Subpart R of the MMA Final Regulation, or any successor regulation promulgated by the
Centers for Medicare and Medicaid Services (“CMS”), and any guidance issued by CMS, and any mandated updates
of required information.
Network Pharmacy: A pharmacy, including a specialty pharmacy and mail order pharmacy which has entered into
or is governed by a contractual arrangement with Contractor under which the pharmacy agrees to provide prescription
drug services to Participants.
Network Provider: The physician, or medical professional or facility which participates in a Network. A provider is
only a Network Provider if they are participating in a Network at the time services are rendered to the Plan Participant.
Overpayments: Payments that exceed the amount payable under the Plan. This term does not include overpayments
caused by untimely or inaccurate eligibility information.
Participant: Employee or dependent who is covered by the Plan.
PHI: Any information Contractor receives or provides on behalf of the Plan which is considered Protected Health
Information as the term is defined in the privacy regulations of the Health Insurance Portability and Accountability
Act of 1996.
Plan: The effective Maricopa County Benefits Plan to which this Agreement applies, but only with respect to those
provisions of the Plan relating to the Self-Funded health benefits Contractor is administering, as described in the
Summary Plan Description.
Plan Administrator: The current or succeeding person, committee, partnership, or other entity designated the Plan
Administrator who is generally responsible for the Plan’s operation.
Proprietary Business Information: Nonpublic information, trade secrets, and other data including, but not limited
to, sales and marketing information, management systems, strategic plans and other information about the disclosing
party’s business, industry, products and services, plans, specifications, operation methods, pricing, costs, techniques,
manuals, know-how and other intellectual property, in written, oral or other tangible form, provided by one party to
another or its representative; and all information, documents, technology, products, and services containing or derived
from Proprietary Business Information which was or may have been transmitted, given or made available to or viewed
by one party or another in the course of the receiving party’s relationship. Contractor’s Proprietary Business
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Information shall include, but not be limited to, discounts pricing, reimbursement terms, payment methodologies and
payment processes, compensation arrangements and any similar commercial information. While the Prescription Drug
List is considered Contractor’s Proprietary Business Information, it may be disclosed in the limited circumstances
outlined in this Agreement. This information is collectively known as “Contractor’s Financial PBI”.
Rebates: All rebates, discounts or other financial incentives (whether access, base, Prescription Drug List (PDL),
incentive, market share, volume, or other), and administrative fees which Contractor receives directly or indirectly
from a pharmaceutical manufacturer and which are obtained in connection with prescription drug products dispensed
to Participants under the Plan's pharmacy benefit or the medical benefit. Rebates do not include any purchasing
discounts, provided that Contractor obtains the same Rebates for prescription drugs regardless of where the
prescription is dispensed. Rebates to customers are administered and paid under the medical benefit plan or pharmacy
benefit plan as outlined in this Agreement.
Self-Fund or Self-Funded: Means that County, on behalf of the Plan, has the sole responsibility to pay, and provide
funds, to pay for all Plan benefits. Contractor has no liability or responsibility to provide these funds. This is true even
if Contractor or its affiliates provides stop loss insurance to County.
Summary of Benefits and Coverage: The document containing a brief summary of what the Plan covers including
covered health benefits, out-of-pocket costs, and the Network of providers, as required by the Patient Protection and
Affordable Care Act.
Summary Plan Description or SPD: The document(s) County provides to Plan Participants describing the terms and
conditions of coverage offered under the Plan.
Systems: Means the systems Contractor owns or makes available to County to facilitate the transfer of information in
connection with this Agreement.
Tax or Taxes: A charge imposed, assessed or levied by any federal, state, local or other governmental entity.
Treasury Department: The Contractor States Department of the Treasury.
Urgent Care Claims: A claim for medical services and supplies which meets ERISA’s definition of Urgent Care
Claim.
Section 2 – Employee Benefit Plan: County Responsibilities
2.1
Responsibility for the Plan. Contractor is not the Plan Administrator of the Plan. Any references in this
Agreement to Contractor “administering the Plan” are descriptive only and do not confer upon Contractor anything
beyond certain agreed upon claim administration duties. Except to the extent this Agreement specifically requires
Contractor to have the fiduciary responsibility for a Plan administrative function, County accepts total responsibility
for the Plan for purposes of this Agreement including its benefit design, the legal sufficiency and distribution of SPDs,
and compliance with any laws that apply to County or the Plan, whether or not County or someone County designates
is the Plan Administrator.
2.2
Plan Consistent with the Agreement. County represents that Plan documents, including the Summary Plan
Description as described in Exhibit B-1to this Agreement, are consistent with this Agreement. Nevertheless, before
distributing any communications describing Plan benefits or provisions to Participants or third parties, County will
provide Contractor with copies of Employee communications which refer to Contractor or Contractor’s services prior
to distributing these materials to Employees or third parties. County will amend them if Contractor reasonably
determines that references to Contractor are not accurate, or any Plan provision is not consistent with this Agreement
or the services that Contractor is providing.
2.3
Plan Changes. County must provide Contractor with notice of any changes to the Plan and/or Summary Plan
Description within a reasonable period of time prior to the effective date of the change to allow Contractor to determine
if such change will alter the services Contractor provides under this Agreement. Any change in the services to be
provided by Contractor under this Agreement which would be caused by any aforementioned changes must be
mutually agreed to in writing prior to implementation of such change. Contractor will notify County if (i) the change
increases Contractor’s cost of providing services under this Agreement or (ii) Contractor is reasonably unable to
implement or administer the change. If the parties cannot agree to a new fee within (60) sixty days of the notice of the
new fee or if Contractor notifies County that Contractor is unable to reasonably implement or administer the change,
Contractor shall have no obligation to implement or administer the change, and County may terminate this Agreement
under the terms and conditions provided under the Contract.
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2.4
Affiliated Employers. County represents that together County and any of its affiliates covered under the
Plan make up a single “controlled group” as defined by the IRC. County agrees to provide Contractor with a list of
County’s affiliates covered under the Plan upon request.
Section 3 – County Other Responsibilities
3.1
Information County Provides to Contractor. County will tell Contractor which of County’s Employees,
their dependents and/or other persons are Participants. This information must be accurate and provided to Contractor
in a timely manner. Contractor will accept eligibility data from County in the format described in Exhibit B-1 to this
Agreement. County will notify Contractor of any change to this information as soon as reasonably possible.
Contractor will be entitled to rely on the most current information in Contractor’s possession regarding eligibility of
Participants in paying Plan benefits and providing other services under this Agreement. Contractor will be required to
make retroactive eligibility changes including processing or reprocessing claims.
County agrees to provide Contractor (or cause County’s vendor to provide Contractor), in a timely manner with all
information that Contractor reasonably requires to provide County’s Participants with disease management services
as described in accordance with Exhibit B-1 to this Agreement and Contractor’s program guidelines. Contractor shall
be entitled to rely on the information that is provided to Contractor in connection with Contractor’s provision of
disease management services to County’s Participants.
3.2
Notices to Participants. County will give Participants the information and documents they need to obtain
benefits under the Plan within a reasonable period of time before coverage begins. In the event this Agreement is
discontinued, County will notify all Participants that the services Contractor is providing under this Agreement are
discontinued.
3.3
Escheat. County is solely responsible for complying with all applicable abandoned property or escheat laws,
making any required payments, and filing any required reports.
Section 4 – Services Provisions
4.1
Administrative Services. Contractor will provide the administrative services described in this Contract
including Section 9.0 - Duties, Exhibit B - Scope of Work (Administrative Service Agreement), Exhibit B-1 -
Services, and Exhibit B-2 – Health Savings Account Enrollment and Contribution, or as otherwise directed by the
County and agreed by Contractor. .
4.2
Network Access, Management and Administration. Contractor will provide access to Networks and
Network Providers, as well as related administrative services including physician (and other health care professional)
relations, clinical profiling, contracting and credentialing, and network analysis and system development. The make-
up of the Network can change at any time. Notice will be given in advance or as soon as reasonably possible.
Contractor does not employ Network Providers and they are not Contractor’s agents or partners. Network Providers
participate in Networks only as independent contractors. Network Providers and the Participants are solely responsible
for any health care services rendered to Participants. Contractor is not responsible for the medical outcomes or the
quality or competence of any provider or facility rendering services, including Network Pharmacies and services
provided through Contractor’s affiliates’ networks, or the payment for services rendered by the provider or facility.
All new Network Providers will be credentialed upon application, and current physicians will be recredentialed on a
rotating timetable of two years.
4.3
Claim Recovery Services.
General. Contractor will provide recovery services for Overpayments and other Plan recovery and savings
opportunities as described herein, including Third Party Liability/Subrogation matters. For purposes of this
Agreement, “Third Party Liability/Subrogation” refers to instances where Plan benefits were paid and are recoverable
by the Plan because payment was or should have been made by a third party for the same medical expense (other than
in connection with coordination of benefits, Medicare, or other Overpayments). Contractor will not itself be
responsible for recovery costs or reimbursement of any unrecovered Overpayment except to the extent the
Overpayment was due to Contractor’s gross negligence. All amounts recovered under these services shall be refunded
or otherwise credited to County at the gross amount.
Payment Integrity Services. Contractor provides services to help prevent, identify, and resolve irregular claims
(“Payment Integrity Services”). Contractor’s Payment Integrity Services help guard against potential errors, fraud,
waste and abuse by reviewing claims on a pre- or post-adjudicated basis.
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Contractor makes available to the County an array of standard and optional Payment Integrity Services, as identified
in Exhibit A - Pricing.
Recovery Process – Payment Integrity Services. County delegates to Contractor the discretion and authority to
develop and use standards and procedures for recovery of Overpayments and Third Party Liability/Subrogation
matters, including but not limited to, what steps to take if Contractor decides to seek recovery.
Prior written approval of any recovery less than 100% must be obtained from the County contact listed below.
County acknowledges that use of Contractor’s standards and procedures may not result in full or partial recovery for
any particular case. Contractor will not pursue any recovery if it is not permitted by any applicable law. Contractor
may initiate litigation to recover payments with County’s written consent, but Contractor has no obligation to do so.
If Contractor initiates litigation, County will cooperate with Contractor in the litigation. United makes available to
Customer an array of standard and optional Payment Integrity Services, as identified in Exhibit A: Vendor Information
and Pricing.
Title: Maricopa County Benefits Deputy Director or designee
Address: 301 West Jefferson Street, Suite. 820, Phoenix, AZ 85003-2143 Telephone: (602) 506-1010
Fax: (602) 506-2354
In any event where Contractor decides not to seek recovery under this Section 4.3, County will be free to seek recovery
on its own, including to direct Contractor to seek recovery, which will be at County’s expense provided that there is
a legal standing to pursue; Contractor won't pursue recovery if it believes it is prohibited by contract, or state or federal
law. County will advise Contractor if it elects to seek such recoveries on its own, and the parties shall mutually agree
to a process by which the County will report any recovered amount to Contractor, so Contractor can update its claim
systems with the recovery information, including any extra fees that would apply for doing so.
Recovery Process – Other Non-Class Action Recoveries. For recoveries other than Third Party
Liability/Subrogation, County delegates to Contractor the discretion and authority to develop and use standards and
procedures for any recovery opportunity, including but not limited to, whether or not to seek recovery, what steps to
take if Contractor decides to seek recovery, whether to initiate litigation or arbitration, the scope of such litigation or
arbitration, which legal theories to pursue in such litigation or arbitration, and all decisions relating to such litigation
or arbitration, including but not limited to, whether to compromise or settle any litigation or arbitration, and the
circumstances under which a claim may be compromised or settled for less than the full amount of the potential
recovery. In all instances where Contractor pursues recovery through litigation or arbitration, County, on behalf of
itself and on behalf of its Plan(s), will be deemed to have granted Contractor an assignment of all ownership, title and
legal rights and interests in and to any and all claims that are the subject matter of the litigation or arbitration.
County acknowledges that use of Contractor’s standards and procedures may not result in full or partial recovery for
any particular claim or for any particular customer. Contractor will not pursue any recovery if it is not permitted by
any applicable law, or if recovery would be impractical, as determined in Contractor’s discretion. While Contractor
may initiate litigation or arbitration to facilitate a recovery, Contractor has no obligation to do so. If Contractor initiates
litigation or arbitration, County will cooperate with Contractor in the litigation or arbitration.
If this Agreement terminates, in whole or in part, Contractor can continue recovery activities for any claims paid when
the Agreement was in effect pursuant to the terms of this Section A2.
Recovery Process – Class Action Recoveries. Where a class action purports to affect County’s (or the Plan(s) it
sponsors or administers) right to and interest in any Overpayment, Contractor has the right to determine whether to
seek recovery of the Overpayment on the County’s (or the Plan(s) it sponsors or administers) behalf through litigation,
arbitration, or settlement. If Contractor elects to seek recovery of such an Overpayment that is at issue in a class action,
Contractor will provide written notice to County of its intention. If County does not want Contractor to seek recovery
of the Overpayment, County shall notify Contractor in writing within thirty (30) days or such time period specified in
the notice, of receiving notice from Contractor. If County does not so notify Contractor, County, on behalf of itself
and on behalf of the Plan(s) it sponsors and administers, assigns to Contractor all ownership, title and legal rights and
interests in and to any and all Overpayments that are the subject matter of the class action. In such cases, County will
cooperate with Contractor in any resulting litigation or arbitration that Contractor may file to pursue the
Overpayments.
If County provides Contractor with written notice that it does not want Contractor to seek recovery of an Overpayment
related to a class action (whether putative or certified) then, pursuant to its standard procedures, Contractor will
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provide County with related Overpayment claims information, at County’s request. County is then solely responsible
for determining whether it (or the Plan(s) it sponsors or administers) will participate in the class action (whether
putative or certified), participate in any class action settlement, pursue recovery of the relevant Overpayment outside
of the class action, or take any other action with respect to any cause of action the County (or the Plan(s) it sponsors
or administers) might have.
Offsets. In some instances, Contractor may be able to obtain Overpayment recoveries by applying (or offsetting) the
Overpayment against future payments to the provider made by Contractor. In effectuating Overpayment recoveries
through offset, Contractor will follow its established Overpayment recovery rules which include, among other things,
the prioritization of Overpayment credits based on the age of the Overpayment in Contractor’s system and funding
type. In Contractor’s application of Overpayment recovery through offset, timing differences may arise in the
processing of claims payments, disbursement of provider checks, and the recovery of Overpayments. As a result, the
Plan may in some instances receive the benefit of an Overpayment recovery before Contractor actually receives the
funds from the provider. Conversely, Contractor may receive the funds before the Plan receives the credit for the
Overpayment. It is hereby understood that the parties may retain any interest that accrues as a result of these timing
differences. Details associated with Overpayment recoveries made through offset will be identified in the monthly
reconciliation report provided to the designated representative for County’s Plan.
Third Party Liability/Subrogation; Non-Contractor Services. If County elects to engage another entity, including
using County resources, to pursue recovery, the parties will mutually agree to the terms of the transition of those
recovery services and any fee owed Contractor for the recovery services provided.
Claim Recovery Service Fees. County will be charged the fees set forth in Exhibit A to the Contract when any of the
Third Party Liability/Subrogation or Overpayment recovery services described in this Section 4.3 are provided by
Contractor through a subcontractor or affiliate. Contractor shall invoice County for fees incurred under this Section
through their banking statement, and payment shall be made by County through the Bank Account, in accordance with
the terms of the Contract.
If this Agreement terminates, or, if Contractor’s recovery services terminate, Contractor can elect to continue to
recover any payments Contractor is in the process of recovering, and the applicable service fees will continue to apply.
4.4
Abuse and Fraud Management. Contractor or its affiliate will provide services related to the detection,
prevention, and recovery of abusive and fraudulent claims.
Contractor will obtain County’s prior written consent prior to initiating litigation to recover payments in regard to
Plan Participant fraud, or if Contractor intends to file a legal action that names Contractor as a listed party in the
pleadings.
Contractor’s Abuse and Fraud Management processes will be based upon Contractor’s proprietary and confidential
procedures, modes of analysis and investigations. Contractor has the discretion and authority to use such procedures
and standards, including the authority to undertake actions, including legal actions, which have the largest impact for
the largest number of customers. However, if Contractor investigates a case where County is the sole customer
affected, Contractor will work with the County to determine a mutually agreeable recovery strategy.
Contractor will use these procedures and standards in delivering Abuse and Fraud Management services to County
and Contractor’s other customers. These procedures and standards include, but are not limited to: whether or not to
seek recovery, what steps to take if Contractor decides to seek recovery, and under what circumstances to compromise
a claim or settle for less than the full amount. The County will be given an opportunity to opt out of any settlement.
Only County has the authority to approve any recovery for less than 100% recovery of the benefits paid amount.
Contractor shall collect and prepare information related to conditional recovery payments under the Plan for
consideration by County, including requests for County to compromise demands or claims for the reimbursement of
the cost of medical care and treatment. In the event that a recovery or settlement offer represents a reduction from
100% recovery of the benefits paid amount, Contractor or its designated subcontractor or affiliate must seek prior
written approval of the potential recovery or settlement from the County contact identified in Section 4.3.
County will be charged the fees set forth in Exhibit A to the Contract when any of the services described in this Section
4.4 are provided by Contractor through a subcontractor or affiliate. All amounts recovered under these services shall
be refunded or otherwise credited to County at the gross amount. Contractor shall invoice County for fees incurred
under this Section through their banking statement, and payment shall be made by County through the Bank Account,
in accordance with the terms of the Contract. County acknowledges that the use of these procedures and standards
may not result in full or partial recovery or in full recovery for any particular case. Contractor does not guarantee or
warranty any particular level of prevention, detection, or recovery. Contractor agrees to perform Abuse and Fraud
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Management services pursuant to the industry standards for such services. If this Agreement terminates, or if
Contractor’s claim recovery services terminate, Contractor can elect to continue fraud and abuse recoveries that are
in progress, and the applicable service fees will continue to apply.
4.5
Medical Benefit Drug Rebate Payments. From time to time, Contractor or a subcontractor may negotiate
with drug manufacturers regarding the payment of medical benefit Rebates on applicable prescription drug products
dispensed to Participants under the Plan's medical benefit. County will receive 100% of the medical benefit Rebates
Contractor receives.
When Contractor negotiates directly with drug manufacturers for the payment of medical benefit Rebates to
Contractor, Contractor will pay County the agreed upon Rebates within thirty (30) calendar days of Contractor’s
receipt of such Rebates from the drug manufacturer. If Contractor is not able to make payment to County within thirty
(30) calendar days, Contractor will pay interest on such Rebates from the date of receipt until Contractor makes
payment to County, less approximately thirty (30) days for processing. Contractor will retain interest earned during
this processing timeframe. Contractor will pay medical benefit Rebates to County in the agreed upon amount no less
than annually. Interest will be paid at the one month London Interbank Offered Rate (LIBOR) in effect on the first
business day of each applicable month.
County will only receive County’s medical benefit Rebates to the extent that medical benefit Rebates are actually
received by Contractor. Thus, for example, if a government action or a major change in pharmaceutical industry
practices prevents Contractor from receiving medical benefit Rebates, the amount County receives may be reduced or
eliminated.
County agrees that during the term of this Agreement, neither County nor the Plan will negotiate or arrange or contract
in any way for medical benefit Rebates on or the purchase of prescription drug products from any manufacturer under
the Plan's medical benefit. If County or the Plan does, Contractor may, without limiting Contractor’s right to other
remedies, immediately terminate County’s and Plan's entitlement to medical benefit Rebates (including forfeiture of
any medical benefit Rebates earned but not paid). In addition, County agrees to reasonably cooperate with Contractor
in order to obtain medical benefit Rebates.
Subcontractor Compensation: If a subcontractor is involved in negotiating with drug manufacturers regarding the
payment of medical benefit Rebates, it may retain a portion of the gross amounts received from drug manufacturers
in connection with such products. Contractor will provide information on the amount, if any, retained by the
subcontractor as compensation for its services, in advance of County’s execution of this Agreement. In addition,
Contractor will provide County with thirty (30) days advance notice of any material increase in or method for
subcontractor compensation. If at any time County does not find the subcontractor compensation acceptable, County
may terminate the medical benefit Rebates services after thirty (30) days advance written notice to Contractor.
Contractor manages the County’s costs for applicable prescription drug products dispensed under the Plan’s medical
benefit several different ways, including, but not limited to medical necessity reviews, site of care requirements,
discounts negotiated directly with providers as part of their contract with Contractor, and medication sourcing
requirements.
4.6
Pharmacy Benefit Services. Contractor or its Affiliate will provide the Pharmacy Benefit Services described
in this Section 4.6. Contractor will make Network Pharmacies available to County’s Participants, through Contractor’s
affiliate. Contractor will determine which pharmacies are Network Pharmacies. Network Pharmacies can change at
any time. Contractor will make a reasonable effort to provide County with advance notice if any material changes
occur to the network. Upon request, Contractor will provide County information on the reimbursement rate to
Contractor’s affiliated Network Pharmacies.
Mail Order Pharmacy Services. Contractor will provide, through its affiliate mail order pharmacy, services for
County’s Participants. County’s pricing terms for mail order pharmacy services are based on package sizes of 100
units, 16 ounce quantities or the next closest quantity available and at least a 46 day supply. Prescriptions filled through
the mail order pharmacy that are less than a 46 day supply will be processed at retail pricing and will be counted with
retail utilization. Contractor will retain the difference between the package size of 100 units or 16 ounces and the
actual manufacturer’s package size which the mail order pharmacy’s price is based on.
Prescription Drug List (PDL). County has adopted one or more of Contractor’s PDLs for use with County’s benefit
plans. County agrees not to copy, distribute, sell, or otherwise provide the PDL to another party without Contractor’s
prior written approval, except to Participants as described below or as required by law. County may post the PDL on
its website for use by Plan participants and their physicians. Contractor acknowledges that County’s website is publicly
accessible. On termination of this Agreement or if County terminates the Pharmacy Benefit Services portion of this
Agreement, County will stop all use of the PDL.
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While County is the ultimate decision-maker on selecting the design of County’s PDL(s), County has requested that
Contractor supply, and Contractor has assisted County with, certain PDL development and management functions
including but not limited to drug tiering decisions. Contractor’s intent is to provide County with the same PDL and
management strategies that Contractor develops and employ in the management of Contractor’s fully insured business.
Contractor makes the final classification of an FDA-approved prescription drug product to a certain tier of the PDL
by considering a number of factors including, but not limited to, clinical and economic factors. Clinical factors may
include, but are not limited to, evaluations of the place in therapy, relative safety or relative efficacy of the prescription
drug product, as well as whether supply limits or notification requirements should apply. Economic factors may
include, but are not limited to, the prescription drug product's acquisition cost including, but not limited to, available
Rebates and assessments on the cost effectiveness of the prescription drug product.
Contractor may periodically change the placement of a prescription drug product among the tiers and/or recommend
specific prescription drug product exclusions from coverage, however Contractor will not exclude or uptier the
placement of a prescription drug product among the tiers more than twice annually. Contractor will provide notice to
County of material changes to the PDL (a material change to the PDL is one that is significant so as to have an effect
on Participants), Contractor’s drug tier classification procedures, coverage exclusions, and clinical programs. If
County chooses not to implement a particular coverage exclusion or clinical program change, County needs to inform
Contractor in writing sixty (60) days prior to the effective date of the exclusion or change. Current drug placement
and related information may be obtained from the participant website, or by calling customer service.
Claims Processing. Contractor will process the claims received from a Network Pharmacy in accordance with the
Summary Plan Description, as well as the pricing and other terms of the Network Pharmacy’s participation agreement.
On retail and mail order pharmacy services, Contractor will retain the difference between what Contractor reimburses
the Network Pharmacy and County’s payment for a prescription drug product or service. Contractor maintains systems
for processing pharmacy claims and may receive access fees as compensation for services Contractor provides to
Network Pharmacies.
4.7
Pharmacy Benefit Rebates.
Allocation and Payment of Rebates. Contractor will negotiate with drug manufacturers for the payment of Rebates
to Contractor. The amount of Rebates that is available depends on many factors, including whether County has an
incentive benefit design, arrangements with drug manufacturers, the volume of prescription drug claims and the
structure of the PDL. Contractor has agreed to pay County 100% of the Rebates; the minimum rebate guarantee is as
outlined in Exhibit A-1 to the Contract.
County will only receive County Rebates to the extent that Rebates are actually received by Contractor. For example,
if a government action or a major change in pharmaceutical industry practices eliminates or materially reduces
manufacturer Rebate programs; County payment amount may be reduced or eliminated. In such event, Contractor
shall promptly notify County and revise or eliminate such payment effective with the date of the reduction or
elimination in Rebate payments. In addition, reduction or elimination of Rebates in this event shall constitute a change
in the Agreement as described in the Service Fees Section such that Contractor has the right to increase the service
fees for the Pharmacy Benefits Management services or increase the percentage of Rebate dollars retained by
Contractor.
Contractor will make payments of County Rebates to County on a quarterly basis, and County will receive payments
within 120 days after the end of the quarter. If Contractor is not able to make payment to County within 120 calendar
days after the end of the quarter, Contractor will pay County interest on such Rebates, starting on the 121st calendar
day going forward until Contractor makes payment to County, calculated at the one month London Interbank Offered
Rate (LIBOR) in effect on the first business day of each applicable month. Contractor may receive and retain interest
on those Rebates until Contractor makes payment to County.
Payments to Pharmacies. In connection with prescription drug claims, there may be a timing difference between
when Contractor withdraws funds from County’s claims account and when Contractor issues payments to pharmacies
and other payees. Contractor may retain interest earned on these amounts during this time. Interest is expected to be
paid at overnight deposit rates by Contractor’s banking institution.
On mail order drugs, specialty drugs, and retail pharmacy drugs and services including dispensing fees, Contractor
will retain the difference between what Contractor reimburses the Network Pharmacy and the County's payment for a
prescription drug product or service. This pricing mechanism ensures Contractor is leveraging negotiating power to
secure lower drug prices from pharmacies which helps offset other administrative fees that would otherwise be passed
to the County, and supports the competitive network discounts Contractor has guaranteed in Exhibit A-1.
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County Compliance. County agrees that during the term of this Agreement, neither County nor the Plan will negotiate
or arrange or contract in any way for Rebates on or the purchase of prescription drug products from any manufacturer
with respect to the pharmacy benefits. If County or the Plan does, Contractor may, without limiting Contractor’s right
to other remedies, immediately terminate County’s and Plan's entitlement to Rebates (including forfeiture of any
Rebates earned but not paid) and/or terminate the pharmacy benefit services. Termination of pharmacy benefit services
shall constitute a change in the Agreement as described in the Service Fees Section such that Contractor has the right
to increase the services fees for medical management services under this Agreement.
In addition, County agrees to reasonably cooperate with Contractor in order to obtain Rebates. County will encourage
County’s Participants to use a Network Pharmacy. County will also encourage County’s Participants to electronically
access the PDL on Contractor’s website, and encourage Participants to share the PDL with their physicians or refer
their physicians to the PDL on Contractor’s website
4.8
Health Savings Account (HSA). Contractor will provide County with an HSA in accordance with Exhibit
B-1 to this Agreement. The HSA is not subject to ERISA, and accordingly, any provisions of this Agreement which
reference ERISA or which establish upon Contractor an obligation to provide reporting or other services standardly
associated with an ERISA plan shall not apply to the HSA and any services relating thereto.
County acknowledges that HSAs are subject to contribution limits and other requirements imposed by the IRC and
associated guidance issued by the IRS/Treasury Department. County acknowledges and agrees that Contractor shall
have no obligation to ensure compliance with any requirements or limitations pertaining to HSAs or their use. To the
extent that County has established contribution amounts and other HSA program requirements applicable to County’s
Enrolling Employees, County will advise Contractor of such requirements.
Contractor will not verify that distributions from County’s Enrolling Employees’ HSAs are for qualified medical
expenses.
Contractor’s affiliate, Optum Bank, Inc., will accept HSA eligibility and account setup information from the Plan
directly for County’s Participants as stated in Exhibit B-2 to this Agreement.
Section 5 – Benefit Determinations and Appeals
5.1
Claim Procedures. County appoints Contractor a named, fiduciary under the Plan with respect to (i)
performing initial benefit determinations and payment, (ii) performing the fair and impartial review of first level
internal appeals, and (iii) performing the fair and impartial review of second level internal appeals. As such, County
delegates to Contractor the discretionary authority to (i) construe and interpret the terms of the Plan, (ii) to determine
the validity of charges submitted to Contractor under the Plan, and (iii) make final, binding determinations concerning
the availability of Plan benefits under the Plan’s internal appeal process.
If it is determined that a benefit is payable, Contractor will issue a check for, or otherwise credit the benefit payment
to the appropriate payee.
If Contractor denies a Plan benefit claim, the claimant shall have the appeal rights set forth in the Summary Plan
Description, and/or which are required under applicable law. If Contractor determines that all or a part of the benefit
is not payable under the Plan, Contractor will notify the claimant of the adverse benefit determination and of the
claimant's right to appeal the adverse benefit determination. This notification will be designed to comply with
applicable requirements for adverse benefit determination notices.
If, after the exhaustion of the two levels of internal appeal with Contractor, Contractor determines that the Plan benefit
is still not available, Contractor will notify the claimant that the adverse benefit determination has been upheld. This
notice will be designed to comply with the applicable requirements for adverse benefit determination notices. This
determination will be final and binding on the claimant, and all other interested parties, except as otherwise provided
under the external review program described in Section 5.2.
Appeals of Urgent Care Claims
Notwithstanding the foregoing, with respect to Urgent Care Claims, Contractor will conduct one review of a denied
Urgent Care Claim and issue a final determination as soon as possible, in accordance with applicable law.
5.2
External Review Program. Contractor will notify claimants of the option to request an external review of
adverse benefit determinations following the required internal appeal process. Contractor will, in accordance with
applicable law: (i) provide claimant with the necessary procedures to obtain the review (ii) coordinate submission of
the claimant’s case to an independent review organization, and (iii) notify the claimant of the final external review
decision. A fee will apply beyond the maximum number of free reviews, as listed in Exhibit B-1 to this Agreement.
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Section 6 – Service Fees
6.1
Reconciliation. For each Plan year period, Contractor will reconcile the total amounts County paid with
respect to Standard Service Fees under Exhibit A to the Contract with the total amounts County owed. If the
reconciliation indicates that Contractor owes County money, County’s next payment will be credited. If the
reconciliation indicates that County owes Contractor money, Contractor will invoice County for the amount due. The
Due Date for these amounts is the first day of the next calendar month. County will pay Contractor within thirty (30)
days after receiving notice of the amounts that County owes Contractor. For payments made after this thirty (30) day
period, County will pay Contractor interest on these amounts at the interest rate that Contractor charges to its other
self-funded customers.
If the Agreement is terminated, Contractor will pay County the amount owed within thirty (30) days after Contractor
performs a final reconciliation. If the final reconciliation indicates that County owes Contractor money, County will
pay Contractor within thirty (30) days after receiving notice of the amount owed.
For payments County makes after thirty (30) days of receiving notice of the amounts that County owes Contractor,
Contractor will charge interest at the interest rate that Contractor charge its other self-funded customers.
Section 7 – Process For Providing Funds For Benefits
7.1
Providing Funds for Benefits. The Plan is Self-Funded. County is solely responsible for providing funds
for payment for all Plan benefits payable to Participants, Network Providers, or non-Network Providers.
7.2
Bank Account. Contractor, on County’s behalf, will open and maintain a Bank Account at the Bank to
provide Contractor the means to access County’s funds for the sole purpose of payment of Plan benefits, Plan expenses
(such as state surcharges or assessments) and, when authorized by County, service fees. The Bank Account will be a
part of the network of accounts that have been established at the Bank for Contractor’s self-funded customers. The
funds in the Bank Account are County’s and will not be comingled with any other customer funds.
7.3
Balance In Account. County will maintain a minimum balance in the Bank Account in an amount equal to
not less than 1 day of expected Bank Account activity. Contractor will establish this amount based on expected Plan
benefit payments, with appropriate adjustments for anticipated non-daily activity (e.g., prescription drug benefits and
service fee payments) as determined by Contractor. Contractor will determine if circumstances warrant increasing this
minimum balance, and will notify County if and when the required balance or the amount identified above changes.
The required minimum balance is based on County’s financial condition as assessed by Contractor. In the event
Contractor determines, based on reasonable information and belief, that County’s financial condition has deteriorated
or County continues to fail to comply with the material financial obligations specified in this Agreement, Contractor
may revise the required balance subject to providing five (5) days written notice to County.
7.4
Issuing and Providing Funds for Checks and Non-Draft Payments. The checks and/or non-draft
payments Contractor writes and issues to pay Plan benefits under this Agreement will be written and/or issued from
one or more common accounts that are a part of the network of accounts maintained at the Bank for Contractor’s self-
funded customers. When the checks for Plan benefits are presented to the Bank, the Bank will notify Contractor and
Contractor will direct the Bank to either reject the checks or to withdraw funds from the Bank Account to fund the
checks that are cashed.
7.5
Transfers of Funds. Funds will also be withdrawn from the Bank Account when a transfer of funds
Contractor made to pay Plan benefits is completed, such as when an electronic funds transfer has been made to a
health care provider to pay benefits under the Plan. Contractor will direct the Bank to withdraw funds from the Bank
Account to fund the non-draft payments as they are issued.
7.6
Calls for Funds. The withdrawals for Plan benefits and service fees are paid for by the balance County
maintains in the Bank Account. This balance will be drawn down each banking day to satisfy the previous day’s
liability.
County will authorize Contractor to initiate wire transfers from County’s designated benefit funding bank account to
the Bank Account for the amount needed to pay claims processed and fees that are due. Every 1 business day(s),
Contractor will notify County of the amount due and Contractor will immediately, via wire, initiate transfers from
County’s designated funding bank account to the Bank Account in an amount necessary to pay Plan benefits.
7.7
Underfunding. If County does not provide the amounts sufficient to maintain the required minimum balance
in the Bank Account, or to cover Bank Account withdrawals: (1) County must immediately correct the deficiency and
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provide prompt notice to Contractor. (2) If Contractor learns of the funding deficiency, Contractor will notify County
within one business day so County can correct the deficiency. (3) Contractor may stop issuing checks and non-draft
payments and suspend any of its other services under this Agreement for the period of time County does not provide
the required funding. (4) If County does not correct the funding deficiency within five business days of Contractor’s
notice to County, Contractor may terminate this Agreement as otherwise set forth in the Contract, such termination to
be effective the first day such claims funding deficiency began. County will pay interest on the amount of underfunding
at the standard rate that Contractor charges to its self-funded customers for underfunding of bank accounts.
7.8
Stop Payments on Outstanding Checks. At County’s expense, Contractor may place stop payments on
checks if Contractor determines that County has insufficient funds in its designated benefits funding bank account to
honor such checks. Contractor will send a search letter to the payee on all checks that have not been cashed within six
(6) months. Contractor will automatically stop payment on all checks that have not been cashed within twelve (12)
months and provide County with reports County needs for the purposes of performing escheat. County is solely
responsible for determining to file and/or filing unclaimed property once notified, or for making unclaimed payee
payments directly.
7.9
Funding After Termination. When the Contract terminates, the funding method for Plan benefits will
remain in place for the length of the run-out period. After the run-out period has ended, that funding method will cease
and County will deposit and maintain in the Bank Account enough funds to cover all checks for Plan benefits that
have been issued but not cashed. This balance will remain in the Bank Account for a limited period of time to fund
the outstanding checks. This period will be reasonable, as determined by Contractor. Contractor will stop payment on
all checks that remain uncashed at the end of this period and County will request in writing to close the Bank Account
and recover any funds remaining in it. Contractor will provide bank statements and Bank Account reconciliation
reports, including reports County needs for the purposes of performing escheat.
Section 8 – Services Begin and End
8.1
Services Begin and End. Contractor will begin providing County services under the Contract and this
Agreement on the Services Effective Date. These services apply only to claims for Plan benefits that are incurred on
or after the Services Effective Date.
Contractor’s services under this Agreement stops on the date the Contract or this Agreement terminates, regardless of
the date that claims are incurred. However, Contractor may agree to continue providing certain run-out claims
administration services beyond the termination date, as provided in Exhibit B-1 to this Agreement.
Section 9 – Records, Information, Audits
9.1
Records. Contractor will keep records relating to the services it provides under this Agreement for six (6)
years or as long as Contractor is required to do so by law, whichever is latest.
9.2
Access to Information. If County needs information in Contractor’s possession for purposes other than an
audit, but in order to administer the Plan, Contractor will provide County access to that information, if it is legally
permissible, the information relates to Contractor’s services under this Agreement, and County gives Contractor
reasonable advance notice and an explanation of the need for such information.
County represents that it has reasonable procedures in place for handling PHI, as required by law. County will only
use or disclose PHI to administer the Plan, to perform under this Agreement or as otherwise permitted under this
Agreement or required by law.
Contractor will provide information only while this Agreement is in effect and for a period of six (6) months after the
Agreement terminates, unless County demonstrates that the information is required by law or for Plan administration
purposes.
Contractor also will provide reasonable access to information to an entity providing Plan administrative services to
County, such as a consultant or vendor, if County requests it. Before Contractor provides PHI to that entity, the parties
must sign a mutually agreed-upon confidentiality agreement and adhere to all obligations under Exhibit C (the HIPAA
Business Associate Agreement) to the Contract, and the parties must agree as to what information is minimally
necessary to accomplish the Plan administrative service.
9.3
Audits. During the term of the Agreement, and at any time within six (6) months following its termination,
County or a mutually agreeable entity may audit Contractor once each calendar year to determine whether Contractor
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is fulfilling the terms of this Agreement. Prior to the commencement of this audit, Contractor must receive a signed,
mutually agreeable confidentiality agreement.
Without limiting the foregoing, with respect to audits regarding the payment of Rebates by pharmaceutical
manufacturers, the audit must be conducted solely by a mutually agreeable public accounting firm that maintains a
separate and stand-alone audit department and is not providing support in conjunction with any litigation pending
against Contractor or its affiliates.
County must advise Contractor in writing of its intent to audit. The place, time, type, duration, and frequency of all
audits must be reasonable and agreed to by Contractor. All audits will be limited to information relating to the calendar
year in which the audit is conducted, and/or the immediately preceding calendar year. With respect to Contractor’s
transaction processing services, the audit scope and methodology will be consistent with generally acceptable auditing
standards, including a statistically valid random sample or other acceptable audit technique as approved by Contractor
(“Scope”).
County will pay any expenses that it incurs in connection with the audit. In addition, County will be charged a
reasonable per claim charge and a $1,000 charge per day for audits outside of the following parameters: (1) more than
one audit per calendar year; (2) any on-site audit visit that is not completed within five (5) business days; (3) sample
sizes exceeding the Scope specified above; or (4) any audit initiated after this Agreement has terminated, unless the
Contract was terminated for default by Contractor. The additional fees cover the additional resources, facility fees,
and other incremental costs associated with an audit that exceeds the Scope.
In addition to County’s expenses and any applicable fees, County will also pay any extraordinary expenses Contractor
incurs in connection with the audit. For any audit initiated after this Agreement is terminated, County will pay all
expenses incurred by Contractor unless the Contract was terminated for default by Contractor.
County will provide Contractor with a copy of any audit reports within thirty (30) days after County receives the audit
report(s) from the auditor.
9.4
Proprietary Business Information. Neither party may disclose the other's Confidential Information or
Proprietary Business Information to any person or entity other than to the disclosing party's employees and Business
Associates needing access to such information to administer the Plan, to perform under this Agreement, or as otherwise
permitted under this Agreement, except that Contractor’s Financial PBI cannot be disclosed by County to any third
party without Contractor’s express written consent. This provision shall survive the termination of this Agreement.
Notwithstanding the foregoing, (i) Contractor may disclose County Confidential Information or Proprietary Business
Information to its affiliates and subcontractors as needed for those entities to provide Services under this Agreement,
(ii) County will not be prohibited from providing provider-specific cost or quality of care information or data, through
a consumer engagement tool or any other means, to referring providers, the Plan Sponsor, Participants, or individuals
eligible to become Participants of the Plan, to the extent required by Law, (iii) County may only use Contractor’s
Confidential Information for Plan administration purposes, and (iv) before Contractor’s Confidential Information can
be disclosed, Contractor may require a mutually agreed upon confidentiality agreement consistent with Law.
Neither party may a) sell, license, or grant any other rights to the other party’s Confidential Information or Proprietary
Business Information, (b) use the other party’s Confidential Information or Proprietary Business Information for the
creation, operation or improvement of any product, service or database for external or commercial use, or c) use the
other Party’s Confidential Information or Proprietary Business Information to contract with or manage healthcare or
pharmacy providers, coalitions or networks.
9.5
Service Auditor Reports. Contractor may make its Type II service auditor report (“Report”) available to
Contractor’s self-funded customers each year for County’s review in connection with Plan administrative purposes
only. The Report will be issued under the guidance of Statement on Standards for Attestation Engagements #18
(SSAE18) SOC 1 Type II. Should new guidelines covering service auditor reports be issued, Contractor may make
the equivalent of, or any successor to, the SSAE18 Type II Report available to Contractor’s self-funded customers.
The Report is Contractor’s Proprietary Business Information and shall not be shared with any third parties without
Contractor’s prior written approval; provided, however, that County can share the Report with: (i) County’s
independent public accounting firm; (ii) County’s consultants, provided that such consultants are not in any way a
competitor of Contractor’s and that County informs its consultants that the report was not prepared for their use; and/or
(iii) as required by law. To the extent that County does provide the Report to its independent public accounting firm
or a consultant as permitted herein, the County shall require that they retain the Report as confidential and that they
not disclose such Report to any other persons or entities.
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9.6
PHI. The parties' obligations with respect to the use and disclosure of PHI are outlined in the Business
Associate Addendum attached to the Contract as Exhibit C.
Section 10 – System Access
10.1
System Access. Contractor grants County the nonexclusive, nontransferable right to access and use the
functionalities contained within the Systems, under the terms specified in this Agreement. County agrees that all rights,
title, and interest in the Systems and all rights in patents, copyrights, trademarks, and trade secrets encompassed in the
Systems will remain Contractor’s. To obtain access to the Systems, County will obtain, and be responsible for
maintaining, at no expense to Contractor, the hardware, software, and Internet browser requirements Contractor
provides to County, including any amendments thereto. County will be responsible for obtaining an Internet Service
Provider or other access to the Internet. County will not (i) access Systems or use, copy, reproduce, modify, or excerpt
any Systems documentation provided by Contractor in order to access or utilize Systems, for purposes other than as
expressly permitted under this Agreement or (ii) share, transfer or lease County’s right to access and use Systems, to
any other person or entity which is not a party to this Agreement. County may designate any third party, with prior
approval from the Contractor to access Systems on County’s behalf, provided the third party agrees to these terms and
conditions of Systems access and County assumes joint responsibility for such access.
10.2
Security Procedures. County will use commercially reasonable physical and software-based measures to
protect the passwords and user IDs provided by Contractor for access to and use of any web site provided in connection
with the services. County shall use commercially reasonable anti-virus software, intrusion detection and prevention
system, secure file transfer and connectivity protocols to protect any email and confidential communications provided
to Contractor, and maintain appropriate logs and monitoring of system activity. County shall notify Contractor within
a reasonable timeframe of any (a) unauthorized access or damage, including damage caused by computer viruses
resulting from direct access connection, and (b) misuse and/or unauthorized disclosure of passwords and user IDs
provided by Contractor which impact the System.
10.3
System Access Termination. Contractor reserves the right to terminate County’s System access (i) on the
date County fails to accept the hardware, software and browser requirements provided by Contractor, including any
amendments thereto or (ii) immediately on the date Contractor reasonably determines that County has (i) breached,
or allowed a breach of, any applicable provision of this Section 10 or (ii) materially breached or allowed a material
breach of, any other applicable provision of this Agreement. County’s System Access will also terminate upon
termination of this Agreement, provided however that if run-out is provided in accordance with Exhibit B-1 to this
Agreement, County may continue to access applicable functionalities within the Systems during the run-out period.
Upon any of the termination events described in this Agreement, County agrees to cease all use of Systems, and
Contractor will deactivate County’s identification numbers, passwords, and access to the System.
Section 11 – Taxes And Assessments
11.1
Payment of Taxes and Expenses. In the event that any Taxes are assessed against Contractor as a claim
administrator in connection with Contractor’s services under this Agreement, including all topics identified in Section
12.3, County will reimburse Contractor through the Bank Account for County’s proportionate share of such Taxes
(but not Taxes on Contractor’s net income). Contractor has the authority and discretion to reasonably determine
whether any such Tax should be paid or disputed. County will also reimburse Contractor for a proportionate share of
any cost or expense reasonably incurred by Contractor in disputing such Tax, including costs and reasonable attorneys'
fees and any interest, fines, or penalties relating to such Tax, unless caused by Contractor’s unreasonable delay or
unreasonable determination to dispute such Tax.
11.2
Tax Reporting. In the event that the reimbursement of any benefits to Participants in connection with this
Agreement is subject to Plan or employer based tax reporting requirements, County agrees to comply with these
requirements.
11.3
State and Federal Surcharges, Fees and Assessments. The Plan will remain responsible for state or Federal
surcharges, assessments, or similar Taxes imposed by governmental entities or agencies on the Plan or Contractor,
including, but not limited to, those imposed pursuant to The Patient Protection and Affordable Care Act of 2010, as
amended from time to time (e.g., the reinsurance fee to be processed by third-party administrators on behalf of the
self-funded plans).
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Section 12 – Plan Benefits Litigation
12.1
Litigation Against Contractor. If a demand is asserted, or litigation or administrative proceedings are begun
by a Participant or healthcare provider against Contractor to recover Plan benefits related to its duties under this
Agreement (“Plan Benefits Litigation”), Contractor will select and retain defense counsel to represent its interest
subject to Section 12.4 below.
12.2
Litigation Against County. If Plan Benefits Litigation is begun against County and/or the Plan, County will
select and retain counsel to represent its interest.
12.3
Litigation Against Contractor and County. If Plan Benefits Litigation is begun against County and/or the
Plan and Contractor jointly, and provided no conflict of interest arises between the parties, the parties may agree to
joint defense counsel. If the parties do not agree to joint defense counsel, then each party will select and retain separate
defense counsel to represent their own interests.
12.4
Litigation Fees and Costs. All reasonable legal fees and costs Contractor incurs will be paid by County
(except where Contractor is obligated to indemnify County as provided in Section 6.1.1 of the Contract) if Contractor
gives County reasonable advance notice of Contractor’s intent to charge County for such fees and costs and obtains
County’s prior approval for such legal fees and costs; provided that (i) Contractor selects counsel from one of County’s
approved legal vendors who has agreed to provide legal services at the County’s rate, or Contractor will select and
retain defense counsel whose fees shall exceed the County’s approved legal vendor’s fees, and (ii) Contractor consults
with County in a manner consistent with Contractor’s fiduciary obligations on Contractor’s litigation strategy.
12.5
Litigation Cooperation. Both parties will cooperate fully with each other in the defense of Plan Benefits
Litigation.
12.6
Payment of Plan Benefits. In all events, County is responsible for the full amount of any Plan benefits paid
as a result of Plan Benefits Litigation.
12.7
Survival. This provision shall survive the termination of this Agreement.
Section 13 – Miscellaneous
13.1
Subcontractors. Subject to the terms and conditions of Section 10.17 of the Contract, Contractor can use its
affiliates or subcontractors to perform Contractor’s services under this Agreement. Contractor will be responsible for
those services to the same extent that Contractor would have been had it performed those services without the use of
an affiliate or subcontractor.
13.2
Waiver/Estoppel. Nothing in this Agreement is considered to be waived by any party, unless the party
claiming the waiver receives the waiver in writing. No breach of the Agreement is considered to be waived unless the
non-breaching party waives it in writing. A waiver of one provision does not constitute a waiver of any other. A failure
of either party to enforce at any time any of the provisions of this Agreement, or to exercise any option which is herein
provided in this Agreement, will in no way be construed to be a waiver of such provision of this Agreement.
13.3
Use of Name. The parties agree not to use each other's name, logo, service marks, trademarks or other
identifying information without the written permission of the other; provided, however, County grants Contractor
permission to use County’s name, logo, service marks, trademarks or other identifying information to the extent
necessary for Contractor to carry out its obligations under this Agreement (e.g. on SPDs and ID cards). County will
request and Contractor will provide logo, service marks, trademarks or other identifying information for County to
use on its benefits website. Contractor grants County permission to use such identifying information as provided by
Contractor on County benefits website without permission.
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EXHIBIT B-1: SERVICES
The following are the administrative services Contractor has agreed to provide to County and which are included the
Standard Service Fees set forth in Exhibit A to the Contract, except where otherwise noted below or in Exhibit A as
an additional or separate fee. County may request that Contractor provide services in addition to those set forth in this
Agreement. County will pay an additional fee, mutually agreed upon by the parties, for these additional services.
The Services described in this Exhibit B-1 will be made available to County’s eligible Participants consistent with the
Summary Plan Description under which the Participant is covered.
A. ACCOUNT MANAGEMENT SERVICES
Service
Comments
Implementation and maintenance of account.
Enrollment meetings and support for locations that
meet Contractor’s criteria.
Standard initial enrollment kit.
Bulk mailing of initial enrollment kits to County
based on Contractor’s criteria.
Ongoing account management including:
Designated account resources, including a Wellness
Consultant.
Ongoing management and review of benefits and
data.
Standard accounting structure based on
Contractor’s criteria:
Suffixes to accommodate separate claims reporting
for different benefit plans.
Claim accounts to accommodate separate claims
data for different locations and groups.
Maximum of 25 distinct suffix/account splits.
Maintenance of up to 2 separate benefit plans which
include the High Deductible Health Plan and the
PPO plan.
The maintenance of the 2 separate benefit plans also
includes the maintenance of the pharmacy and
behavioral health portions of both plans.
Electronic Bill Presentment and Payment (EBPP),
which provides capabilities to:
View invoices online.
Sort and search enrollee information.
Download billing information.
Remit payment online.
Online administration services accessed through
Contractor’s Employer eServices Web site including
online eligibility maintenance and claim status inquiry.
Reporting to the County is included to the extent indicated
in Section D. eServices Customer Reporting Services.
Issuance of HIPAA Certificates of Creditable
Coverage
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Service
Comments
Summary Plan Description (SPD) Assistance.
Contractor will prepare a customized draft of an SPD,
either for each plan or multiple plans, as mutually agreed
upon with a commercially reasonable number of
additional drafts, in response to County’s comments,
and a final draft SPD. “Plan”, for purposes of this
paragraph,
means
each
individual
plan
design
administered by Contractor. The SPD will be in English.
Contractor will provide County with the final draft SPD.
If the SPD is not finalized sufficiently in advance of the
Services Effective Date of Contractor’s services,
Contractor will either (i) utilize the summary of Plan
benefits and exclusions that Contractor has created based
on its understanding of County’s Plan design and which
County has reviewed and approved or (ii) create, at
Contractor’s discretion, an operational SPD which will
be based upon the summary of Plan benefits that County
has reviewed and approved. Contractor will administer
claims and otherwise provide its services in accordance
with this summary of Plan benefits and exclusions or
operational SPD, as the case may be, and it will govern
and remain in full force and effect until a final SPD is
provided to Contractor.
If Contractor is providing Drafts only or if County is
producing the Final SPDs, Printing of SPDs will be at an
additional cost.
Summary of Benefits and Coverage (SBC):
Electronic version in Contractor’s standard format.
For medical Plans administered by Contractor.
Initial request and up to 4 amendments per year per
separate benefit plan.
Contractor will provide, at no additional charge, standard
format, electronic copies of the SBC documents (up to
four (4) SBC documents per year for each separate
benefit plan) for medical benefit plans administered by
Contractor. County logos can be included on the SBC at
no additional charge.
Additional fees will apply for other services. Contractor
will not create SBCs for medical plans it does not
administer.
B. ELIGIBILITY MANAGEMENT SERVICES
Service
Comments
Standard ID Card production and issuance.
Contractor has assumed the addition of County’s logo in
an acceptable format to the ID card.
Alternative participant ID numbers generated by
Contractor (not based on SSN).
Electronic Eligibility Processing
Electronic Enrollment processing:
Each submission to be a single consolidated file.
Separate eligibility submissions for COBRA.
Initial load of primary physician data (when
applicable) to be supplied electronically with
ongoing changes submitted via Employer
eServicesSM Web site.
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Service
Comments
Submission format:
UnitedHealth Group® Standard 3005 Format;
HIPAA 834 Compliant Format; or HR-XML
format.
Single data source required.
Submission frequency:
Changes file daily in combination with a full
population file on a monthly schedule.
Or
Changes file weekly or bi-weekly in combination
with a full population file on a monthly or quarterly
schedule.
Or
Full file weekly or bi-weekly.
Transmission method:
FTP with Contractor’s approved encryption or
direct connect.
Qualified Medical Support Order and Disabled Dependent
Audit
United will enroll a dependent as directed by Customer.
UnitedHealthcare will send ID Card and Summary Plan
Description to dependents and/or their custodial parents who are
subject to a Qualified Medical Support order. UnitedHealthcare
will process claims and send EOBs to the dependent and or their
custodial parents.
United will conduct an annual audit and reverification of all
coverage disabled dependents enrolled in the plan following the
start of the plan year to ensure that there is no change in their
disabled status that would warrant a termination of coverage.
C. UNDERWRITING AND FINANCIAL SERVICES
Service
Comments
Overall program accounting (year-end
reconciliation).
Claim projections.
Annual Projection of cost impact for benefit design
changes.
Annual Projection of conventional premium
equivalent rates.
Annual Reserve estimates.
Annual government filings of 1099 reports to the
IRS regarding payments made to physicians and other
health care professionals.
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D. SERVICES ® CUSTOMER REPORTING SERVICES
Service
Comments
An online customer reporting system including up to
five customer IDs.
Reporting Access Levels:
Standard – Basic report package of “subscription”
financial and utilization information produced on a
pre-scheduled basis.
Select – In addition to the Standard features,
interactive access to eCR tools allowing the user to
customize report parameters to facilitate detailed
views of the data. Includes a broad array of
membership and utilization reports.
Expanded – In addition to the Select features,
allows the user greater ad-hoc and customizable
capabilities to obtain detailed performance
information.
County will receive the Expanded reporting access level
at no additional cost.
Non-standard or ad hoc reports
Fees are determined on a report-specific basis at a rate of
$125 an hour
Contractor reserves the right, from time to time, to change the content, format and/or type of its reports.
E. CLAIMS ADMINISTRATIVE SERVICES
Service
Comments
Claims for Plan benefits must be submitted in a form that is satisfactory to Contractor in order for it to determine
whether a benefit is payable under the Plan’s provisions. County delegates to Contractor the discretion and
authority to use Contractor’s claim procedures and standards for Plan benefit claim determination.
Implementation of County’s benefit plans.
Claim history load from one prior carrier using
Contractor’s standard process.
Standard claims processing including:
Re-pricing and payment of claims.
Auto and manual adjudication using proprietary
software.
Claim edit/review and cost containment program
Pending and subsequent claim review.
Standard claim forms (when applicable).
Contractor will retain claim fiduciary responsibility
as described in Section 5.
Medical claim review of specific health care claims to
promote coding accuracy, benefit interpretation, and
apply reimbursement policy.
External Reviews as identified in Section 5.2.
For each subsequent external review beyond 10 total
reviews per year, a fee of $500 will apply per review.
Production and distribution of monthly Health
Statements.
Production and mail distribution of hard copy
Explanation of Benefits for each claim processed.
Processing of run-out claims (meaning claims incurred
prior to the termination date) 18 months at no charge
If the Agreement terminates because County fails to pay
Contractor fees due, fails to provide the funding for the
payment of benefits or Contractor terminates for any
other material breach, Contractor will have no obligation
to conduct processing of run-out claims.
Termination of Run-out Processing
Run-out claims processing will terminate if County fails
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to provide the required funds for payment of benefits
under the terms of this Agreement. Such
termination shall apply to all claims regardless of dates
of service.
F. PARTICIPANT SERVICES
Service
Comments
Toll-free access to a customer care unit using a
dedicated 800 number from 5 am to 8pm in the
Participant’s time zone.
Services also include a pre-participant customer service
line
Employee access to a participant website enabling
Participants to:
Check claim status.
Check eligibility information.
Search for providers and online health information.
Services also include a pre-participant web-site
G. PAYMENT INTEGRITY SERVICES
Service
Comments
Coordination of benefits
See Exhibit A to the Contract
OrthoNet Focused Claim Review (FCR) where same
specialty physicians conduct targeted reviews of 16
high-cost procedures and compare medical notes to
codes billed identifying billing errors.
See Exhibit A to the Contract
Application of subrogation services which includes
all aspects of subrogation – right of reimbursement or
third-party liability recovery – including identification,
evaluation, notification to all impacted parties, file
management, negotiation and settlement, recovery and
electronic fund transfer to the customer’s plan.
See Exhibit A to the Contract
Hospital Bill Audit Program.
See Exhibit A to the Contract
Credit Balance Recovery Program.
See Exhibit A to the Contract
Advanced Analytics and Recovery Services
See Exhibit A to the Contract
Contractor or its affiliate will use a combination of large
scale analytics, information and analysis to identify post-
adjudication
claims
for
additional
overpayment
opportunities.
Enhanced Fraud and Abuse Program
See Exhibit A to the Contract
H. MEDICARE SERVICES
Service
Comments
Medicare Secondary Payer Reporting. Contractor
shall provide to applicable parties the applicable reports
in a time and manner as required according to the
Medicare Secondary Payer Mandatory Reporting
Provisions ("Reporting Requirements") in Section 111
of the Medicare, Medicaid, and SCHIP Extension Act of
2007. Contractor shall not be responsible for any
noncompliance penalties in connection with the
Reporting Requirements that are related to County’s
failure to provide the required data.
County agrees to provide to Contractor in a timely manner
and in an agreed upon format any and all data that
Contractor requires to comply with the Reporting
Requirements.
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I. NETWORK SERVICES
Service
Comments
Network access, management and administrative
activities
Standard on all network plans.
UnitedHealth PremiumSM Designation Program
Available in designated markets. Arizona is a designated
Premium Designation Program market.
Network access to chiropractic and complementary
alternative medicine providers
Transplant Solutions (TS) Services
Transplant Network via Centers of Excellence
(COE)
Transplant Access Program (TAP) Network
Extra-Contractual Services - contracting on a case-
by case basis for transplant care outside of the COE
or TAP Networks for a standard negotiating fee.
Reasonable and customary charge guidelines for out of
network surgical, medical, lab and x-ray claims.
Maximum Non-Network Reimbursement Program
(MNRP) for non-emergency non-network claims.
Contractor will reimburse non-network expenses
according to 140% of Medicare’s cost-based payment
methodology, as mutually agreed upon by the parties.
Under the MNRP reimbursement for non-emergency
treatment is 140% of the published rates allowed by
Medicare for the same or similar services.
The MNRP option is only applicable if County elects the
service in lieu of utilizing reasonable and customary
charge guidelines. There is no additional cost to elect
the MNRP.
Naviguard Program
•
Offers reimbursement methodologies for
emergent and non-emergent out of network
claims which calculates allowed amounts based
on what a healthcare provider generally accepts
for the same or similar service.
•
Includes an advocacy component where
Participants can access resources, and on- line
tools and materials to help Participants stay in
network and where assistance is provided in
explaining reimbursement methodologies.
For claims above a threshold established by
UnitedHealthcare, the advocacy component includes
UnitedHealthCare negotiating with a provider on behalf
of a Participant with respect to Participant’s balance
billed amount.
Within 130 days of the plan year end, UnitedHealthcare
will provide an annual reconciliation of the Naviguard
program including detailed cost, member savings, and
plan savings.
See Exhibit A to the Contract
Access to Extended Networks (leased networks)
Available at an additional charge.
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J. CARE MANAGEMENT AND OUTREACH SERVICES
Service
Comments
Personal Health Support, an integrated personal
health management program using a designated team
of nurses and incorporating elements of care
management core activities such as case management
and support around specific treatment decisions. A
pregnancy program, consumer engagement notification
program including gaps in care messaging, and a
predictive model specific to County are also included.
Coordination with external vendors is subject to an
additional fee.
Designated HealthAdvisor team
Medical policy functions, as guided by a medical
director.
Standard on all managed plans.
Disease Management Programs for congestive heart
failure (CHF), chronic obstructive pulmonary disease
(COPD), coronary artery disease (CAD), diabetes and
asthma.
Coordination with external vendors is subject to an
additional fee.
Complex Medical Conditions:
Cancer Resource Services
Congenital Heart Disease Resource Services
Healthy Back
Maternity Support
Kidney Resource Services
Parent Steps Infertility Discount Program
Included at no additional fee
Point solutions and or participant tools including
those in the UHC Hub which are not limited to the
following;
Virta Diabetes Reversal, Diabetes Management,
Obesity Reversal
Included at no additional administrative fee (claim costs
may apply)
Hinge – Digital MSK Exercise therapy
Included at no additional administrative fee (claim costs
may apply)
Real Appeal – Wellness/Weight Management
Included at no administrative additional fee (claim costs
may apply)
One Pass – Fitness center membership discounts
Included at no additional administrative fee
AbleTo – Digital Behavioral Health
Included at no additional fee
Rally – Wellness Rewards
Included at no additional fee
Personal Health Record
Included at no additional fee
Complementary & Alternative Medicine (CAM)
Discount Network
Included at no additional fee
Diabetes Prevention and Control Alliance Services
Contractor will provide County eligible Participants
with access to the Diabetes Prevention Program
(“DPP”) and the Diabetes Control Program (“DCP”).
The program is intended to:
achieve earlier identification of diagnosed and
undiagnosed Participants with pre-diabetes and
diabetes
improve individual compliance with evidence-
based medicine
achieve better health outcomes and lower costs for the
DPCA Services are rendered by Contractor’s networks of
certain community-based providers (DPCA Providers).
Contractor is not responsible for the medical outcomes or
the quality or competence of any DPCA Providers.
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County and County Participants.
Alternate Care Proposals (ACP) which provide
appropriate and cost effective health care services
and supplies alternatives that would otherwise not
be covered by the Plan.
County consents to Contractor’s use and administration
of the ACP program and delegate to Contractor the
discretion and authority to develop and revise ACPs.
K. EMPLOYEE HEALTH EDUCATION AND MEDICAL SELF-CARE PROGRAM SERVICES
HealthAtoZ – providing participants with access to
online Health and Wellness content/health
assessments/health coaching, personal health records,
and automated messaging.
L. UNITED ALLIES ® DISCOUNT PROGRAM
Service
Comments
Core UnitedHealth Allies® Discount Program
enabling plan participants to access pre-negotiated
savings on certain out-of-pocket health care purchases.
The discount value program is not a health insurance
plan.
The Core UnitedHealth Allies® Discount Program can be
made available to non-covered employees or employees
participating in plans not administered by Contractor for
an additional fee.
Service
Comments
Activation programs to engage Participants
including, monthly health statements participant call
services, and access to participant portal with consumer
messaging.
Predictive modeling, using data from a proprietary
system, to identify individuals at risk and offer
proactive programs to improve their health status.
Standard on all managed plans. Additional charges
apply for integrating an outside vendor’s pharmacy data.
The cost for 2 data feeds per month is $15,000 in 1st year
and $10,000 every year thereafter.
Integration of ongoing external pharmacy vendor
data into predictive model
As long as County uses a pharmacy benefit manager
(PBM) with which Contractor has an existing data
sharing agreement, PBM data integration costs are
included in Contractor’s standard administrative fees.
Contractor currently has an existing data sharing
agreement in place with Catamaran.
Integration of historical external pharmacy vendor
data into predictive model
As long as County uses a pharmacy benefit manager
(PBM) with which Contractor has an existing data
sharing agreement, PBM data integration costs are
included in Contractor’s standard administrative fees.
Obesity and Diabetes Prevention Services,
customizable program delivered to eligible
Participants with a goal of preventing diabetes and
other obesity related diseases. The program uses a 52-
week approach with online technology and live
audio/video capabilities.
Services are delivered by Contractor Network Providers.
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M. MANAGED PHARMACY SERVICES
Service
Comments
Integrated Pharmacy Services including:
Claims processing
Eligibility management
Benefits management
Reporting (available through eServices)
Retail Pharmacy Network Management.
Mail Order Services.
Customer Care Center Services - Toll-free access
to customer care voice response unit (for location
of network pharmacies), and a pharmacist
Specialty Pharmacy
Support staff and account management
Assumes administration for HSA benefit only,
Postage paid return envelopes are not included and are
not available.
See Exhibit A-1 to the Contract.
Standard Clinical programs such as standard
notification, quantity level limits, and quantity per
duration.
Additional programs such as dispense as written
(DAW) interventions, retail flags and edits, maximum
allowable cost pricing (retail), and generic and mail
order programs.
N. BEHAVIORAL HEALTH SOLUTIONS – MENTAL HEALTH AND SUBSTANCE
ABUSE SERVICES
Service
Comments
Behavioral Health Solutions including:
Network access, development and maintenance
including physician (and other health care provider)
relations, credentialing and contracting, network
analysis and system development.
Claims processing, adjudication and participant
services.
Ongoing case management by licensed care manager
coordinated through a network of psychiatrists,
psychologists, social workers, and facilities.
Intensive inpatient care management, including
utilization management, discharge planning, post
discharge care management and follow-up services.
Interventions for Inpatient and Outpatient outliers
using data, analytics and algorithms
Account management, and standard reporting
Integration with internal employee assistance
program (EAP) and non-UBH EAP vendors.
Applied Behavioral Analysis (Network, Claims
processing & adjudication and Utilization
Management) for Autism as part of the standard
benefit
Participant referrals to licensed care manager from
medical disease and case management programs.
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O. HEALTH SAVINGS ACCOUNT (HSA) SERVICES
Service
Comments
Standard HSA services, Contractor’s affiliate will be
County’s preferred HSA custodian for eligible
employees’ HSAs. Contractor will provide the
following services in relation to those HSA custodial
services:
Pre-enrollment brochures – one per employee.
Human Resources Communication Toolkit.
Provide access to bank account information through
a participant website for account holders enrolled in
health plans administered by Contractor.
If County is passing batch eligibility to Optum
Bank, Inc., Contractor will facilitate the opening of
HSAs for eligible employees through automated
batch eligibility feed to Contractor’s affiliate under
the terms of Exhibit B-2 to this Agreement.
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Important Note About This Exhibit: Federal and state laws and regulations require Contractor to have an
executed document with County in advance of implementation of County’s Participant HSAs, most notably
prior to the receipt of HSA eligibility and account setup information from County. This only applies if County
opts to send HSA information for Participants directly to Contractor. If County chooses this option, Contractor
needs to expedite signature of this Exhibit so as to not delay HSA implementation. This Exhibit is structured
to be executed separately from the agreement if need be.
EXHIBIT B-2: HEALTH SAVINGS ACCOUNT ENROLLMENT AND CONTRIBUTION
This Health Savings Account Enrollment and Contribution Exhibit (the “HSA Exhibit”) is made to the
Administrative Services Agreement (“Agreement”) between United HealthCare Services, Inc. on behalf of itself
and its Affiliates, including Optum Bank, Inc., a Utah chartered FDIC insured financial institution, (the “Bank”),
and Maricopa County (“County ” in this Agreement), and is effective on January 1, 2025.
The Parties hereby agree as follows:
1. HSA Documentation. A deposit and custodial agreement (together with other HSA notices, disclosures or
information as each may be amended from time to time, the “HSA Documentation”) between eligible employees
who are approved by the Bank to establish a HSA (“Account Holders”) and the Bank governs the rights and
obligations of the Account Holder and Bank with regard to the HSA custodial services and nothing in the
Agreement or this HSA Exhibit modifies or amends the terms of any HSA Documentation.
2. Contributions. County may forward payroll deduction contributions and other contributions to Bank in a manner
and form acceptable to Bank. Bank shall have no liability for any payroll deduction files or funds not received by
Bank or for any error in crediting contributions to HSAs in reliance on data provided by County. County’s HSA
contributions are non-forfeitable and subject to the rules restricting recoupment by employers.
3. Account Holder Employment Termination. County shall notify Bank of an Account Holder’s termination of
employment through eligibility to United HealthCare Services, Inc. as soon as administratively feasible and in a
manner acceptable to Bank and shall provide Bank with any other information requested by Bank from time to
time to comply with applicable law.
4. Representations, Warranties and Obligations. If County provides assistance in opening and administering
HSAs, then County represents and warrants that it has been designated by each prospective Account Holder as
their authorized agent and County: (i) has verified the identity and eligibility pursuant to Section 223 of the Code
of each prospective Account Holder in accordance with applicable laws; (ii) has designed its benefits enrollment
systems to prevent fraud in the enrollment process; (iii) will, for a period of seven (7) years, maintain records of
(a) County’s designation as authorized agent, (b) authorizations from each prospective Account Holder authorizing
County to open and administer a HSA with Bank, (c) prospective Account Holder enrollments and debit card
request, and (d) any other information and documents related to County opening and administering the HSA; and
(iv) agrees to take such actions or provide any information requested by the Bank in order to open and administer
a HSA and comply with any statute, regulation or governmental mandate as deemed necessary and appropriate by
Bank.
5. Patriot Act Notice. As authorized agent for each Account Holder, County hereby: (i) accepts the following Patriot
Act Notice: “IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW
ACCOUNT — To help the government fight the funding of terrorism and money laundering activities,
federal law requires all financial institutions to obtain, verify, and record information that identifies each
person who opens an account. What this means for you: When you open an account, we will ask for your
name, address, date of birth, and other information that will allow us to identify you. We may also ask to
see your driver’s license or other identifying documents” and (ii) represents and warrants that County has
provided each prospective Account Holder with the Patriot Act Notice during enrollment.
6. Request to Open Account. As an authorized agent with respect to each prospective Account Holder, County
hereby requests that Bank open a HSA for and issue a debit card to each prospective Account Holder and
County agrees that monthly account statements related to each HSA shall be provided to each Account Holder
electronically.
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7. Communications. County will provide the Bank a list of all personnel authorized by County to receive and furnish
information under the Agreement and County hereby authorizes Bank to honor or act upon any facsimile, electronic
direction/data transmission, mail and other order, instruction, action or transmission from County or its authorized
personnel (Employer Communication). County is responsible for the accuracy and completeness of any Employer
Communication and County is solely responsible for any adverse consequences that may result from errors or
inaccuracies within any Employer Communication. Bank will act within a reasonable time after receipt of any
communication County shall be responsible for all costs and expenses incurred by Bank for error correction
undertaken by Bank as a result of an erroneous Employer Communication to Bank.
8. Limitation of Liability. Bank will not be responsible for claims, damages or liabilities resulting from: (i) acts or
omissions based on instructions or directions received from County or its agents, representatives or employees;
or (ii) errors caused by incomplete, inaccurate or untimely information provided by County or its agents,
representatives or employees, or County's failure to perform its obligations as required by the Agreement and this
HSA Exhibit. Section 13.2 of the Agreement shall not apply to the Bank or to services performed pursuant to this
HSA Exhibit.
9. Mutual Fund Investments. In the event County elects to offer eligible Account Holders the ability to invest HSA
funds, County acknowledges and agrees that: (a) the Bank is not a fiduciary in any capacity is not responsible for
any mutual funds selected by its registered investment advisor or County; (b) the Bank will not provide any
investment advice to any Account Holder; (c) the Bank has no duty to determine whether Account Holders are
afforded a reasonable choice of investment options, monitor the mutual funds, or determine the suitability of such
funds; (d) the Bank is under no obligation to substitute, replace and/or remove any mutual funds offered to Account
Holders; (e) if the Bank has agreed in writing to allow County to select additional or alternative mutual funds, any
such mutual funds consist of a subset of mutual fund investments offered under County’s 457(b) plan; and (f)
Health Savings Account balance must be $1,000 or more for the account holder to invest it. County will be liable
to and will defend, indemnify and hold harmless the Bank, its Affiliates and their respective officers, directors,
employees, successors and permitted assigns from and against any and all liability, damages, costs, losses and
expenses, penalties or excise taxes, including attorneys’ fees, disbursements and court costs, imposed upon or
incurred by the Bank in connection with any threatened, pending, or adjudicated claim, demand, action, suit or
proceeding arising in connection with any mutual fund added at County’s request.
10. Election to Pay Fees. In the event County or its designee pays the monthly service fee for an Account Holder,
County shall continue to pay such fee on behalf of the Account Holder until the first of the month following thirty-
one (31) calendar days after the date the Bank receives written notice that County will no longer pay such fees on
behalf of the Account Holder. Unpaid fees may be charged by the Bank to each Account Holder’s HSA.
11. Confidentiality and Privacy. All of the Bank’s confidentiality obligations to an Account Holder are contained in
the HSA Documentation. Confidential Information about an Account Holder that is provided to the Bank, by either
the Account Holder, or County as an authorized agent, is provided pursuant to the HSA Documentation between
Account Holders and the Bank. The Bank is not receiving County’s Confidential Information pursuant to the
Agreement or this HSA Exhibit. To the extent County receives information about HSAs and Account Holders
from the Bank, County shall employ measures designed to ensure the security and confidentiality of Account
Holder information in connection with the HSAs and Account Holders, protect against reasonably foreseeable
threats to the security or integrity of such information, protect against unauthorized access to or use of such
information and ensure the proper disposal of Account Holder information. County understands that Bank is not
a “covered entity”, “business associate” or “plan sponsor” as those terms are defined by the Health Insurance
Portability and Accountability Act of 1996, and the amendments and regulations related thereto.
12. Termination. Bank may terminate the services described in this HSA Exhibit immediately if at any time County
fails to comply with any of its material obligations, County is appointed a receiver, a general assignment is made
for the benefit of its creditors, a bankruptcy proceeding has been commenced, or any representation made or
information provided is false or misleading in any material respect when made or provided. Termination of this
HSA Exhibit or the Agreement will not terminate Bank’s provision of services to Account Holders.
13. Amendments. The Bank may unilaterally amend the Agreement as it may determine, in its reasonable discretion,
if necessary for the HSA Exhibit to comply with applicable laws, rules and regulations (including without
limitation, HIPAA) by providing written notice of such amendment to County (an “Amendment Notice”). Such
amendment shall be effective upon receipt of the Amendment Notice or such other date specified in the
Amendment Notice. All other amendments shall be by mutual written agreement by an authorized officer of each
of the parties.
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14. Regulatory Audits. County shall make its facilities, systems, personnel, and records, related to its performance
under this Agreement available for audit when required by applicable law or by state or federal bank regulatory
authorities with jurisdiction over Bank.
15. Survival. The provisions of this Agreement that by their operation or effect apply after the expiration or
termination of this Agreement will apply after such expiration or termination, including but not limited to Sections
4, 7, 8, 10, 12, 15, 16 and 17.
16. Governing Law. County is a political subdivision of the State of Arizona. This contract shall be governed by the
laws of the State of Arizona. Venue for any actions or lawsuits involving this contract will be in Maricopa County
Superior Court, Phoenix, Arizona.
By signing below, each party agrees to the terms of this HSA Exhibit.
United HealthCare Services, Inc.
185 Asylum Street
Hartford, CT 06103-3408
Maricopa County
301 W. Jefferson St. Suite 700
Phoenix, Arizona 85003-1647
By: ______________________________________
By: ______________________________________
Authorized Signature
Authorized Signature
Print Name: ______________________________
Print Name: ______________________________
Print Title: _______________________________
Print Title: _______________________________
Date: ____________________________________
Date: ____________________________________
Holly Durinick
Regional Contract Manager
6/03/2024
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Maricopa County Business Associate Agreement
10/31/2023
EXHIBIT C: BUSINESS ASSOCIATES AGREEMENT
MARICOPA COUNTY
BUSINESS ASSOCIATE AGREEMENT
This BUSINESS ASSOCIATE AGREEMENT (“Agreement”) is effective [insert effective date] (“Effective
Date”) and is entered into by MARICOPA COUNTY, by and through its HIPAA-covered component,
Maricopa County Human Resources (“COUNTY” or “Covered Entity”), and United HealthCare Services,
Inc. (“Business Associate” or “Associate”). This Agreement sets out the responsibilities and obligations of
Business Associate, as a Business Associate of Maricopa County, a hybrid entity with covered components
governed by the Health Insurance Portability and Accountability Act (“HIPAA”) and the Health Information
Technology for Economic and Clinical Health (“HITECH”) Act.
RECITALS
This Agreement is made a part of the parties’ contract or engagement letter for services (the “Contract”),
pursuant to which Business Associate provides services to Maricopa County that involve the use or
disclosure of Protected Health Information (“PHI”) that Maricopa County may transfer to Business
Associate.
AGREEMENT
Business Associate and Maricopa County agree to the terms and conditions of this Agreement in order to
comply with the rules on handling of PHI under the HIPAA Regulations for Privacy of Individually Identifiable
Health Information, 45 C.F.R. Part 160 and Part 164, Subpart E (“Privacy Rule”), the HIPAA Security Rule,
45 C.F.R. Part 160 and Part 164, Subpart C (“Security Rule”), and the HIPAA Breach Notification
Regulations, 45 C.F.R. Part 164, Subpart D (“Breach Notification Rule”), all as amended from time to time.
Business Associate and Maricopa County will comply with the terms of this Agreement for the duration of
the Contract and for such other continuing periods as provided in this Agreement.
1. Definitions
a. Unless otherwise provided in this Agreement, all capitalized terms in this Agreement will have the
same meaning as provided under the Privacy Rule, Security Rule, and the Breach Notification Rule.
b. “Protected Health Information” or “PHI” means PHI as defined in 45 C.F.R. Part 160 and 164, that
is received from Maricopa County, or created, maintained, or transmitted on behalf of Maricopa
County, by Business Associate.
2. Uses and Disclosure of PHI
a. Except as otherwise provided in this Agreement or by law, Business Associate may use or disclose
PHI only for those purposes necessary to perform the services described in the Contract.
b. Business Associate may use PHI for the proper management and administration of Business
Associate’s business, or to carry out its legal responsibilities. Business Associate may disclose PHI
to a third party for such purposes only if:
i. the disclosure is required by law; or
ii. Business Associate obtains written assurances, prior to making any disclosure to a third party
that the third party will (a) hold the PHI confidentially; (b) used or disclose the PHI only as
required by law or for the purpose for which it was disclosed to the third party; and (c) notify
Business Associate of any other use or disclosure of PHI.
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c. In accordance with 45 C.F.R. § 164.502(e)(1), if Business Associate’s subcontractor creates,
receives, maintains, or transmits PHI on behalf of Business Associate, Business Associate will
enter into a written agreement with such subcontractor that contains the same restrictions and
conditions on the use and disclosure of PHI as contained in this Agreement.
d. Business Associate may use and disclose de-identified health information, if (i) the use is disclosed
to Maricopa County and permitted by Maricopa County in its sole discretion, (ii) that the de-
identification is in compliance with 45 C.F.R. § 164.502(d), and (iii) the de-identified health
information meets the standard and implementation specifications for de-identification under 45
C.F.R. § 164.514(a) and (b). Business Associate may perform data aggregation services as
permitted by 45 C.F.R. § 164.504(e)(2)(i)(B).
e. To the extent Business Associate is to carry out Maricopa County’s obligations under the Privacy
Rule, Business Associate will comply with the requirements of the Privacy Rule that apply to
Maricopa County’s compliance with such obligations.
3. Safeguards
a. Business Associate will implement and maintain appropriate safeguards to prevent the use or
disclosure of PHI other than as provided by this Agreement including administrative, physical, and
technical safeguards to protect the confidentiality, integrity, and availability of the electronic PHI
that Business Associate creates, receives, maintains, and transmits on behalf of Maricopa County.
b. Business Associate agrees to take reasonable steps, including providing adequate training to its
employees to ensure compliance with this Agreement and to ensure that the actions or omissions
of its employees or agents do not cause Business Associate to breach the terms of this Agreement.
c. Upon request of Maricopa County, Business Associate will provide evidence to Maricopa County
that these safeguards are in place and are properly managed.
d. Business Associate will comply with the HIPAA Security Rule.
4. Reporting Improper Use or Disclosure of PHI, Security Incidents, and Breaches
a. Business Associate will report to Maricopa County in writing any use or disclosure of PHI not
provided for by this Agreement within 48 hours of when it becomes aware of such.
b. Business Associate will report to Maricopa County in writing any Security Incident involving
unsecured PHI of which Business Associate becomes aware. Specifically, Business Associate will
report to Maricopa County any successful unauthorized access, use, disclosure, modification, or
destruction of electronic PHI, or interference with system operations in an information system
containing electronic PHI, of which Business Associate becomes aware within 48 hours of Business
Associate learning of such Security Incident. Business Associate will also report the aggregate
number of unsuccessful, unauthorized attempts to access, use, disclose, modify, or destroy
electronic PHI or interfere with system operations in an information system containing electronic
PHI, of which Business Associate becomes aware, provided that:
i. such reports will be provided only as frequently as the parties mutually agree, but no more than
once per month; and
ii. if the definition of “Security Incident” under the Security Standards is amended to remove the
requirement for reporting “unsuccessful” attempts to use, disclose, modify, or destroy e-PHI,
the portion of this Section 4 addressing the reporting of unsuccessful, unauthorized attempts
will no longer apply as of the effective date of such amendment.
c. Business Associate will report in writing to Maricopa County any Breach of unsecured PHI, as
defined in the Breach Notification Rule, within 48 hours of Business Associate’s learning of such
Breach. Business Associate will provide such information to Maricopa County as required in the
Breach Notification Rule. Business Associate will reimburse Maricopa County for all reasonable
expenses incurred in notifying individuals of a Breach caused by Business Associate or Business
Associate’s subcontractors or agents, and for reasonable expenses incurred in mitigating harm to
those individuals. Business Associate will also defend, hold harmless, and indemnify Maricopa
County and its employees, agents, officers, directors, and affiliated entities, from and against any
claims, losses, damages, liabilities, costs, expenses, penalties, or obligations (including attorneys’
fees), which Maricopa County may incur due to a Breach caused by Business Associate or
Business Associate’s subcontractors or agents.
d. Business Associate will report in writing to Maricopa County within 48 hours of learning of any
potential unauthorized use or disclosure, Security Incident, or Breach that may contain PHI and
that would take more than 48 hours to determine whether PHI was actually involved.
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5. Mitigation of Disclosures of PHI
Business Associate will take reasonable measures to mitigate, to the extent practicable, any harmful
effect that is known to Business Associate of any use or disclosure of PHI by Business Associate or its
agents or subcontractors in violation of the requirements of this Agreement.
6. Obligations Regarding Business Associate Personnel
Business Associate will inform all of its employees, agents, and subcontractors (“Business Associate
Personnel”) who will be involved in providing services related to the Contract, of the Business
Associate’s obligations under this Agreement. Business Associate represents and warrants that the
Business Associate Personnel are under legal obligation to Business Associate, by contract or
otherwise, sufficient to enable Business Associate to fully comply with the provisions of this Agreement.
Business Associate will maintain a system of sanctions for any Business Associate Personnel who
violates this Agreement.
7. Audit Report
a. Upon request, Business Associate will provide Maricopa County, with a copy of its most recent
independent HIPAA compliance report (AT-C 315), HITRUST certification, or other mutually agreed
upon independent standards based third party audit report.
b. Maricopa County agrees not to re-disclose Business Associate’s audit report.
8. Access to PHI
a. Within five business days of a request by Maricopa County for access to PHI, Business Associate
will make the requested PHI available to Maricopa County and will provide copies upon request.
b. If an individual requests access to an individual’s PHI directly to Business Associate, Business
Associate will within five business days forward that request in writing to Maricopa County.
Maricopa County will be responsible for making all determinations regarding the grant or denial of
an individual’s request for PHI and Business Associate will make no such determinations. Maricopa
County will release PHI to an individual pursuant to such a request, or direct Business Associate
in writing to make the disclosure.
9. Amendment of PHI
a. Within five business days of a request and instruction from Maricopa County, Business Associate
will amend PHI or a record about an individual that is maintained by, or otherwise within the
possession of, Business Associate in accordance with procedures established by 45 C.F.R. §
164.526.
b. If an individual requests that Business Associate amend an individual’s PHI, Business Associate
within five business days will forward this request to Maricopa County. Any decision to amend PHI
will be the sole responsibility of Maricopa County.
10. Accounting of Disclosures of PHI
a. Business Associate will document any disclosures of PHI made by it to account for such disclosures
as required by 45 C.F.R. § 164.528. Business Associate also will make available information related
to such disclosures as would be required for Maricopa County to respond to a request for an
accounting of disclosures in accordance with 45 C.F.R. § 164.528. Business Associate will maintain
its record of disclosures for six years from the termination of this Agreement.
b. At a minimum, Business Associate will record the following information:
i. the date of disclosure of PHI;
ii. the name of the entity or person who received PHI, and, if known, the address of such entity or
person;
iii. a description of the PHI disclosed; and
iv. a brief statement of the purpose of the disclosure that includes the basis for such disclosure.
c. Within five business days of receiving a written request from Maricopa County, Business Associate
will provide Maricopa County its records of disclosures.
d. If an individual requests an accounting of disclosures directly from Business Associate, Business
Associate will within five business days forward the request and its records of disclosures to
Maricopa County. Maricopa County will be responsible for preparing and delivering the accounting
to the individual, and Business Associate will not provide an accounting of its disclosures directly
to any individual.
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11. Availability of Books and Records
a. Business Associate will within five business days of Maricopa County’s written request, make
available during normal business hours at Business Associate’s offices, or otherwise mutually
agreed upon location, all its internal practices, books, agreements, records, and policies and
procedures relating to the use and disclosure of PHI for purposes of allowing Maricopa County or
its agents or auditors to determine Business Associate’s compliance with HIPAA and this
Agreement.
b. Business Associate will make its internal practices, books, and records relating to the use and
disclosure of PHI available to the Secretary of the Department of Health and Human Services to
the extent required for determining compliance with the Privacy Rule, or the Breach Notification
Rule.
c. No attorney-client, accountant-client, or other legal privilege will be deemed waived by Business
Associate or Maricopa County because of this Section.
12. Restrictions on Use of Disclosure of PHI
If Maricopa County advises Business Associate of any changes in, or restrictions to, the permitted use
or disclosure of PHI, Business Associate will restrict the use or disclosure of PHI consistent with
Maricopa County’s instructions.
13. Data Return or Destruction of PHI
a. Business Associate’s data stewardship does not confer data ownership rights on Business
Associate with respect to any data shared with it under this Agreement, including all forms thereof.
b. Within 30 days of termination of the Contract or this Agreement, Business Associate will return to
Maricopa County all PHI that Business Associate and its subcontractors and agents maintain in
any form or format. Alternatively, Business Associate may, upon Maricopa County’s consent,
destroy all such PHI and provide Maricopa County with written documentation of such destruction.
Business Associate will be responsible for recovering any PHI from its subcontractors and agents,
or documenting their destruction of such PHI, consistent with this section.
c. If Business Associate believes that returning or destroying PHI at the termination of this Agreement
is infeasible, it will provide written notice to Maricopa County within 30 days from the termination of
this Agreement explaining its circumstances. Maricopa County will promptly respond wither it
agrees. If Maricopa County agrees, then Business Associate may keep the PHI and will extend all
protections, limitations, and restrictions of this Agreement to the PHI, and will limit the use and
disclosure of the PHI to only those circumstances that make return or destruction infeasible.
Business Associate will ensure the same protections and limitations are followed by its agents and
subcontractors. If Maricopa County does not agree that that return or destruction of PHI is
infeasible, Maricopa County will notify Business Associate, and Business Associate and its agents
and subcontractors will return or destroy the PHI within 30 days.
d. The obligations of Business Associate and contractors or agents of Business Associate under this
Section shall survive the termination of this Agreement.
14. Term and Termination
a. This Agreement will become effective on the date first written above and will continue in effect until
all obligations of the Parties have been met under the Contract and under this Agreement.
b. Maricopa County may terminate immediately this Agreement, the Contract, and any other related
agreements if Maricopa County makes a determination that Business Associate has breached this
Agreement and Business Associate has failed to cure that breach to Maricopa County’s reasonable
satisfaction within 30 days after written notice from Maricopa County. Maricopa County may report
the problem to the Secretary of HHS if termination is not feasible.
15. General Provisions
a. Amendments. The parties agree to take such action as is necessary to amend this Agreement
from time to time as is necessary for Maricopa County and Business Associate to comply with the
requirements of applicable federal and state law. All amendments to this Agreement shall be in
writing and signed by both parties.
b. Construction of Terms. The terms of this Agreement will be construed considering any applicable
interpretation or guidance on the Privacy Standards and Security Standards issued by the
Department of Health and Human Services and other applicable state or federal laws, rules, and
regulations as amended from time to time.
SERIAL 240028-ITN
c. No Third-Party Beneficiaries. Nothing in this Agreement will confer upon any person other than
the parties and their respective successors or assigns, any rights, remedies, obligations, or
liabilities, whatsoever.
d. Assignment of Rights and Delegation of Duties. This Agreement is binding upon and inures to
the benefit of the parties and their respective successors and permitted assigns. However, neither
party may assign any of its rights or delegate any of its obligations under this Agreement without
prior written consent of the other party, which consent shall not be unreasonable withheld or
delayed.
e. No Waiver. Failure or delay on the part of either party to exercise any right, power, privilege, or
remedy shall not constitute a waiver. No provision of this Agreement may be waived by either party
except by a writing signed by an authorized representative of the party making the waiver.
f.
Severability. The provisions of this Agreement shall be severable, and if any provision of this
Agreement shall be held or declared to be illegal, invalid, or unenforceable, the remainder of this
Agreement shall continue in full force and effect.
g. Entire Agreement. This Agreement constitutes the entire agreement between the parties with
regard to the Privacy Rule, Security Rule, and the Breach Notification Rule. There are no
understandings or agreements relating to this Agreement that are not fully expressed in this
Agreement and no change, waiver, or discharge of obligations arising under this Agreement will be
valid unless in writing and executed by the party against whom such change, waiver, or discharge
is sought to be enforced.
h. Written Agreement. This Agreement is considered as an integral part of the underlying Contract
and is incorporated as though fully set forth within the Contract. This Agreement will govern in the
event of conflict or inconsistency with any provision of Contract.
i.
Venue and Choice of Law. Any suit, action, or other legal proceeding arising out of, or relating to,
this Agreement shall be brought in the venue designated in the Contract or, if no designation is
made, either in Maricopa County Superior Court or in the United States District Court for the District
of Arizona, sitting in Phoenix, Arizona. This Agreement and the rights and obligations of the parties
shall be governed by the laws of the State of Arizona, without regard to applicable conflict of law
principles.
j.
Counterparts. This Agreement may be executed in two or more counterparts, each of which shall
be deemed an original and when taken together shall constitute one agreement.
k. Facsimile and Electronic Signatures. Facsimile and electronic signatures shall be deemed to be
original signatures for all purposes of this Agreement.
l.
Notices. For purposes of this Agreement and complying with all of its provisions, including all
reporting, notification, and disclosures required in this Agreement or in accordance with applicable
law, all notices shall be sent in accordance with the notice provisions under the Contract.
m. Relationship of the Parties. In the performance of the Contract and the duties and obligations
described in this Agreement, each party is at all times an independent contractor and at no time
shall the relationship between the parties be construed as a partnership, joint venture, employment,
or agency relationship.
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Agreed to by Business Associate and Maricopa County:
MARICOPA COUNTY
BUSINESS ASSOCIATE
By:
By:
Chairman, Board of Supervisors
Name:
Date:
Title:
ATTEST:
Date:
Clerk of the Board
Date:
APPROVED AS TO FORM:
Attorney for Maricopa County
Date:
Holly Durinick
Regional Contract Manager
6/3/2024
SERIAL 240028-ITN
EXHIBIT D: SERVICE LEVEL AGREEMENT (SLA)
This Service Level Agreement (“SLA”) dated January 1, 2025 is entered into between Maricopa County, a political
subdivision of the State of Arizona (“County”), and United HealthCare Services, Inc., a Connecticut corporation
(“Contractor”) (collectively, the “Parties”), and is made a part of the Parties’ Contract (ITN) No. 240028 (the
“Contract”) effective January1, 2025. For purposes of the Contract and Exhibit B to the Contract (the Scope of
Work – Administrative Services Agreement), Contractor shall be evaluated using performance standards listed
below.
These arrangements apply to medical benefits and are effective for the periods identified below (each a "Guarantee
Period"). With respect to the aspects of Contractor's performance addressed in this exhibit, these fee adjustments are
County's exclusive financial remedies.
Contractor shall track its performance under the categories delineated in this SLA and report results quarterly to
County (a “Quarterly Report”). The allocation of fees at risk may be modified or amended on an annual basis by
County no later than thirty (30) days prior to the anniversary of the Contract’s Services Effective Date and are subject
to mutual agreement of the Parties. Pursuant to Section 3.2 of the Contract, adjustments to the total quarterly
Standard Service Fees shall be applied to the next monthly invoice for Standard Services Fees issued by Contractor
to County following the Quarterly Report.
UnitedHealthcare Operations Performance
Guarantees Operations Performance Guarantees
Effective for the Guarantee Period: January 1, 2025 through January 1, 2029
Performance Standards and
Credit
Category
Guarantee Description
Measurement Criteria
Amount
Administrative
Services
Implementation
1. Summary Plan
Description (SPD)
A final SPD to be provided prior to open enrollment if
final plan decisions are received 45 days prior to open
enrollment date.
Tracking and reporting by
Account Management Team
$11,130
Revisions to drafts must be turnaround within 5
business days of receipt of feedback from the County.
In no case, shall the SPD remain unapproved after the
start of the plan year.
2. Eligibility File
Eligibility file error reporting on all eligibility file
updates will be provided to Maricopa County within
two (2) business days of the file being sent to the
Contractor
Tracking and reporting by
Account Management Team
$11,130
-98% of the file errors will be resolved withing 2 days
of receiving the file error reporting.
-98% of the files will be reported.
Claim Operations
1. Time to Process:
percent of claims
paid in 10 business
days
94.00 % in ten business days
Site level, by standard claim
operations reports.
Gradients are
94.00% within 11 business days
$8,904
94.00% within 12 business days
$17,808
94.00% within 13 business days
$26,711
94.00% within 14 business days
$35,615
94.00% within 15 or more business days
$44,519
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2. Dollar Accuracy:
Percentage of
claims dollars
processed
accurately.
99.00%
Policy level.
Gradients are
98.99%-98.50%
$8,904
98.49%-98.00%
$17,808
97.99%-97.50%
$26,711
97.49%-97.00%
$35,615
Below 97.00%
$44,519
3. Procedural
Accuracy: percent
of claims processed
without non-
financial error.
97.00%
Policy level.
Gradients are
96.99%-96.50%
$8,904
96.49%-96.00%
$17,808
95.99%-95.50%
$26,711
95.49%-95.00%
$35,615
Below 95.00%
$44,519
County Phone
Service
1. Average Speed to
Answer.
30 seconds or less
Team level
Gradients are
32 seconds or less
$8,904
34 seconds or less
$17,808
36 seconds or less
$26,711
38 seconds or less
$35,615
Greater than 38 seconds
$44,519
2. Abandonment
Rate.
1.80%
Team level
Gradients are
1.81%-2.30%
$8,904
2.31%-2.80%
$17,808
2.81%-3.30%
$26,711
3.31%-3.80%
$35,615
Greater than 3.80%
$44,519
3. Call Quality
Score
93.00%
Office level
Gradients are
92.99%-91.00%
$8,904
90.99%-89.00%
$17,808
88.99%-87.00%
$26,711
86.99%-85.00%
$35,615
Below 85.00%
$44,519
Participant Satisfaction
1. Claimant & Key
Customer Overall
Satisfaction
The overall satisfaction will be determined by the
question that reads: If you are enrolled in the
UnitedHealthcare PPO or UnitedHealthcare High
Deductible Health Plan, how satisfied are you with
the following aspects of your medical plan? (rate
from Very Satisfied, Satisfied, Somewhat Satisfied,
Dissatisfied, Very Dissatisfied, Not Applicable)
o The customer service provided by your medical
plan
Customer Conducted Survey
$11,130
Healthplan responsible for
tracking and reporting this
metric
Percentage of respondents, on
average, indicating a grade of
Completely Satisfied,
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o The accuracy of your claims processed by your
medical plan
o Communication from your medical plan in ways
that are easy to understand
o Assistance with helping you understand your
medical plan and what services are covered
o Ease in being able to locate a doctor or provider
in the Provider Directory
o Availability of health and wellness information
and programs through your medical plan
o Your medical plan’s responsiveness for solving
your problems
Overall, how satisfied are you with
UnitedHealthcare?*
*Note: No penalty will be owed to the County if 90%
of employees who completed the survey indicate that
overall, they are Very Satisfied, Satisfied, or
Somewhat Satisfied with UnitedHealthcare).
Very Satisfied and Somewhat
Satisfied
2. Account
Servicing
Core AMT (SCE, Client Manager, Customer
Advocate) will respond to calls and/or e mail from
within 24 business hours. Escalated issues will be
resolved as quickly as prudently possible. Maricopa
will acknowledge if issue is (not resolve). Maricopa
will provide evidence and notification of missed
response times within 30 days after the end of the
guarantee period. Note: Client will inform the
UnitedHealthcare of any issues that have not been
handled in a timely manner.
Customer level - Tracked and
reported by AMT
$11,130
Overall UHC
Satisfaction
1. Employer health
care decision
makers
Based on the response to the question, "Overall, how
satisfied are you with UnitedHealthcare?" If the
response is a score of 5-10 on the 0-10 scale where 0
means very dissatisfied and 10 means very satisfied,
the guarantee has been met.
Based on Employer health care
decision makers' overall
satisfaction with
UnitedHealthcare.
$11,130
Total At Risk
$322,763
Medicare Supplemental plans are excluded from Performance Guarantees.
SERIAL 240028-ITN
EXHIBIT E: CLAIMS GUARANTEE
Maricopa County
2025 Claim Trend Guarantee - PPO plan
Introduction
UnitedHealthCare is pleased to present this Claim Trend Guarantee to Maricopa County. The outline below
demonstrates UnitedHealthCare’s dedication and commitment to controlling Maricopa County’s health care
costs. UnitedHealthCare is pleased to be presented with this opportunity and look forward to partnering
with Maricopa County.
Trend Guarantee Development
UnitedHealthCare will provide a 2025 Claim Trend Guarantee, for PPO participants, which will be
developed by reviewing Maricopa County’s full year 2024 Claim experience and applying an adjustment
based on a combination of Trend and the application of UnitedHealthCare programs designed to lower
Maricopa County’s claim costs. As part of the offer UnitedHealthCare will develop a Guaranteed Claim
Trend Factor that will apply against the actual 2024 Claims to develop a 2025 Claim trend projection
(incurred in 12/paid in 15 contract basis), which will be the basis of UnitedHealthCare’s guarantee.
UnitedHealthCare will also provide a Claim Trend Guarantee for 2026, 2027, 2028 and 2029 using the
blend of the Aon and Segal trend survey minus one and a half percent for each year to set the claim target.
Required Claim Data (Current United Population Only)
UnitedHealthCare will base the Claim Trend Guarantee calculation on full year 2024 Claims.
UnitedHealthCare will use, 2024 monthly incurred Claims, value based contracting charges, capitation
charges, and large claimant losses, paid through March 31, 2025 with corresponding monthly Participant
enrollment for the Maricopa County population eligible to select UnitedHealthCare in 2025.
UnitedHealthCare will also use the 2024 census file containing plan election and coverage tier information
and the plan designs for all 2024 plans.
Required Claim Data (New United Enrolled Population)
UnitedHealthCare will base the Claim Trend Guarantee calculation on full year 2024 Claims.
UnitedHealthCare will require, by plan, 2024 monthly incurred Claims, value based contracting charges,
capitation charges, and large claimant losses, paid through March 31, 2025 with corresponding monthly
Participant enrollment for the Maricopa County population newly enrolled in UnitedHealthCare in 2025.
UnitedHealthCare will also require a 2024 census file containing plan election and coverage tier
information. The Summary of Benefits Coverage (SBC) must be provided for all 2024 plans if not available
publicly online.
Claim Adjustments
UnitedHealthCare’s trend projection is based upon the implementation of the listed programs. If Maricopa
County does not elect certain programs, UnitedHealthCare’s trend projection will be adjusted.
Item
Personal Health Support Tier 3
Payment Integrity (Full Program)
Naviguard
Behavioral Health Solutions
Plan Relativity Adjustments will be applied, depending on the final plan designs and configuration, relative
to the plan designs in force in 2024.
SERIAL 240028-ITN
UnitedHealthCare’s Commitment:
Guarantee
UnitedHealthCare will apply an adjustment to the ASO fees based upon UnitedHealthCare’s performance
in achieving the 2025 Claim Trend developed by applying the Guaranteed Claim Trend Factor shown
below to the 2024 PMPM incurred Claim experience. The guarantee will include a 2.0% risk free corridor.
The Claim Trend Development is illustrated in the Table shown below.
Basis of UnitedHealthCare’s Guarantee:
Illustrative 2025 Claim Development
A.
2024 PMPM Incurred Claims (Claims Incurred from
January 1, 2024 through December 31, 2024, and Paid
through March 31, 2025)
$786.83
B.
Application of the Guaranteed Claim Trend Factor
5.00%
C.
Risk Free Corridor
2.00%
D. {A x (1+B) x (1+C) x
(1+D)}
Guaranteed Composite Claim PMPM for the Incurral
Period January 1, 2025 through December 31, 2025, and
Paid through March 31, 2026 (12/15 Basis) [Threshold for
Penalty]
$842.69
Penalties:
The Table below provides a schedule of Penalties based on UnitedHealthCare’s performance relative to
achieving the 2025 Trend commitment. The maximum penalty is up to 15.0% of the Standard Medical
Service Fees (excluding Optional and Non-Standard Fees) for the assumed subscribership payable by
Maricopa County under the Administrative Services Agreement.
Actual 2025 Trend
Adjustment to 2025
ASO Fee
Annual
Adjustment $$
Value*
Below 7.1%
No Penalty
No Penalty
7.1% - 9.1%
-5.00%
-$94,113
9.2% - 11.1%
-10.00%
-$188,226
11.2% and Above
-15.00%
-$282,338
* Penalty amount will be based on enrollment amount
The PPO claim trend guarantee and the HDHP/HSA claim trend guarantee will be reconciled separately,
but then blended together to determine whether a payout penalty applies using the blended trend
results. The payout penalty amounts reflected in the table above are based on the estimated combined
PPO and HDHP/HSA population’s ASO fees.
Timeline Illustration for setting of Year 1 Target:
Claims incurred in 2024
with 3 months runout under
current arrangement
June of 2025. Actual target
set based on review of
Claims incurred in 2024 and
paid through March 31, 2025.
June of 2026.
Reconciliation is
completed to determine
Claim Trend Guarantee
results.
Prior Year - 2024
Year 1 with United
Year CTG is Reconciled
UnitedHealthCare’s Claim Trend Guarantee is subject to the following
requirements:
● United Choice Plus PPO network is required.
SERIAL 240028-ITN
● Medicare eligible participants are excluded.
● Incurred in 12/Paid in 15 Contract Basis.
● Guarantee applies to first policy year only. Guarantees for 2026 through 2029 will be set prior to
each year.
● If Maricopa County does not renew in Year 2, UnitedHealthCare’s Claim Target guarantee will not
apply.
The following are the assumptions used to develop this guarantee. UnitedHealthCare reserves the
right to revise (or revoke) this guarantee if there are changes in these assumptions:
● No changes in the proposed benefits that were requested in the RFP which would influence the
value of UnitedHealthCare’s stated claim adjustments.
● Claims in excess of $350,000 per Participant will be included up to $350,000.00.
● Pharmacy Claims are Included.
● GLP1 Drug Claims are Excluded.
● Mental Health/Substance Abuse claims are Included.
● COBRA enrollees are Included.
● Early retirees are Excluded.
● Obesity coverage is Included.
● Infertility coverage is Included.
● If the number of covered medical Employees varies by 15% or more from the assumed enrollment
of 7,618 Employees.
● An average contract size of 2.28. If the average contract size, defined as the total number of
enrolled Participants divided by the total number of enrolled Employees, varies by 15% or more from the
assumed average contract size of 2.28.
● A demographic factor will be used to adjust for changes in the demographic distribution of
employees from the base period and the claims guarantee period.
● The actual enrollment by product varies by 15 percent or more from the following:
Product
Employees
Choice + (PPO)
4,491
●
● Changes in federal, state or other applicable legislation or regulation may require changes to this
proposal.
● The benefits or service requirements requested and/or quoted change prior to or after the effective
date.
● Minimum In-Network Utilization of 92%.
● UnitedHealthCare’s trend guarantee takes into account gross savings expected from
UnitedHealthCare’s Value Based Contracting programs and/or initiatives. As such, any fees and/or bonus
payment to providers associated with these programs and/or initiatives may be excluded from the
reconciliation of this guarantee.
● UnitedHealthCare reserves the right to revise the guarantee if bulk recovery is suppressed.
● Maximum payout for this guarantee is 15.0% of UnitedHealthCare’s billed Administrative Service
fees.
● In the event of a pandemic, UnitedHealthCare reserves the right to revisit or revoke this guarantee.
● UnitedHealthCare shall not be required to meet any of the guarantees provided for in this
Agreement or amendments thereto to the extent UnitedHealthCare’s failure is due to County's actions or
inactions or if UnitedHealthCare fails to meet these standards due to fire, embargo, strike, war, accident,
act of God, acts of terrorism or UnitedHealthCare’s required compliance with any law, regulation, or
governmental agency mandate or anything beyond UnitedHealthCare’s reasonable control.
● Unanticipated impacts of the Health Care Reform and its regulations that would impact the scope of
this guarantee would be itemized and reconciled accordingly in the trend guarantee.
SERIAL 240028-ITN
● In the event of labor strife within a market, UnitedHealthCare reserves the right to revisit the
guarantee to evaluate the one-time effects of the event on the utilization of benefits or other demographic
shifts that would be beyond the scope and intent of the trend guarantee.
● The Trend Guarantee assumes that there are no unique or special discount arrangements between
the incumbents and Maricopa County such as higher negotiated facility or physician discount that is
exclusive to Maricopa County and not available to other customers using the same incumbent carriers.
● Due to the fact that a Trend Guarantee measurement inherently captures the overall effect of
discounts, employee behavior changes, and care/clinical management effectiveness, any fees that may be
paid out on each of the individual guarantees for Network Discounts and Optum Health will be deducted
from any potential fees owed as part of this Trend Guarantee reconciliation.
Maricopa County
2025 Claim Trend Guarantee -- HDHP plan
Introduction
UnitedHealthCare is pleased to present this Claim Trend Guarantee to Maricopa County. The outline below
demonstrates UnitedHealthCare’s dedication and commitment to controlling Maricopa County’s health care costs.
UnitedHealthCare is pleased to be presented with this opportunity and look forward to partnering with Maricopa
County.
Trend Guarantee
Development
UnitedHealthCare will provide a 2025 Claim Trend Guarantee, for HDHP participants, which will be developed by
reviewing Maricopa County’s full year 2024 Claim experience and applying an adjustment based on a combination of
Trend and the application of UnitedHealthCare programs designed to lower Maricopa County’s claim costs. As part
of the offer UnitedHealthCare will develop a Guaranteed Claim Trend Factor that will apply against the actual 2024
Claims to develop a 2025 Claim trend projection (incurred in 12/paid in 15 contract basis), which will be the basis of
UnitedHealthCare’s guarantee. UnitedHealthCare will also provide a Claim Trend Guarantee for 2026, 2027, 2028
and 2029 using the blend of the Aon and Segal trend survey minus one and a half percent for each year to set the
claim target.
Required Claim Data (Current United Population Only)
UnitedHealthCare will base the Claim Trend Guarantee calculation on full year 2024 Claims. UnitedHealthCare will
require use 2024 monthly incurred Claims, value based contracting charges, capitation charges, and large claimant
losses, paid through March 31, 2025 with corresponding monthly Participant enrollment for the Maricopa County
population eligible to select United in UnitedHealthCare in 2025. UnitedHealthCare will also use a 2024 census file
containing plan election and coverage tier information. The plan designs must be provided for all 2024 plans.
Required Claim Data (New United Enrolled Population)
UnitedHealthCare will base the Claim Trend Guarantee calculation on full year 2024 Claims. UnitedHealthCare will
require, by plan, 2024 monthly incurred Claims, value based contracting charges, capitation charges, and large
claimant losses, paid through March 31, 2025 with corresponding monthly Employee and Participant enrollment for
the Maricopa County population eligible to select UnitedHealthCare in 2025. UnitedHealthCare will also require a
2024 census file containing plan election and coverage tier information. The plan designs must be provided for all
2024 plans.
SERIAL 240028-ITN
Claim Adjustments
UnitedHealthCare’s trend projection is based upon the implementation of the listed programs. If Maricopa County
does not elect certain programs, UnitedHealthCare’s trend projection will be adjusted.
Item
Personal Health Support Tier 3
Payment Integrity (Full Program)
Naviguard
Behavioral Health Solutions
Plan Relativity Adjustments will be applied, depending on the final plan designs and configuration, relative to the plan
designs in force in 2024.
UnitedHealthCare’s Commitment:
Guarantee
UnitedHealthCare will apply an adjustment to the ASO fees based upon UnitedHealthCare’s performance in achieving
the 2025 Claim Trend developed by applying the Guaranteed Claim Trend Factor shown below to the 2024 PMPM
incurred Claim experience. The guarantee will include a 2.0% risk free corridor. The Claim Trend Development is
illustrated in the Table shown below.
Basis of UnitedHealthCare’s Guarantee:
Illustrative 2025 Claim Development
A.
2024 PMPM Incurred Claims (Claims Incurred from January
1, 2024 through December 31, 2024, and Paid through
March 31, 2025)
$531.61
B.
Application of the Guaranteed Claim Trend Factor
5.00%
C.
Risk Free Corridor
2.00%
D. {A x (1+B) x (1+C) x
(1+D)}
Guaranteed Composite Claim PMPM for the Incurral Period
January 1, 2025 through December 31, 2025, and Paid
through March 31, 2026 (12/15 Basis) [Threshold for
Penalty]
$ 569.35
Penalties:
The Table below provides a schedule of Penalties based on UnitedHealthCare’s performance relative to achieving the
2025 Trend commitment. The maximum penalty is up to 15.0% of the Standard Medical Service Fees (excluding
Optional and Non-Standard Fees) for the assumed subscribership payable by Maricopa County under the
Administrative Services Agreement.
Actual 2025 Trend
Adjustment to
2025 ASO Fee
Annual Adjustment
$$ Value*
Below 7.1%
No Penalty
No Penalty
7.1% - 9.1%
-5.00%
-$94,113
9.2% - 11.1%
-10.00%
-$188,226
11.2% and Above
-15.00%
-$282,338
* Penalty amount will be based on enrollment amount
The PPO claim trend guarantee and the HDHP/HSA claim trend guarantee will be reconciled separately, but then
blended together to determine whether a payout penalty applies using the blended trend results. The payout penalty
amounts reflected in the table above are based on the estimated combined PPO and HDHP/HSA population’s ASO
fees.
SERIAL 240028-ITN
Timeline Illustration for setting of Year 1 Target:
Claims incurred in 2024 with
3 months runout under current
arrangement
June of 2025. Actual target set
based on review of Claims
incurred in 2024 and paid
through March 31, 2025.
June of 2026.
Reconciliation is
completed to
determine Claim
Trend Guarantee
results.
Prior Year - 2024
Year 1 with United
Year CTG is
Reconciled
UnitedHealthCare’s Claim Trend Guarantee is subject to the following requirements:
● UnitedHealthCare HSA Choice Plus network is required.
● Medicare eligible participants are excluded.
● Incurred in 12/Paid in 15 Contract Basis.
● Current carrier data used to set the baseline year must be provided within 12 months of the initial effective date
of the guarantee period, otherwise the guarantee is void.
● Guarantee applies to first policy year only. Guarantees for 2026 through 2029 will be set prior to each year.
● If Maricopa County does not renew in Year 2, UnitedHealthCare’s Claim Target guarantee will not apply.
The following are the assumptions used to develop this guarantee. UnitedHealthCare reserves the right to
revise (or revoke) this guarantee if there are changes in these assumptions:
● No changes in the proposed benefits that were requested in the RFP which would influence the value of
UnitedHealthCare’s stated claim adjustments.
● Claims in excess of $350,000 per Participant will be included up to the $350,000.
● Pharmacy Claims are Included.
● GLP1 Drug Claims are Excluded.
● Mental Health/Substance Abuse claims are Included.
● COBRA enrollees are Included.
Early retirees are Excluded.
● Obesity coverage is Included.
● Infertility coverage is Included.
● If the number of covered medical Employees varies by 15% or more from the assumed enrollment of 7,618
Employees.
● An average contract size of 2.25. If the average contract size, defined as the total number of enrolled
Participants divided by the total number of enrolled Employees, varies by 15% or more from the assumed average
contract size of 2.28.
● A demographic factor will be used to adjust for changes in the demographic distribution of employees from the
base period and the claims guarantee period.
● The actual enrollment by product varies by 15% percent or more from the following:
Product
Employees
Choice + HSA (HDHP) UHC and
Cigna migration participants
3,127
● If there is a change to the current contribution strategy.
● Changes in federal, state or other applicable legislation or regulation may require changes to this proposal.
● The benefits or service requirements requested and/or quoted change prior to or after the effective date.
● Minimum In-Network Utilization of 92%.
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● UnitedHealthCare’s trend guarantee takes into account gross savings expected from UnitedHealthCare’s Value
Based Contracting programs and/or initiatives. As such, any fees and/or bonus payment to providers associated with
these programs and/or initiatives may be excluded from the reconciliation of this guarantee.
● UnitedHealthCare reserves the right to revise the guarantee if bulk recovery is suppressed.
● Maximum payout for this guarantee is 15.0% of UnitedHealthCare’s billed Administrative Service fees.
● In the event of a pandemic, UnitedHealthCare reserves the right to revisit or revoke this guarantee.
● UnitedHealthCare shall not be required to meet any of the guarantees provided for in this Agreement or
amendments thereto to the extent UnitedHealthCare’s failure is due to County's actions or inactions or if
UnitedHealthCare fails to meet these standards due to fire, embargo, strike, war, accident, act of God, acts of terrorism
or UnitedHealthCare’s required compliance with any law, regulation, or governmental agency mandate or anything
beyond UnitedHealthCare’s reasonable control.
● Unanticipated impacts of the Health Care Reform and its regulations that would impact the scope of this
guarantee would be itemized and reconciled accordingly in the trend guarantee.
● In the event of labor strife within a market, UnitedHealthCare reserves the right to revisit the guarantee to
evaluate the one-time effects of the event on the utilization of benefits or other demographic shifts that would be
beyond the scope and intent of the trend guarantee.
● The Trend Guarantee assumes that there are no unique or special discount arrangements between the
incumbents and Maricopa County such as higher negotiated facility or physician discount that is exclusive to
Maricopa County and not available to other customers using the same incumbent carriers
● Due to the fact that a Trend Guarantee measurement inherently captures the overall effect of discounts,
employee behavior changes, and care/clinical management effectiveness, any fees that may be paid out on each of the
individual guarantees for Network Discounts and Optum Health will be deducted from any potential fees owed as part
of this Trend Guarantee reconciliation.