CSP901321_DMH007_REV_Contract.pdf

Index No.: DMH007

Eff. Date: 09/01/24

STATE OF OHIO

DEPARTMENT OF ADMINISTRATIVE SERVICES

GENERAL SERVICES DIVISION

OFFICE OF PROCUREMENT SERVICES

4200 SURFACE ROAD, COLUMBUS, OH 43228-1395

MANDATORY USE CONTRACT FOR: PRESCRIPTION ADJUDICATION SERVICES

CONTRACT NUMBER: CSP901321 EFFECTIVE DATES: 11/01/20 TO 08/31/23

* Renewal through 08/31/26

The Department of Administrative Services has accepted Proposals submitted in response to Request for Proposal (RFP) No.

CSP901321 that opened on 06/22/20. The evaluation of the Proposal responses has been completed. The Offeror listed herein has been determined to be the highest-ranking Offeror and has been awarded a Contract for the services listed. The respective Proposal response including, Contract Terms & Conditions, any Proposal amendment, special Contract Terms & Conditions, specifications, pricing schedules and any attachments incorporated by reference and accepted by DAS become a part of this Services Contract.

This Requirements Contract is effective beginning and ending on the dates noted above unless, prior to the expiration date, the Contract is renewed, terminated, or cancelled in accordance with the Contract Terms and Conditions.

This Requirements Contract is available to the Ohio Department of Mental Health and Addiction Services as applicable.

The agency is eligible to make purchases of the contracted services in any amount and at any time as determined by the agency. The State makes no representation or guarantee that department will purchase the volume of services as advertised in the Request for Proposal.

This Requirements Contract and any Amendments thereto are available from the DAS Web site at the following address:

www.ohio.gov/procure

*Renewal Contract for 24 months per Amendment 2.

Eff. Date: 09/01/23

MUTUALLY AGREED UPON CHANGES

1. MAC List may be adjusted no more than quarterly.

2. Level of Effort (LOE) Fees are paid to the compound pharmacy dispensing the medication.

a. Compound LOE greater than 11 requires DMH authorization

b. DMH may also provide the approved authorizations in advance via spreadsheet to Medcall

3. PROHIBITION OF THE EXPENDITURE OF PUBLIC FUND FOR OFFSHORE SERVICES

* No State Cabinet Agency, Board or Commission will enter into any contract to purchase services provided outside of the United States or that allows State data to be sent, taken, accessed, tested, maintained, backed-up, stored, or made available remotely outside (located) of the United States, unless a duly signed waiver from the State has been attained. Notwithstanding any other terms of this Contract, the State reserves the right to recover any funds paid for services the Contractor performs outside of the United States for which it did not receive a waiver. The State does not waive any other rights and remedies provided to the State in the Contract.

Further, no State agency, board, commission, State educational institution, or pension fund will make any purchase from or investment in any Russian institution or company. Notwithstanding any other terms of this Contract, the State reserves the right to recover any funds paid to Contractor for purchases or investments in a Russian institution or company in violation of this paragraph. The provisions of this paragraph will expire when the applicable Executive Order is no longer effective.

The Contractor must complete the Contractor/Subcontractor Affirmation and Disclosure Form affirming the Contractor understands and will meet the requirements of the above prohibition. During the performance of this Contract, if the Contractor changes the location(s) disclosed on the Affirmation and Disclosure Form, Contractor must complete and submit a revised Affirmation and Disclosure Form reflecting such changes.

* Add the Mutually Agreed Upon Changes, for the Prohibition of the Expenditure of Public Funds for Offshore Services to the contract.

https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fprocure.ohio.gov%2Fpdf%2FEO2022-02D%2F04-Affirmation%2520and%2520Disclosure%2520Form_3-4-22.pdf&data=04%7C01%7Ckristen.howard%40das.ohio.gov%7C67b3dec0fbd34bb061bc08da167d0103%7C50f8fcc494d84f0784eb36ed57c7c8a2%7C0%7C0%7C637847023397759707%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000&sdata=xn01IrXdSqhxp4NGrdEXVYP%2FP1lKHOF0ZD9awFkpBhY%3D&reserved=0

Eff. Date: 11/01/20

COST SUMMARY FORM

Prescription Adjudication Services

CSP901321

UNSPSC CATEGORY CODE: 80101500

Item No.

Description

Cost 38642 Administrative Fee Per Prescription $ 6.00 / AMT 38643 Brand Drugs AWP – 15% 38644 Generic Drugs MAC 38645 Pharmacy Dispensing Fee Per Prescription $ 3.35 / AMT

N/A Pharmacy Level of Effort (LOE) for Compounding per Compound (Paid to Pharmacy)

38646 Compound LOE 11 Per Prescription $15.00 / AMT 38647 Compound LOE 12 Per Prescription $20.00 / AMT 38648 Compound LOE 13 Per Prescription $30.00 / AMT 38649 Compound LOE 14 Per Prescription $45.00 / AMT 38650 Compound LOE 15 Per Prescription $60.00 / AMT N/A Specialty Drugs

38651 Axitinib Tab 5 MG (Brand - NDC 00069015111) AWP – 15% 38652 Cabozantinib S-Malate Tab 60 MG (Base Equivalent) (Brand – 42388002326) AWP – 15% 38653 Dimethyl Fumarate Capsule Delayed Release 120 MG (Brand – NDC 64406000501) AWP – 14% 38654 Dimethyl Fumarate Capsule Delayed Release 240 MG ( Brand – NDC 64406000602) AWP – 16% 38655 Fedratinib HCl Cap 100 MG (Brand – NDC 59572072012) AWP – 17% 38656 Gilteritinib Fumarate Tablet 40 MG (Base Equivalent) (Brand – NDC 00469142590) AWP – 22%

38657 Immune Globulin (Human) IV or Subcutaneous Soln 10 GM/100ML (Brand – NDC

13533080071) AWP – 13%

38658 Immune Globulin (Human) IV or Subcutaneous Soln 20 GM/200ML (Brand – NDC

13533080024) AWP – 13%

38659 Immune Globulin (Human) IV or Subcutaneous Soln 40 GM/400ML (Brand – NDC

13533080040) AWP – 13%

38660 Lenalidomide Cap 10 MG (Brand – NDC 59572041028) AWP – 12% 38661 Lenalidomide Cap 15 MG (Brand – NDC 59572041521) AWP - 14%

38662 Lenvatinib Cap Ther Pack 10 MG & 2 x 4 MG (18 MG Daily Dose) (Brand – NDC

62856071830) AWP – 16%

38663 Lenvatinib Cap Therapy Pack 10 (2) & 4 MG (24 MG Daily Dose) (Brand – NDC

62856072430) AWP – 20%

38664 Lenvatinib Cap Therapy Pack 2 x 4 MG (8 MG Daily Dose) (Brand – NDC 62856070805) AWP – 16% 38665 Lenvatinib Cap Therapy Pack 4 MG (4 MG Daily Dose) (Brand – NDC 6286070405) AWP – 16% 38666 Nintedanib Esylate Cap 150 MG (Base Equivalent) (Brand – NDC 00597014560) AWP – 19% 38667 Palbociclib Cap 100 MG (Brand – NDC 00069018821) AWP - 12% 38668 Pomalidomide Cap 2 MG (Brand – NDC 59572050200) AWP – 15% 38669 Pomalidomide Cap 2 MG (Brand – NDC 59572050221) AWP – 12% 38670 Ponatinib HCl Tab 15 MG (Base Equiv) (Brand – NDC 63020053530) AWP – 18% 38671 Ruxolitinib Phosphate Tab 5 MG (Base Equivalent) (Brand – NDC 50881000560) AWP – 10% 38672 Sorafenib Tosylate Tab 200 MG (Base Equivalent) (Brand – NDC 50419048858) AWP – 13% 38673 Teriflunomide Tab 14 MG (Brand – NDC 58468021002) AWP – 15% 38674 Teriflunomide Tab 14 MG (Brand – NDC 58468021004) AWP – 14% 38675 Teriflunomide Tab 7 MG (Brand – NDC 58468021101) AWP – 15% 38676 Teriflunomide Tab 7 MG (Brand – NDC 58468021104) AWP – 14% 38677 Treprostinil Inj Soln 50 MG/20ML (2.5 MG/ML) (Brand – NDC 66302010201 ) AWP – 13%

All costs must be in U.S. Dollars.

The State will not be responsible for any costs not identified.

There will be no additional reimbursement for travel or other related expenses.

Eff. Date: 09/01/23

CONTRACTOR INDEX

CONTRACTOR AND TERMS: CONTRACT NO.: CSP901321

0000224167 Medcall, LLC DELIVERY: As Specified 4505 Falls of Neuse Rd., STE 550 Raleigh, NC 27609 TERMS: Net 30

* CONTRACTOR'S CONTACT: Greg Hansen Telephone: 919-746-8350

FAX: 866-865-7590

E-Mail: ghansen@careservicesllc.com

*Update the Contractor Contact Information mailto:ghansen@careservicesllc.com

Eff. Date: 09/01/24

SUMMARY OF AMENDMENTS

Amendment

Number Effective

Date Description

2 09/01/24

This amendment is issued to notify that as a result of mutual agreement between the State of Ohio and the Contractor, this contract is renewed for an additional 24 months, effective 09/01/24 through 08/31/26.

All other prices, terms and conditions remain unchanged.

1 09/01/23

This amendment is issued to notify that as a result of mutual agreement between the State of Ohio and the Contractor, this contract is renewed for an additional twelve (12) months, effective 09/01/23 through 08/31/24.

This amendment is also issued to include updated language regarding the Prohibition of the Expenditure of Public Funds for Offshore Services, Summary of Amendments, and the Contractor Contact Information.

All other prices, terms and conditions remain unchanged.