Document:

Exhibit 10.3

    

     

    

    
      CONTRACT NUMBER: 2019-000052J

      AMENDMENT TO THE CONTRACT BETWEEN

      ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

      and

      TRIPLE-S SALUD, INC.

      to

      ADMINISTER THE PROVISION OF PHYSICAL AND BEHAVIORAL HEALTH SERVICES UNDER THE GOVERNMENT HEALTH PLAN

      

      

      THIS AMENDMENT TO THE CONTRACT BETWEEN ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES) AND TRIPLE-S SALUD, INC., FOR THE PROVISION OF PHYSICAL
        AND BEHAVIORAL HEALTH SERVICES UNDER THE GOVERNMENT HEALTH PLAN (the “Amendment”) is by and between Triple-S Salud, Inc. (“the Contractor”), a managed care
        organization duly organized and authorized to do business under the laws of the Commonwealth of Puerto Rico, with employer identification number 66-0555677 and represented by its President, Madeline Hernandez Urquiza, of legal age, single, resident
        of San Juan, Puerto Rico, and the Puerto Rico Health Insurance Administration (Administración de Seguros de Salud de Puerto Rico, hereinafter referred to as
        “ASES” or “the Administration”), a public corporation of the
        Commonwealth of Puerto Rico, with employer identification number 66-0500678, represented by its Executive Director, Jorge E. Galva Rodríguez, JD, MHA, of legal age, married and resident of Vega Alta, Puerto Rico.

      

      

      WHEREAS, the Contractor and ASES executed a Contract for the
        provision of Physical Health and Behavioral Health Services under the Government Health Plan for the Commonwealth of Puerto Rico, on September 21, 2018, (hereinafter referred to as the “Contract”);

      

      

      WHEREAS, the Contract provides, pursuant to Article 55, that
        the Parties may amend such Contract by mutual written consent;

      

      

      WHEREAS, all provisions of the Contract will remain in full
        force and effect as described therein, except as otherwise provided in this Amendment.

      

      

      NOW, THEREFORE, and in consideration of the mutual promises
        herein contained and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the Parties agree to clarify and/or amend the Contract as follows:

      

      

      	I.	
              AMENDMENTS

            

      

      

      	

            	1.	
              Section 21.4.1 shall be amended as follows:

            

      

      

      	

            	21.4.1	
              Notwithstanding anything to the contrary in this Contract, because the Parties have not completed the revision of the PMPM Payments by the expiration of the current
                rating period which ended on June 30, 2020 (the “Expired Rating Period”) such that the new rating period must commence without revised PMPM Payments, then the following shall occur:

            

       

      

      
        

        
          

        

      

      	

            	21.4.1.1	
              ASES shall continue to pay Contractors at the PMPM Payment rates that existed during the Expired Rating Period;

            

      

      

      	

            	21.4.1.2	
              As soon as practicable, but in no event more than sixty (60) days following the expiration of the Expired Rating Period, or sooner if the revised PMPM Payments
                (“Updated PMPM Payments”) become available, the Parties shall complete in good faith the review of the Updated PMPM Payments.

            

      

      

      	

            	21.4.1.3	
              Following agreement upon the Updated PMPM Payments, the Parties shall execute an amendment to Attachment 11 of the Contract setting forth the Updated PMPM Payments.
                Such amendment and the Updated PMPM Payments shall be effective as of July 1st, 2020 as if the Updated PMPM Payments had been agreed upon at the expiration of the Expired Rating Period, provided that,

            

      

      

      	

            	21.4.1.3.1	
              Notwithstanding the foregoing, because Updated PMPM Payments are subject to CMS and the Financial Oversight and Management Board (“FOMB”) approval, ASES will
                continue to pay Contractors at the PMPM Payment rates that existed during the Expired Rating Period until such time as CMS and the FOMB have approved the Updated PMPM Payments, and;

            

      

      

      	

            	21.4.1.3.2	
              Within thirty (30) calendar days following CMS’s and the FOMB’s approval of the Updated PMPM Payments, the Parties shall begin to reconcile any difference between
                (i) PMPM Payments that ASES made to Contractors after the Expired Rating Period and (ii) Updated PMPM Payments.

            

       

      

      	II.	
              RATIFICATION

            

      

      

      All other terms and provisions of the original Contract, as amended by Contracts Number 2019- 000052 A, B, C, D,
        E, F, G, H, and I and of any and all documents incorporated by reference therein, not specifically deleted or modified herein shall remain in full force and effect. The Parties hereby affirm their respective undertakings and representations as set
        forth therein, as of the date thereof. Capitalized terms used in this Amendment, if any, shall have the same meaning assigned to such terms in the Contract.

      

      

      	III.	
              EFFECT; CMS APPROVAL

            

      

      

      The Parties agree and acknowledge that this Amendment, including any attachments, is subject to approval by the
        United States Department of Health and Human Services Centers for Medicare and Medicaid Services (“CMS”) and the Financial Oversight and Management Board for
        Puerto Rico (“FOMB”), and that ASES shall submit this Amendment for CMS and FOMB approval.

       

      

      
        

        
          

        

      

      	IV.	
              AMENDMENT EFFECTIVE DATE

            

      

      

      Contingent upon approval of CMS, this Amendment shall become effective August 1, 2020 (the “Amendment Effective Date”) and remain in effect until August 30, 2020 or the date on
        which a new amendment setting forth the Updated PMPM Payments is executed, whichever is sooner.

      

      

      	V.	
              ENTIRE AGREEMENT

            

      

      

      This Amendment constitutes the entire understanding and agreement of the Parties with regards to the subject
        matter hereof, and the Parties by their execution and delivery of this Amendment to the Contract hereby ratify all of the terms and conditions of the Contract Number 2019-000052, including amendments A, B, C, D, E, F, G, H, I and this Amendment J.

      

      

      The Parties agree that ASES will be responsible for the submission and registration of this Amendment in the
        Office of the Comptroller General of the Commonwealth, as required under law and applicable regulations.

      

      

      ACKNOWLEDGED BY THE PARTIES by their duly authorized
        representatives on this 31st day of July 2020.

      

      

      ADMINISTRACIÓN DE SEGUROS DE SALUD DE PUERTO RICO (ASES)

      

      

      	
              _/s/ Jorge E. Galva Rodríguez

            	
              7/31/2020

            
	
              Name: Jorge E, Galva Rodríguez, JD, MHA

            	
              Date

            

      EIN: 66-05000678

      

      

      TRIPLE-S SALUD, INC.

      

      

      	
              /s/ Madeline Hernández Urquiza

            	
              7/31/2020

            
	
              Ms. Madeline Hernández Urquiza, President

            	
              Date

            

      
        EIN: 66-0555677

      

       

      

      Account No. 256-5325 to 5330Document

EXHIBIT 10a

Execution Version

AMENDMENT AND WAIVER
AMENDMENT AND WAIVER (this “Amendment and Waiver”), dated as of June 17, 2020, by and among BRISTOL-MYERS SQUIBB COMPANY, a Delaware corporation (the “Company”), the Lenders (as defined below) party hereto and the Administrative Agent (as defined below), which amends that certain FIVE YEAR COMPETITIVE ADVANCE AND REVOLVING CREDIT FACILITY AGREEMENT (as amended, supplemented or otherwise modified from time to time, the “Credit Agreement”) dated as of September 29, 2011, among the Company, the BORROWING SUBSIDIARIES (as defined in the Credit Agreement) from time to time party thereto, the lenders from time to time party thereto (the “Lenders”), certain Agents, JPMORGAN CHASE BANK, N.A., as Administrative Agent (in such capacity, “JPMCB”), and CITIBANK, N.A., as Administrative Agent (in such capacity, “CBNA”; JPMCB and CBNA are referred to herein individually as an “Administrative Agent” and collectively as the “Administrative Agents”) and as competitive advance facility agent.
W I T N E S S E T H:
WHEREAS, the Company has requested that the Lenders agree to waive and amend certain provisions of the Credit Agreement as set forth herein;
WHEREAS, ‎Section 8.7 of the Credit Agreement permits the Credit Agreement to be waived or amended from time to time by the Company and the Required Lenders; and
WHEREAS, the Company and the Required Lenders desire to waive and amend the Credit Agreement on the terms set forth herein;
NOW, THEREFORE, it is agreed: 
Section 1.Defined Terms.
Capitalized terms used but not defined herein shall have the meaning assigned to such terms in the Credit Agreement.
Section 2.Waiver and Amendment.
Notwithstanding anything to the contrary contained in Section 2.5(a) of the Credit Agreement, solely with respect to the anniversary of the Effective Date occurring on September 29, 2020, the Company may submit an Extension Letter on any date commencing on the Amendment and Waiver Effective Date through the date that is 80 days prior to the anniversary of the Effective Date occurring on September 29, 2021 requesting an extension of the Maturity Date to September 29, 2024.
Section 3.Amendment.
Effective as of the Amendment and Waiver Effective Date, the final sentence of Section 2.5(c) of the Credit Agreement is hereby amended and restated as follows: 

Notwithstanding the foregoing, no extension of the Maturity Date shall become effective unless, on the effective date of such extension the conditions set forth in paragraphs (a) and (b) of Section 4.2 shall be satisfied or waived (with all references in such paragraphs to a Borrowing being deemed to be references to the effective date of such extension) and CBNA shall have received a certificate to that effect dated the effective date of such extension and executed by a Financial Officer of the Company.

Section 4.Conditions to Effectiveness of Amendment and Waiver.
This Amendment and Waiver shall become effective on the date on which CBNA (or its counsel) shall have received from the Company and the Required Lenders either (a) a counterpart of this Amendment  and Waiver signed on behalf of such party or (b) written evidence satisfactory to CBNA (which may include email or facsimile of a signed signature page of this Amendment and Waiver) that such party has signed a counterpart of this Amendment and Waiver (such date, the “Amendment and Waiver Effective Date”).
CBNA shall notify the Company and the Lenders of the Amendment and Waiver Effective Date, and such notice shall be conclusive and binding absent manifest error.
Section 5.Effects on Loan Documents.
This Amendment and Waiver shall constitute a “Loan Document” for purposes of the Credit Agreement and the other Loan Documents. From and after the Amendment and Waiver Effective Date, all references to the Credit Agreement and each of the other Loan Documents shall be deemed to be references to the Credit Agreement as amended and waived by this Amendment and Waiver. Except as expressly amended or waived pursuant to the terms hereof, all of the representations, warranties, terms, covenants and conditions of the Loan Documents shall remain unamended and not waived and shall continue to be in full force and effect. The execution, delivery and effectiveness of this Amendment and Waiver shall not, except as expressly provided herein, operate as a waiver of any right, power or remedy of any Lender or the Administrative Agent under any of the Loan Documents.
Section 6.Miscellaneous.
(a)The Company represents and warrants to the Lenders and the Administrative Agents that (i) the representations and warranties set forth in ‎Article III of the Credit Agreement are true and correct in all material respects (provided that such representations and warranties qualified as to materiality shall be true and correct in all respects) on the date hereof, except to the extent such representations and warranties expressly relate to an earlier date, in which case such representations and warranties were true and correct in all material respects (provided that such representations and warranties qualified as to materiality shall be true and correct in all respects) as of such earlier date and (ii) no Default or Event of Default exists on the Amendment and Waiver Effective Date.
(b)This Amendment and Waiver may be executed in multiple counterparts, each of which shall constitute an original but all of which taken together shall constitute but one contract. 
2

A counterpart hereof, or signature page hereto, delivered to the Administrative Agent by facsimile or e-mail shall be effective as delivery of an original manually-signed counterpart.
(c)The provisions of Sections ‎8.5, ‎8.11, ‎8.13 and ‎8.14 of the Credit Agreement are incorporated herein by reference as if fully set forth herein, mutatis mutandis.
Section 7.Applicable Law.
THIS AMENDMENT AND WAIVER SHALL BE CONSTRUED IN ACCORDANCE WITH AND GOVERNED BY THE LAWS OF THE STATE OF NEW YORK.
Section 8.Electronic Execution. 
The words “execution,” “signed,” “signature,” and words of like import in this Amendment and Waiver or in any amendment or other modification hereof (including waivers and consents) shall be deemed to include electronic signatures or the keeping of records in electronic form, each of which shall be of the same legal effect, validity or enforceability as a manually executed signature or the use of a paper-based recordkeeping system, as the case may be, to the extent and as provided for in any applicable Law, including the Federal Electronic Signatures in Global and National Commerce Act, the New York State Electronic Signatures and Records Act, or any other similar state laws based on the Uniform Electronic Transactions Act.
[Signature pages follow]

3

IN WITNESS WHEREOF, the parties hereto have caused this Amendment and Waiver to be duly executed by their respective authorized officers as of the day and year first above written.
						
	BRISTOL-MYERS SQUIBB COMPANY	
		
	By:	/s/ Jeffrey Galik
		Name: Jeffrey Galik
		Title: Treasurer
		
	By:	/s/ Katherine R. Kelly
		Name: Katherine R. Kelly
		Title: Corporate Secretary

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	CITIBANK, N.A., as Administrative Agent and as a Lender
	
		
		
	By:	/s/ Richard Rivera
		Name: Richard Rivera
		Title: Vice President

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	JPMORGAN CHASE BANK, N.A., as Administrative Agent and as a Lender
	
		
		
	By:	/s/ Stacey Zoland
		Name: Stacey Zoland
		Title: Executive Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	BANK OF AMERICA, N.A., as a Lender
	
		
	By:	/s/ Darren Merten
		Name: Darren Merten
		Title: Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	MORGAN STANLEY BANK, NA, as a Lender
	
		
		
	By:	/s/ Jackson Eng
		Name: Jackson Eng
		Title: Authorized Signatory  

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	MUFG Bank, Ltd., as a Lender
	
		
	By:	/s/ David Meisner
		Name: David Meisner
		Title: Vice President

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	WELLS FARGO BANK, NATIONAL ASSOCIATION, as a Lender
	
		
		
	By:	/s/ Jordan Harris
		Name: Jordan Harris
		Title: Managing Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	BARCLAYS BANK PLC, as a Lender
	
		
	By:	/s/ Jake Lam
		Name: Jake Lam
		Title: Assistant Vice President

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	DEUTSCHE BANK AG NEW YORK BRANCH, as a Lender
	
		
		
	By:	/s/ Ming K. Chu
		Name: Ming K. Chu
		Title: Director
		
	By:	/s/ Annie Chung
		Name:Annie Chung
		Title: Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	BNP Paribas, as a Lender
	
		
	By:	/s/ Michael Pearce
		Name: Michael Pearce
		Title: Managing Director
		
	By:	/s/ John Bosco
		Name: John Bosco
		Title: Managing Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	MIZUHO BANK, LTD., as a Lender
	
		
	By:	/s/ Tracy Rahn
		Name: Tracy Rahn
		Title: Executive Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	CREDIT SUISSE AG, CAYMAN ISLANDS BRANCH, as a Lender
	
		
		
	By:	/s/ Lingzi Huang
		Name: Lingzi Huang
		Title: Authorized Signatory
		
	By:	/s/ Bastien Dayer
		Name: Bastien Dayer
		Title: Authorized Signatory

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	GOLDMAN SACHS BANK USA, as a Lender
	
		
		
	By:	/s/ Annie Carr
		Name: Annie Carr
		Title: Authorized Signatory

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	HSBC Bank USA, N.A., as a Lender
	
		
	By:	/s/ Iain Stewart
		Name: Iain Stewart
		Title: Managing Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	STANDARD CHARTERED BANK, as a Lender
	
		
		
	By:	/s/ James Beck
		Name: James Beck
		Title: Associate Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	THE BANK OF NEW YORK, as a Lender
	
		
	By:	/s/ Clifford A. Mull
		Name: Clifford A. Mull
		Title: Director

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	Banco Santander, S.A., as a Lender
	
		
	By:	/s/ Pablo Tarrio
		Name: Pablo Tarrio
		Title: Attorney
		
	By:	/s/ Luis Casero
		Name: Luis Casero
		Title: Attorney

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

						
	The Northern Trust Company, as a Lender
	
		
	By:	/s/ Andrew D. Holtz
		Name: Andrew D. Holtz
		Title: Senior Vice President

[Signature Page to Amendment to Bristol-Myers Squibb 2011 Credit Agreement]

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