7212 Contract Vivitrol.DOC.Aurora.pdf

C O N T R A C T

Services: DOC Opioid Addiction Treatment Program Services, (Service), provided for the Department of Corrections, Division of Community Corrections.

Contract Period: The Contract shall commence and be effective as of the date when all parties hereto have affixed their respective signatures below and shall continue in effect to June 30, 2020 from that date three possible 1-year renewal options by mutual agreement between the Provider and the Department of Corrections may occur.

Provider: Aurora Medical Center of Oshkosh, Inc.

Reference Number: ELB-7212

Contract Number: 410036-W20-ELB7212-GEN-05

I. DEFINITIONS:

Agency: Office, department or agency or other body in state government created by the constitution or any law, including the legislature and the courts but not including an authority.

Clean Claim: A claim which has no defect, impropriety or special circumstances including incomplete documentation that delays processing.

Provider: Successful vendor or provider awarded the Contract.

County: A region created by territorial division for the purpose of local government.

DAI: Division of Adult Institutions administers all adult state correctional incarceration facilities with administrative offices at DOC Central Offices, 3099 E Washington Ave., Madison, WI 53704.

DCC: Division of Community Corrections supervises adult offenders outside secure facilities.

DJC: Division of Juvenile Corrections operates one juvenile correctional institution and supervises some delinquent youth in the community with administrative offices at DOC Central Offices, 3099 E Washington Ave., Madison, WI 53704.

DOA: Department of Administration has statutory authority [WI Stats. Chapter 16] to define, regulate and delegate all aspects of procurement of services and commodities for state agencies.

DOC: Wisconsin Department of Corrections also referred to as the department or the DOC headquartered at DOC Central Offices, 3099 E Washington Ave., Madison, WI 53704.

Offender: Person under the custody or supervision of the Wisconsin Department of Correction.

Prison: A correctional institution where persons are confined after being convicted of a crime.

State: State of Wisconsin.

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SubProvider: SubProvider is a person who is awarded a portion of an existing Contract by a principal or general Provider.

Third Party: Refers to a person or entity who is not a party to this Contract.

Vendor: An awarded bidder which supplies a service or commodity to the Department of Corrections.

II. RELATIONSHIP BETWEEN PARTIES

A. This Contractual agreement (“Contract”) is entered into for the period from the final signature date through June 30, 2020 with three options to extend one additional year each by and between the State of Wisconsin Department of Corrections, whose principal business address is 3099 East Washington Ave., P.O. Box 7925, Madison, WI 53707-7925, (the “DOC”), and Aurora Medical Center of Oshkosh, Inc., a Wisconsin nonstock corporation (the “Provider”). The DOC acknowledges that Aurora is not a federal Provider and will not become a federal Provider by entering into this Agreement.

B. The DOC employee responsible for administration of this Contract will be Michael F Meulemans, Program and Policy Analyst (“Contract Administrator”) whose principal business address is Division of Community Corrections 1251 Jacobsen Rd., Suite B Neenah, WI 54956. In the event that the Contract Administrator is unable to administer this agreement, DOC will contact Provider and designate a new Contract Administrator.

III. CONTRACT AUTHORITY

This Contract is entered under the authority of Wis. Stats.16.75 and Wis. Adm. Code Chapter Adm 10.

IV. STATEMENT OF DELIVERABLES

A. The Provider will deliver Service at its location located at 414 Bowen Street, Oshkosh, Wisconsin or such other sites as agreed upon by the parties.

B. This Contract detail for providing Service hereunder is specified in Attachment 1 which is attached hereto and incorporated herein by reference.

V. CONTRACT DOCUMENTS

DOA-3681 (“Supplemental Standard Terms and Conditions for Procurement of Services”) is incorporated into this Contract by reference. To the extent that any term or condition set forth in either Form DOA-3681 differs or conflicts with this Contract, the term, condition, or Contract provision determined by the DOC to be the more favorable to the DOC in any given situation shall govern and control.

Notwithstanding any other provision of this Contract, DOC waives the provisions of Section 3.2 of Form DOA-3681 to the extent that it would interfere with Provider’s rendering of medical care to any person.

VI. CONTRACT REVISIONS / ADDENDUMS

Any subsequent addendum to this Contract must be in writing and signed by the parties.

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VII. GENERAL SERVICE PROVISIONS

A. The Provider must complete or currently have on file a facility self-survey and a program and policy self-evaluation to address compliance with the Americans with Disability Act. (Public Law 101- 336, July 26, 1990, 104 Stat. 327 and Title 42, U.S.C.A., ss. 12101 to 12213). During the course of the Contract, the Provider must take action to comply with the facility, program and employment provisions of the Americans with Disability Act. Applicants may obtain information on the Americans with Disability Act by contacting the Director, Office of Diversity and Employee Services, Wisconsin Department of Corrections, 3099 E. Washington Ave., P.O. Box 7925, Madison, Wisconsin 53707-7925.

B. Provider may not subcontract, refer to outside/community resources, or assign any part or obligations of this Contract without providing notice to the DOC. Provider is responsible for having subcontracts in place to provide the service to the subcontracted agencies under this Contract.

Provider retains responsibility for fulfillment of all terms and conditions of this Contract when it enters into sub Contractual agreements. In some circumstances, Provider may have a provider who is employed by another Aurora entity or one of Aurora’s primary physicians may be unavailable, and Provider would contract with someone to provide services on their behalf under this Contract, in those circumstances, DOC hereby approves of Provider rendering services through non-employed individuals who are under contract with Provider and are performing services on behalf of Provider . In that case, Provider still retains responsibility for fulfillment of all terms and conditions of this Contract

C. This Contract and the performance of the parties' obligations hereunder will be governed by and construed and enforced in accordance with the laws of the State of Wisconsin, other than any conflict-of-laws provisions thereof that would otherwise require the application of the law of any other jurisdiction. Provider consents to personal jurisdiction in the State of Wisconsin. The venue for any action hereunder shall be in Dane County, Wisconsin.

D. No waiver by either party of any default hereunder shall be deemed as a waiver of any prior or subsequent default of the same or other provisions of this Contract.

E. If any provision hereof is held invalid or unenforceable by a court of competent jurisdiction, such invalidity shall not affect the validity or operation of any other provision and said provision shall continue to apply to the extent allowed by said court or, if not so allowed, be deemed severed from this Contract entirely.

F. [Intentionally Omitted]

G. To the extent permitted by applicable law and with the exception of medical records, DOC will own all right, title, and interest in all data, documentation, programs, information systems, innovations, and all other original works of authorship developed under or associated with this Contract. All such materials shall be deemed works made for hire, subject to a non-exclusive perpetual license, with the right to sublicense reserved by Provider, of DOC for all purposes of copyright law, and any copyright shall belong solely to DOC. In the event that any such work is adjudged not to be a work made for hire, Provider agrees to assign, and hereby assigns, all copyright in such work to DOC. Title to such materials will pass to DOC at the time of acceptance of the deliverable into which the materials and/or Services are incorporated, subject to payment in full for the deliverable and/or Service by DOC. Provider shall, at the expense of DOC, assist DOC or its nominees to obtain copyrights or trademarks for all such works in the United States or other countries. Provider agrees to execute all papers and to give all facts known to it necessary to secure United States or foreign country copyrights and trademarks, and to transfer or cause to transfer to DOC all the right, title and interest in and to such works. DOC reserves a royalty-free, DocuSign Envelope ID: DE635943-EE7C-42F8-8240-FB2FF46E896BDocuSign Envelope ID: D8876EBC-D346-41C1-A0F0-A20D4DF3D438 nonexclusive, and irrevocable license to reproduce, publish, or otherwise use, and to authorize others to use, all aforementioned materials specially developed under this Contract. Any discovery or invention arising out of, or developed in the course of work or Services aided by this Contract, shall be promptly and fully reported to the DOC.

H. Providers are prohibited from responding to legal or legislative matters as a representative of DOC.

All legal or legislative inquires requiring a response by DOC are to be referred to DOC Secretary’s Office in a timely manner for an appropriate response.

I. The parties hereto agree that Provider, its officers, agents, and employees, in the performance of this Contract shall act in the capacity of an independent Provider and not as an officer, employee, or agent of DOC. Provider agrees to take such steps as may be necessary to ensure that each of its subProviders will be deemed to be an independent Provider and will not be considered or permitted to be an agent, servant, joint venturer, or partner of DOC. Furthermore, neither DOC nor Provider will represent itself as the agent or legal representative of the other or as partner or joint venturers for any purpose whatsoever, and neither shall have any right to create or assume any obligations of any kind, express or implied, for or on behalf of the other in any way whatsoever.

J. Any and all notices or other communications necessary or desirable to be given hereunder will be deemed given and received when personally delivered or sent by facsimile, delivered prepaid same-day or overnight delivery service, proof of delivery requested, or deposited in U.S. certified or registered mail, postage prepaid, return receipt requested, addressed as follows:

(i) If to DOC:

Department of Corrections, DOC Contract Administrator: Michael F. Meulemans Facsimile number: 920-751-4601

Email: Michael.meulemans@wisconsin.gov

(ii) If to Provider:

Aurora Medical Center of Oshkosh, Inc.

855 N. Westhaven Drive Oshkosh, WI 54904 Attn: President

With a copy to:

Advocate Aurora Health, Inc.

750 W. Virginia Street Milwaukee, WI 53204 Attn: Chief Legal Officer

VIII. PAYMENT TERMS AND INVOICING

A. Provider will bill any insurances that the patient may be eligible for, be that Medicare, Medicaid, or private health insurance. Provider will bill DOC, only if other insurances deny the claim or if the patient doesn’t have insurance, as the payer of last resort. DOC will not be responsible for any unpaid patient balances. Fee schedule is in Attachment 1.

B. DOC shall initiate payment to Provider upon receipt of a clean claim. The Provider shall submit to DOC only claims that DOC would be responsible for. At a minimum the claim will show the

DocuSign Envelope ID: DE635943-EE7C-42F8-8240-FB2FF46E896BDocuSign Envelope ID: D8876EBC-D346-41C1-A0F0-A20D4DF3D438 description of Service, contracted unit of measure, contract price and purchase order to the designated site. The claim shall be submitted within 60 days of the last day of the month during which Service was provided or the claim was denied by Medicare, Medicaid, or an insurance policy.

C. If for any reason the DOC is dissatisfied with the quality of the Service the DOC may, at DOC’s sole discretion, provide written notice to the Provider of the deficiency. If the Provider fails to correct the deficiency by the identified date, the DOC may, at DOC’s sole discretion, terminate this Contract. Nothing set forth herein shall prevent or prohibit the DOC from availing itself of other legal or equitable remedies.

D. REPORTING AND AUDITING

a. Provider shall comply with the reporting and auditing requirements of DOC including, without limitation, the requirement that Provider retain all documents applicable to the Contract for a period of not less than three (3) years after the final Contract payment is made and, as permitted by applicable law, allowing DOC to inspect information to ensure the Services are provided consistent with this Agreement. Any required reports shall be forwarded to the Contract Administrator according to the schedule of DOC, see Attachment 2 If Provider does not submit the reports as required, and DOC may cease all payments for Services to Provider under this Contract.

b. DOC may require, at its discretion that Provider provide an audit covering all DOC funds paid pursuant to the Contract. In the event that Provider fails to comply with a DOC audit request including all follow-up requests for information pertaining to said audit, DOC reserves the right to conduct an independent audit and DOC’s costs for completing the same will be charged back to Provider. Provider agrees to retain and make available to DOC all program and fiscal records until the audit and, if necessary, subsequent audit resolution processes have been completed.

c. No Service is to be provided until an official State of Wisconsin Purchase Order is issued by DOC to Provider. When there is more than one State fiscal year (July 1 through June

30) or a portion of a fiscal year in the Contract period, a separate purchase order will be issued for each fiscal year in accordance with Department policy on the issuance of purchase orders. The fiscal years or portions thereof which apply to this Contract are:

FY2020.

d. To the extent permitted by applicable law, Provider agrees to inform DOC within three (3) working days of any inquiry from outside entities regarding a participant, former participant or the program provided under this Contract. This includes requests for information from the media, legislature, local officials, neighbors and participant's family members. Nothing in this Contract prohibits the Provider from freely communicating with any entity regarding the program or participants to the extent allowed by confidentiality requirements.

e. Program evaluation is intended to document program implementation, as well as return useful information to program sites for the purpose of program improvement. The Provider agrees to collaborate and participate in program evaluation activities set by the DOC.

IX. RECORDS

A. Provider shall maintain such records as are required by State and Federal law and shall comply with all applicable confidentiality laws and requirements pertaining to said records and the information contained therein.

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B. Provider will allow inspection of records and programs, insofar as is permitted by State and Federal law, by representatives of DOC and its authorized agents, and Federal agencies, in order to confirm Provider's compliance with the specifications of this Contract.

C. Provider agrees to retain and make available to DOC all program and fiscal records until the audit and subsequent audit resolution processes have been completed.

D. To ensure confidentiality of records and safeguard access to these records, Provider must maintain sufficient confidentiality and security protections consistent with applicable legal requirements.

E. Provider agrees to have a written policy on confidential destruction of case records.

X. INSURANCE RESPONSIBILITY

A. Provider shall:

Throughout the term of this contract and any renewal periods, the Provider shall maintain insurance in the types and with the limits outlined below. Policies must be issued with a 30-day cancellation notice, by an insurance company licensed to do business in the State of Wisconsin and has at a minimum AM Best Company rating of A-, or better, by the State of Wisconsin Office of the Commissioner of Insurance Bureau of Financial Examination. The Provider shall provide a Certificate of Insurance to the Contract Manager, prior to the contract start date or the commencement of services.

Worker’s Compensation Statutory Requirements $100,000 each accident $500,000 disease-policy liability limit $100,000 disease-policy liability limit for each employee

Commercial General $1,000,000 each occurrence of bodily injury and property damage

Liability $1,000,000 general aggregate, including product liability and completed operations

Automobile Liability $1,000,000 per occurrence combined single limit for liability and (covering all owned, property damage non-owned and hired vehicles)

Professional liability $2,000,000 each incident (malpractice)

The certificate shall name the “State of Wisconsin, its officers, employees and agents” as an additional insured under the commercial general, automobile and professional liability policies.

The certificate holder: Wisconsin Dept. of Corrections

3099 E. Washington Ave.

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Madison, WI 53704

Prior to the expiration date of each policy, the Provider will provide a renewal certificate evidencing continued insurance coverage.

XI. EMPLOYMENT OF CURRENT OFFENDERS AND EMPLOYMENT AND RETENTION

OF INDIVIDUALS ARRESTED, CHARGED OR CONVICTED OF CRIMINAL

OFFENSES.

A. No individual performing Services under this Agreement may be an individual who is on probation, parole, extended supervision, lifetime supervision or an inmate who is supervised by Intensive Sanctions for any position where the primary duties and responsibilities involve the supervision or treatment of inmates, probationers or parolees or involve access to offenders' records or funds.

B. Provider will ensure that its hiring practices are consistent with the Wisconsin Caregiver Background Check and Wisconsin Fair Employment laws and will implement the following provisions consistent with those policies and laws to ensure that:

a. Job applicants or current employees who will be providing Services under this Agreement shall be dealt with as follows:

(i) For a job applicant who has a pending criminal charge: Where the circumstances of said criminal charge substantially relate to the circumstances of a particular job or licensed activity, the applicant will not be hired for that job;

(ii) For a current employee who has a pending criminal charge: Where the circumstances of said criminal charge substantially relate to the circumstances of a particular job or licensed activity, the employee will not be continued in that particular job;

(iii) For a job applicant who is convicted of a criminal charge: Where the circumstances of said criminal charge substantially relate to the circumstances of a particular job or licensed activity, the applicant will not be hired for that job; and

(iv) For a current employee who is convicted of a criminal offense: Where the circumstances of said conviction of a criminal or other offense that substantially relates to the circumstances of the current job or licensed activity, the employee will not be retained in that particular job; and

(v) For a job applicant who is required to use an Ignition Interlock Device (IID):

Where the circumstances of said court ordered requirement substantially relate to the circumstances of a particular job or licensed activity, the applicant will not be hired for that job; and

(vi) For a current employee who is required to use an Ignition Interlock Device (IID):

Where the circumstances of said court ordered requirement substantially relate to the circumstances of a particular job or licensed activity, the employee will not be retained in that particular job.

b. Nothing in this Contract prohibits the Provider from reassigning or suspending the employee or, in the case of a conviction, terminating the employee.

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C. In hiring and retention decisions, Provider may consider records of pending criminal charges and convictions when it can be demonstrated that the circumstances of the offense substantially relate to the circumstances of the job or licensed activity. When determining whether the circumstances of a pending charge or conviction are substantially job related, Provider should take into consideration elements related to the position, the offense, and the individual.

D. To make determinations on substantial relationships to the circumstances of the job, Provider must have consistent practices on how the applicant for employment and the employee will be reviewed consistent with applicable laws. To guide the development of the policy, the Provider may obtain a copy of Chapter 301, attachment A of the Department of Corrections Supervisor's Manual from the Contract Administrator.

XII. FRATERNIZATION

The Provider agrees to have a written employee notice on fraternization which includes the following:

E. Prohibiting certain relationships and conduct between Provider's employees, adult and juvenile offenders, and their relatives. This must also be substantially equivalent to DOC's policy as expressed in Executive Directive 16, August 2004 -Revised January 2019. A copy of Executive Directive 16 may be obtained from the DOC Contract Administrator.

F. The employee notice shall provide for the following definitions

a. Employee- definition must be consistent with DOC’s definition of employee

b. Relationship

c. Offender

d. Social Media

e. Sexual Contact

f. Sexual Intercourse

g. Sexual Misconduct.

G. A statement detailing prohibited relationships.

H. A statement detailing prohibited sexual conduct.

I. The duty of an employee to inform Provider of unplanned contacts with offenders.

J. A statement that Provider-directed contacts or those which are part of the employee's job requirements are exempt from the employee notice.

XIII. FAITH-BASED ORGANIZATIONS

A. A faith-based organization is eligible to be a Provider on the same basis as any other private organization. If Provider is a faith-based organization it shall retain its independence from the State of Wisconsin, including without limitation Provider’s control over the definition, development, practice, and expression of its religious beliefs. Except as otherwise provided by state or federal law, DOC shall not interpret this Contract to require a faith-based organization to alter its form of internal governance or remove religious art, icons, scriptures, or other symbols.

B. A religious organization does not, by Contracting with the State of Wisconsin, lose the exemption provided under Section 702 of the Civil Rights Act (42 U.S.C. 2000e-1(a)) regarding its employment practices. Furthermore, if a faith-based organization segregates the government funds

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C. Neither DOC’s selection of a faith-based Provider to provide the Services described herein nor the expenditure of funds under this Contract is an endorsement of the Provider’s religious character, practices, or expression. The purpose of this Contract is the provision of Services; none of DOC’s expenditures have as their objective the funding of sectarian worship, instruction, or proselytization. As such, a faith-based Provider of Non-secular Services under this Contract shall post at its place(s) of business the following written notice and personally apprise all assisted offenders of the same unless its programming is exclusively secular and it does not display conspicuous symbols of its religious character, practices, or expression:

Neither the State of Wisconsin’s selection of a faith-based Provider of services or the expenditure of funds under any Contract with said Provider is an endorsement of that Provider’s religious character, practices, or expression. No Provider of services may discriminate against you on the basis of religion, a religious belief, or your refusal to actively participate in a religious practice. If you object to a particular Provider because of its religious character, you may request assignment to a different non-sectarian Provider by contacting your Agent.

XIV. TERMINATION / CANCELLATION:

In addition to grounds for termination set forth elsewhere in the Contract, this Contract may be terminated under any of the following conditions:

A. DOC may terminate the Contract at any time, with or without cause and without penalty by delivering thirty (30) days written notice to the Provider.

B. Provider may terminate the Contract at any time, with or without cause and without penalty by delivering thirty (30) days written notice to the DOC.

C. DOC has a Vendor Performance Evaluation process for soliciting feedback from Contract users about vendor performance and compliance with Contract specifications. Vendor noncompliance with the terms, conditions or specifications that is persistent and/or significantly impacts the quality and performance provided pursuant to the Contract may be considered in breach of Contract.

Negative Vendor Performance Evaluation Surveys may result in non-renewal or termination of Contract.

D. The State of Wisconsin reserves the right to cancel this Contract if the Provider fails to follow the requirements of statutes regarding registration and certification for collection of sales and use tax including Wis. Stats. 77.66.

E. If at any time the Provider performance threatens the health and/or safety of DOC employees, offenders or the public, DOC has the right to cancel and terminate the Contract without notice.

F. Failure to maintain the required Certificates of Insurance, Permits and Licenses shall be cause for Contract termination. If the Provider fails to maintain and keep in force insurance, DOC has the right to cancel and terminate the Contract without notice.

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G. If at any time a petition in bankruptcy shall be filed against the Provider and such petition is not dismissed within 90 calendar days, or if a receiver or trustee of Provider's property is appointed and such appointment is not vacated within 90 calendar days, DOC has the right, in addition to any other rights of whatsoever nature that it may have at law or inequity, to terminate the Contract by giving 10 calendar days’ notice in writing of such termination.

H. Failure of DOC to comply with Contract terms, conditions or specifications shall provide the sole cause for which the Provider is entitled to terminate the Contract. The Provider shall notify the Department in writing within thirty (30) days after the Provider becomes aware of the alleged noncompliance with a complete description of the same. If the DOC does not, within forty-five

(45) days after its receipt of the Provider’s notice, either (1) effect a cure or (2) if the noncompliance is not one that can reasonably be cured within forty-five (45) days, develop a plan to cure the noncompliance and diligently proceed according to that plan unto a cure is affected, then the Provider may terminate the Contract for cause by written notice to DOC.

XV. EXECUTED CONTRACT TO CONSTITUTE ENTIRE AGREEMENT

A. The contents of this Contract (including all attachments) and the bid of the successful bidder, and additional terms agreed to, in writing, by DOC and the Provider shall become part of the Contract.

The following priority for Contract documents will be used if there are conflicts or disputes:

State of Wisconsin supplemental standard terms and conditions Final Signed Contract including amendments Official State of Wisconsin Purchase Order Statement of Deliverables Other exhibits/attachments

XVI. CONFIDENTIALITY

A. All confidential health, mental health, drug and alcohol information or educational information reviewed and collected in connection with this Contract shall be handled by the Provider in a manner consistent with the applicable state and federal confidentiality laws.

B. Provider acknowledges that some of the data and documentation it may become privy to in the performance of this Contract is of a confidential nature. Provider shall make all reasonable efforts to ensure that it or its employees and subProviders do not disseminate such confidential information without the Purchaser’s prior permission and in a manner that complies with all applicable confidentiality laws and requirements.

C. Provider or its employees may have direct or indirect contact with offenders, staff, or other parties.

All services provided to offenders are confidential in nature. Provider shall make all reasonable efforts to ensure that it or its employees and subProviders do not disseminate such confidential information, including but not limited to identity of offenders or services being received. Provider must have a policy regarding ethics and confidentiality for their staff to follow consistent with applicable laws and regulations.

D. Provider or its employees and subProviders will not reuse, sell, or make use in any format the data researched or compiled for this Contract for any venture, profitable or not, outside this Contract.

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E. Provider agrees to observe complete confidentially with respect to all aspects of any confidential information, proprietary data and/or trade secrets and any parts thereof, whether such contents are the State's or the manufacturer's, proposer's, or distributor's whereby Provider or any Provider's personnel may gain access while engaged by the State or while on State premises.

F. The restrictions herein shall survive the termination of this Contract for any reason and shall continue in full force and effect and shall be binding upon the Provider or its agents, employees, successors, assigns, subProviders, or any party claiming an interest in this Contract on behalf of or under the rights of Provider following any termination. Provider shall advise all Providers’ agents, employees, successors, assigns and subProviders which are engaged by the State of the restrictions, present and continuing, set forth herein. Provider shall defend and incur all costs, if any, for actions that arise as a result of noncompliance by Provider, its agents, employees, successors, assigns and subProviders regarding the confidentiality restrictions herein.

XVII. CONCEALED CARRY

Provider is prohibited under Executive Directive 80, signed October 31, 2011 from possession of any weapon by Provider's employees while providing services to DOC offenders.

Provider will prohibit firearms/weapons in any owned, leased/rented, or available location in which program services are provided for DOC. Signs shall be posted at every public entrance. Each sign must be at least five inches by seven inches state the restriction on carrying a firearm, and inform people that weapons or firearms are prohibited. Sample signage will be available through the Contract Administration

XVIII. DEBARMENT

Federal Executive Order 12549, titled “Debarment”, requires that all Providers receiving individual awards, using federal funds, and all sub recipients certify that the organization and its principals are not debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency from doing business with the Federal Government. Information on debarment is available at the following websites: www.epls.gov and www.arnet.gov/far/. In the event the Provider is debarred, the DOC reserves the right to cancel the Contract upon notice.

[Signatures appear on next page]

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In WITNESS THEREOF, the undersigned authorized officers have subscribed their names on behalf of the parties to this Contract.

By: ____________________________________________ _________________________

Provider's Authorized Representative Date

Name: __________________________________________

Title: ___________________________________________

Kevin A. Carr, Secretary Date

WI Department of Corrections

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1/6/2020

1/10/2020

Jeff Bard

EVP North Wisconsin

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1/14/2020

ATTACHMENT 1

Deliverables and Rate Schedule 11/1/19-6/30/20

Contract: 410036-W20-ELB7212-GEN-05

Initial visit (quantity 1) Visit Charge 99203=$389.00 (new patient to system) or 99214=$393.00 (patient already established in system) Lab charges Creatinine, Serum = $38.00

AST= $35.00

ALT= $35.00

Bilirubin Total = $37.00 Urine Pregnancy (female only) = $52.00 Hep C Screening (only if liver enzymes elevated) = $132.00

Vivitrol charges Injection IM = $90.00 Vivitrol = $1360.00

Monthly Injections (nurse only) (8 visits) Injection IM = 90.00 Vivitrol = $1360.00 Urine Pregnancy (female only) = 52.00

Follow up with provider (3 visits) 99213=265.00 (no complications) or 99214=393.00 (while complications)

AST= 35.00

ALT= 35.00

Bilirubin Total = 37.00 Urine Pregnancy (female only) = 52.00 Injection IM = 90.00 Vivitrol = 1360.00

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ATTACHMENT 2

Reporting Requirements:

Utilization report listing patient, Services provided, cost of services, dates, HCFA1500 data points.

Reports on how many no show patient visits occurred per month.

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