8577 - Informal Amendment 1 Executed
DocuSign Transmittal Coversheet
File Name
Purchasing Contact
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
8577 Medical Network and Claims Administrators and Pharmacy Benefit
Christina Dormady
Procurement
901 B Texas St., Denton, TX 76209 (940) 349-7100
OUR CORE VALUES
Inclusion Collaboration Quality Service Strategic Focus Fiscal Responsibility
December 29, 2025
United Healthcare Services, Inc.
9700 Health Care Lane
Minnetonka, MN 55343
Re: File # 8577 – Medical Network & Claims Administrators/Pharmacy Benefits, Amendment
Dear Name
Thank you for being such a valued partner. By signing this Amendment below, COD and United
Healthcare Services, Inc. agree that the Contract is hereby deemed amended to the updated Schedule
of Charges, as shown in Attachment A.
Except as amended by this Amendment, the Contract is not otherwise amended and all other terms
and conditions of the Contract remain in full force and effect, as amended hereby. This Amendment
may be executed in any number of counterparts, each of which shall be deemed an original and all of
which together shall constitute one and the same instrument. Signatures transmitted electronically
shall have the same effect as the delivery of original signatures.
We look forward to future business with your firm.
Regards,
____________________________ ___________________________
Christina Dormady, Buyer
Procurement or Authorized Representative
City of Denton United Healthcare Services, Inc.
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
FINANCIAL RENEWAL AND TERMS AMENDMENT
This Amendment (“Amendment”) is made to the Contract (“Contract”) by and between United HealthCare Services,
Inc. (“Contractor” or “United” or “Our” or “Us” or “We”) and City of Denton (“City” or “Customer” or “You” or
“Your”), and is effective on January 1, 2026 unless otherwise specified.
The agreements that are being amended include any and all amendments, if any, that are effective prior to the effective
date of this Amendment.
Nothing shown in this Amendment alters, varies or affects any of the terms, provisions or conditions of the agreements
other than as stated herein.
The parties, by signing below, agree to amend the agreements as contained herein.
City of Denton
By ____________________________________
Authorized Signature
Print Name ______________________________
Print Title ______________________________
Date ___________________________________
United HealthCare Services, Inc.
By ___________________________________
Authorized Signature
Print Name ______________________________
Print Title _______________________________
Date ___________________________________
Renewal 2Q 2025
Agreement No. 00096929.1
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Attachment A
1/6/2026
Jennifer Dumas
Regional Contract Manager
Christina Dormady
Buyer
1/8/2026
The Contract is amended on January 1, 2026 as noted below.
This Amendment will not affect any of the terms, provisions or conditions of the Contract except as stated herein.
1. Section 2 set forth in Attachment D-1 of the Contract is amended to include the following sub-section:
Offsetting Process - Surest. Overpayment recoveries may occur by offsetting the Overpayment against future
payments to the provider made by United. In effectuating Overpayment recoveries through offset, United will follow
its established Overpayment recovery rules which include, among other things, prioritizing Overpayment credits based
on: (1) the age of the Overpayment for electronic payments, and (2) the funding type and the age of the Overpayment
for check payments. United may recover the Overpayment by offsetting, in whole or in part, against future benefits
that are payable under the Plan in connection with services provided to any Participants. Reallocations pursuant to this
process do not impact the decision as to whether or not a benefit is payable under the Plan.
In United’s application of Overpayment recovery through offset, timing differences may arise in the processing of
claims payments, disbursement of provider checks, and the recovery of Overpayments. As a result, the Plan may in
some instances receive the benefit of an Overpayment recovery before United actually receives the funds from the
provider. Conversely, United may receive the funds before the Plan receives the credit for the Overpayment. It is
hereby understood that the Parties may retain any interest that accrues as a result of these timing differences. Details
associated with Overpayment recoveries made on behalf of the Plan through offset will be identified in the monthly
reconciliation report provided to the Customer’s Plan.
2. The following replaces Attachment D-5 - Fees:
Attachment D-5 - Fees
These are the Fees Customer agrees to pay to United in exchange for the Services.
Medical Fees
The following financial terms are effective for the period January 1, 2026 through December 31, 2029, unless
otherwise specified.
PEPM means Per Employee Per Month
Final Claims Fiduciary: United
Customer acknowledges that UHC Hub products and services are offered and provided by third party vendors that are
not affiliated with United. UHC Hub vendors are subcontractors under the Agreement. Customer agrees that United
is not responsible or liable in any way for performance guarantees or financial return guarantees made by those third
party vendors. Certain UHC Hub products are subject to state sales Tax. United will invoice and Customer agrees to
pay United for any required taxes. A third party vendor's participation in UHC Hub may terminate in the middle of
the Initial Term or Renewal Term of this Agreement. In that instance, the product or service will no longer be provided
from that vendor and no further Fees will be charged for that product or service. Fees for UHC Hub products and
services will be paid through a withdrawal from the Bank Account.
ASO MEDICAL FEES
Fees assume an Average Contract Size of 2.42
ASO Fees (PEPM) Current Year 1 Year 2 Year 3 Year 4
01/01/20
25 1/1/2026 1/1/2027 1/1/2028 1/1/2029
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Plan Year through through through through through
12/31/20
25 12/31/2026 12/31/2027 12/31/20
28
12/31/20
29
EPO $36.11 $37.19 $38.68 $39.84 $41.03
Surest N/A $53.00 $54.59 $56.23 TBD
Credits
Administrative Credit (General Purpose) $66,000 $66,000 $66,000 N/A N/A
Wellness Credit $100,000 $100,000 $100,000 N/A N/A
The following services may require an additional cost (not applicable to Surest plans
unless otherwise noted):
Additional Disease Management, Specialty and
Wellness Programs (Fees are on a PEPM basis
unless specifically noted)
Current Year 1 Year 2 Year 3 Year 4
1/1/2025 1/1/2026 1/1/2027 1/1/2028 1/1/2029
through through through through through
12/31/2025 12/31/2026 12/31/20
27
12/31/20
28
12/31/20
29
Clinical Specialty Network Programs:
Bariatric Resource Services (BRS) Included Included Included Included Included
Medical Management Programs
Core Medical Necessity Included Included Included Included Included
Physical Health Solutions:
Chiropractic Network Included Included Included Included Included
Physical Therapy/Occupational Therapy/Speech
Therapy Network Included Included Included Included Included
Complementary Alternative Medicine (CAM)
Network Management Included Included Included Included Included
Other Programs/Services:
TX Custom PHS 3.0 Included Included Included Included Included
Behavioral Health Solutions Included Included Included Included Included
Claim Fiduciary Included Included Included Included Included
Data Extracts Included Included Included Included Included
BAR Processing Exception Included Included Included Included Included
Other Programs/Services (Fees collected through
Bank Account):
Kaia Health $615 Per
Participant
Per Year
$615 Per
Participant
Per Year
TBD TBD TBD
Second Opinion Services $2,136 Per
Case
$2,136 Per
Case TBD TBD TBD
Specialist Management Solutions $1,500 Per
Case
$1,500 Per
Case TBD TBD TBD
Programs below apply to Surest only:
Behavioral Health Network N/A Included Included Included Included
Surest Clinical Support N/A Included Included Included Included
Core Medical Necessity N/A Included Included Included Included
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Physical Therapy/Occupational Therapy/Speech
Therapy Network N/A Included Included Included Included
Transplant Resource Services N/A Included Included Included Included
Chiropractic Network N/A Included Included Included Included
Second Opinion Services (2nd MD) N/A Included Included Included Included
Claim Fiduciary N/A Included Included Included Included
Data Extracts N/A Included Included Included Included
The following services are required but not included in the above ASO Fees:
Additional Services
(Fees Collected through Bank Account unless otherwise noted) Fee
1/1/2026 -
12/31/2026
1/1/2027
-
12/31/20
27
1/1/2028
-
12/31/20
28
1/1/2029
-
12/31/20
29
Naviguard $3.00 PEPM $3.25
PEPM
$3.50
PEPM
$3.75
PEPM
Transplant Resource Services Transplant Cost Negotiation Program $8,333 per negotiation (charged in year end
reconciliation)
Payment
Integrity:
Coordination of Benefits 30% of the gross recovery or prevented amount
Pre-Pay 30% of the gross recovery or prevented amount
Post-Pay 30% of the gross recovery amount
Subrogation Services 33.3% of the gross recovery amount
The following are included in the ASO Fees (applies to Active and Pre-65 Retiree population only, not applicable to
Surest plans unless otherwise noted):
- UnitedHealthcare Pharmacy. If the pharmacy is carved out to another vendor, the
ASO fees and Credits are subject to change. - eServices Reporting - (interactive fully Web-based
reporting) - Federal External Review Program (third level appeals) - our Medical ASO fee includes a maximum of 5 reviews. Reviews
in excess of this limit will be charged at $500 per review.
- Advocate4Me Customer Service Model that provides participants with access to a one-stop
advocacy resource for an unprecedented range of
needs, including support and access to services across medical benefits, claims,
pharmacy, clinical, incentives, and more. - Customer Service, our quoted customer service model offers members a high-touch, personal
guide who provides support in navigating benefits,
understanding payment options, resolving claim issues and working through the health
care system. In addition to acting as a one-stop shop
where members can be directed to the most appropriate existing services,
representatives can provide additional information relevant to
personal needs and take ownership of inquires end-to-end. For those not resolved
during the initial call, customer service representatives
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
take ownership until resolution including call back to
the member. - Employer Internet Solution –
www.employereservices.com - Our quote includes the management of over 100 disease states/conditions, as part of our Personal
Health Support (PHS) program. We believe this
approach will adequately address the clinical conditions present within the population
- though we are open to discussing and proposing
alternative programs, should clinical prevalence
indicate an appropriate ROI. - Consumer Activation, including basic navigation guide, health statements with
individualized messaging, advanced concierge call services,
and access to member portal with consumer
activation messaging - United will duplicate requested plan of benefits in principle and in a manner
compatible with our understanding of the basic plan
designs. Our quotation may be adjusted contingent upon review of all Medical plan
design specifics. Our fees may be adjusted, or changes
to the plans may be required to enable us to
administer claim payments.
Pricing Assumptions - The Plan or its sponsor is responsible for state or federal surcharges, assessments, or similar taxes or fees imposed by
governmental entities or agencies on the Plan, Plan Sponsor or us, including but not limited to those imposed pursuant to
the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended from time to time. This includes
responsibility for determining the amount due, funding, and remitting the PPACA Transitional Reinsurance fee and the
PCORI fee which are remitted to the government (federal and/or state).
- The fees quoted do not include state or federal surcharges, assessments, or similar taxes/fees imposed by governmental
entities or agencies on the Plan, Plan Sponsor or United. We reserve the right to adjust the rates (i) in the event of any
changes in federal, state or other applicable legislation or regulation; (ii) in the event of any changes in plan design or
procedures required by the applicable regulatory authority or by the sponsor; and (iii) as otherwise permitted in the
Administrative Services Agreement.
- The administrative fees set forth herein do not include fees related to the requirements set forth in the Consolidated
Appropriations Act, 2021, including the No Surprises Act. Additional fees for these new regulatory requirements will be
provided at a future date once regulatory guidance is received and final compliance requirements are determined.
- United reserves the right to revise this quotation under the following
circumstances:
- The total number of enrolled medical employees varies by more
than 10 percent from the assumed medical enrollment of 1735
- The average contract size, defined as the total number of enrolled employees plus dependents divided by
the total number of enrolled employees, varies by 10 percent or more from the assumed average contract
size of 2.42.
- The benefits or service requirements requested
and/or quoted change prior to or after the effective
date.
- In the event of any changes in federal, state or other applicable
legislation or regulation that require changes to this quotation.
- In the event of any changes in plan design required by the
applicable regulatory authority or by the Plan sponsor.
- In the event that any taxes, surcharges, assessments, or similar charges are imposed by governmental
entities or agencies on the Plan or United, in its role as administrator or insurer.
- As otherwise permitted in our
Administrative Services
Agreement - Our mature quotation includes the processing of runout claims for 12 months
following the termination of our contract. - If pharmacy benefits are carved out the ASO fees quoted above may
be revised.
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
- Customer will only receive Rebates to the extent that Rebates are actually received by United. For example, if a
government action or a major change in pharmaceutical industry practices eliminates or materially reduces manufacturer
Rebate programs, Customer’s payment amount may be reduced or eliminated. In such event, United shall promptly notify
Customer and revise or eliminate such payment effective with the date of the reduction or elimination in Rebate payments.
In addition, reduction or elimination of Rebates in this event shall constitute a change in the Agreement as described in the
Fees Section such that United has the right to increase the fees for the Pharmacy Benefits Management services or increase
the percentage of Rebate dollars retained by United.
- We reserve the right to adjust our rebate guarantee if changes made to our prescription drug list (PDL) for the purpose of
achieving lower net drug cost for Customer and our other ASO customers result in significant reductions to the rebate
level.
- Quoted fees include United retention of all medical
benefit Rx rebates
- Commissions are excluded.
- This quotation assumes United will retain claim fiduciary responsibility
- United will provide a Wellness Credit, Administrative Credit (General Purpose) to help Customer mitigate costs associated
with additional wellness services from United, administration of the plan
These credits are available as follows:
- The parties must have an executed
Agreement.
- The first month of service fees under the
Agreement has been received by United.
- Customer’s enrollment with United must always exceed 1562 Employees.
- Annual credits must be used within the Plan Year specified for that credit. One-time credits must be
used between 01/01/2026 and 12/31/2029. Any Credits not used during this time period are forfeit.
- Upon request from Customer, a credit will be
issued in United’s fee billing system.
- If Customer terminates the Agreement prior to 12/31/2029, Customer will repay United a prorated
portion of the credit paid in the year of termination based on the termination date. Credits in prior years
are not subject to repayment. All unpaid credits are forfeit.
- If enrollment with United falls below the enrollment threshold, Customer will repay United an amount
proportional to the enrollment reduction based on the amount of the credit paid at the time enrollment
falls below the threshold.
- The amount of the credit not yet paid is reduced
proportional to the enrollment reduction.
- If during the course of the first year unforeseen or additional expense items arise related to the Customer
implementation, United reserves the right to use a portion of this credit to offset such expenses.
Service Description
Fees for the programs are listed above.
Coordination of Benefits: Prospective use of analytics, algorithms, and proprietary datasets to identify members that have
other insurance as primary
Pre-Pay: Prospective services to help ensure accurate claim payment.
• Detection and recovery of wasteful, abusive, and/or fraudulent claims.
• Search claims for patterns which indicate possible waste or error by identifying specific claims for additional review or for
an adjustment.
• Evaluate claims to identify inappropriate levels of care, coding, and/or resource utilization.
• Review of claims for inappropriate billing of services not documented in clinical notes by Board certified, same-specialty
medical directors.
• Prospective review of facility claims based on an itemized bill review. Analytics identify claims, record request sent to
provider, claim is adjusted/denied based on review of those records
• More expansive edits after the internal payment policy edits and are more expansive to identify claims that may need an
adjustment.
Post-Pay: Retrospective services to help ensure accurate claim payment.
• Detection and recovery of wasteful, abusive, and/or fraudulent claims.
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Naviguard Program
• Offers reimbursement methodologies for emergent and non-emergent out of network claims which calculates allowed
amounts based on what a healthcare provider generally accepts for the same or similar service.
• Includes an advocacy component where Participants can access resources, and on-line tools and materials to help
Participants stay in network and where assistance is provided in explaining reimbursement methodologies.
• For claims above a threshold established by United, the advocacy component includes United negotiating with a provider
on behalf of a Participant with respect to Participant’s balance billed amount (e.g., non-emergent, choice claim).
• If the provider objects to what it was paid from the application of the allowed amount, or member contacts United for
support with resolving a balance bill, United will increase compensation for a particular claim if: (a) United reasonably
concludes that the particular facts and circumstances related to a claim provide justification for reimbursement greater than
that which would result from the application of the allowed amount, and (b) United believes that it would serve the best
interests of the Plan and its Participants (including interests in avoiding costs and expenses of disputes over payment of
claims).
• Fees are based on the Savings Obtained, which is the amount billed by a health care provider minus the final amount paid
to the health care provider pursuant to the out-of-network program selected by the Plan which includes amounts payable
by the Participant.
The interest rate on unpaid Fees and underfunding the Bank Account is the Prime rate plus 4%.
For clinical support. if applicable, Customer will pay a Fee for United’s services, equal to 2.5% of chiropractic allowed
expenses, whether in or out of network.
Second Opinion Services. Participants will have access to personalized consultations by video or phone from medical experts.
A designated care team coordinator guides Participants through the entire process, including follow up. The information
provided through this service does not constitute medical advice and does not diagnose, treat, or prescribe treatment of medical
conditions.
Specialist Management Solution (SMS)
Concierge services and surgical care navigation, guiding Participants to providers who perform outpatient surgical
specialties/procedures. Services include the following:
• Advocate, a single point of contact through the entire continuum of care.
• Participant activation and outreach campaign support.
• Customer data and reporting.
• Gross Savings means the established episode market average for hospital outpatient department cost per case (based on
historic claims data) compared to the actual cost for Participants who had the same procedure in an ambulatory surgical
center.
Disclosure: A United affiliate provides payment services to the healthcare industry and offers medical providers with various
payment methods and options, including electronic payments, virtual cards and checks. Some options are available to medical
providers for a fee and may result in the receipt of transaction fees or other compensation (e.g., 1% to 3% of the total transaction
amount, or at the election of the provider a per transaction fee of up to $10) by a United affiliate. This has no impact on the Fees
paid by Customer under this Agreement.
3. The following replaces Attachment D-6 – Guarantees UnitedHealthcare:
Service Description
• Search claims for patterns which indicate possible waste or error by identifying specific claims for additional review.
• In-depth review of hospital medical records or other related documentation compared to claimed amounts to ensure billing
accuracy.
• Review, validate, and recover credit balances (dollars) on existing patient accounts through a combination of analysis and
technology, on-site at hospitals and facilities.
• Large-scale analytics to identify additional recovery opportunities; claims re-examined every month for up to 12 months.
Subrogation: Services to prevent the payment of Plan benefits, or recover Plan benefits, which should be paid by a third party.
• Plan benefits, which should be paid by a third party.
• Does not include benefits paid in connection with coordination of benefits, Medicare, or other Overpayments.
• Customer will not engage any entity except United to provide such services without prior United approval.
Litigation and Arbitration Fees for Recoveries
• Litigation or arbitration to recover any Overpayments and other Plan recovery opportunities.
• Outside attorneys’ fees and costs directly incurred with litigation or arbitration.
• Pre-adjudicated claims or post-adjudication claims.
Payment Integrity Service Fees related to pre-adjudicated or prevented amount savings are calculated using logic that accounts
for claim level detail and past claims payment experiences, and other relevant inputs including, but not limited to, historical
amounts billed and allowed for similar providers, services, and specialties.
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Attachment D-6 – Guarantees UnitedHealthcare
The Fees at risk do not include Customer-elected optional and non-standard programs Fees, all credits, Payment
Integrity Programs Fees, Out-of-Network Programs Fees, Commission Funds, Consultant Funds, and ancillary
product Fees. Any Customer credits set forth in Exhibit D – Fees will reduce the total Fees at risk.
The Fees payable by Customer under this Agreement will be adjusted through a credit to Customer’s Fees in
accordance with the guarantees set forth below unless otherwise defined in the guarantee. Unless otherwise specified,
these guarantees are effective for the period beginning January 1, 2026 through December 31, 2026 (each twelve-
month period is a “Guarantee Period”). With respect to the aspects of United’s performance addressed in this Exhibit,
these Fee adjustments are Customer’s exclusive financial remedies.
United shall not be required to meet any of the guarantees provided for in this Agreement or amendments thereto to
the extent United’s failure is due to Customer’s actions or inactions or if United fails to meet these standards due to
fire, embargo, strike, war, accident, act of God, acts of terrorism or United’s required compliance with any law,
regulation, or governmental agency mandate or anything beyond United’s reasonable control.
Prior to the end of the Guarantee Period, and on the condition that this Agreement remains in force, United may specify
to Customer in writing new guarantees for the subsequent Guarantee Period. If United specifies new guarantees,
United will also provide Customer with a new Exhibit that will replace this Exhibit for that subsequent Guarantee
Period.
Claim is defined as an initial and complete written request for payment of a Plan benefit made by an enrollee,
physician, or other healthcare provider on an accepted format. Unless stated otherwise, the claims are limited to
medical claims processed through the claims systems. Claims processed and products administered through any other
system, including claims for other products such as vision, dental, flexible spending accounts, health reimbursement
accounts, health savings accounts, or pharmacy coverage, are not included in the calculation of the measurements.
Also, services provided under capitated arrangements are not processed as a typical claim, therefore capitated
payments are not included in the measurements.
Claim Operations
Time to Process in 10 Days
Definition The percentage of all claims United receives will be processed within the designated number of business days
of receipt.
Measurement Percentage of claims processed 94%
Time to process, in business days or less after receipt of claim business
days 10
Criteria Standard claim operations reports
Level Site Level
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $11,000
Payment Amount Of the Fees at Risk for this metric, percentage at risk for each gradient 20%
Gradients 11 business days
12 business days
13 business days
14 business days
15 business days or more
Procedural Accuracy
Definition Procedural accuracy rate of not less than the designated percent.
Measurement Percentage of claims processed without procedural (i.e. non-financial) errors 97%
Criteria Statistically significant random sample of claims processed is reviewed to determine the percentage of claim
dollars processed without procedural (i.e. non-financial) errors.
Level Office Level
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $11,000
Payment Amount Of the Fees at Risk for this metric, percentage at risk for each gradient 20%
Gradients 96.99% - 96.50%
96.49% - 96.00%
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
95.99% - 95.50%
95.49% - 95.00%
Below 95.00%
Dollar Accuracy (DAR)
Definition Dollar accuracy rate of not less than the designated percent in any quarter.
Measurement Percentage of claims dollars processed accurately 99%
Criteria Statistically significant random sample of claims processed is reviewed to determine the percentage of claim
dollars processed correctly out of the total claim dollars paid.
Level Office Level
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $11,000
Payment Amount Of the Fees at Risk for this metric, percentage at risk for each gradient 20%
Gradients 98.99% - 98.50%
98.49% - 98.00%
97.99% - 97.50%
97.49% - 97.00
Below 97.00%
Member Phone Service
Phone service guarantees and standards apply to Participant calls made to the customer care center that primarily services
Customer’s Participants. If Customer elects a specialized phone service model the results may be blended with more than one call
center and/or level. They do not include calls made to care management personnel and/or calls to the senior center for Medicare
Participants, nor do they include calls for services/products other than medical, such as mental health/substance abuse, pharmacy
(except when United is Customer’s pharmacy benefit services administrator), dental, vision, Health Savings Account, etc.
Average Speed of Answer
Definition Calls will sequence through United’s phone system and be answered by customer service within the
parameters set forth.
Measurement Percentage of calls answered 100%
Time answered in seconds, on average seconds 30
Criteria Standard tracking reports produced by the phone system for all calls
Level Team that services Customer’s account
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $11,000
Payment Amount Of the Fees at Risk for this metric, percentage at risk for each gradient 20%
Gradients 32 seconds or less
34 seconds or less
36 seconds or less
38 seconds or less
Greater than 38 seconds
Abandonment Rate
Definition The average call abandonment rate will be no greater than the percentage set forth
Measurement Percentage of total incoming calls to customer service abandoned, on average 1.80%
Criteria Standard tracking reports produced by the phone system for all calls
Level Team that services Customer’s account
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $11,000
Payment Amount Of the Fees at Risk for this metric, percentage at risk for each gradient 20%
Gradients 1.81% - 2.30%
2.31% - 2.80%
2.81% - 3.30%
3.31% - 3.80%
Greater than 3.80%
Call Quality Score
Definition Maintain a call quality score of not less than the percent set forth
Measurement Call quality score to meet or exceed 93%
Criteria Random sampling of calls is each assigned a customer service quality score, using United’s standard internal
call quality assurance program.
Level Office that services Customer’s account
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $11,000
Payment Amount Of the Fees at Risk for this metric, percentage at risk for each gradient 20%
Gradients 92.99% - 91.00%
90.99% - 89.00%
88.99% - 87.00%
86.99% - 85.00%
Below 85.00%
Satisfaction
Employee (Member) Satisfaction
Definition The overall satisfaction will be determined by the question that reads “Overall, how satisfied are you with the
way we administer your medical health insurance plan?”
Measurement Percentage of respondents, on average, indicating a grade of satisfied or higher 80%
Criteria Operations standard survey, conducted over the course of the year; may be customer specific for an additional
charge.
Level Office that services Customer’s account
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $5,500
Payment Amount Of the Fees at Risk for this metric, percentage at risk for each gradient N/A
Gradients Not applicable
Customer Satisfaction
Definition The overall satisfaction will be determined by the question that reads “How satisfied are you overall with
UnitedHealthcare?”
Measurement Minimum score on a 10-point scale score 5
Criteria Standard Customer Scorecard Survey
Level Customer specific
Period Annually
Payment Period Annually
Fees at Risk Total Dollars at Risk for this metric $5,500
Payment Amount Of the Fees at Risk for this metric, percentage at risk for each gradient N/A
Gradients Not applicable
In the event any of the terms herein are inconsistent with the requirements of any federal, state or other applicable
law or regulation, then the inconsistent terms will be null and void and United will have the right to revise, reprice or
revoke this arrangement.
Pharmacy Financials
Definition Pharmacy rate guarantees.
Measurement 01/01/2025 01/01/2026 01/01/2027
and Criteria Component Discount Guarantee - Standard Select/CVS Network
Retail Brand, Average Wholesale Price (AWP) less 19.50% 19.50% 19.50%
Retail Brand -- 90 Day Supply, AWP less 22.50% 22.50% 22.50%
Retail Generic - 30 and 90 Day Supply, AWP less 84.50% 84.50% 84.50%
Mail Order Brand, AWP less 25.50% 25.50% 25.50%
Mail Order Generic, AWP less 86.50% 86.50% 86.50%
The Guaranteed Discount amount will be determined by multiplying the AWP by the guaranteed discount
off AWP by each component.
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Dispensing Fees - Standard Select/CVS
Network
Retail Brand - 30 Day $0.35 $0.35 $0.35
Retail Brand -- 90 Day Supply $0.05 $0.05 $0.05
Retail Generic - 30 Day $0.35 $0.35 $0.35
Retail Generic -- 90 Day Supply $0.05 $0.05 $0.05
Dispensing fee totals are calculated by multiplying the actual scripts for each type by the contracted rate for
that script type.
Minimum Rebate Guarantee (Traditional PDL)
Rebate Sharing Percentage 100.0% 100.0% 100.0%
Basis, per script Brand Brand Brand
Retail - 30 and 90 Day $730.25 $901.85 $1,066.98
Mail Order $1,000.49 $1,189.93 $1,370.47
Specialty Included In
Retail
Included In
Retail
Included In
Retail
Level Customer Specific
Period Annually
Payment
Period
Annually
Payment
Amount --
Discounts
The amount the actual discounts are less than the guaranteed discount amount for each individual
component.
Payment
Amount --
Dispensing
Fees
The amount the combined actual dispensing fee exceeds the combined contracted
dispensing fee.
Payment
Amount --
Rebates
The amount the combined actual Rebate amount is less than the combined guaranteed Rebate amount.
Conditions Discount & Dispense Fee Specific Conditions
• Discounts are based on actual Network Pharmacy brand and generic usage of retail and mail order drugs.
The guaranteed discount amount will be determined by multiplying the AWP by the contracted discount
rate off AWP by component.
• Does not apply to items covered under the Plan for which no AWP measure exists.
• Discounts calculated based on AWP less the ingredient cost; discount percentages are the discounts
divided by the AWP. Discounts for retail and mail order generic prescriptions represent the average AWP
based on savings off Maximum Allowable Cost (MAC) pricing for MAC generics and percentage discount
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
savings off AWP for non-MAC generics. All other discounts represent the percentage discount savings off
of AWP.
• The arrangement excludes compound drugs, retail out of network claims, mail order drugs (for dispensing
fee arrangement) and Indian Health Service Claims.
• The Arrangement excludes usual & customary claims, vaccines, long term care facility claims.
• The Arrangement includes veterans’ affairs facility claims, over-the-counter claims.
• The 90 day supply Retail guarantee includes drugs dispensed for 84 days or greater.
• The Mail Order guarantee includes drugs dispensed for 46 days or greater; claims with less than 46 days
supply are reconciled at retail.
• When a drug is identified as a brand name drug, it will be considered a brand name drug for the
calculation of discount guarantees. When a drug is identified as a generic drug, it will be considered a
generic drug for the calculation of discount guarantees.
• Specialty drugs dispensed outside United's specialty Pharmacy Network are included in the retail
guarantees. Specialty drugs dispensed through United's specialty Pharmacy Network are excluded from the
Retail and Mail guarantees.
Rebate Specific Conditions
• Assumes implementation of United's Traditional
PDL
• Client directed deviations from the PDL and PDL exclusions or uptiers, or clinical programs may result in
changes to pricing and guarantees, which will be factored in at the time of rebate payment and/or
reconciliation.
• Calculation of the guaranteed rebate amount will exclude ineligible claims including:
- claims where the plan is not the primary payer (e.g., coordination of benefits and subrogation claims)
- claims approved by formulary exception
- claims not covered by Customer's benefit design or PDL
- claims receiving 340B pricing
- long term care pharmacy claims
- federal government pharmacy claims
- claims for non-FDA approved products
- compound drug claims
- direct member reimbursement claims
• Over-the-counter and repackaged drugs are excluded from the claim counts; Insulins are not excluded.
• Devices are excluded from the claim counts; Test Strips are not excluded.
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
• Vaccines are excluded from the claim counts.
• Rebate guarantee payments or reconciliations may be adjusted in the event of a change impacting the level
of Rebates due to the introduction of therapeutically equivalent, lower Rebate drugs (e.g. biosimilar,
authorized brand alternative, lower cost non-Generic Drug alternative) or the reduction of Wholesale
Acquisition Cost on a Brand Drug subject to Rebates. In the event a payment or reconciliation adjustment
is required, such adjustment will be based on the difference between a) pharmaceutical manufacturer
revenue prior to the introduction of the lower Rebate drugs and b) the actual pharmaceutical manufacturer
revenue received after the introduction of the lower Rebate drugs. Such adjustment does not apply to
Generic Drugs that launch after the Brand Drug no longer has patent protection.
• The Rebate guarantees set forth herein account for projected Rebate reductions in the following classes of
Prescription Drugs in connection with the elimination of the Average Manufacturer’s Price (AMP) Cap
pursuant to the American Rescue Plan Act of 2021: Insulin products and Respiratory Medications. United
reserves the right to modify or eliminate any Rebate guarantees if there are any additional changes to
Rebates received from pharmaceutical manufacturers.
United reserves the right to modify or eliminate this arrangement as follows based upon changes in
Rebates:
• if changes made to United's PDL, for the purpose of achieving a lower net drug cost for Customer and
United's other ASO customers, result in significant reductions to the Rebate level
• in the event that there are material deviations to the anticipated timing of drugs that will come off patent
and no longer generate Rebates
• if there is a change impacting the availability or amount of Rebates offered by drug manufacturer(s),
including changes related to the elimination or material modification of a drug manufacturer(s) historic
models or practices related to the provision of Rebates
• United will pay Rebates consistent with the Agreement. A reconciliation of the Rebate amounts will occur
after the end of each annual contract period and when Rebate payments are substantially complete. The
reconciliation calculates the minimum rebate amount by multiplying the actual number of scripts filled by
the applicable rebate amount for that script type.
• Specialty rebates are included in the guaranteed retail per-script rebates above.
• Manufacturer Administrative Fees are the administrative fees paid by drug manufacturers to United’s
PBM affiliate as consideration for maintaining systems and processes necessary for managing and
administering Rebate programs. Manufacturer Administrative Fees are not included in the guaranteed
rebate arrangement.
• If Customer terminates pharmacy benefit services with United prior to the end of the Pharmacy Pricing
Term, United will retain any and all pending or future Rebates payable under the Agreement as of the
effective date of the termination of pharmacy benefit services and no reconciliation of minimum rebate
guarantees will apply.
Market Check
Customer may conduct one market check during the Pharmacy Pricing Term to confirm its financial terms
are competitive with those currently available in the market for substantially similar customers. Such
analysis shall:
· be initiated in the third quarter after the first anniversary of the Effective Date of the
Agreement
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
· be conducted by a mutually agreed upon third
party, approval not to be unreasonably withheld
· include no fewer than four substantially similar customers under active contracts as determined by the
following criteria which must be included in the market check report:
· Within 10% of total membership count
· Same customer type (carve-in, coalition,
etc.)
· Same line of business (commercial, Medicare, Medicaid, etc.)
· Same types of services (retail, home delivery, specialty, etc.)
· Comparison of pricing for same contract
year
· Pricing quoted within past six-month period
· A majority of membership located in a comparable geographic
region
· The market check will compare the aggregate value of pricing terms including the combined net value of:
· Ingredient cost discounts and dispensing fees from retail pharmacies, home delivery pharmacies, and
specialty pharmacies
· Rebates , including manufacturer derived administrative fees
· Administrative fees.
· Client Credits
If the market check report validates an annualized savings of greater than three (3) percent between the
median of the financial terms for such substantially similar customers and Customer’s financial terms for
time period that is the subject of the market check, the parties will negotiate in good faith to revise the
financial terms. United responds to Customer within 30 days of receipt of the complete market check report
containing sufficient information for United to validate that the analysis was conducted in accordance with
the above criteria. Any revisions to financial terms resulting from the parties’ negotiations are effective the
first day of the following contract year, subject to the parties having executed an amendment to the
Agreement at least 60 days prior to the effective date.
General Conditions
• All pricing guarantees shall remain in effect for the entire contract period of 01/01/2025 through
12/31/2027 ("Pharmacy Pricing Term"). Each twelve month period is a Guarantee Period.
• Specialty drugs typically covered under the medical benefit (administered / handled by a provider,
administered in a physician's office, ambulatory or home infusion), and/or transitioned to the pharmacy
benefit, are excluded from all guarantees.
• Drugs, products, supplies approved, covered and/or prescribed for the diagnosis, treatment or prevention
of COVID-19 are excluded from all guarantees.
• On mail order drugs, specialty drugs, and retail pharmacy drugs and services including dispensing fees,
United will retain the difference between what United reimburses the Network Pharmacy and Customer's
payment for a prescription drug product or service.
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
• Pricing and guarantees assume enrollment of 1,708 Employees and 4,142 Participants; pricing and
guarantees may be revised or withdrawn if actual enrollment varies by 10% or more from assumptions.
• The lesser of three logic (non-ZBL) will apply to Participant payments. Participants pay the lesser of the
discounted price, the usual and customary charge or the cost share amount.
• All pricing guarantees require the selection of United’s PBM as exclusive provider of pharmacy benefit
services, including but not limited to retail, mail order, and specialty networks.
United will have no financial guarantee obligation under the Agreement for any partial Guarantee Period if
Customer terminates with an effective date prior to the end of the Pharmacy Pricing Term.
• United shall on Customer’s behalf, administer a fee (“Consultant Fee”) to be paid to Lockton
(“Consultant”). The Consultant Fees are included in Customer’s pharmacy financial terms. United shall
provide Consultant with a monthly payment for all Consultant Fees collected in the amount(s) of $2.00
pmpm. The Customer acknowledges there is a contract between Customer and Consultant. Therefore, in
the event that there is a dispute between Customer and Consultant over continuing to make the Consultant
Fee payment(s) or in the delivery of consulting services, Customer shall hold United harmless in such
disputes. In the event of any change whatsoever in the Consultant Fee, Customer shall immediately notify
United of such change and United may propose changes to the pharmacy financial terms.
• In the event any of the terms herein is inconsistent with the requirements of any federal, state or other
applicable law or regulation, then the inconsistent term(s) will be null and void and United will have the
right to revise, reprice or revoke this arrangement.
• United reserves the right to revise or revoke this arrangement if: a) changes in federal, state or other
applicable law or regulation require modifications; b) there are material changes to the AWP as published
by the pricing agency that establishes the AWP as used in these arrangements; c) Customer makes benefit
changes that impact the arrangements; d) there is a material industry change in pricing methodologies
resulting in a new source or benchmark; e) it is not accepted within ninety (90) days of the issuance of our
quote; f) if Customer changes their mail service benefit; g) Customer utilizes a vendor, that facilitates
steering members to different drugs or pharmacies to the extent these services impact the financial
guarantees under this Agreement.
Brand / Generic Reconciliation Definition
• Brand Drug: An FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy Study
Implementation) drug, or product, which is manufactured and distributed by an innovator drug company, or
its licensee , set forth in Medi-Span’s National Drug Data File as a brand drug identified by all of the
products meeting at least one of the following criteria:
- Medi-Span Multi-Source Code ("MSC") is equal to M, O, or N.
• Generic Drug: An FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy
Study Implementation) drug, or product, that is therapeutically equivalent to other pharmaceutically
equivalent products, as set forth in Medi-Span’s National Drug Data File as a generic drug identified by all
products meeting at least one of the following criteria:
- Medi-Span Multi-Source Code ("MSC") is equal to Y.
TRRX
(05/2024)
Specialty Pharmacy
Specialty Pharmacy Discount Guarantee
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Definitio
n Specialty drug discount level based on actual specialty drug utilization for the specialty drugs dispensed through
United's specialty Pharmacy Network. United reserves the right to change the designation of a drug from
specialty to non-specialty based on market conditions.
Measure
ment Listed 01/01/
2025
01/
01/
202
6
01/01/
2027
All Include LDD 21.00
%
21.
00
%
21.00
%
Unlisted 01/01/
2025
01/
01/
202
6
01/01/
2027
All Include LDD 14.00
%
14.
00
%
14.00
%
Criteria
Actual utilization, using Average Wholesale Price (AWP) in dollars, using our data, of listed specialty drugs
through Our specialty Pharmacy Network will be multiplied against the discount target to determine the overall
discount target dollars.
The overall discount target dollars may be adjusted based on utilization of unlisted drugs to which the separate
unlisted discount applies. This total will be compared to actual discounts achieved for these drugs during the
Guarantee Period.
Level
Customer Specific
Period Annual
Payment
Period Annual
Payment
Amount
The amount the combined actual specialty drug discounts are less than the composite discount
drug target.
Conditio
ns
• Discounts calculated based on the AWP less the
ingredient cost; discount percentages are the discounts
divided by the AWP. Discounts for generic
prescriptions represent the average savings off AWP
based on Maximum Allowable Cost (MAC) pricing for
MAC generics and percentage discount savings
off AWP for non-MAC generics. All other discounts
represent the percentage discount savings off of AWP.
• Specialty drugs dispensed outside United's specialty Pharmacy Network and drugs for which no AWP measure
exists are excluded.
• Listed drugs which cease to be defined as specialty drugs during the Guarantee Period will be reconciled outside
of the Specialty Pharmacy guarantee in the channel in which they are dispensed (retail or mail order).
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
• Limited Distribution (LDD) status is subject to change based on manufacturer decision.
• Specialty drugs typically covered under the medical benefit (administered / handled by a provider, administered
in a physician's office, ambulatory or home infusion), and/or transitioned to the pharmacy benefit, are excluded
from all guarantees.
• United reserves the right to revise or revoke this guarantee if:
a) material changes in federal, state or other applicable law or regulation require
modifications;
b) there are material changes to the AWP as published by the pricing agency that establishes the AWP
as used in this guarantee;
c) Customer makes benefit changes that impact the guarantee;
d) there is a material industry change in pricing methodologies resulting in a new source or
benchmark;
• On specialty drugs, United will retain the difference between what United reimburses the Network Pharmacy
and Customer's payment for a prescription drug product or service.
Specialty
Drug
Categor
y
Drug Name
LD
D
In
dic
ato
r
Includ
ed/Exc
luded
From
Guara
ntee
Specialt
y Drug
Categor
y
Drug
Name
LD
D
Ind
icat
or
Includ
ed/Exc
luded
From
Guara
ntee
ANEMI
A ARANESP No
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
HULI
O No
Includ
ed
ANEMI
A EPOGEN No
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
HUMI
RA No
Includ
ed
ANEMI
A PROCRIT No
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
HYRI
MOZ No
Includ
ed
ANEMI
A RETACRIT No
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
IDACI
O No
Includ
ed
ANTICO
NVULS
ANT DIACOMIT Yes
Includ
ed
INFLA
MMAT
ORY
ILUM
YA No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
CONDI
TIONS
ANTICO
NVULS
ANT EPIDIOLEX Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
KEVZ
ARA No
Includ
ed
ANTICO
NVULS
ANT FINTEPLA Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
KINE
RET Yes
Includ
ed
ANTICO
NVULS
ANT ZTALMY Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
OLUM
IANT Yes
Includ
ed
ANTIHY
PERLIPI
DEMIC JUXTAPID Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
OPZE
LURA No
Includ
ed
ANTI-
INFECTI
VE ARIKAYCE Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
OREN
CIA No
Includ
ed
ANTI-
INFECTI
VE DARAPRIM Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
OTEZ
LA No
Includ
ed
ANTI-
INFECTI
VE PYRIMETHAMINE No
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
RIDA
URA No
Includ
ed
ANTIVI
RAL LIVTENCITY Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
RINV
OQ No
Includ
ed
ASTHM
A FASENRA Yes
Includ
ed
INFLA
MMAT
ORY SILIQ Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
CONDI
TIONS
ASTHM
A NUCALA Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
SIMP
ONI No
Includ
ed
ASTHM
A XOLAIR Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
SKYR
IZI No
Includ
ed
CARDIO
VASCUL
AR CAMZYOS Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
SOTY
KTU No
Includ
ed
CARDIO
VASCUL
AR DROXIDOPA No
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
STEL
ARA No
Includ
ed
CARDIO
VASCUL
AR NORTHERA Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
TALT
Z No
Includ
ed
CARDIO
VASCUL
AR VYNDAMAX Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
TREM
FYA No
Includ
ed
CARDIO
VASCUL
AR VYNDAQEL Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
VELSI
PITY No
Includ
ed
CNS
AGENT
S AUSTEDO No
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
XELJ
ANZ No
Includ
ed
CNS
AGENT
S DAYBUE Yes
Includ
ed
INFLA
MMAT
ORY
XELJ
ANZ
XR No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
CONDI
TIONS
CNS
AGENT
S
ENSPRYNG Yes Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
YUFL
YMA No Includ
ed
CNS
AGENT
S EXSERVAN Yes
Includ
ed
INFLA
MMAT
ORY
CONDI
TIONS
YUSI
MRY No
Includ
ed
CNS
AGENT
S FIRDAPSE Yes
Includ
ed
IRON
OVERL
OAD
DEFE
RASIR
OX Yes
Includ
ed
CNS
AGENT
S HETLIOZ Yes
Includ
ed
IRON
OVERL
OAD
DEFE
RIPRO
NE No
Includ
ed
CNS
AGENT
S INGREZZA Yes
Includ
ed
IRON
OVERL
OAD
EXJA
DE Yes
Includ
ed
CNS
AGENT
S RADICAVA Yes
Includ
ed
IRON
OVERL
OAD
FERRI
PROX Yes
Includ
ed
CNS
AGENT
S RELYVRIO Yes
Includ
ed
IRON
OVERL
OAD
JADE
NU No
Includ
ed
CNS
AGENT
S RILUTEK No
Includ
ed
KIDNE
Y
DISEAS
E
TARP
EYO Yes
Includ
ed
CNS
AGENT
S RILUZOLE No
Includ
ed
LIVER
DISEAS
E
OCAL
IVA Yes
Includ
ed
CNS
AGENT
S SABRIL Yes
Includ
ed
MONO
CLONA
L
ANTIB
ODY
MISCE
LLANE
OUS
BENL
YSTA Yes
Includ
ed
CNS
AGENT
S SKYCLARYS Yes
Includ
ed MOOD
DISOR
SPRA
VATO No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
DER
DRUGS
CNS
AGENT
S SODIUM OXYBATE Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
AMPY
RA No
Includ
ed
CNS
AGENT
S TASIMELTEON Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
AUBA
GIO No
Includ
ed
CNS
AGENT
S TETRABENAZINE No
Includ
ed
MULTI
PLE
SCLER
OSIS
AVON
EX No
Includ
ed
CNS
AGENT
S TIGLUTIK Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
BAFIE
RTAM Yes
Includ
ed
CNS
AGENT
S VIGABATRIN No
Includ
ed
MULTI
PLE
SCLER
OSIS
BETA
SERO
N No
Includ
ed
CNS
AGENT
S VIGADRONE Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
COPA
XONE No
Includ
ed
CNS
AGENT
S XENAZINE Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
DALF
AMPR
IDIN No
Includ
ed
CNS
AGENT
S XYREM Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
DIME
THYL
FUMA
RATE No
Includ
ed
CNS
AGENT
S XYWAV Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
EXTA
VIA No
Includ
ed
CYSTIC
FIBROSI
S BETHKIS No
Includ
ed
MULTI
PLE
SCLER
OSIS
FING
OLIM
OD No
Includ
ed
CYSTIC
FIBROSI
S BRONCHITOL Yes
Includ
ed MULTI
PLE
GILE
NYA No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
SCLER
OSIS
CYSTIC
FIBROSI
S CAYSTON Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
GLATI
RAME
R No
Includ
ed
CYSTIC
FIBROSI
S KALYDECO Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
GLAT
OPA No
Includ
ed
CYSTIC
FIBROSI
S KITABIS PAK No
Includ
ed
MULTI
PLE
SCLER
OSIS
KESI
MPTA No
Includ
ed
CYSTIC
FIBROSI
S ORKAMBI Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
MAVE
NCLA
D Yes
Includ
ed
CYSTIC
FIBROSI
S PULMOZYME No
Includ
ed
MULTI
PLE
SCLER
OSIS
MAYZ
ENT No
Includ
ed
CYSTIC
FIBROSI
S SYMDEKO Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
PLEG
RIDY Yes
Includ
ed
CYSTIC
FIBROSI
S TOBI No
Includ
ed
MULTI
PLE
SCLER
OSIS
PONV
ORY Yes
Includ
ed
CYSTIC
FIBROSI
S TOBI PODHALER No
Includ
ed
MULTI
PLE
SCLER
OSIS REBIF No
Includ
ed
CYSTIC
FIBROSI
S TOBRAMYCIN No
Includ
ed
MULTI
PLE
SCLER
OSIS
REBIF
REBI
DOSE No
Includ
ed
CYSTIC
FIBROSI
S TRIKAFTA Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
TASC
ENSO Yes
Includ
ed
DERMA
TOLOGI
C LITFULO Yes
Includ
ed MULTI
PLE
TECFI
DERA No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
SCLER
OSIS
ENDOC
RINE BETAINE Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
TERIF
LUNO
MIDE No
Includ
ed
ENDOC
RINE BUPHENYL No
Includ
ed
MULTI
PLE
SCLER
OSIS
VUME
RITY Yes
Includ
ed
ENDOC
RINE CHENODAL Yes
Includ
ed
MULTI
PLE
SCLER
OSIS
ZEPO
SIA Yes
Includ
ed
ENDOC
RINE CORTROPHIN Yes
Includ
ed
MUSCU
LOSKE
LETAL
AGENT
S
EVRY
SDI Yes
Includ
ed
ENDOC
RINE CUPRIMINE No
Includ
ed
MUSCU
LOSKE
LETAL
AGENT
S
VOXZ
OGO Yes
Includ
ed
ENDOC
RINE CUVRIOR Yes
Includ
ed
NARCO
LEPSY
LUMR
YZ Yes
Includ
ed
ENDOC
RINE CYSTADANE Yes
Includ
ed
NARCO
LEPSY
WAKI
X Yes
Includ
ed
ENDOC
RINE CYSTADROPS Yes
Includ
ed
NEUTR
OPENI
A
FULP
HILA No
Includ
ed
ENDOC
RINE CYSTARAN Yes
Includ
ed
NEUTR
OPENI
A
FYLN
ETRA No
Includ
ed
ENDOC
RINE DEPEN TITRATABS No
Includ
ed
NEUTR
OPENI
A
GRAN
IX No
Includ
ed
ENDOC
RINE DICHLORPHENAMIDE Yes
Includ
ed
NEUTR
OPENI
A
LEUK
INE No
Includ
ed
ENDOC
RINE EGRIFTA Yes
Includ
ed
NEUTR
OPENI
A
NEUL
ASTA No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
ENDOC
RINE FIRMAGON No
Includ
ed
NEUTR
OPENI
A
NEUP
OGEN No
Includ
ed
ENDOC
RINE GATTEX Yes
Includ
ed
NEUTR
OPENI
A
NIVES
TYM No
Includ
ed
ENDOC
RINE H.P. ACTHAR Yes
Includ
ed
NEUTR
OPENI
A
NYVE
PRIA No
Includ
ed
ENDOC
RINE IMCIVREE Yes
Includ
ed
NEUTR
OPENI
A
UDEN
YCA No
Includ
ed
ENDOC
RINE ISTURISA Yes
Includ
ed
NEUTR
OPENI
A
ZARX
IO No
Includ
ed
ENDOC
RINE JAVYGTOR Yes
Includ
ed
NEUTR
OPENI
A
ZIEXT
ENZO No
Includ
ed
ENDOC
RINE JYNARQUE Yes
Includ
ed
ONCOL
OGY -
INJECT
ABLE
ELIG
ARD No
Includ
ed
ENDOC
RINE KEVEYIS Yes
Includ
ed
ONCOL
OGY -
INJECT
ABLE
INTR
ON A Yes
Includ
ed
ENDOC
RINE KORLYM Yes
Includ
ed
ONCOL
OGY -
INJECT
ABLE
LEUP
ROLI
DE No
Includ
ed
ENDOC
RINE KUVAN Yes
Includ
ed
ONCOL
OGY -
INJECT
ABLE
SYNR
IBO Yes
Includ
ed
ENDOC
RINE LANREOTIDE No
Includ
ed
ONCOL
OGY -
ORAL
ABIR
ATER
ONE No
Includ
ed
ENDOC
RINE MYALEPT Yes
Includ
ed
ONCOL
OGY -
ORAL
AFINI
TOR No
Includ
ed
ENDOC
RINE MYCAPSSA Yes
Includ
ed
ONCOL
OGY -
ORAL
AFINI
TOR
DISPE
RZ No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
ENDOC
RINE NATPARA Yes
Includ
ed
ONCOL
OGY -
ORAL
ALEC
ENSA Yes
Includ
ed
ENDOC
RINE OCTREOTIDE ACETATE No
Includ
ed
ONCOL
OGY -
ORAL
ALKE
RAN No
Includ
ed
ENDOC
RINE PENICILLAMINE No
Includ
ed
ONCOL
OGY -
ORAL
ALUN
BRIG Yes
Includ
ed
ENDOC
RINE PHEBURANE Yes
Includ
ed
ONCOL
OGY -
ORAL
AYVA
KIT Yes
Includ
ed
ENDOC
RINE PROCYSBI Yes
Includ
ed
ONCOL
OGY -
ORAL
BALV
ERSA Yes
Includ
ed
ENDOC
RINE RAVICTI Yes
Includ
ed
ONCOL
OGY -
ORAL
BEXA
ROTE
NE No
Includ
ed
ENDOC
RINE RECORLEV Yes
Includ
ed
ONCOL
OGY -
ORAL
BOSU
LIF Yes
Includ
ed
ENDOC
RINE SAMSCA Yes
Includ
ed
ONCOL
OGY -
ORAL
BRAF
TOVI Yes
Includ
ed
ENDOC
RINE SANDOSTATIN No
Includ
ed
ONCOL
OGY -
ORAL
BRUK
INSA Yes
Includ
ed
ENDOC
RINE SAPROPTERIN Yes
Includ
ed
ONCOL
OGY -
ORAL
CABO
METY
X Yes
Includ
ed
ENDOC
RINE SIGNIFOR Yes
Includ
ed
ONCOL
OGY -
ORAL
CALQ
UENC
E Yes
Includ
ed
ENDOC
RINE SODIUM PHENYLBUTYRATE No
Includ
ed
ONCOL
OGY -
ORAL
CAPE
CITAB
INE No
Includ
ed
ENDOC
RINE SOMATULINE DEPOT No
Includ
ed
ONCOL
OGY -
ORAL
CAPR
ELSA Yes
Includ
ed
ENDOC
RINE SOMAVERT Yes
Includ
ed
ONCOL
OGY -
ORAL
COME
TRIQ Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
ENDOC
RINE SYPRINE No
Includ
ed
ONCOL
OGY -
ORAL
COPI
KTRA Yes
Includ
ed
ENDOC
RINE THIOLA Yes
Includ
ed
ONCOL
OGY -
ORAL
COTE
LLIC Yes
Includ
ed
ENDOC
RINE TIOPRONIN No
Includ
ed
ONCOL
OGY -
ORAL
DAUR
ISMO Yes
Includ
ed
ENDOC
RINE TOLVAPTAN No
Includ
ed
ONCOL
OGY -
ORAL
ERIVE
DGE Yes
Includ
ed
ENDOC
RINE TRIENTINE No
Includ
ed
ONCOL
OGY -
ORAL
ERLE
ADA No
Includ
ed
ENDOC
RINE XERMELO Yes
Includ
ed
ONCOL
OGY -
ORAL
ERLO
TINIB Yes
Includ
ed
ENDOC
RINE XURIDEN Yes
Includ
ed
ONCOL
OGY -
ORAL
ETOP
OSIDE No
Includ
ed
ENZYM
E
DEFICIE
NCY CARBAGLU Yes
Includ
ed
ONCOL
OGY -
ORAL
EVER
OLIM
US No
Includ
ed
ENZYM
E
DEFICIE
NCY CARGLUMIC Yes
Includ
ed
ONCOL
OGY -
ORAL
EXKI
VITY Yes
Includ
ed
ENZYM
E
DEFICIE
NCY CHOLBAM Yes
Includ
ed
ONCOL
OGY -
ORAL
FARY
DAK Yes
Includ
ed
ENZYM
E
DEFICIE
NCY CYSTAGON Yes
Includ
ed
ONCOL
OGY -
ORAL
FOTIV
DA Yes
Includ
ed
ENZYM
E
DEFICIE
NCY GALAFOLD Yes
Includ
ed
ONCOL
OGY -
ORAL
GAVR
ETO Yes
Includ
ed
ENZYM
E MIGLUSTAT No
Includ
ed
ONCOL
OGY -
ORAL
GEFIT
INIB No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
DEFICIE
NCY
ENZYM
E
DEFICIE
NCY NITISINONE No
Includ
ed
ONCOL
OGY -
ORAL
GILO
TRIF Yes
Includ
ed
ENZYM
E
DEFICIE
NCY NITYR Yes
Includ
ed
ONCOL
OGY -
ORAL
GLEE
VEC No
Includ
ed
ENZYM
E
DEFICIE
NCY ORFADIN Yes
Includ
ed
ONCOL
OGY -
ORAL
GLEO
STINE No
Includ
ed
ENZYM
E
DEFICIE
NCY PALYNZIQ Yes
Includ
ed
ONCOL
OGY -
ORAL
HYCA
MTIN No
Includ
ed
ENZYM
E
DEFICIE
NCY STRENSIQ Yes
Includ
ed
ONCOL
OGY -
ORAL
IBRA
NCE Yes
Includ
ed
ENZYM
E
DEFICIE
NCY SUCRAID Yes
Includ
ed
ONCOL
OGY -
ORAL
ICLUS
IG Yes
Includ
ed
ENZYM
E
DEFICIE
NCY TEGSEDI Yes
Includ
ed
ONCOL
OGY -
ORAL
IDHIF
A No
Includ
ed
ENZYM
E
DEFICIE
NCY ZAVESCA Yes
Includ
ed
ONCOL
OGY -
ORAL
IMATI
NIB
MESY
LATE No
Includ
ed
GASTR
OINTES
TINAL
AGENT
S VOWST Yes
Includ
ed
ONCOL
OGY -
ORAL
IMBR
UVIC
A Yes
Includ
ed
GAUCH
ERS
DISEAS
E CERDELGA Yes
Includ
ed
ONCOL
OGY -
ORAL
INLYT
A Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
GENETI
C
DISORD
ER DOJOLVI Yes
Includ
ed
ONCOL
OGY -
ORAL
INQO
VI Yes
Includ
ed
GENETI
C
DISORD
ER VIJOICE No
Includ
ed
ONCOL
OGY -
ORAL
INRE
BIC Yes
Includ
ed
GENETI
C
DISORD
ER ZOKINVY Yes
Includ
ed
ONCOL
OGY -
ORAL
IRESS
A No
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY GENOTROPIN No
Includ
ed
ONCOL
OGY -
ORAL
JAKA
FI Yes
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY HUMATROPE No
Includ
ed
ONCOL
OGY -
ORAL
JAYPI
RCA Yes
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY INCRELEX Yes
Includ
ed
ONCOL
OGY -
ORAL
KISQ
ALI No
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY NGENLA No
Includ
ed
ONCOL
OGY -
ORAL
KISQ
ALI
FEMA
RA No
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY NORDITROPIN No
Includ
ed
ONCOL
OGY -
ORAL
KOSE
LUGO Yes
Includ
ed
GROWT
H
HORMO
NE NUTROPIN AQ No
Includ
ed
ONCOL
OGY -
ORAL
KRAZ
ATI Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
DEFICIE
NCY
GROWT
H
HORMO
NE
DEFICIE
NCY OMNITROPE No
Includ
ed
ONCOL
OGY -
ORAL
LAPA
TINIB No
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY SAIZEN No
Includ
ed
ONCOL
OGY -
ORAL
LENA
LIDO
MIDE Yes
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY SEROSTIM Yes
Includ
ed
ONCOL
OGY -
ORAL
LENV
IMA Yes
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY SKYTROFA No
Includ
ed
ONCOL
OGY -
ORAL
LONS
URF Yes
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY SOGROYA No
Includ
ed
ONCOL
OGY -
ORAL
LORB
RENA Yes
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY ZOMACTON No
Includ
ed
ONCOL
OGY -
ORAL
LUMA
KRAS Yes
Includ
ed
GROWT
H
HORMO
NE
DEFICIE
NCY ZORBTIVE Yes
Includ
ed
ONCOL
OGY -
ORAL
LYNP
ARZA Yes
Includ
ed
HEMAT
OLOGIC BERINERT Yes
Includ
ed
ONCOL
OGY -
ORAL
MATU
LANE Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
HEMAT
OLOGIC CABLIVI Yes
Includ
ed
ONCOL
OGY -
ORAL
MEKI
NIST Yes
Includ
ed
HEMAT
OLOGIC CINRYZE Yes
Includ
ed
ONCOL
OGY -
ORAL
MEKT
OVI Yes
Includ
ed
HEMAT
OLOGIC DOPTELET Yes
Includ
ed
ONCOL
OGY -
ORAL
MELP
HALA
N No
Includ
ed
HEMAT
OLOGIC EMPAVELI Yes
Includ
ed
ONCOL
OGY -
ORAL
MESN
EX No
Includ
ed
HEMAT
OLOGIC FIRAZYR Yes
Includ
ed
ONCOL
OGY -
ORAL
NERL
YNX Yes
Includ
ed
HEMAT
OLOGIC HAEGARDA Yes
Includ
ed
ONCOL
OGY -
ORAL
NEXA
VAR Yes
Includ
ed
HEMAT
OLOGIC ICATIBANT Yes
Includ
ed
ONCOL
OGY -
ORAL
NILA
NDRO
N No
Includ
ed
HEMATOL
OGIC MOZOBIL No
Include
d
ONCOL
OGY -
ORAL
NILUTA
MIDE No
Include
d
HEMAT
OLOGIC MULPLETA No
Includ
ed
ONCOL
OGY -
ORAL
NINL
ARO No
Includ
ed
HEMAT
OLOGIC OXBRYTA Yes
Includ
ed
ONCOL
OGY -
ORAL
NUBE
QA Yes
Includ
ed
HEMAT
OLOGIC PLERIXAFOR No
Includ
ed
ONCOL
OGY -
ORAL
ODO
MZO No
Includ
ed
HEMAT
OLOGIC PROMACTA Yes
Includ
ed
ONCOL
OGY -
ORAL
ONUR
EG No
Includ
ed
HEMAT
OLOGIC REZUROCK Yes
Includ
ed
ONCOL
OGY -
ORAL
ORGO
VYX Yes
Includ
ed
HEMAT
OLOGIC RUCONEST Yes
Includ
ed
ONCOL
OGY -
ORAL
ORSE
RDU Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
HEMAT
OLOGIC SAJAZIR Yes
Includ
ed
ONCOL
OGY -
ORAL
PAZO
PANIB Yes
Includ
ed
HEMAT
OLOGIC TAKHZYRO Yes
Includ
ed
ONCOL
OGY -
ORAL
PEMA
ZYRE Yes
Includ
ed
HEMAT
OLOGIC TAVALISSE Yes
Includ
ed
ONCOL
OGY -
ORAL
PIQR
AY No
Includ
ed
HEMOP
HILIA -
INFUSE
D ADVATE No
Includ
ed
ONCOL
OGY -
ORAL
POMA
LYST Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D ADYNOVATE No
Includ
ed
ONCOL
OGY -
ORAL
PURI
XAN No
Includ
ed
HEMOP
HILIA -
INFUSE
D AFSTYLA No
Includ
ed
ONCOL
OGY -
ORAL
PYRU
KYND Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D ALPHANATE/VON WILLEBRAND No
Includ
ed
ONCOL
OGY -
ORAL
QINL
OCK Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D ALPHANINE SD No
Includ
ed
ONCOL
OGY -
ORAL
RETE
VMO Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D ALPROLIX No
Includ
ed
ONCOL
OGY -
ORAL
REVLI
MID Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D ALTUVIIIO No
Includ
ed
ONCOL
OGY -
ORAL
ROZL
YTRE
K No
Includ
ed
HEMOP
HILIA -
INFUSE
D BENEFIX No
Includ
ed
ONCOL
OGY -
ORAL
RUBR
ACA Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D COAGADEX Yes
Includ
ed
ONCOL
OGY -
ORAL
RYDA
PT No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
HEMOP
HILIA -
INFUSE
D CORIFACT No
Includ
ed
ONCOL
OGY -
ORAL
SCEM
BLIX No
Includ
ed
HEMOP
HILIA -
INFUSE
D ELOCTATE No
Includ
ed
ONCOL
OGY -
ORAL
SORA
FENIB No
Includ
ed
HEMOP
HILIA -
INFUSE
D ESPEROCT No
Includ
ed
ONCOL
OGY -
ORAL
SPRY
CEL No
Includ
ed
HEMOP
HILIA -
INFUSE
D FEIBA No
Includ
ed
ONCOL
OGY -
ORAL
STIVA
RGA Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D HEMOFIL M No
Includ
ed
ONCOL
OGY -
ORAL
SUNIT
INIB Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D HUMATE-P No
Includ
ed
ONCOL
OGY -
ORAL
SUTE
NT Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D IDELVION No
Includ
ed
ONCOL
OGY -
ORAL
TABL
OID No
Includ
ed
HEMOP
HILIA -
INFUSE
D IXINITY No
Includ
ed
ONCOL
OGY -
ORAL
TABR
ECTA No
Includ
ed
HEMOP
HILIA -
INFUSE
D JIVI No
Includ
ed
ONCOL
OGY -
ORAL
TAFIN
LAR Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D KOATE No
Includ
ed
ONCOL
OGY -
ORAL
TAGR
ISSO Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D KOATE-DVI No
Includ
ed
ONCOL
OGY -
ORAL
TALZ
ENNA Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
HEMOP
HILIA -
INFUSE
D KOGENATE FS No
Includ
ed
ONCOL
OGY -
ORAL
TARC
EVA Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D KOVALTRY No
Includ
ed
ONCOL
OGY -
ORAL
TARG
RETIN No
Includ
ed
HEMOP
HILIA -
INFUSE
D MONONINE No
Includ
ed
ONCOL
OGY -
ORAL
TASIG
NA Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D NOVOEIGHT No
Includ
ed
ONCOL
OGY -
ORAL
TAZV
ERIK Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D NOVOSEVEN RT No
Includ
ed
ONCOL
OGY -
ORAL
TEMO
DAR No
Includ
ed
HEMOP
HILIA -
INFUSE
D NUWIQ No
Includ
ed
ONCOL
OGY -
ORAL
TEMO
ZOLO
MIDE No
Includ
ed
HEMOP
HILIA -
INFUSE
D PROFILNINE No
Includ
ed
ONCOL
OGY -
ORAL
TEPM
ETKO Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D REBINYN No
Includ
ed
ONCOL
OGY -
ORAL
THAL
OMID Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D RECOMBINATE No
Includ
ed
ONCOL
OGY -
ORAL
TIBSO
VO Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D RIXUBIS No
Includ
ed
ONCOL
OGY -
ORAL
TRETI
NOIN No
Includ
ed
HEMOP
HILIA -
INFUSE
D SEVENFACT No
Includ
ed
ONCOL
OGY -
ORAL
TRUS
ELTIQ Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
HEMOP
HILIA -
INFUSE
D TRETTEN Yes
Includ
ed
ONCOL
OGY -
ORAL
TUKY
SA Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D VONVENDI Yes
Includ
ed
ONCOL
OGY -
ORAL
TURA
LIO Yes
Includ
ed
HEMOP
HILIA -
INFUSE
D WILATE No
Includ
ed
ONCOL
OGY -
ORAL
TYKE
RB No
Includ
ed
HEMOP
HILIA -
INFUSE
D XYNTHA No
Includ
ed
ONCOL
OGY -
ORAL
VENC
LEXT
A Yes
Includ
ed
HEMOPHI
LIA -
INJECTAB
LE HEMLIBRA Yes
Include
d
ONCOL
OGY -
ORAL
VERZE
NIO Yes
Include
d
HEPATI
TIS C EPCLUSA No
Includ
ed
ONCOL
OGY -
ORAL
VITR
AKVI Yes
Includ
ed
HEPATI
TIS C HARVONI No
Includ
ed
ONCOL
OGY -
ORAL
VIZIM
PRO Yes
Includ
ed
HEPATI
TIS C LEDIPASVIR/SOFOSBUVIR No
Includ
ed
ONCOL
OGY -
ORAL
VONJ
O Yes
Includ
ed
HEPATI
TIS C MAVYRET No
Includ
ed
ONCOL
OGY -
ORAL
VOTR
IENT Yes
Includ
ed
HEPATI
TIS C PEGASYS No
Includ
ed
ONCOL
OGY -
ORAL
WELI
REG Yes
Includ
ed
HEPATI
TIS C SOFOSBUVIR/VELPATASVIR No
Includ
ed
ONCOL
OGY -
ORAL
XALK
ORI Yes
Includ
ed
HEPATI
TIS C SOVALDI No
Includ
ed
ONCOL
OGY -
ORAL
XELO
DA No
Includ
ed
HEPATI
TIS C VIEKIRA PAK No
Includ
ed
ONCOL
OGY -
ORAL
XOSP
ATA Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
HEPATI
TIS C VOSEVI No
Includ
ed
ONCOL
OGY -
ORAL
XPOV
IO Yes
Includ
ed
HEPATI
TIS C ZEPATIER No
Includ
ed
ONCOL
OGY -
ORAL
XTAN
DI Yes
Includ
ed
HEPATO
LOGY BYLVAY Yes
Includ
ed
ONCOL
OGY -
ORAL
YONS
A No
Includ
ed
HEPATO
LOGY LIVMARLI Yes
Includ
ed
ONCOL
OGY -
ORAL
ZEJUL
A Yes
Includ
ed
HEREDI
TARY
ANGIO
DEMA ORLADEYO Yes
Includ
ed
ONCOL
OGY -
ORAL
ZELB
ORAF Yes
Includ
ed
IGA
NEPHR
OPATHY FILSPARI Yes
Includ
ed
ONCOL
OGY -
ORAL
ZOLI
NZA No
Includ
ed
IMMUN
E
MODUL
ATOR ACTIMMUNE Yes
Includ
ed
ONCOL
OGY -
ORAL
ZYDE
LIG Yes
Includ
ed
IMMUN
E
MODUL
ATOR ARCALYST Yes
Includ
ed
ONCOL
OGY -
ORAL
ZYKA
DIA Yes
Includ
ed
IMMUN
OLOGIC
AL
AGENT
S JOENJA Yes
Includ
ed
ONCOL
OGY -
ORAL
ZYTI
GA No
Includ
ed
IMMUN
OLOGIC
AL
AGENT
S LUPKYNIS Yes
Includ
ed
ONCOL
OGY -
TOPICA
L
TARG
RETIN No
Includ
ed
IMMUN
OLOGIC
AL
AGENT
S PALFORZIA Yes
Includ
ed
ONCOL
OGY -
TOPICA
L
VALC
HLOR Yes
Includ
ed
IMMUN
OLOGIC
AL TAVNEOS Yes
Includ
ed
OPHTH
ALMIC
OXER
VATE Yes
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
AGENT
S
INFERTI
LITY CETRORELIX No
Includ
ed
OSTEO
POROSI
S
FORT
EO No
Includ
ed
INFERTI
LITY CETROTIDE No
Includ
ed
OSTEO
POROSI
S
TERIP
ARATI
DE No
Includ
ed
INFERTI
LITY CHORIONIC GONADOTROPIN No
Includ
ed
OSTEO
POROSI
S
TYML
OS No
Includ
ed
INFERTI
LITY FOLLISTIM AQ No
Includ
ed
PARKI
NSONS
DISEAS
E
APOK
YN Yes
Includ
ed
INFERTI
LITY FYREMADEL No
Includ
ed
PARKI
NSONS
DISEAS
E
APOM
ORPH
INE Yes
Includ
ed
INFERTI
LITY GANIRELIX ACETATE No
Includ
ed
PARKI
NSONS
DISEAS
E
INBRI
JA Yes
Includ
ed
INFERTI
LITY GONAL-F No
Includ
ed
PARKI
NSONS
DISEAS
E
KYN
MOBI No
Includ
ed
INFERTI
LITY GONAL-F RFF No
Includ
ed
PULMO
NARY
DISEAS
E
ESBRI
ET No
Includ
ed
INFERTI
LITY MENOPUR No
Includ
ed
PULMO
NARY
DISEAS
E OFEV Yes
Includ
ed
INFERTI
LITY NOVAREL No
Includ
ed
PULMO
NARY
DISEAS
E
PIRFE
NIDO
NE No
Includ
ed
INFERTI
LITY OVIDREL No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
ADCI
RCA No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
INFERTI
LITY PREGNYL No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
ADEM
PAS Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS ABRILADA No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N ALYQ No
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS ACTEMRA No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
AMBR
ISENT
AN Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS ADALIMUMAB-ADAZ No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
BOSE
NTAN No
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS ADALIMUMAB-ADBM No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
LETAI
RIS Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS ADALIMUMAB-FKJP No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
LIQRE
V Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS ADBRY Yes
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
OPSU
MIT Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS AMJEVITA No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
OREN
ITRA
M Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS BIMZELX No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
REVA
TIO No
Includ
ed
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
INFLAM
MATOR
Y
CONDIT
IONS CIBINQO No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
SILDE
NAFIL No
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS CIMZIA No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
TADA
LAFIL No
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS COSENTYX No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
TADLI
Q Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS CYLTEZO No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
TRAC
LEER No
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS DUPIXENT No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
TYVA
SO Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS EMFLAZA Yes
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
UPTR
AVI Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS ENBREL No
Includ
ed
PULMO
NARY
HYPER
TENSIO
N
VENT
AVIS* Yes
Includ
ed
INFLAM
MATOR
Y
CONDIT
IONS HADLIMA No
Includ
ed
*Includes Nebulizer
1Q 2024
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Docusign Envelope ID: 2504B90C-938D-494D-80A4-C57B9B9C9FAC
Certificate Of Completion
Envelope Id: 2504B90C-938D-494D-80A4-C57B9B9C9FAC Status: Completed
Subject: ***Purchasing Approval*** 8577 Medical Network and Claims Administrators Pharmacy Benefit Managers
Source Envelope:
Document Pages: 41 Signatures: 4 Envelope Originator:
Certificate Pages: 6 Initials: 3 Christina Dormady
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-06:00) Central Time (US & Canada)
901B Texas Street
Denton, TX 76209
christina.dormady@cityofdenton.com
IP Address: 198.49.140.10
Record Tracking
Status: Original
12/29/2025 10:50:38 AM
Holder: Christina Dormady
christina.dormady@cityofdenton.com
Location: DocuSign
Signer Events Signature Timestamp
Christina Dormady
christina.dormady@cityofdenton.com
Buyer
City of Denton
Security Level: Email, Account Authentication
(None)
Completed
Using IP Address: 198.49.140.10
Sent: 12/29/2025 10:56:32 AM
Viewed: 12/29/2025 10:56:52 AM
Signed: 12/29/2025 10:57:00 AM
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Lori Hewell
lori.hewell@cityofdenton.com
Purchasing Manager
City of Denton
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.10
Sent: 12/29/2025 10:57:03 AM
Viewed: 12/29/2025 11:36:54 AM
Signed: 12/29/2025 2:41:28 PM
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Marcella Lunn
marcella.lunn@cityofdenton.com
Senior Deputy City Attorney
City of Denton
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 63.98.76.33
Sent: 12/29/2025 2:41:32 PM
Viewed: 12/29/2025 2:41:58 PM
Signed: 12/29/2025 4:52:17 PM
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Jennifer Dumas
jennifer_dumas@uhc.com
Regional Contract Manager
Security Level: Email, Account Authentication
(None)Signature Adoption: Pre-selected Style
Using IP Address: 136.226.3.9
Sent: 12/29/2025 4:52:21 PM
Resent: 1/5/2026 2:26:34 PM
Resent: 1/5/2026 2:28:00 PM
Viewed: 1/6/2026 7:54:13 AM
Signed: 1/6/2026 7:54:55 AM
Electronic Record and Signature Disclosure:
Accepted: 1/6/2026 7:54:13 AM
ID: 0d9c34df-ad7a-438d-86a9-ea48df06923f
Signer Events Signature Timestamp
Megan Gilbreath
Megan.gilbreath@cityofdenton.com
HR Director
City of Denton - Human Resources
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.10
Sent: 1/6/2026 7:55:00 AM
Resent: 1/7/2026 1:22:36 PM
Viewed: 1/8/2026 11:33:49 AM
Signed: 1/8/2026 11:33:54 AM
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Christina Dormady
christina.dormady@cityofdenton.com
Buyer
City of Denton
Security Level: Email, Account Authentication
(None)
Signature Adoption: Pre-selected Style
Using IP Address: 198.49.140.104
Sent: 1/8/2026 11:34:00 AM
Viewed: 1/8/2026 11:38:33 AM
Signed: 1/8/2026 11:38:44 AM
Electronic Record and Signature Disclosure:
Not Offered via Docusign
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Cheyenne Defee
cheyenne.defee@cityofdenton.com
Procurement Administration Supervisor
City of Denton
Security Level: Email, Account Authentication
(None)
Sent: 1/8/2026 11:38:49 AM
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Sara Kjos
Sara.kjos@cityofdenton.com
Assistant Director of Human Resources
Security Level: Email, Account Authentication
(None)
Sent: 1/8/2026 11:38:50 AM
Electronic Record and Signature Disclosure:
Not Offered via Docusign
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 12/29/2025 10:56:32 AM
Envelope Updated Security Checked 12/29/2025 2:40:23 PM
Envelope Updated Security Checked 12/29/2025 2:40:23 PM
Envelope Updated Security Checked 12/29/2025 2:40:23 PM
Envelope Updated Security Checked 12/29/2025 2:40:23 PM
Envelope Summary Events Status Timestamps
Envelope Updated Security Checked 12/29/2025 2:40:23 PM
Envelope Updated Security Checked 12/29/2025 2:40:23 PM
Envelope Updated Security Checked 12/29/2025 2:40:23 PM
Certified Delivered Security Checked 1/8/2026 11:38:33 AM
Signing Complete Security Checked 1/8/2026 11:38:44 AM
Completed Security Checked 1/8/2026 11:38:50 AM
Payment Events Status Timestamps
Electronic Record and Signature Disclosure
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, City of Denton (we, us or Company) may be required by law to provide to
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Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through your DocuSign user account all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or
made available to you during the course of our relationship with you. To reduce the chance of
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Electronic Record and Signature Disclosure created on: 7/21/2017 3:59:03 PM
Parties agreed to: Jennifer Dumas
How to contact City of Denton:
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