State Supplement to Pharmacy Participation Agreement

The SevaRx Pharmacy Network Participation Agreement and the SevaRx Pharmacy Network Participation Terms and Conditions (collectively, the “Agreement”) is hereby amened as set forth in the Terms and Conditions to incorporate the following language. Should any provision of this State Supplement conflict with the language of the Agreement, the terms of this Supplement shall govern.

Alabama

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Alabama law, or a Basic Health Program (“BHP”) operated by Alabama (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Alabama.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

Pharmacy shall hold patients harmless for the payment of the cost of Covered Prescription Services in any event, including, but not limited to, nonpayment of the HMO or the HMO’s insolvency. This provision of supplemental charges or copayments on the HMO’s behalf that are made in accordance with the terms of any applicable agreement between the HMO and the Member. Code § 27-21A-3(b)(4).

Pharmacy hereby agrees that in no event, including, but not limited to, non-payment, HMO insolvency, or breach of this Agreement, shall Pharmacy bill, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against Member, or persons other than the HMO acting on behalf of the Member for Covered Prescription Services provided pursuant to this Agreement. This provision shall not prohibit collection of patient pay amounts on the HMO’s behalf made in accordance with the terms of the Agreement between the HMO and Member. Ala. Admin. Code 420-5.6-10.

Provider further agrees that (a) this provision shall survive the termination of this Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of the HMO subscriber; and that (b) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Pharmacy and Member, or persons on their behalf. Ala. Admin. Code 420-5.6-10.

Pharmacy may not charge, amend, or waive any provision of this Agreement without prior written consent of SevaRx. Any attempts to change, amend, or waive this Agreement are void. Admin. Code 420-5.6-10(2)(q),
If a covered health care provider requests payment under a health insurance plan from a health insurer or its contracted vendor or a regional care organization be made using ACH electronic funds transfer, that request must be honored. Furthermore, such a request may not be used to delay or reject a transaction, or attempt to adversely affect the covered health care provider. Code § 27-1-17(b).

Alaska

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Alaska law, or a Basic Health Program (“BHP”) operated by Alaska (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Alaska.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

Pharmacy shall be responsible for providing Covered Prescription Services. Alaska Stat. § 21.07.010(a)(1).
Pharmacy shall be compensated at the rate set forth in the Agreement. Alaska Stat. § 21.07.010(a)(2).
The Agreement may be terminated as set forth in the Terms and Conditions and as in accordance with Alaska Stat. § 21,07.010(a)(3).
In the event of a dispute between Pharmacy and PBM, a fair, prompt, and mutual dispute resolution process shall be used. The resolution process shall consist of the following:
1. The Parties shall hold an initial meeting at which all Parties are present or represented by individuals with authority regarding the matters in dispute. The meeting shall be held within ten (10) business days after SevaRx receives written notice of the dispute or gives written notice to Pharmacy, unless the Parties otherwise agree in writing to a different schedule;
2. If, within thirty (30) days following the initial meeting, the Parties have not resolved the dispute, the dispute shall be submitted to mediation directed by a mediator who is mutually agreeable to the parties and who is not regularly under contract to or employed by either Party. Each Party shall bear its proportionate share of the costs of mediation, including mediator fees;
3. If, after a period of sixty (60) days following commencement of mediation, the Parties are unable to resolve the dispute, either Party may seek other relief allowed by Law; and
4. The Parties agree to negotiate in good faith in the initial meeting and in mediation. Alaska Stat. § 21.07.010(a)(4).
Pharmacy shall not be penalized, neither shall Pharmacy’s contract be terminated by SevaRx, because Pharmacy acts as an advocate for a Member in seeking appropriate, medically necessary medical care services. Alaska Stat. § 21.07.010(a)(5).
Pharmacy shall be free to communicate openly with a Member about all appropriate diagnostic testing and treatment options. Alaska Stat. § 21.07.010(a)(6).
Capitalized terms used in the Agreement and this Supplement shall have the meaning set forth in the Definitions section of the Terms and Conditions. Alaska Stat. § 21.07.010(a)(7).
Nothing in the Agreement shall be construed as creating a direct financial incentive to Pharmacy for withholding covered health care services that are medically necessary. Alaska Stat. § 21.07.010(b)(1).
Nothing in this Agreement shall have the effect of requiring Pharmacy to contract for all products that are currently offered or that may be offered in the future by Plan Sponsor. Alaksa Stat. § 21.07.010(b)(2).
Nothing in this Agreement shall be construed as requiring Pharmacy to provide Covered Prescription Services at the same rate as Pharmacy has contracted with various managed care entities. Alaska Stat. § 21.07.010(b)(3).
Notwithstanding anything to the contrary in the Agreement, Provider shall not be required to indemnify or hold harmless SevaRx or Plan Sponsors for their own acts or conduct. Alaska Stat. § 21.07.010(c).
In the event the Agreement is terminated, Pharmacy shall continue to provide Covered Prescription Services to members who are pregnant or being actively treated by Pharmacy on the date of termination of the Agreement, and the Agreement shall remain in force with resect to continuing treatment. If a Member is pregnant or being actively treated by Pharmacy on the date of the termination of the Agreement, the Member may continue to receive medical care services from Pharmacy as provided in this subsection, and the Agreement shall remain in force with respect to continuing treatment. The Member shall be treated for the purposes of benefit determination or claim payment as if Pharmacy were still under contract with SevaRx. However, treatment is required to continue only while the applicable Plan remains in effect and: (a) for the period that is the longest of (i) the end of the current Plan year; (ii) up to ninety (90) days after the termination date, if the event triggering the right to continuing treatment is part of an ongoing course of treatment; or (iii) through completion of postpartum care, if the Member is pregnant on the date of termination; or (b) until the end of the medically necessary treatment for the condition, disease, illness, or injury if the person has a terminal condition, disease, illness, or injury. For purposes of this section, “terminal” means a life expectancy of less than one (1) year. Alaska Stat. § 21.07.030(f).
To the extent Pharmacy provides Covered Prescription Services to subscribers of a medical services corporation under Alaska law, Pharmacy agrees:
1. That Pharmacy shall provided Covered Prescription Services to subscribers and that the obligation to furnish these services shall be a direct obligation of Pharmacy to subscribers as well as to SevaRx and Plan Sponsors;
2. That Pharmacy shall be compensated for Covered Prescription Services rendered in accordance with the terms of the Agreement and that Pharmacy may not request or receive compensation for services that are not in accord with those terms;
3. That compensation for Covered Prescription Services may be prorated and settled under the circumstances and in a manner referred to in Alaska Stat. § 21.87.300; and
4. That if Pharmacy withdraws from the Agreement, the withdrawal may not be effective as to a subscriber’s contract in force on the date of the withdrawal until the termination of the subscriber’s contract or the next anniversary of the subscriber’s contract. Alaska Stat. § 21.87.140.

Colorado

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Colorado law, or a Basic Health Program (“BHP”) operated by Colorado (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Colorado.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

Pharmacy shall not be prohibited from protesting or expressing disagreement with a medical decision, medical policy, or medical practice of the Plan Sponsor or SevaRx. Colo Rev. Stat. § 10-16-121(1)(a); 3 Colo. Admin. Code § 702-4:4-2-15(5).
Neither SevaRx no Plan Sponsor shall be prohibited from protesting or expressing disagreement with a medical decision, medical policy, or medical practice of Pharmacy. Rev. Stat. § 10-16-121(1)(a); 3 Colo. Admin. Code § 702-4:4-2-15(5).
SevaRx shall not terminate the Agreement with Pharmacy because Pharmacy expresses disagreement with a Plan Sponsor’s decision to deny or limit benefits to a Member or because Pharmacy assists the Member in seeking reconsideration of the Plan Sponsor’s decision or because Pharmacy discusses with a current, former, or prospective patient any aspect of the patient’s medical condition, any proposed treatments or treatment alternatives, whether covered by Plan Sponsor or not, policy provisions of a Plan, or Pharmacy’s personal recommendation regarding selection of a health plan based on Pharmacy’s personal knowledge of the health needs of such patients. Rev. Stat. § 10-16-121(1)(b)(i); 3 Colo. Admin. Code § 702-4:4-2-15(5).
SevaRx shall not terminate the Agreement with Pharmacy because Pharmacy, acting in good faith, (a) communicates with a public official or other person concerning public policy issues related to health-care items or services; (b) files a complaint, makes a report, or comments to an appropriate governmental body regarding actions, policies, or practices of the carrier the Pharmacy believes might negatively affect the quality of, or access to, patient care; (c) provides testimony, evidence, opinion, or any other public activity in any forum concerning a violation or possible violation of any provision of this section; (d) reports what the Pharmacy believes to be a violation of Law to an appropriate authority; or (e) participates in any investigation into a violation or possible violation of any provision of this section. Rev. Stat. § 10-16-121(1)(b)(ii).
Pharmacy shall not be subjected to financial disincentives based on the number of referrals made to participating providers in the health plan for covered benefits so long as the Pharmacy adheres to the Plan Sponsor’s and SevaRx’s utilization review policies and procedures. Rev. Stat. § 10-16-121(1)(d).
Pharmacy shall hold Members harmless for money owed to Pharmacy by Plan Sponsors and agrees that Members shall, in no circumstances, be liable for money owed to Pharmacy by Plan Sponsors. Pharmacy agrees that in no event, including, but not limited to, non-payment by the Plan Sponsor or insolvency of the Plan Sponsor, or breach of this Agreement, shall Pharmacy bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement form, or have any recourse against a member, or persons (other than the Plan Sponsor) acting on their behalf for services provided pursuant to this Agreement. This provision does not prohibit Pharmacy from collecting supplemental charges, Cost Sharing Amounts, or fees for uncovered services delivered on a “fee-for-service” basis to Members. Rev. Stat. § 10-16-705(3); 3 Colo. Admin. Code § 702-4:4-7-1(12)(B)(1).

Pharmacy agrees that this provision shall survive the termination of this Agreement, for authorized services rendered prior to the termination of this Agreement, regardless of the cause giving rise to termination and shall be construed to be for the benefit of the Members. This provision is not intended to apply to services provided after this Agreement has been terminated. Pharmacy agrees that this provision supersedes any oral or written contrary agreement now or existing hereafter entered into between Pharmacy and the Member, or persons acting on their behalf insofar as such contrary agreement relates to liability for payment of services provided under the terms and conditions of this Agreement. Any modification, addition, or deletion to this provision shall become effective on a date no earlier than thirty (#0) days after the Colorado Insurance Commissioner has received written notification of proposed changes. 3 Colo. Admin, Code § 702-4:4-7-1(12)(B)(2)-(4).

Pharmacy and SevaRx shall provide at least sixty (60) days’ written notice to each other before terminating this Agreement without cause. SevaRx shall make a good faith effort to provide written notice of termination within fifteen (15) business days after receipt of or issuance of a notice of termination to all Members that are patients seen on a regular basis by Pharmacy whose contract is terminating, regardless of whether the termination was for cause or without cause. Within five (5) business days after the date that Pharmacy either gives or receives notice of termination, Pharmacy shall supply SevaRx with a list of those patients of Pharmacy that are covered by PBM’s Plan Sponsors. Rev. Stat. § 10-16-705(7).
Pharmacy agrees to maintain continuity of care in the following circumstances:
1. In the event that notice of Pharmacy’s termination has not been provided to Members as outlined in Section 6 above, Pharmacy shall continue to provide Covered Prescription Services in accordance with the terms of the Agreement to Members for sixty (60) days form the date Pharmacy is terminated without cause.
2. In the event Plan Sponsor terminates coverage for any reason other than non-payment of the premium, fraud, or abuse, Pharmacy agrees to continue to provide Covered Prescription Services to Members being treated at an in-patient facility until the patient is discharged. Rev. Stat. § 10-16-705(4).
Pharmacy shall not discriminate, with respect to the provision of medically necessary covered benefits, against Members that are participants in a publicly financed program. Rev. Stat. § 10-16-705(9).
Pharmacy agrees that the sole responsibility for obtaining any necessary preauthorization rests with Pharmacy, not with Member. Rev. Stat. § 10-16-705(14)(a).
Pharmacy shall not assign or delegate the rights and responsibilities set forth in the Agreement without prior written consent. Rev. Stat. § 10-16-705(8).
SevaRx complies with 3 Colo. Admin. Code § 702-4:4-2-23 (Procedures for Pharmacy-Carrier Dispute Resolution) to the extent applicable, Pharmacy, or its representative (a) may designate a representative in the dispute resolution process; (b) may present the rationale for the dispute resolution request in person, or in cases where Pharmacy determines that a face-to-face meeting is not practical, Pharmacy may utilize alternative methods such as teleconference or videoconference to present the rationale for the dispute resolution request; and (c) must send disputes in writing to:

SevaRx, Inc.

Attn: Provider Relations

10996 Four Seasons Place

Suite 100C

Crown Point, IN 46307

Pharmacy may require appropriate confidentiality agreements from representatives as a condition to participating in the dispute resolution process. 3 Colo. Admin. Code § 702-4:4-2-23(5)(D).

Nothing in the regulation shall be construed to supersede contract provisions that do not directly conflict with the terms of this regulation. 3 Colo. Admin. Code § 702-4:4-2-23(5)(G). For example, after a final determination is made by SevaRx in accordance with the requirements set forth in the regulation, any further consideration of the request shall be handled in accordance with the Agreement between Pharmacy and PBM.

PBM’s MAC price appeal process shall meet the following requirements: (a) a twenty-one (21) day limit on Pharmacy’s right to appeal following the initial claim; (b) SevaRx shall investigate and resolve the appeal within twenty-one (21) days after the appeal is filed; (c) Pharmacy may contact the person(s) responsible for processing SevaRx MAC appeals via telephone at 833.273.2254; (d) SevaRx shall provide a reason for any appeal denial and the identification of the national drug code of a drug that may be purchased by a pharmacy at a price at or below the benchmark price as determined by SevaRx; and (e) if the appeal is upheld, SevaRx shall make an adjustment to a date no later than one day after the date of the determination. Rev. Stat. § 10-16-122.6.
After the date SevaRx receives a clean claim submitted by Pharmacy, SevaRx shall not retroactively reduce payment on the claim after the point of sale except as the result of an audit conducted in accordance with § 10-16-122.5. Rev. Stat. Ann. § 10-16-122.3(2)(a).

Delaware

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Delaware law, or a Basic Health Program (“BHP”) operated by Delaware (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Delaware.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

Pharmacy agrees that in no event, including, but not limited to, non-payment by SevaRx or Plan Sponsor, insolvency of SevaRx or Plan Sponsor, or breach of this Agreement, shall Pharmacy bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against a Member or a person (other than SevaRx or Plan Sponsor) acting on behalf of the Member for services provided pursuant to this Agreement. The Agreement does not prohibit Pharmacy from collecting Cost Share Amounts as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to Members, as long as Pharmacy clearly informs the Member that Plan Sponsor will not cover the services. 18 Del. Admin. Code § 1403-7.0(7.1.1).
In the event of the insolvency of SevaRx or Plan Sponsor or other cessation of operations, Covered Prescription Services to members will continue through the period for which a premium has been paid to Plan Sponsor on behalf of a Member or until the Member’s discharge from an inpatient facility, whichever time period is greater. Covered benefits to Members confined in an inpatient facility on the date of insolvency or other cessation of operations will continue until their continued confinement in an inpatient facility is no longer medically necessary. 18 Del. Admin. Code § 1403-7.0(7.1.2).
Sections 1 and 2 above shall be construed in favor of Members, shall survive the termination of the Agreement regardless of the reason for termination, including the insolvency of SevaRx or Plan Sponsor, and shall supersede any oral or written contrary agreement between Pharmacy and a Member or the representative of a Member if the contrary agreement is inconsistent with the hold harmless and continuation of covered services provisions required by Sections 1 and 2 above. This provision is not intended to apply to services provided after the Agreement has been terminated. 18 Del. Admin. Code § 1403-7.0(7.2).
If the Agreement is terminated, except in cases where termination is due to unsafe health care practices that compromise the health or safety of Members, Pharmacy shall continue to provide Covered prescription Services at the contract price for up to one hundred twenty (120) days in cases where it is medically necessary for the Member to continue treatment with Pharmacy. In cases of the pregnancy of a Member, medical necessity shall be deemed to have been demonstrated and Pharmacy shall continue to provide services through completion of postpartum care. 18 Del. Admin. Code § 1403-9.0(9.3.2).
Nothing in this Agreement shall be construed as prohibiting Pharmacy from giving Member information regarding diagnosis, prognoses, and treatment options. Del Code Ann. tit. 18 § 6414.
Nothing in this Agreement shall be construed as offering Pharmacy incentives to provide less than medically necessary services to a Member. 18 Del. Admin. Code § 1403-10.0(10.1).
Neither SevaRx nor Plan Sponsor shall penalize Pharmacy because Pharmacy, in good faith, reports to state authorities any act or practice by SevaRx or Plan Sponsor that jeopardizes patient health or welfare. 18 Del. Admin. Code § 1403-10.0(10.2).
Notwithstanding the definitions set forth in the Agreement, the definitions and provisions set forth in the Code of Delaware Regulations shall control. 18 Del. Admin. Code § 1403-7.0(7.3).
The rights and responsibilities under this Agreement shall not be assigned or delegated by Pharmacy without the prior written consent of SevaRx.
Pharmacy shall furnish covered benefits to all Members without regard to the Members enrollment in the Plan as a private purchaser of the Plan or as a participant in publicly financed programs of health care services. This requirement does not apply to circumstances when Pharmacy should not render services due to limitations arising from lack of training, experience, skill, or licensing restrictions.
Pharmacy shall collect applicable Cost Share Amounts from Members pursuant to the evidence of coverage and shall notify Members of their personal financial obligations for non-covered services. 18 Del. Admin. Code § 1403-8.0(8.3).
Pharmacy shall maintain or provide for the maintenance of a medical records system which meets the accepted standards of the health care industry and state and federal regulations, provide sufficient space and equipment for processing and safe storage of records, and shall protect medical records from loss, damages and unauthorized use. 18 Del. Admin. Code § 1403-12.0.
Pharmacy shall, with the exception of medical records of minors (individuals under the age of 18 years), preserve medical records as original records, on microfilm, or electronically stored for no less than five (5) years after the most recent patient care usage, after which time records may be destroyed at the discretion of the MCO. 18 Del. Admin. Code § 1403-12.1.2.
Pharmacy shall ensure that the Delaware Department of Health and Social Services has access to medical records for purposes of monitoring and review of Pharmacy practices. 18 Del. Admin. Code § 1403-12.1.3.
Pharmacy shall notify SevaRx of any changes in the status of any of the required criteria impacting Pharmacy’s credentialing. 18 Del. Admin. Code § 1403-11.2.4.4.
SevaRx shall not retroactively deny reimbursement for a covered service provided to a Member by Pharmacy if Pharmacy relied upon the written or verbal authorization of SevaRx prior to providing the service to the member, except in cases where SevaRx can show that there was material misrepresentation, fraud, or the patient was found not to have coverage. 18 Del. Admin. Code § 1403-11.0(11.4.6.4).
SevaRx shll not refuse to contract with Pharmacy or compensate Pharmacy for Covered Prescription Services solely because Pharmacy has in good faith communicated with one or more of Pharmacy’s current, former, or prospective patients regarding the provisions, terms, or requirements of Plan Sponsors’ products or services as they relate to the needs of the Pharmacy’s patients. Code Ann. tit. 18 § 3339(a).
If SevaRx proposes to terminate or not renew the Agreement with Pharmacy, it shall give Pharmacy a minimum of sixty (60) days’ written notice prior to the effective date of the termination. This notice shall include a statement of Pharmacy’s right to request a written explanation and to request an internal administrative review within twenty (20) days. Upon Pharmacy’s request pursuant to this section, SevaRx shall provide written explanation by certified or registered mail of the reasons for the proposed termination or nonrenewal (unless such explanation has already been provided) and an opportunity for an internal administrative review of the decision to terminate. Pharmacy’s request for written explanation and administrative review must be made within twenty (20) days after receipt of SevaRx’s notice of termination or nonrenewal. SevaRx shall provide the written explanation and administrative review not less than twenty (20) days after receipt of Pharmacy’s request. If Pharmacy reasonably believes that SevaRx’s decision to terminate or not renew the Agreement was based solely on Pharmacy’s good faith communication with patients as referenced in Section 17 above, Pharmacy may request that this concern be addressed in the written explanation and administrative review provided by SevaRx. Upon request, Pharmacy shall submit to SevaRx a list of the Members with whom Pharmacy has communicated and upon whom Pharmacy relies to support the belief and a statement of the nature of the information provided to each Member that is protected by Section 17 above. If SevaRx has used economic profiling to evaluate Pharmacy’s practice and performance and has referenced the economic profiling data in its written explanation of termination or nonrenewal to Pharmacy, SevaRx shall supply the data to Pharmacy. The data shall be confidential and shall not be disclosed by Pharmacy or SevaRx to third parties without the consent of the other Party. This section does not apply to a decision by SevaRx to terminate or not renew the Agreement because of breach of contract, loss of professional liability insurance, indictment or arrest, or conviction of a felony or crime of moral turpitude, final internal disciplinary action (excluding judicial appeals) by a hospital, licensing board or other governmental agency that impairs Pharmacy’s ability to practice, failure to meet the minimum requirements for participation in SevaRx’s networks or Plan Sponsors’ Plans, as previously disclosed to Pharmacy, adjudication or fraud, or in cases involving imminent harm to patient care. Code Ann. tit. 18 § 3339(b)-(f).
Pharmacy may contact 833.273.2254 to process a MAC appeal. Code Ann. tit. 18 § 3324A(b).

Florida

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Florida law, or a Basic Health Program (“BHP”) operated by Florida (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Florida.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

The Agreement shall be canceled upon issuance of an order by the Florida department of Insurance pursuant to Florida State §§ 624.4411(3), 636.036(3), or 641.234(3).
In the event SevaRx or Plan Sponsor fails to pay for Covered Prescription Services already rendered to a Member by Pharmacy, Plan Sponsor is liable for such fees rather than the Member as provided in Florida Statutes §§ 627.6472(4)(e), 636.035, 641.3154, and 641.43.
Nothing in this Agreement shall be construed as or shall have the effect of requiring Pharmacy to accept the terms of other providers’ contracts with Plan Sponsors or other plans under common management and control with Plan Sponsors. Stat. §§ 627.6474(1), 641.315(10).
Pharmacy shall provide no less than ninety (90) days’ (for prepaid limited health services organizations) or sixty (60) days’ (for HMOs) advance written notice to SevaRx and the Department of Insurance before canceling the Agreement for any reason. Non-payment for goods or services rendered by Pharmacy shall not be a valid reason for avoiding the ninety (90) or sixty (60), as applicable, advance notice of cancellation. Stat. §§ 636.035(6), 641.315(2)(a).
SevaRx shall provide ninety (90) days’ (for prepaid limited health services organizations) or sixty (60) days’ (for HMOs) advance written notice to Pharmacy and the Department of Insurance before canceling, without cause, the Agreement, except where a patient’s health is subject to imminent danger or Pharmacy’s ability to practice is effectively impaired by an action by a government agency. Stat. §§ 636.035(8), 641.315(2)(b).
If any provision of this Agreement is held to be unenforceable or otherwise contrary to any applicable Laws, regulations, or rules, such provision shall have no effect and shall be severable without affecting the validity or enforceability of the remaining provisions of this Agreement. Stat. § 636.035(9).
Nothing in this Agreement shall be construed as restricting Pharmacy’s ability to communicate information to Pharmacy’s patient regarding care or treatment options for the patient when Pharmacy deems knowledge of such information by the patient to be in the best interest of the health of the patient. Stat. §§ 636.035(10), 641.315(5).
Nothing in this Agreement shall be construed as either prohibiting or restricting Pharmacy from entering into a commercial contract with any other plan or from prohibiting or restricting SevaRx or Plan Sponsor from entering into a commercial contract with any other provider. Stat. § 641.315(6).
Pharmacy shall prominently display a consumer assistance notice in its reception area that is clearly noticeable by all Members. Such notice shall state the addresses and toll-free telephone numbers of the Agency for Health Care Administration, the Statewide Provider and Subscriber Assistance Program, and the Department of Insurance. The consumer assistance notice must also clearly state that the addresses and toll-free telephone numbers of SevaRx’s and Plan Sponsors’ grievance department shall be provided to Members upon request. Stat. § 641.511(8).
In the event this Agreement is terminated for any reason other than for cause, Pharmacy shall continue to provide services to Members undergoing active treatment when medically necessary, through completion of treatment of the condition for which the Member was receiving care at the time of the termination, until the Member selects another treating provider, or during the next enrollment period offered by Plan Sponsor, whichever is longer, but no longer than six (6) months termination of the Agreement. Pharmacy shall continue to provide services to a Member who has initiated a course of prenatal care, regardless of the trimester in which care was initiated, until completion of postpartum care. This provision does not prevent Pharmacy from refusing to continue to provide care to a Member who is abusive, non-compliant, or in arrears in payments for services provided. For care continued under this provision, Pharmacy shall continue to be bound by the terms of the Agreement. Changes made within thirty (30) days before termination of the Agreement are effective only if agreed to by both Parties. Stat. § 641.51(8).
Pharmacy shall maintain appropriate levels of medical malpractice insurance or its equivalent in compliance with Florida Statute. Admin. Code r. §69O-191.069(1).
SevaRx shall (a) update the MAC pricing information at least every seven (7) calendar days, and (b) maintain a process that will, in a timely manner, eliminate drugs from the MAC lists or modify drug prices to remain consistent with changes in pricing data used in formulating MAC prices and product availability. Stat. §§ 627.64741, 627.6572, 641.314.
SevaRx shall not limit Pharmacy’s ability to disclose whether the Cost Share Amount exceeds the U&C Price and the availability of more affordable alternative drugs. Stat. § 465.0244.
At the time of adjudication for electronic claims or the time of reimbursement for nonelectronic claims, SevaRx shall provide the Pharmacy with a remittance, including such detailed information as is necessary for the Pharmacy or pharmacist to identify the reimbursement schedule for the specific network applicable to the claim and which is the basis used by SevaRx to calculate the amount of reimbursement paid. This information must include, but is not limited to, the applicable network reimbursement ID or plan ID as defined in the most current version of the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Implementation Guide, or its nationally recognized successor industry guide. Stat. Ann. § 626.8825(3)(a).
SevaRx must ensure that any basis of reimbursement information is communicated to the Pharmacy in accordance with the NCPDP Telecommunication Standard Implementation Guide, or its nationally recognized successor industry guide, performing reconciliation for any effective rate guarantee, and that such basis of reimbursement information communicated is accurate, corresponds with the applicable network rate, and may be relied upon the Pharmacy. Stat. Ann. § 626.8825(3)(b).
SevaRx may not charge, withhold, or recoup direct or indirect remuneration fees, dispensing fees, brand name or generic effective rate adjustments through reconciliation, or any other monetary charge, withholding, or recoupments as related to discounts, multiple network reconciliation offsets, adjudication transaction fees, and any other instance when a fee may be recouped form the Pharmacy. This prohibition does not apply to:
1. Any incentive payments provided by SevaRx to Pharmacy for meeting or exceeding predefined quality measures, such as Healthcare Effectiveness Data and Information Set measures; recoupment due to an erroneous claim, fraud, waste, or abuse; a claim adjudicated in error; a maximum allowable cost appeal pricing adjustment; or an adjustment made as party of an audit pursuant to § 624.491.
2. Any recoupment that is returned to the State for programs in chapter 409 or the state group insurance program in § 110.123. Stat. Ann. § 623.8825(3)(c).
SevaRx may not unilaterally change the terms of any participation contract. Stat. Ann. § 626.8825(3)(d).
Unless otherwise prohibited by law, SevaRx may not prohibit the Pharmacy or a pharmacist from:
1. Offering mail or delivery services on an opt-in basis at the sole discretion of the Member;
2. Mailing or delivering a Prescription Drug to a Member upon their request; or
3. Charging a shipping or handling fee to a Member requesting a Prescription Drug be mailed or delivered if the Pharmacy or pharmacist discloses to the member before the mailing or deliver the amount of the fee that will be charged and that the fee may not be reimbursable by the Member’s pharmacy benefits plan or program. Stat. Ann. § 626.8825(3)(e).
SevaRx must provide Pharmacy, upon request, a list of pharmacy benefits plans or programs in which the Pharmacy is a part of the network. Updates to the list must be communicated ot the Pharmacy within seven (7) days. SevaRx may not restrict the Pharmacy or a pharmacist from disclosing this information to the public. Stat. Ann. § 626.8825(3)(f).
SevaRx must ensure that the electronic Remittance Advice contains claim level payment adjustments in accordance with the American National Standards Institute Accredited Standards Committee, X12 format, and includes or is accompanied by the appropriate level of detail for the Pharmacy to reconcile any debts or credits, including, but not limited to, Pharmacy NCPDP or NPI identifier, date of service, prescription number, refill number, adjustment code, if applicable, and transaction amount. Stat. Ann. § 626.8825(3)(g).
SevaRx shall provide a reasonable administrative appeal procedure to allow Pharmacy to challenge the maximum allowable cost (“MAC”) pricing information and the reimbursement made under the MAC as defined in Fla. Stat. Ann. § 627.64741 for a specific drug as being below the acquisition cost available to the Pharmacy.
1. SevaRx must respond to the administrative appeal within thirty (30) business days after receipt of the appeal.
2. If the appeal is upheld, SevaRx must:
  1. Update the MAC pricing information to at least the acquisition cost available to the Pharmacy;
  2. Permit the Pharmacy to reverse and rebill the claim in question;

Provide the Pharmacy the National Drug Code (“NDC”) on which the increase or change is based; and

Make the increase or change effective for each similarly situated pharmacy or pharmacist who is subject to the applicable MAC pricing information.

If the appeal is denied, SevaRx must provide the Pharmacy the NDC and the name of the national or regional pharmaceutical wholesalers operating in this state which have the drug currently in stock at a price below the MAC pricing information.

Every ninety (90) days, SevaRx shall report to the office the total number of appeals received and denied in the preceding 90-day period, with an explanation or reason for each denial, for each specific drug for which an appeal was submitted pursuant to this paragraph. Fla. Stat. Ann. § 626.8825(3)(h).

Maryland

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Maryland law, or a Basic Health Program (“BHP”) operated by Maryland (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Maryland.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

Pharmacy and SevaRx shall provide notice to the other Party of intent to terminate this Agreement at least ninety (90) days prior to the termination unless the termination by SevaRx is for fraud, patient abuse, incompetency, or loss of Pharmacy’s license. Pharmacy shall continue to provide services pursuant to this Agreement from the date it provides notice of intent to terminate until the termination. Code Ann., Ins. §§ 15-112(b)(1)(ii), 15-112.2(e).
SevaRx and Plan Sponsor shall not, as a condition of this Agreement, prohibit Pharmacy form discussing with or communicating to a Member, public official or other person, information that is necessary or appropriate for the delivery of health care services, including:
1. Communications that relate to treatment alternatives;
2. Communications that are necessary or appropriate to maintain the Pharmacy-patient relationship while the patient is under Pharmacy’s care;
3. Communications that relate to a Member’s right to appeal a coverage determination of Plan Sponsor with which Pharmacy or Member does not agree; and
4. Opinions and the basis of an opinion about public policy issues. Code Ann., Ins. § 15-116(b).
Pharmacy shall cooperate fully and timely in the investigation and resolution of any complaint or grievance filed by a Member or their authorized representative. Code Ann., Ins. §§ 15-10A-02 et seq.
SevaRx shall not terminate Pharmacy on the basis of (a) gender, race, age, religion, national origin, or a protected category under the federal Americans with Disabilities Act; (b) the type or number of appeals that Pharmacy files; (c) the number of grievances that Pharmacy files on behalf of a Member; or (d) the type or number of complaints or grievances that Pharmacy files or requests for review under SevaRs’ and/or Plan Sponsor’s internal review system. Code Ann., Ins. § 15-112(h).
SevaRx shall not terminate or otherwise penalize Pharmacy for (a) advocating the interests of a Member through SevaRx’s or Plan Sponsor’s internal review system; (b) filing an appeal; or (c) filing a grievance or complaint on behalf of a Member. Code Ann. § 15-112(k).
SevaRx audits of Maryland pharmacies that do not involve probably or potential fraud or willful misrepresentation by Maryland pharmacists are conducted as follows:
1. Pharmacy on-site audits are not scheduled during the first five (5) days of a month unless requested by Pharmacy. Pharmacy is provided at least two (2) weeks’ written notice before conducting the initial on-site audit for each audit cycle. Audits are limited to the claims occurring during the two (2) year period immediately before the audit unless a longer period is authorized under federal or state law.
2. If an audit requires the clinical or professional judgement of a licensed pharmacist, a SevaRx licensed pharmacist shall be engaged to review the audit.
3. Pharmacy may use written or electronic hospital or physician records to validate the Pharmacy record with respect to orders or refills of a drug.
4. SevaRx’s audits of Maryland pharmacies are conducted under the same standards and procedures as other similarly situated pharmacies.
5. Preliminary audit reports are provided to Pharmacy within one hundred twenty (120) days after the completion of the audit, with reasonable extensions permitted, and Pharmacy is given at least thirty (30) business days, with reasonable extensions permitted, to appeal any disputed claim in the preliminary audit report. The preliminary audit report shall contain the contact information of the SevaRx auditor to whom an appeal may be addressed and an explanation of the appeals process. Pharmacy may produce documentation to address any discrepancy found during the audit.
6. The final audit report is delivered within six (6) months after delivery of the preliminary audit report unless Pharmacy files an appeal in which case the final audit report is provided within thirty (30) days after the conclusion of the appeals process. The final audit report also contains the final decision of SevaRx with respect to Pharmacy’s appeal.
7. SevaRx audits do not employ the accounting practice of extrapolation to calculate overpayments or underpayments.
8. The recoupment of a claims payment from Pharmacy is based on an actual overpayment or denial of an audited claim unless the projected overpayment or denial is part of a settlement agreed to by Pharmacy.
9. Recoupment by setoff of any moneys due to SevaRx identified through an audit is only made at least thirty (30) business days after the final audit report has been delivered to Pharmacy, except if the identified discrepancy for all disputed claims in a preliminary audit report for an individual audit exceeds $25,000.
10. Any underpayment identified through an audit shall be remitted to Pharmacy within thirty (30) business days after the final audit report is delivered to Pharmacy.
11. Nothing herein shall be construed to afford Pharmacy a private right of action against SevaRd unless expressly allowed under applicable Maryland law. Code Ann., Ins. § 15-1629.
SevaRx’s MAC price appeal process shall meet the following requirements: (a) a twenty-one (21) day limit on Pharmacy’s right to appeal following the initial adjudicated claim; (b) SevaRx shall investigate, resolve, and report the determination of the appeal within twenty-one (21) days after the appeal is filed; (c) Pharmacy may contact [TELEPHONE NUMBER] to speak to a person responsible for processing MAC appeals who will respond within three (3) business days; (d) SevaRx shall provide a reason for any appeal denial, the National Drug Code (“NDC”) of a drug, the name of the wholesale distributor from which the drug was available on the date the claim was adjudicated at a price at or below the MAC price determined by SevaRx and the mathematical calculation used to determine the maximum allowable cost; (e) if the appeal is upheld, for the Pharmacy, SevaRx shall adjust the MAC price for the drug as of the date of the original claim for payment and without requiring the appealing Pharmacy to reverse and rebill the claims, provide reimbursement for the claim and any subsequent and similar claims under similarly applicable contracts with SevaRx for the original claim, in the first remittance to Pharmacy after the date the appeal was determined and for subsequent and similar claims under similarly applicable contracts, in the second remittance to Pharmacy after the date the appeal was determined; and (f) if the appeal is upheld, for a similarly situated contracted pharmacy in the state SevaRx shall adjust the MAC price for the drug as of the date the appeal was determined and provide notice to Pharmacy or PSAO that an appeal has been upheld and without filing a separate appeal, Pharmacy or PSA may reverse and rebill a similar claim. Code Ann. Ins. § 15-1628.1.
SevaRx complies with Md. Code Regs. 31.10.11.06, as applicable, by accepting the Universal Prescription Drug Claim Form, or its electronic equivalent, as the sole instrument for filing claims for Prescription Drugs, and by not charging Pharmacy a handling fee for processing the Universal Prescription Drug Claim Form. In accordance with Md. Code Ann., Ins. § 15-10049d)(1)(i)-(iv), Pharmacy may send Universal Prescription Drug Claim Forms, to the extent required under Md. Code Regs. 31.10.11.06, to the following address: [ADDRESS]. Code Regs. 31.10.11.06; Md. Code Ann., Ins., § 15-1004.
Neither SevaRx nor the Plan Sponsor may require Pharmacy to indemnify SevaRx or Plan Sponsor or hold SevaRx or Plan Sponsor harmless from a coverage decision or negligent act of SevaRx or Plan Sponsor. Code Ann., Health-Gen. § 19-710(t).
To the extent required by MD. Code Ann., Ins. § 15-1005(e)(1) Pharmacy shall be allowed one hundred eighty (180) days from the date a Covered Prescription Service is rendered to submit a claim for reimbursement for the service. Code Ann., Ins. § 15-1005.
Pharmacy may request SevaRx to review a failure to pay the contractual reimbursement amount of a claim within one hundred eighty (180) days after the date the submitted Claim was paid by SevaRx. Code Ann., Ins. § 15-1630.
At the time of entering into a contract with Pharmacy, and at least thirty (30) business days before any contract change, SevaRx shall disclose to Pharmacy: (a) the applicable terms, conditions, and reimbursement rates; (b) the process and procedures for verifying pharmacy benefits and beneficiary eligibility; (c) the dispute resolution and audit appeals process; and (d) the process and procedures for verifying the Prescription Drugs included on the formularies used by SevaRx. Code Ann., Ins. § 15-1628.
Pharmacy shall not, under any circumstances, including non-payment of moneys due to Pharmacy by SevaRx or Plan Sponsor, SevaRx’s or Plan Sponsor’s insolvency, or breach of this Agreement, bill, charge, collect a deposit, seek compensation, remuneration, or reimbursement from, or have any recourse against the Member or any other person acting on behalf of the Member, for services provided in accordance with this Agreement, except for collection from the Member of the Cost Share Amount or charges for non-covered items. This provision shall survive the termination of this Agreement, regardless of the cause of termination. Code Ann., Health-Gen. § 19-710(i).
Notwithstanding any provision of the Agreement to the contrary, SevaRx shall not require Pharmacy as a condition of participating in a non-HMO provider panel, to participate in an HMO provider panel, but SevaRx may require Pharmacy, as a condition of participating in a non-HMO provider panel or an HMO provider panel, to participate in a managed care organization. Code Ann., Ins. § 15-112.2(b).
SevaRx’s pricing and reimbursement appeal process shall meet the following requirements: (a) a twenty-one (21) day limit on Pharmacy’s right to appeal following the date a direct or indirect remuneration fee is charged, or another date as determined by the Commissioner; (b) SevaRx shall provide a reason for any appeal denial and the mathematical calculation used to determine the amount of reimbursement; and (c) if the appeal is upheld, SevaRx shall make adjustments as necessary to comply with the compensation program as stated in the Provider Agreement as of the date the appeal was determined and provide notice to Pharmacy or PSAO that an appeal has been upheld. Code Ann., Ins. § 15-1628.2(a).
Experimental or Investigational Services – medical, surgical, diagnostic, psychiatric, mental health, substance-related and addictive disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications, or devices that, at the time SevaRx makes a determination regarding coverage in a particular case, are determined to be any of the following:
1. Not approved by the U.S. Food and Drug Administration (“FDA”) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States Pharmacopeia Dispensing Information as appropriate for the proposed use.
2. Subject to review and approval by any institutional review board for the proposed use (Devices which are FDA approved under the Humanitarian use Device exemption are not considered to be Experimental or Investigational).
3. The subject of an ongoing clinical trial that meets the definition of Phase I, II, or III clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight. Code Ann., Ins. § 15-1239d).
SevaRx may not charge Pharmacy a fee or performance-based reimbursement related to the adjudication of a claim, an incentive program, or re-adjudication of a claim resulting from upholding an appeal under Md. Code Ann., Ins. § 15-1628.2(d); and SevaRx may not make or allow any direct or indirect reduction in payment for Covered Prescription Services under a reconciliation process, or any other reduction or aggregate reduction of payments. Code Ann., Ins. § 15-1628.2(c); Md. Code Ann., Ins. § 15-1628.3(a) and (b).
SevaRx may amend the Agreement by giving written notice to Pharmacy of the terms of the amendment at least thirty (30) days before the change is effective. Changes requiring advance written notice are: (a) exclusion of coverage for classes of drugs as specified by the Agreement; (b) changes in prior or preauthorization procedures; and (c) selection of new prescription claims processors. Code Ann., Health-Gen. § 19-712.2.
Except for an overpayment as defined in Md. Code Ann., Ins. § 15-1629(h), if a claim has been approved by SevaRx through adjudication, SevaRx may not retroactively deny or modify reimbursement to a provider for the approved claim unless: (a) the claim was fraudulent; (b) Pharmacy had been reimbursed for the claim previously; or (c) the services reimbursed were not rendered by the Pharmacy. Code An.., Ins. § 15-1631.
SevaRx may only retroactively deny reimbursement for services subject to coordination of benefits with another carrier, the Maryland medical Assistance Program, or the Medicare Program during the 18-month period after the date that SevaRx paid Pharmacy; and may only retroactively deny reimbursement for other claims during the 6-month period after the date that SevaRx paid Pharmacy. SevaRx shall provide Phamacy with a written statement specifying the basis for the retroactive denial. If the retroactive denial of reimbursement results from coordination of benefits by a carrier that is not a managed care organization, the written statement shall provide the name and address of the entity acknowledging responsibility for payment of the denied claim. Code Ann., Ins. § 15-1008(c).
If the Agreement contains more than one fee schedule, the Agreement will not contain a provision that requires a Pharmacy as a condition of participation to accept each fee schedule included in the Agreement. Code Ann., Ins. § 15-112.2(d)(2).
Pharmacy or its designee may file a complaint with the Maryland Insurance Commissioner after exhausting the SevaRx disputed claims process. Code Regs. 31.10.47.05.

Mississippi

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Mississippi law, or a Basic Health Program (“BHP”) operated by Mississippi (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Mississippi.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

Pharmacy may not waive, discount, rebate, or distort a Cost Share Amount of a Plan Sponsor or Plan. Code Ann. § 83-9-6(4).
If Pharmacy provides a Covered Prescription Service to a Member of a a Plan Sponsor that meets the terms and requirements of the Plan Sponsor under a Plan, Pharmacy shall provide the Covered Prescription Service to all Members of the Plan on the same terms and requirements of Plan Sponsor. Code Ann. § 83-9-6(4).
If SevaRx or Plan Sponsor fails to pay for Covered Prescription Services as set forth in this Agreement, Member shall not be liable to Pharmacy for any sums owed by SevaRx or Plan Sponsor. Pharmacy shall not collect or attempt to collect from a Member sums owed by SevaRx or Plan Sponsor. Pharmacy, or its agent, trustee, or assignee thereof, shall not maintain any action at law against a Member to collect sums owed by SevaRx or Plan Sponsor. Code Ann. § 83-41-325(13)-(15).
In the event of the insolvency of SevaRx or Plan Sponsor, Pharmacy shall continue to provide Covered Prescription Services for the duration of the period after the insolvency for which premium payments have been made to Plan Sponsor and until the Members’ discharge from inpatient facilities. Code Ann. § 83-41-325(16).
If Pharmacy terminates this Agreement, Pharmacy shall give SevaRx at least sixty (60) days’ advance notice of termination. Code Ann. § 83-41-325(17).
Pharmacy shall comply with all state and federal laws designed to protect the confidentiality of medical records. Code Ann. § 83-41-409(f).
If following an appeal of an unfavorable preliminary audit report in which issues raised in the appeal are not resolved to the satisfaction of either Party, that Party may ask for mediation of those unresolved issues. A certified mediator may be chosen by agreement of the Parties from the Court Annexed Mediators List maintained by the Mississippi Supreme Court. Code Ann. § 73-21-185(3).
Pharmacy agrees that in no event, including, but not limited to, non-payment by SevaRx or the Plan Sponsor, insolvency of SevaRx or the Plan Sponsor, or breach of this Agreement, shall Pharmacy bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against a Member or a person (other than SevaRx or the Plan Sponsor) acting on behalf of the Member for services provided pursuant to this Agreement. This Agreement does not prohibit Pharmacy from collecting Cost Share Amounts as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to Members. Nor does this Agreement prohibit Pharmacy (except for a health care professional who is employed full-time on the staff of a Plan Sponsor and has agreed to provide services exclusively to that Plan Sponsor’s covered persons and no others) and a Member from agreeing to continue services solely at the expense of the Member, so long as Pharmacy has clearly informed the Member that the Plan Sponsor may not cover or continue to cover a specific service or services. Except as provided herein, this Agreement does not prohibit Pharmacy from pursuing any available legal remedy. 19 Code Miss. R. pt. 3, R. 14.6(B).

In the event of SevaRx’s or a Plan Sponsor’s insolvency or other cessation of operations, Covered Prescription Services to Members will continue through the period for which a premium has been paid to the Plan Sponsor on behalf of the Member or until the Member’s discharge from an inpatient facility, whichever time is greater. Covered Prescription Services to Members confined in an inpatient facility on the date of insolvency or other cessation of operations will continue until their continued confinement in an inpatient facility is no longer medically necessary. 19 Code Miss. R. pt. 3, R. 14.6(C).

This section shall be construed in favor of the Member, shall survive the termination of the Agreement regardless of the reason for termination, including the insolvency of SevRx or the Plan Sponsor, and shall supersede any oral or written contrary agreement between Pharmacy and a Member of the representative of a Member if the contrary agreement is inconsistent with the hold harmless and continuation of covered services provisions in this section. 19 Code Miss. R. pt. 3, R. 14.6(D).

In no event shall Pharmacy collect or attempt to collect from a Member any money owed to Pharmacy by SevaRx. 19 Code Miss. R. pt. 3, 14.6(E).
SevaRx has developed credentialing standards for the selection of pharmacies in SevaRx’s network(s). The credentialing standards do not: (a) allow the Plan Sponsor to avoid high-risk populations by excluding providers because they are located in geographic areas that contain populations or providers presenting a risk of higher-than-average claims, losses, or health services utilization; or (b) exclude providers because they treat or specialize in treating populations presenting a risk of higher-than-average claims, losses, or health services utilization. This section shall not be construed to prohibit SevaRx from declining to select a provider who fails to meet the other legitimate selection criteria developed in compliance with applicable Mississippi law. SevaRx is not required to employ specific providers or types of providers that may meet SevaRx’s credentialing standards, or to contract with or retain more providers or types of providers than are necessary to maintain an adequate network. 19 Code Miss. R. pt. 3, R. 14.6(F).
SevaRx shall not offer an inducement under the managed care plan to Pharmacy to provide less than medically necessary services to Members. 19 Code Miss. R. pt. 3, R. 14.6(I).
SevaRx shall not prohibit Pharmacy from discussing treatment options with Member irrespective of SevaRx’s position on the treatment options, or from advocating on behalf of Members with utilization review or grievance processes established by SevaRx. 19 Code Miss. R. pt. 4, 14.6(J).
Pharmacy shall make health records available to appropriate state and federal authorities involved in assessing the quality of care or investigating the grievances or complaints of Members, and to comply with the applicable state and federal laws related to the confidentiality of medical or health records. 19 Code. Miss. R. pt. 3, R. 14.6(K).
SevaRx and Pharmacy shall provide at least sixty (60) days’ written notice to each other before terminating the Agreement without cause. SevaRx shall make a good faith effort to provide written notice of a termination within thirty (30) days of receipt or issuance of a notice of termination to all Members who are patients seen on a regular basis by Pharmacy whose agreement is terminating, irrespective of whether the termination was for cause or without cause. 19 Code Miss. R. pt. 3, R. 14.6(L).
The rights and responsibilities under a contract between SevaRx and Pharmacy shall not be assigned or delegated by Pharmacy without the prior written consent of SevaRx. 19 Code Miss. R. pt. 3, R. 14.6(M).
To the extent any definition of this Agreement or other provisions in this Agreement conflict with the definitions or provisions contained in the managed care plan or 19 Code Miss. R. Pt. 3, R. 14.6, such conflicting or other definition shall not apply. 19 Code Miss. R. pt. 3, 14.6(T).
With respect to MAC appeals, (a) the right to appeal shall be limited to thirty (30) business days following the initial claim. Pharmacy must provide all of the following information with their appeal: fill date, prescription number, Pharmacy name, Pharmacy NCPDP number, chain/affiliation code, phone number, email address, and Rx BIN. Pharmacy may contact cnichols@seva-rx.com or call 833.273.2254 to submit a MAC appeal; (b) SevaRx shall respond to the challenge within thirty (30) business days after receipt of the challenge; (c) if the MAC appeal is upheld, SevaRx will within thirty (30) business days make the change in the MAC list payment to at least the pharmacy acquisition cost, permit the Pharmacy to reverse and rebill the claim in question, provide the Pharmacy with the National Drug Code (“NDC”) that the increase or change is based on, and make the change effective for each similarly situated pharmacy as defined by the Payer; and (d) if the MAC appeal is denied, SevaRx will provide the challenging Pharmacy with the NDC and the name of the national or regional pharmaceutical wholesaler in Mississippi that has the drug currently in stock at a price below MAC as listed on the MAC list, or if the NDC provided by SevaRx is not available below the pharmacy acquisition cost from the pharmaceutical wholesaler from whom the Pharmacy purchases the majority of Prescription Drugs for resale, then SevaRx shall adjust MAC as listed on the MAC list above the challenging Pharmacy’s acquisition cost and permit the Pharmacy to reverse and rebill each claim affected by the inability to procure the drug at a cost that is equal to or less than the previously challenged MAC. Code Ann. § 73-21-156.

Nebraska

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Nebraska law, or a Basic Health Program (“BHP”) operated by Nebraska (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Nebraska.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

If SevaRx or Plan Sponsor fails to pay for health care services as set forth in this Agreement for any reason whatsoever, including, but not limited to, insolvency or breach of this Agreement, Members shall not be liable to Pharmacy for any sum owed by SevaRx or Plan Sponsor. Pharmacy and its agents, trustees, or assignees may not maintain any action at law or attempt to collect form a Member sums owed to Pharmacy by SevaRx or Plan Sponsor. This section does not prohibit Pharmacy from collecting copayments from Members. This section shall survive the termination of this Agreement, regardless of the reason giving rise to the termination. Rev. Stat. Ann. §§ 44-32, 141; 44-4717(1)-(4).
If Pharmacy terminates this Agreement, it must give SevaRx at least sixty (60) days’ notice of termination. Rev. Stat. Ann. § 44-32, 142.
Termination of this Agreement shall not release Pharmacy form the obligations and duties imposed by this Agreement to complete treatments in progress on Members for specific conditions for a period not to exceed thirty (30) days at the same schedule of copayment or other applicable charges in effect upon the effective date of termination of this Agreement. Rev. Stat. Ann. § 44-4717(5).
Prepaid limited health service organizations shall submit to, and receive approval from, the Director of the Nebraska Department of Insurance any amendment to the provisions in this Agreement prior to becoming effective. Rev. Stat. Ann. § 44-4717(6).
Pharmacy shall cooperate fully and timely in the investigation and resolution of any complaint or grievance filed by a Member. Rev. Stat. Ann. §§ 44-32, 102; 44-32, 136; 44-4712; 44-7307 et seq.
Pharmacy agrees that in no event, including, but not limited to, non-payment by the Plan or SevaRx, insolvency of the Plan or SevaRx, or breach of this Agreement, shall Pharmacy bill, charge, collect, a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against a Member or person, other than the Plan or SevaRx, acting on behalf of the Member for Covered Prescription Services provided pursuant to this Agreement. This Agreement does not prohibit Pharmacy from collecting Cost Share Amounts as specifically provided in the evidence of coverage, or fees for uncovered services delivered on a fee-for-service basis to Members. Nor does this Agreement prohibit Pharmacy and a Member agreeing to continue Pharmacy’s services solely at the expense of the Member, as long as Pharmacy has clearly informed the Member that the Plan may not cover or continue to cover the Covered Prescription Services. Except as provided herein, this Agreement does not prohibit Pharmacy from pursuing any available legal remedy. For closed plans or combination plans having a closed component, in the event of a Plan or SevaRx insolvency or other cessation of operations, Pharmacy agrees that Covered prescription Services to Members will continue through the period for which the premium has been paid to the Plan on behalf of the Member or until the Member’s discharge from an inpatient facility, whichever time is greater. Covered Prescription Services to Members confined in an inpatient facility on the date of insolvency or other cessation of operations will continue until their continued confinement in an inpatient facility is no longer medically necessary. This section shall be construed in favor of the Member, shall survive the termination of the Agreement regardless of the reason for termination, including the insolvency of the Plan or SevaRx, and shall supersede any oral or written contrary agreement between Pharmacy and a Member or the representative of a Member if the contrary agreement is inconsistent with the hold harmless and continuation of care required by Neb. Rev. Stat. Ann. § 44-7106(2)(b) and (c); Neb. Rev. Stat. Ann. § 44-7106(2)(b)-(d).
Pharmacy shall not collect or attempt to collect from a Member any money owed to Pharmacy by the Plan or SevaRx. Rev. Stat. Ann. § 44-7106(2)(e).
Nothing in this Agreement is intended to be an offer of inducement under the Plan to Pharmacy to provide less than medically necessary Covered Prescription Services to a Member. Rev. Stat. Ann. § 44-7106(2)(h).
Nothing in this Agreement is intended to prohibit Pharmacy from discussing treatment options with Members irrespective of the Plan’s position on the treatment options or from advocating on behalf of Members within the utilization review or grievance processes established by the Plan or SevaRx. Rev. Stat. Ann. § 44-7106(2)(i).
Pharmacy shall make health records available to appropriate state and federal authorities involved in assessing the quality of care or investigating the grievances or complaints of Members, and to comply with the applicable state and federal laws related to the confidentiality of medical or health records. Rev. Stat. Ann. § 44-7106(2)(j).
SevaRx and Pharmacy shall provide at least sixty (60) days’ written notice to each other before terminating the Agreement without cause. SevaRx shall make a good effort to provide written notice of a termination within fifteen (15) business days of receipt or issuance of a notice of termination to all Members who are patients seen on a regular basis by Pharmacy whose contract is terminating, irrespective of whether the termination was for cause or without cause. Rev. Stat. Ann. § 44-7106(2)(k).
The rights and responsibilities under the Agreement shall not be assigned or delegated by Pharmacy without the prior written consent of SevaRx. Rev. Stat. Ann. § 44-7106(2)(l).
SevaRx shall ensure that Pharmacy furnishes Covered Prescription Services to all Members without regard to the Member’s enrollment in a Plan as a private purchaser of the Plan or as a participant in publicly financed programs of health care services. This requirement does not apply to circumstances when Pharmacy should not render Covered Prescription Services due to limitations arising from lack of training, experience, skill, or licensing restrictions. Rev. Stat. Ann. § 44-7106(2)(m).
Pharmacy’s obligations, if any, to collect applicable Cost Share Amounts from Members pursuant to the evidence of coverage, or Pharmacy’s obligations, if any, to notify Members of their personal financial obligations for non-covered services are as set forth in this Agreement. Rev. Stat. Ann. § 44-7106(2)(n).
SevaRx and Plan shall not penalize Pharmacy because Pharmacy, in good faith, reports to state or federal authorities any act or practice by SevaRx or the Plan that jeopardizes patient health or welfare. Rev. Stat. Ann. § 44-7106(2)(o).
Capitalized terms as used in the Agreement shall not conflict with the definitions or provisions contained in the managed care plan or the Managed Care Plan Network Adequacy. Rev. Stat. Ann. § 44-7106(2)(r).
SevaRx shall meet the following MAC requirements:
1. Update any MAC price list at least every seven (7) business days, noting any price change from the previous list, and provide a means by which Pharmacy may promptly review a current price in an electronic, print, or telephonic format within one (1) business day of any such change at no cost to the pharmacy. Rev. Stat. Ann. § 44-4608(1)(a).
2. Maintain a procedure to eliminate a product from the MAC price list in a timely manner to remain consistent with any change in the marketplace (Neb. Rev. Stat. Ann. § 44-4608(1)(b)); and
3. Make the MAC price list available to each contracted pharmacy in a format that is readily accessible and usable to the contracted pharmacy. Rev. Stat. Ann. § 44-4608(1)(c).
4. SevaRx shall not place a Prescription Drug on a MAC price list unless the drug is available for purchase by pharmacies in Nebraska from a national or regional drug wholesaler and is not obsolete. Rev. Stat. Ann. § 44-4608(2).
5. SevaRx’s MAC appeal process shall include:
  1. A fifteen (15) business-day limit on the right to appeal following submission of an initial claim by Pharmacy (Neb. Rev. Stat. Ann. § 44-4608(3)(a));
  2. A requirement that any appeal be investigated and resolved within seven (7) business days after the appeal is received by SevaRx (Neb. Rev. Stat. Ann. § 44-4608(3)(b)); and

A requirement that SevaRx provide a reason for any denial of an appeal and identify the national drug code for the drug that may be purchased by the Pharmacy at a price at or below the price on the MAC price list as determined by SevaRx. Neb. Rev. Stat. Ann. § 44-4608(3)(c).

If an appeal is determined to be valid by SevaRx, SevaRx shall:
1. Make an adjustment in the drug price no later than one (1) day after the appeal is resolved (Neb. Rev. Stat. Ann. § 44-4608(4)(a)); and
2. Permit the Pharmacy to reverse and rebill the claim in question, using the date of the original claim. Rev. Stat. Ann. § 44-4608(4)(b).
SevaRx’s right to audit claims will be reviewed for compliance with the audit parameters set forth in Neb. Rev. Stat. Ann. § 44-4607. Additionally, SevaRx’s auditing procedures shall meet the following requirements:
1. Unless otherwise prohibited by federal law, an auditing entity conducting an audit shall:
  1. Give the Pharmacy notice fifteen (15) business days prior to conducting an initial onsite audit (Neb. Rev. Stat. Ann. § 44-4607(1)(a));
  2. For any audit that involves clinical or professional judgement, conduct such audit by or in consultation with a pharmacist (Neb. Rev. Stat. Ann. § 44-4607(1)(b)); and

Audit each pharmacy under the same standards and parameters as other similarly situated pharmacies. Neb. Rev. Stat. Ann. § 44-4607(1)(c).

Unless otherwise prohibited by federal law, for any pharmacy audit conducted by an auditing entity:
1. The auditing entity shall provide the Pharmacy a masked list containing any prescription number or date range that the auditing entity is seeking to audit (Neb. Rev. Stat. Ann. § 44-4607(2)(c));
2. No onsite audit shall take place during the first five (5) business days of the month without the consent of the Pharmacy (Neb. Rev. Stat. Ann. § 44-4607(2)(d));

No auditor shall enter the area of the Pharmacy where patient-specific information is available without being escorted by an employee of the Pharmacy and, to the extent possible, each auditor shall remain out of the sight and hearing range of any Pharmacy customer (Neb. Rev. Stat. Ann. § 44-4607(2)(e));

No recoupment shall be deducted from or applied against a future remittance until after the appeal process is complete and both Parties receive the results of the final audit (Neb. Rev. Stat. Ann. § 44-4607(2)(f));
SevaRx shall not require information to be written on a prescription unless such information is required to be written on the prescription by state or federal law (Neb. Rev. Stat. Ann. § 44-4607(2)(g));
Recoupment may be assessed for information not written on a prescription if:
1. Such information is required in this Agreement (Neb. Rev. Stat. Ann. § 44-4607(2)(h)(i)(A); or
2. The information is required by the federal Food and Drug Administration or the drug manufacturer’s product safety program (Neb. Rev. Stat. Ann. § 44-4607(2)(h)(i)(B)); and
3. The information required under subsection (1) or (2) of this subdivision (vi) is not readily available for the auditing entity at the time of the audit (Neb. Rev. Stat. Ann. § 44-4607(2)(h)(ii); and

No auditing entity or agent shall receive payment based on a percentage of any recoupment. Neb. Rev. Stat. Ann. § 44-4607(2)(i).

For recoupment under the Pharmacy Benefit Manager Licensure and Regulation Act, the auditing entity shall:
1. Include consumer-oriented parameters based on manufacturer listings in the audit parameters (Neb. Rev. Stat. Ann. § 44-4607(3)(a));
2. Consider the Pharmacy’s Usual and Customary Price for a compounded medication as the reimbursement cost, unless the pricing method is outlined in this Agreement (Neb. Rev. Stat. Ann. § 44-4607(3)(b);

Base a finding of overpayment or underpayment on the actual overpayment or underpayment and not a projection that relies on the number of patients serviced who have a similar diagnosis, the number of similar orders, or the number of refills for similar drugs (Neb. Rev. Stat. Ann. § 44-4607(3)(c));

Not use extrapolation to calculate the recoupment or penalties unless required by state or federal law (Neb. Rev. Stat. Ann. § 44-4607(3)(d));
Not include a dispensing fee in the calculation of an overpayment, unless a prescription was not actually dispensed, the Prescriber denied authorization, the prescription dispensed was a medication error by the Pharmacy, or the identified overpayment is based solely on an extra dispensing fee (Neb. Rev. Stat. Ann. § 44-4607(3)(e));
Not consider as fraud any clerical or record-keeping error, such as typographical error, scrivener’s error, or computer error regarding a required document or record. Such error may be subject to recoupment (Neb. Rev. Stat. Ann. § 44-4607(3)(f));

Not assess any recoupment in the case of an error that has no actual financial harm to the Member of health benefit plan. An error that is the result of the Pharmacy failing to comply with a formal corrective action plan may be subject to recoupment (Neb. Rev. Stat. Ann. § 44-4607(3)(g)); and
Not allow interest to accrue during the audit period for either Party, beginning with the notice of the audit and ending with the final audit report. Rev. Stat. Ann. § 44-4607(3)(h).

To validate a Pharmacy record and the delivery of Covered Prescription Services, the Pharmacy may use an authentic and verifiable statement or record, including a medication administration record of a nursing home, assisted-living facility, hospital physician, or other authorized practitioner or an additional audit documentation parameter located in this Agreement. Rev. Stat. Ann. § 44-4607(4)(a).

Any legal prescription that meets the requirements of this section may be used to validate a claim in connection with a prescription, refill, or change in a prescription, including a medication administration record, fax, e-prescription, or documented telephone call from the prescriber to the prescriber’s agent. Neb. Rev. Stat. Ann. § 44-4607(4)(b).

The auditing entity conducting the audit shall establish a written appeal process which shall include procedures for appealing both a preliminary audit report and a final audit report. Rev. Stat. Ann. § 44-4607(5).
A preliminary audit report shall be delivered to Pharmacy within one hundred twenty (120) days after conclusion of the audit. Rev. Stat. Ann. § 44-4607(6)(a).

An auditing entity shall remit any money due to Pharmacy as the result of an underpayment of a claim within forty-five (45) days after the appeal process has been exhausted and the final audit report has been issued. Neb. Rev. Stat. Ann. § 44-4607(6)(d).

The audit requirements of § 44-4607 do not apply to any investigative audit that involves suspected fraud, willful misrepresentation, or abuse, or any audit completed by a state-funded health care program. Rev. Stat. Ann. § 44-4607(8).

SevaRx shall not require a Member purchasing a Covered Prescription Service to pay any amount greater than the lesser of the Member’s Cost Share Amount under the terms of the health benefit plan or the amount the Member would pay for the drug if the Member were paying the cash price. Rev. Stat. Ann. § 44-4606(5)(a).

Any amount paid by a Member under subdivision 19(a) of this section shall be attributable toward any deductible or, to the extent consistent with § 2707 of the federal Public Health Service Act, 42 U.S.C. § 300gg-6, as such section existed on January 1, 2022, the annual out-of-pocket maximum under the Member’s health benefit plan. Neb. Rev. Stat. Ann. § 44-4606(5)(b).

New York

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under New York law, or a Basic Health Program (“BHP”) operated by New York (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in New York.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

New York State Department of Health Standard Clauses: The “New York State Department of Health Standard Clauses for Managed Care Provider/IPA/ACO Contracts,” are expressly incorporated into this Agreement and are binding upon the Article 44 plans and Pharmacies that contract with such plans, and who are a party to this Agreement. In the event of any inconsistent or contrary language between the Standard Clauses and any other part of this Agreement, including, but not limited to, the Terms and Conditions, Amendments, Appendices, and Exhibits, the Parties agree that the provisions of the Standard Clauses shall prevail, except to the extent applicable law requires otherwise and/or to the extent a provision of this Agreement exceeds the minimum requirements of the Standard Clauses.
Subject to this Agreement, payment shall be made to Pharmacy for Covered Prescription Services rendered to Members within the time required by state law, which currently requires payment within thirty (30) days of receipt of claims submitted electronically, except in cases where the obligation to make payment is not reasonably clear or where there is evidence that the claim may be fraudulent. The Parties agree to comply with the time frames for submission and payment of claims specified in N.Y. Ins. Law § 3224-a(a), (b). Y. Ins. Law. § 3224-a.
SevaRx shall not terminate the Agreement or refuse to renew a contract for participation in the in-network benefits portion of an insurer’s network for a managed care product solely because Pharmacy has: (a) advocated on behalf of a Member; (b) filed a complaint against SevaRx and/or Plan Sponsor; (c) appealed a decision of SevaRx and/or Plan Sponsor; (d) provided information or filed a report pursuant to N.Y. Pub. Health Law § 4406-c; or (e) requested a hearing or review. Y. Pub. Health Law § 4406-c(3), (4).
The Parties may exercise a right of non-renewal at the expiration of this Agreement, or for a contract without a specific expiration date, on each January first occurring after the contract has been in effect for at least one (1) year, upon sixty (60) days’ notice to the other Party; provided, however, that any non-renewal shall not constitute a termination. Y. Pub. Health Law § 4406-d(3).
SevaRx shall not prohibit or restrict Pharmacy from disclosing to Members or Members’ designated representative, any information that Pharmacy deems appropriate regarding: (a) a condition or course of treatment, including the availability of other therapies, consultations, or tests; or (b) the provisions, terms, or requirements of SevaRx’s or Plan Sponsor’s products as they relate to Member, where applicable. Y. Pub. Health Law § 4406-c(2).
SevaRx shall not prohibit or restrict Pharmacy from filing a complaint, making a report or commenting to an appropriate governmental body regarding the policies or practices of SevaRx or Plan Sponsor, which the Pharmacy believes may negatively impact upon the quality of, or access to, patient care. Y. Pub. Health Law § 4406-c(3).
SevaRx shall not prohibit or restrict Pharmacy from advocating to SevaRx and/or Plan Sponsor on behalf of Member for approval of coverage of a particular course of treatment or for the provision of health care services. Y. Pub. Health Law § 4406-c(4).
In the event of Plan Sponsor’s or SevaRx’s insolvency, Pharmacy may not: (a) collect or attempt to collect from Members sums owed by Plan Sponsor or SevaRx; or (b) maintain any action at law against Members to collect sums owed to Pharmacy by Plan Sponsor or SevaRx. Y. Comp. Codes R. & Regs. tit. 10, § 98-1.6(c).
For Pharmacies who provide services to members of the Department of Social Services medical assistance program:
1. Pharmacy shall prepare and maintain contemporaneous records demonstrating its right to receive payment under the medical assistance program and to keep for a period of (6) years from the date services or supplies were furnished, all records necessary to disclose the nature and extent of services furnished and all information regarding claims for payment submitted by, or on behalf of Pharmacy. Pharmacy further agrees to furnish such records and information, upon request, to the Department of Social Services, the Secretary of the United States Department of Health and human Services, the Deputy Attorney General for Medicaid Fraud Control and the New York State Department of Health. Y. Comp. Codes R. & Regs. tit. 18, § 504.3(a).
2. Pharmacy shall comply with the disclosure requirements of Part 502 of Title 18 of the New York Codes, Rules and Regulations, with respect to ownership and control interests, significant business transactions, and involvement with convicted persons. Y. Comp. Codes R. & Regs. tit. 18 § 504.3(b).
3. Pharmacy shall accept payment from the medical assistance program as payment in full for all care, services, and supplies billed under the program, except where specifically provided in law to the contrary. Y. Comp. Codes R. & Regs. tit. 18, § 504.3(c).
4. Pharmacy shall not bill Members for Covered Prescription Services covered by Plan Sponsor, except for collection of applicable Cost Share Amounts. Y. Comp. Codes R. & Regs. tit. 10, §§ 98-1.5(b)(6)(ii), 98-1.6(c), 98-1.13(i).
5. Pharmacy shall not discriminate on the basis of handicap, race, color, religion, national origin, sex, or age. Y. Comp. Codes R. & Regs. tit. 18, § 504.3(d).
6. Pharmacy shall submit claims for payment only for medically necessary services actually furnished to Members or otherwise authorized under the Social Services law. Pharmacy shall submit claims on officially authorized claims forms in the manner specified by the New York Department of Social Services in conformance with the standards and procedures for claims submission. Any information provided in relation to any claim for payment shall be true, accurate, and complete. Y. Comp. Codes R. & Regs. tit. 18 § 504.3(e), (f), (h).
7. Pharmacy shall permit audits, by the persons and agencies denominated in subparagraph (a) of this section, of all books and records or, in the discretion of the auditing agency, a sample thereof, relating to services furnished and payments received under the medical assistance program, including patient histories, case files, and patient-specific data. Y. Comp. Codes. R. & Regs. tit. 18, § 504.3(g).
If Pharmacy is a health care professional licensed, registered, or certified under Title 8 of the Education Law, SevaRx must provide notice to Pharmacy at least ninety (90) days prior to the effective date of any adverse reimbursement change as required by Public Health Law § 4406-c(5-c). “Adverse reimbursement change” shall mean a proposed change that could reasonably be expected to have a negative impact on the aggregate level of payment to Pharmacy. This provision does not apply if the reimbursement change is required by law, regulation, or applicable regulatory authority; is required as a result of changes in fee schedules, reimbursement methodology, or payment policies established by the American Medical Association current procedural terminology (“CPT”) codes, reporting guidelines and convictions; or such change is expressly provided for under the terms of the Agreement by the inclusion or reference to a specific fee or fee schedule, reimbursement methodology, or payment policy indexing scheme. Y. Pub. Health Law § 4406-c(5-c)(a).
The Parties agree that claims cannot be denied solely on the basis that a Plan Sponsor has not received information from the Member concerning other health insurance coverage, in accordance with N.Y. Ins. Law § 3224-c.
The “New York State Department of Health Standard Clauses for managed Care Provider/IPA Contracts for the Fully-Integrated Duals Advantage Program” (the “FIDA Standard Clauses”) are expressly incorporated into this Agreement and are binding upon the Parties to this Agreement. In the event of any inconsistent or contrary language between the FIDA Standard Clauses and any other part of this Agreement, including, but not limited to, the Terms and Conditions, Exhibits, Amendments, and Appendices, the Parties agree that the provisions of the FIDA Standard Clauses shall prevail, except to the extent applicable law requires otherwise and/or to the extent a provision of this Agreement exceeds the minimum requirements of the FIDA Standard Clauses.
With respect to MAC appeals, SevaRx’s MAC appeal process will include the following: (a) the right to appeal by Pharmacy and/or Pharmacy’s contracting agent shall be limited to thirty (30) days following the initial claim submitted for payment; (b) Pharmacy may contract the person(s) responsible for handling MAC appeals at 833.273.2254 or emailing it to cnichols@seva-rx.com.
for the purpose of filing an appeal; (c) SevaRx shall send an electronic mail message acknowledging receipt of the appeal. SevaRx will respond in an electronic mail message to Pharmacy and/or Pharmacy’s contracting agent filing the appeal within seven (7) business days indicating its determination. If the appeal is determined to be valid, the MAC for the drug will be adjusted for the appealing Pharmacy effective as of the date of the original claim for payment. SevaRx shall require the appealing Pharmacy to reverse and resubmit the claim in question in order to obtain the corrected reimbursement; (d) if an update to the MAC is warranted, SevaRx shall adjust the MAC of the drug effective for all similarly situated pharmacies in its network in New York on the date the appeal was determined to be valid; and (e) if an appeal is denied, SevaRx, shall identify the National Drug Code of a therapeutically equivalent drug ,as determined by the Federal Food and Drug Administration, that is available for purchase by pharmacies in New York from wholesalers registered pursuant to subdivision 4 of § 6808 of the N.Y. Education Law at a price which is equal to or less than the MAC for that drug as determined by SevaRx. Y. Pub. Health Law § 280-a(4).
Pharmacy shall have a process to timely submit provider directory information to Plan Sponsors. Y. Ins. Law § 3217-b(m).
Pharmacy shall reimburse all Members for the full amount paid by Members in excess of the in-network cost-sharing amount, plus interest at an interest rate determined by the superintendent in accordance with 42 U.S.C. § 300gg-139(b), for the Covered Prescription Service when member is provided with inaccurate network status information by Plan Sponsor in a provider directory or in response to a request that stated that Pharmacy was a participating provider when the Pharmacy was not a participating provider. In the event Plan Sponsor provides inaccurate network status information to Member indicating the Pharmacy was a participating provider when Pharmacy was not a participating provider, the Plan Sponsor shall reimburse Pharmacy for the out-of-network services regardless of whether Member’s coverage includes out-of-network services. Y. Ins. Law § 3217-b(n).

North Carolina

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under North Carolina law, or a Basic Health Program (“BHP”) operated by North Carolina (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in North Carolina.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

In the event of termination of this Agreement or the insolvency of Plan Sponsor or SevaRx, Pharmacy agrees to continue to provide Covered Prescription Services to a patient receiving inpatient care until the patient is ready for discharge and for the period of which the patient’s premium has been paid. C. Gen. Stat. Ann. § 58-67-120. 11 N.C. Admin. Code 20.0202(5)(b).
In the event of termination of this Agreement or the insolvency of Plan Sponsor or SevaRx, Pharmacy’s obligation to transition administrative duties and records are as set forth in this Agreement. 11 N.C. Admin. Code 20.0202(5)(a).
Pharmacy shall maintain licensure, accreditation, and credentials sufficient to meet SevaRx’s credential verification program requirements and shall notify SevaRx of subsequent changes in status of any information relating to Pharmacy’s professional credentials. 11 N.C. Admin. Code 20.0202(6).
Pharmacy shall maintain professional liability insurance coverage in an amount acceptable to SevaRx and notify SevaRx of subsequent changes in status of professional liability insurance on a timely basis. 11 N.C. Admin. Code 20.0202(7).
Pharmacy shall not bill any Member for Covered Prescription Services, except for specified Cost Share Amounts. This provision doe not prohibit Pharmacy and a Member from agreeing to continue non-covered services at the Member’s own expense, as long as Pharmacy has notified the Member in advance that SevaRx or Plan Sponsor may not cover or continue to cover specific services that the member chooses to receive the service. 11 N.C. Admin. Code 20.0202(8)(a).
Pharmacy agrees to arrange for call coverage or other backup to provide services in accordance with Plan Sponsor’s standards for Pharmacy accessibility. 11 N.C. Admin. Code 20.0202(9).
SevaRx shall provide mechanisms that allow Pharmacy to verify eligibility, based on current information held by SevaRx and Plan Sponsor, before rendering services. 11 N.C. Admin. Code 20.0202(10).
Pharmacy shall: (a) maintain confidentiality of Member’s medical records and personal information as required by G.S. 58, Art. 39 and other health records as required by law; (b) maintain adequate medical and other health records according to industry and Plan Sponsor’s standards as required by law; (c) make copies of such records available to SevaRx and Plan Sponsor and the North Carolina Department of Insurance in conjunction with its regulation of Plan Sponsor. 11 N.C. Admin. Code 20.0202(11).
Pharmacy shall cooperate with Members in grievance procedures available to Members. 11 N.C. Admin. Code 20.0202(12).
Pharmacy shall not discriminate against Members on the basis of race, color, national origin, gender, age, religion, marital status, health status, or health insurance coverage. 11 N.C. Admin. Code 20.0202(13).
SevaRx shall provide information to Pharmacy of, and Pharmacy shall comply with, SevaRx and Plan Sponsor’s benefit exclusions, administrative and utilization management programs, credential verification programs, quality management programs, and provider sanction programs, but none of these programs shall override the professional or ethical responsibility of Pharmacy or interfere with Pharmacy’s ability to provide information or assistance to Members. SevaRx will notify Pharmacy of changes in benefit exclusions, administrative and utilization management requirements, credentialing and Quality Assurance programs, and provider sanction policies and such changes will not be effective any earlier than sixty (60) days after Pharmacy receives such notice. 11 N.C. Admin. Code 20.0202(15)(b), (16).
Pharmacy authorizes and SevaRx agrees to include the name of Pharmacy in the provider directory distributed to Plan Sponsor’s Members. 11 N.C. Admin. Code 20.0202(17).
Pharmacy’s duties and obligations under this Agreement shall not be assigned, delegated, or transferred without the prior written consent of SevaRx. SevaRx shall notify Pharmacy, in writing, of any duties or obligations that are to be delegated or transferred, before the delegation or transfer. 11 N.C. Admin. Code 20.0202(19).
A managed care health benefit plan will file this form of Agreement with, and receive approval from, the North Carolina Department of Insurance prior to usage, and any material changes to the approved contract form shall also be filed with the Department for approval before use. A material change includes a change in the means of calculating payment to Pharmacy (e.g., change from fee-for-service to capitation), a change in the distribution of risk between Parties, or a change in the delegation of clinical and administrative responsibilities. 11 N.C. Admin. Code 20.0201, 11 N.C. Admin. Code 20.0203.
In the event that SevaRx or Plan Sponsor fails to pay for health care services as set forth in this Agreement, the Member shall not be liable to Pharmacy for any sums owed by SevaRx or Plan Sponsor. No other provision of this Agreement shall, under any circumstances, change the effect of this section. Pharmacy, its agent, trustee, or assignee, may not maintain any action at law against a Member to collect any sums owed by SevaRx or Plan Sponsor. C. Gen. Stat. Ann. § 58-67-115(a).
SevaRx and Plan Sponsor shall not limit either of the following: (a) Pharmacy’s ability to discuss with a Member the clinical treatment options medically available, the risks associated with the treatments, or a recommended course of treatment; (b) Pharmacy’s professional obligations to patients as specified under Pharmacy’s professional license. C. Gen. Stat. Ann. § 58-3-176(a).
Pharmacy shall cooperate fully and timely in the investigation and resolution of any complaint or grievance filed by a Member or their authorized representative. C. Gen. Stat. Ann. § 58-50-62.
Pharmacy acknowledges and agrees that Plan Sponsors retain the right and ability to approve or disapprove Pharmacy’s participation as well as the ability to monitor and oversee Pharmacy’s offering of services to Members. 11 N.C. Admin. Code 20.0204(b)(2), (4).
A claim of recovery for overpayment or offsetting future payment by SevaRx shall be made within two (2) years after the date of the original claim payment unless SevaRx has reasonable belief of fraud or other intentional misconduct by Pharmacy, or the claim involves Pharmacy receiving payment for the same service from a government payer. A claim of underpayment or non-payment shall be made by Pharmacy within two (2) years after the date of the original claim adjudication unless the claim involves Pharmacy receiving payment for the same service from a government payer. C. Gen. Stat. Ann. § 58-3-225(h).
Notices sent by either Party via first-class postage prepaid in the United States mail is deemed to be received on the fifth (5^th) business day following the date the notice was placed into first-class postage prepaid in the United States mail. Nothing in this section prohibits the use of an electronic medium for a communication other than an amendment if agreed to by the insurer and Pharmacy. For the purposes of this section, “amendment” is defined under N.C. Gen. Stat. Ann. § 58-50-270(1) as any change to the terms of a contract, including terms incorporated by reference, that modifies fee schedules. A change required by federal or state law, rule, regulation, administrative hearing or court order is not an amendment. C. Gen. Stat. Ann. § 58-50-275(b); N.C. Gen. Stat. Ann. § 58-50-270(1).
In the event of a conflict between a SevaRx policy and procedure and the Agreement, the terms of the Agreement shall prevail. C. Gen. Stat. Ann. § 58-50-285(b).
SevaRx may amend the Agreement, including this State Supplement and the Terms and Conditions, by giving notice to Pharmacy of the terms of the amendment and specifying the date the amendment becomes effective. Pharmacy has at least sixty (60) days from the date of receipt to object to the proposed amendment. The proposed amendment shall be effective upon Pharmacy’s failure to object in writing within sixty (60) days. If Pharmacy objects to a proposed amendment, then the proposed amendment is not effective, and SevaRx shall be entitled to terminate this Agreement upon sixty (60) days’ written notice Pharmacy. “Amendment” has the same meaning as defined in section 20 above. Nothing in this section prohibits SevaRx and Pharmacy from negotiating contract terms that provide for mutual consent to an amendment, a process for reaching mutual consent, or alternative notice contracts. C. Gen. Stat. Ann. § 58-50-280.
SevaRx complies with N.C. Gen. Stat. Ann. § 58-3-225(b)-(d), (f) as follows, to the extent applicable:
1. Within thirty (30) days of receipt of a claim, send by electronic or paper mail to Pharmacy payment of the claim, notice of denial of the claim, notice that the proof of loss is inadequate or incomplete; or notice that the claim is not submitted on the form required by the Plan, by the Agreement between SevaRx and Pharmacy, or by applicable law; notice that coordination of benefits information is needed in order to pay the claim; and notice that the claim is pending based on non-payment of fees or premiums.
2. If the claim is contested or cannot be paid because the proof of loss is inadequate or incomplete, or not paid pending receipt of requested coordination of benefits information, SevaRx’s notice shall contain the specific good faith reason or reasons why the claim has not been paid and an itemization or description of all of the information needed by SevaRx to complete the processing of the claim.
3. If SevaRx requests additional information but does not receive the additional information within ninety (90) days after the request was made, SevaRx shall deny the claim and send the notice of denial to Pharmacy in accordance with N.C. Gen. Stat. Ann. § 58-3-225(d).
4. All claims must be submitted within one hundred eighty (180) days after the date of the provision of Covered Prescription Services to Members by Pharmacy and, in the case of health care provider facility claims, within one hundred eighty (180) days after the date of the patient’s discharge from the facility. Unless otherwise agreed to by SevaRx and Pharmacy, failure to submit a claim within the time required does not invalidate or reduce any claim if it was not reasonably possible for Pharmacy to file the claim within that time, provided that the claim is submitted as soon as reasonably possible and in no event, except in the absence of legal capacity of the Member, later than one (1) year from the time submittal of the claim is otherwise required.
To the extent applicable, SevaRx shall provide all of the preferred providers with whom it holds contracts information about the insurer and the insurer’s preferred provider benefit plans, including for each insurer and preferred provider benefit plan the benefit designs and incentives that are used to encourage insureds to use preferred providers. C. Gen. Stat. Ann. § 58-50-56(f).
To the extent applicable, concerning disclosure of “reimbursement policies” as that term is define dunder N.C. Gen. Stat. Ann. § 58-3-227(a)(5), the Terms and Conditions contain SevaRx’s reimbursement policies and SevaRx shall provide Pharmacy with no less than thirty (30) days’ prior written notice of changes to the reimbursement policies. C. Gen. Stat. Ann. § 58-3-227(f).
C. Gen. Ch. 58, Art. 56A. Article 56 of North Carolina General Chapter 58 contains, among other requirements, a series of statutory protections for pharmacists, pharmacies, and consumers and imposes a series of statutory obligations on pharmacy benefit managers and insurers. Pharmacy is encouraged to familiarize themselves with the provisions of Article 56A of North Carolina General Chapter 58.

Washington

To the extent that Pharmacy shall provide Covered Prescription Services to Members enrolled with a Health Maintenance Organization (“HMO”), Managed Care Organization (“MCO”), Health Care Services Organization, Insurer, or Carrier licensed under Washington law, or a Basic Health Program (“BHP”) operated by Washington (collectively and/or individually, “Plan Sponsor”), Pharmacy agrees to comply with any requirements for participation as a Pharmacy in Washington.

Without limiting the generality of the foregoing, and to the extent applicable, Pharmacy and PBM agree as follows:

In the event that SevaRx fails to pay for health care services as provided in this Agreement, the Member shall not be liable to Pharmacy for sums owed by SevaRx or Plan Sponsor. This requirement shall survive termination of the Agreement. Rev. Code §§ 48.44.020(4)(a)-(b), 48.46.243(1). Pharmacy further agrees that it may collect only the actual cost of providing health care services to a member of an HMO, if any, as specified in the Member’s agreement with Plan Sponsor, if the Member received services that they were not entitled to receive under the terms of the Member’s agreement with Plan Sponsor. This provision does not apply if the Member or the Member’s family member gave or withheld information, which misled or misinformed Pharmacy as to the Member’s right to receive such services. Wash. Rev. Code § 48.46.110(3). Pharmacy shall not willfully collect or attempt to collect an amount from a Member, knowing that collection to be in violation of the Agreement constitutes a class C felony punishable under Wash. Rev. Code chapter 9A.20. Wash. Rev. Code § 48.80.030(5)-(6).
Pharmacy agrees, in the event of Plan Sponsor’s insolvency, to continue to provide the services promised in the Provider Agreement to Members for the duration of the period for which premiums on behalf of the Member were paid to Plan Sponsor or until the Member’s discharge form an inpatient facility, whichever time is greater. Rev. Code § 48.46.245.
Notwithstanding any other provision of the Agreement, nothing in this Agreement shall be construed to modify the rights and benefits contained in a Member’s health plan. In the event of any conflict between the Agreement and an a Member’s health plan, the benefits, terms, and conditions of the health plan shall govern with respect to coverage provided to Members. Admin. Code 284-170-421.
Pharmacy may not bill a Member for Covered Prescription Services (except for Cost Share Amounts) where SevaRx or Plan Sponsor denies payments because Pharmacy has failed to comply with the Terms or Conditions or the provisions of this Agreement. Admin. Code 284-170-421.
Pharmacy further agrees that the provisions of section 1, 2, 3, and 4 of this State Supplement shall survive termination of the Agreement regardless of the cause giving rise to termination and shall be construed to be fore the benefit of the Member. Pharmacy further agrees that this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between Pharmacy and the Members or persons acting on their behalf. Rev. Code §§ 48.44.020(4)(a), 48.46.243(1).
If Pharmacy contracts with other providers or facilities who agree to provide covered services to Members with the expectation of receiving payment directly or indirectly from SevaRx or Plan Sponsor, such providers or facilities must agree to abide by the provisions of section 1, 2, 3, and 4 of this State Supplement. Rev. Code § 48.80.030(5)-(6); Wash. Rev. Code § 48.46.245; Wash. Admin. Code 284-170-421.
SevaRx’s analytical process to establish a MAC is at a product level for generics and multi-source brand products. A review of marketplace dynamics, product availability, and different pricing sources is used along with applying proprietary formulas to establish a MAC unit price. Pricing sources may include Medi-Span (or similar nationally recognized reference), wholesalers, MAC lists published by CMS, and retail pharmacies.
With respect to MAC appeals:
1. Pharmacy may contact SevaRx during normal business hours and speak with an individual responsible for processing appeals at 833.273.2253.
2. SevaRx will be available to answer calls from Pharmacy from 833.273.2253.
3. Pharmacy can submit information regarding an appeal by faxing it to 833.273.2254 or emailing it to cnichols@seva-rx.com.
4. Upon receipt of an appeal, SevaRx will perform a review inclusive of the information submitted by Pharmacy as well as marketplace dynamics, product availability, and different pricing sources. Upon making a determination, SevaRx will respond with the outcome of the appeal within thirty (30) days from the time Pharmacy submitted the appeal. Rev. Code § 48.200.280; Wash. Admin. Code § 284-180-505.

State Addendum

State Supplement to Pharmacy Participation Agreement