Document:

ex10_1.htm

 

 

THE SECURITIES OFFERED HEREBY HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED  (THE “ACT”) OR ANY OTHER APPLICABLE SECURITIES LAW OF ANY STATE OR OTHER JURISDICTION, AND HAVE BEEN ISSUED IN RELIANCE UPON AN EXEMPTION FROM THE REGISTRATION REQUIREMENTS OF THE ACT INCLUDING BUT NOT LIMITED TO REGULATION S PROMULGATED UNDER THE ACT. THESE SECURITIES CANNOT BE TRANSFERRED, OFFERED, OR SOLD IN THE UNITED STATES OR TO A “U.S. PERSON” (AS THAT TERM IS DEFINED IN REGULATION S PROMULGATED UNDER THE ACT) UNLESS SUCH SECURITIES ARE REGISTERED UNDER THE ACT OR AN EXEMPTION FROM REGISTRATION IS AVAILABLE, THE AVAILABILITY OF WHICH IS TO BE ESTABLISHED TO THE SATISFACTION OF THE COMPANY AND ITS COUNSEL.  HEDGING TRANSACTIONS INVOLVING THE SECURITIES MAY NOT BE CONDUCTED UNLESS IN COMPLIANCE WITH THE ACT.

 

SUBSCRIPTION AGREEMENT

FOR

AMERICAN POWER CORP.,

a Nevada corporation

This subscription agreement (this “Subscription Agreement”) is entered into by and between American Power Corp., a Nevada corporation (the “Company”), and the person or entity executing the Subscription Agreement (the “Subscriber”).  In this Subscription Agreement, the pronoun “it” means “he,” “she,” or “it,” as appropriate.  All terms not otherwise defined herein shall have the original meaning as defined in that certain Stock Issuance Agreement dated September 10, 2010 between the Company and Subscriber (the “Stock Issuance Agreement”). This Subscription Agreement is intended to be read in conjunction with the Company’s quarterly and annual reports and any definitive proxy statements (collectively, the “Reports”) filed with the Securities and Exchange Commission (“SEC”).  All of the Company’s SEC filings, including the Reports, may be reviewed and accessed via the SEC’s website at http://www.sec.gov.  (As used herein, Subscription Agreement, Stock Issuance Agreement and Reports shall collectively be referred to as the “Disclosure Documents”).

1.           Offering.  The Company is offering for sale to the Subscriber, and the Subscriber is offering to purchase from the Company, Units at the Unit Price determined to be $0.84 per Unit on the date hereof (the “Offering”), subject to the terms, conditions, acknowledgements, representations, and warranties stated herein and in the Stock Issuance Agreement.  Each Unit consists of one (1) share of common stock of the Company (“Share”) and one share purchase warrant (each a “Warrant”). Each Warrant shall entitle the Subscriber to purchase one additional share (each a “Warrant Share”) of Common Stock, at an exercise price equal to 150% of the Unit Price at which the Unit containing the Warrant being exercised was issued, for a period of three (3) years from the date such Warrant is issued.

2.           Subscription.  The Subscriber hereby irrevocably subscribes to purchase from the Company the number of Units and at the aggregate purchase price (the “Purchase Price”) set forth on the execution page to this Subscription Agreement titled “SUBSCRIPTION AGREEMENT SIGNATURE PAGE.”

3.           Purchase.  The Subscriber shall have tendered and delivered an Advance to the Company in the amount representing the Purchase Price set forth on the Subscription Agreement Signature Page, along with the execution and delivery of this Subscription Agreement.

4.           Acceptance or Rejection of Subscription.  The Subscriber understands and agrees that the Company reserves the right, in its sole discretion, to reject this subscription, in whole or in part if the Subscriber (a) failed to deliver the Advance as payment of the Purchase Price, (b) failed to deliver a completed Subscription Agreement, or (c) constitutes a “U.S. Person” as such term is defined in Rule 902(k) of Regulation S under the Securities Act of 1933, as amended (the “Act”), until there has been notice of acceptance of the Subscriber’s subscription.  In the event of rejection of this subscription, the Company and Subscriber shall take all actions deemed necessary or advisable to remedy such disqualifying matter causing rejection of the subscription.  Upon acceptance of the subscription by the Company, the Company will deliver to the Subscriber an “accepted” Subscription Agreement, and cause the Units to be promptly issued to the Subscriber.

5.           Subscriber’s Representations, Warranties, Covenants.  The Subscriber hereby represents, warrants and covenants to the Company as follows, realizing that the Company intends to rely on these representations, warranties, and covenants, which shall survive the acceptance of the Subscriber’s subscription by the Company:

5.1           Purchase For Own Account.  The Subscriber (a) is purchasing the Units, or Shares underlying the Warrants (the Units, Shares, Warrants and Shares underlying the Warrants are collectively referred to hereafter as the “Securities”) for its own benefit and account (not as a nominee or agent) for investment purposes only and not with an intent or view to, or for, resale, distribution or fractionalization thereof, in whole or in part, (b) has no present arrangement or intention to sell or distribute the Securities, or to grant participation in the Securities, and (c) does not have any contract, undertaking, agreement or arrangement with any person to sell, transfer or grant participation to such person, or to any third person, with respect to any of the Securities.

5.2           Speculative Investment.  The Subscriber represents and warrants that it understands that an investment in the Securities is speculative and involves substantial risks, including the possible loss of the entire investment, and Subscriber represents and warrants that it is in a position to lose the entire amount of such investment.  In order to understand the risks involved with such investment, Subscriber represents and warrants that it has carefully read and understood the Disclosure Documents and “Risk Factors” set forth in Section 6 of this Subscription Agreement.

5.3           Independent Review.  In making the decision to invest in the Company and subscribe for Units, the Subscriber has (a) received, read and is familiar with the Subscription Agreement, Stock Issuance Agreement and Reports (b) been given access and the opportunity to ask any and all questions it had, and to receive answers from the Company or any person acting on its behalf concerning the Company, its business plan, management and current financial condition, and/or the terms and conditions of the offer and sale of the Units, and Subscriber has received complete and satisfactory answers to any such inquiries, (c) has relied solely upon the information contained within this Subscription Agreement or upon information obtained in its own investigation, and represents and warrants that neither the Company, nor any officer, employee, agent, or affiliate of the Company has made any representations other than those contained within this Subscription Agreement, (d) understands that the attorneys, accountants or other professionals who have been employed to perform services on the Company’s behalf have NOT been employed to represent the interests of the Subscriber, and understands that it should consult with and rely on its own counsel or advisors for independent legal, accounting, financial and tax advice concerning this investment in the Company, including but not limited to advice as to the legality of any resale of the Securities, tax or other consequences of such investment in the Company, and the suitability of the investment for the Subscriber, and (e) acknowledges that the Reports have been accessible and available for inspection and that the appropriate officers of the Company have been available to answer any questions concerning this investment.  The Subscriber represents and warrants it is solely responsible for its own due diligence investigation of the Company and its analysis of the merits and risks of an investment in the Company.

5.4           Pre-existing Relationship with the Company or Sufficient Business and Financial Experience.  The Subscriber represents and warrants that: (i) it has a preexisting personal or business relationship with the Company or any of the Company’s officers, directors or controlling persons, or (ii) by reason of its business or financial experience or the business or financial experience of its professional advisors who are unaffiliated with and who are not compensated by the Company or any affiliate or selling agent of the Company, directly or indirectly, it could be reasonably assumed to have the capacity to protect its own interests in connection with the purchase of the Securities.  A “preexisting personal or business relationship” will be deemed to exist where the Subscriber has personal or business contacts with the Company, or any officer, director or controlling person of the Company, of such a nature and duration that would enable a reasonably prudent purchaser to be aware of the character, business acumen and general business and financial circumstances of the Company or person with whom such relationship exists.

5.5           No Advertisement or General Solicitation.  The offer and sale of the Units has not been advertised through any article, notice or other communication published in any newspaper, magazine, or similar media or broadcast over television or radio, or through any seminar or meeting whose attendees have been invited by any general solicitation or general advertising, and the Subscriber is not purchasing as a result of any such advertisement or solicitation.

5.6           Authority to Purchase the Units and to Execute Subscription Agreement.  The Subscriber has all the requisite power, authority and capacity to acquire and hold the Securities and to execute, deliver and comply with the terms of each of the instruments required to be executed and delivered by the Subscriber in connection with the subscription for the Units as contemplated by this Subscription Agreement, and such execution, delivery and compliance does not conflict with, or constitute a default under, any instruments governing the Subscriber, any law, regulation or order, or any agreement to which the Subscriber is a party or by which the Subscriber may be bound.  The Subscriber hereby adopts, accepts and agrees to be bound by all the terms and provisions of this Subscription Agreement, and, if this subscription is accepted in whole or in part, to perform and comply with any obligations therein imposed.

5.7           Partnership, Corporation or Trust.  If the Subscriber is a partnership, corporation or trust, the person executing this Subscription Agreement on its behalf represents and warrants that (i) it has made due inquiry to determine the truthfulness of the representations and warranties made pursuant to this Subscription Agreement, and (ii) it is duly empowered, authorized, and qualified (and if the Subscriber is a trust, by the trust agreement) to make this investment and to enter into and execute this Subscription Agreement on behalf of such entity.

5.8           Restricted Securities.  The Subscriber acknowledges that the Securities have not been registered or qualified under any federal or state securities laws in reliance upon exemptions from the registration requirements of such laws, and the Securities may not be transferred by the undersigned except in compliance with the registration requirements of such laws or pursuant to available exemptions from registration.  The offer and sale of the Securities has not been approved or disapproved by the SEC or any state regulatory authority, and any representation to the contrary is unlawful.

5.9           Legend.  The Subscriber understands and agrees that the certificate(s) or the documents representing the Securities will bear one or more restrictive legends determined by counsel to the Company to be necessary or appropriate in order to comply with United States federal or state securities law or to secure or protect any applicable exemptions from registration or qualification, including a legend in substantially the following form and the Subscriber agrees to abide by the terms thereof:

  

  

  

 

THE SECURITIES REPRESENTED HEREBY HAVE NOT BEEN REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED  (THE “ACT”) OR ANY OTHER APPLICABLE SECURITIES LAW OF ANY STATE OR OTHER JURISDICTION, AND HAVE BEEN ISSUED IN RELIANCE UPON AN EXEMPTION FROM THE REGISTRATION REQUIREMENTS OF THE ACT PROVIDED BY REGULATION S PROMULGATED UNDER THE ACT. THESE SECURITIES CANNOT BE TRANSFERRED, OFFERED, OR SOLD IN THE UNITED STATES OR TO A “U.S. PERSON” (AS THAT TERM IS DEFINED IN REGULATION S PROMULGATED UNDER THE ACT) UNLESS SUCH SECURITIES ARE REGISTERED UNDER THE ACT OR AN EXEMPTION FROM REGISTRATION IS AVAILABLE, THE AVAILABILITY OF WHICH IS TO BE ESTABLISHED TO THE SATISFACTION OF THE CORPORATION AND ITS COUNSEL. HEDGING TRANSACTIONS INVOLVING THE SECURITIES MAY NOT BE CONDUCTED UNLESS IN COMPLIANCE WITH THE ACT.

5.10           Compliance with Securities Law.  The Subscriber will not sell or otherwise transfer the Securities except as permitted under the Act and applicable United States state securities laws or an exemption therefrom, provided that the Subscriber delivers to the Company an opinion of counsel (which opinion and counsel are satisfactory to the Company) confirming the availability of such exemption upon the Company’s request.

5.11           Resale.  Subscriber may resell the Securities hereunder only pursuant to registration under the Act, or pursuant to an available exemption from registration and subject to an available exemption under Rule 144 promulgated under the Act (“Rule 144”). The Securities may be sold following six (6) months from the date Subscriber purchases the Securities so long as the Subscriber is not an “affiliate” of the Company and all the conditions set forth under Rule 144 have been satisfied.

5.12           Company’s Reliance on Information Provided.  The Subscriber understands that the Securities are being offered and sold to it in reliance on specific exemptions from the registration requirements of the United States federal and state securities laws and that the Company is relying upon the truth and accuracy of the representations, warranties, agreements, acknowledgments and understandings of the Subscriber set forth herein to determine the applicability of such exemptions and the suitability of the Subscriber to acquire the Securities.

5.13           Not a U.S. Person.  The Subscriber represents and warrants that it is not a “U.S. person” as such term is defined in Rule 902(k) of Regulation S under the Act.  A definition of “U.S. person” includes but is not limited to the following: (i) any natural person resident of the U.S.; (ii) any partnership or corporation organized or incorporated under the laws of the U.S.; (iii) any estate of which any executor or administrator is a U.S. person; and (iv) any partnership or corporation if (1) organized or incorporated under the laws of any foreign jurisdiction, and (2) formed by a U.S. person principally for the purpose of investing in securities not registered under the Act, unless it is organized or incorporated, and owned, by accredited investors who are not natural persons, estates or trusts.  The Subscriber represents that it is a bona fide resident of, and is domiciled in, the country so designated on the signature page hereto.

5.14            No Written or Oral Representations. No person or entity, including the Company or agents of the Company, has made any written or oral representations or warranties, expressly or by implication to the Subscriber, (a) that any person will resell or repurchase the Securities, (b) that any person will refund the Purchase Price for the Units, (c) as to the future price or value of the Securities, (d) as to the appropriate or exact length of time that Subscriber will be required to hold the Securities, (e) as to the percentage of profit and/or amount or type of consideration, profit, or loss to be realized, if any, as a result of an investment in the Securities, or (f) as to the amount of distributions that the Company will make.

5.15            Subscription Rejection Right.  The Subscriber acknowledges that the Company reserves the right to reject its subscription, to accept any subscription in part only, or to prorate subscriptions, if the Subscriber (a) fails to deliver the Advance as payment of the Purchase Price, (b) fails to deliver a completed Subscription Agreement, or (c) constitutes a “U.S. Person” as such term is defined in Rule 902(k) of Regulation S under the Act.

5.16            Subsequent Changes.  All information which the Subscriber has provided to the Company, including but not limited to all information given herein concerning itself, investor status, address, residence, financial position and knowledge and experience of financial and business matters are correct and complete as of the date of the execution of the Subscription Agreement, and that if there should be any material change in such information prior to this Subscription Agreement being accepted by the Company, the Subscriber will immediately provide the Company with such information.  The Subscriber will promptly notify the Company of any material fact or circumstance that would cause any of the foregoing representations to be untrue, incomplete, or misleading.

6.           Risk Factors.  In addition to the risks otherwise disclosed in the Reports and elsewhere in this Subscription Agreement, the Subscriber acknowledges and understands the risks involved with an investment to purchase the Units, including, but not limited to, the risks described below:

6.1           Speculative.  The Subscriber understands that an investment in the Securities is speculative and involves substantial risks, including the possible loss of the entire investment, and understands the risks and uncertainties discussed in this Subscription Agreement.

6.2           Investment Risk; No Operating History.  The Subscriber understands that the Company is currently in a development stage and has no operating history nor any history of profitability.  The Company reserves the right to obtain additional capital to develop its operations and complete its business plans.  There is no assurance that the Company can obtain additional capital to accomplish the foregoing or successfully complete its business plans.  As such, the Subscriber’s investment in the Company involves a high degree of risk which may result in a loss of all or substantially all of the Subscriber’s investment.

6.3           No Review of Fairness.  No federal or state agency has passed upon the Securities nor has made any finding, recommendation or determination as to the fairness of this investment.

6.4           No Representations Concerning Suitability.  The Company has made no representations or recommendations to the Subscriber concerning whether the purchase of the Securities is a suitable investment for it.  The Subscriber and its representative, if any, have the sole responsibility for determining whether this investment is suitable for the Subscriber.  The Company is not responsible to the Subscriber for making any such determination.

6.5           Unit Price May Fluctuate.  In accordance with the Stock Issuance Agreement, the Unit Price and the exercise price of the Warrants may fluctuate from time to time based upon market conditions and trading activity of the Company’s Common Stock.

6.6           Illiquid Investment.  The Subscriber’s investment in the Company is an illiquid investment, and the Subscriber must bear the economic risk of its investment.

6.7           The Securities Are Not Registered With The SEC Nor With Any State Securities Authorities.  The Securities will not be registered under the Act nor under any state securities laws nor the securities laws of any other country in reliance upon specific exemptions from registration under the provisions of the Act and applicable state securities laws and the laws of other countries.  The Securities issued will be deemed "restricted securities" and may not be sold, transferred or otherwise disposed of without an effective registration statement under the Act or an exemption therefrom.  As a result, the Securities may be transferred or resold only if the Securities have been registered or there is an available exemption from registration and the certificates representing the Securities will bear a legend to this effect.  The Securities are being offered in reliance upon an exemption from the registration provisions of the Act, pursuant to Regulation S promulgated thereunder.

6.8           Dilution in Initial Equity Interest.  Any further issuance by the Company of any additional Securities of the Company will dilute any equity interest of the Subscriber.  No assurances can be given that the Company will not issue additional securities that will have the effect of diluting the equity interest of the Subscriber.

6.9           Due Diligence and Investigation.  The offer and sale of the Units is not underwritten by or being offered through investment bankers or underwriters.  There has not been an independent review of matters covered in the Subscription Agreement by any such professionals or other professionals.  Subscriber must rely solely upon its own investigation and analysis of the risks in making this investment decision.

6.10           No Established Public Trading Market.  Even though the Company’s Common Stock is traded over-the-counter by quotation on the OTC Bulletin Board under the symbol “AMNP” the Subscriber realizes there is no established public trading market for the Securities.

6.11           Penny Stock Regulations Affect the Company’s Stock Price, Which May Make it More Difficult to Sell.  Broker-dealer practices in connection with transactions in “penny stocks” are regulated by certain penny stock rules adopted by the SEC. Penny stocks generally are equity securities with a price per share of less than $5.00 (other than securities registered on certain national securities exchanges or quoted on the NASDAQ Stock Market, provided that current price and volume information with respect to transactions in such securities is provided by the exchange or system). The penny stock rules require a broker-dealer, prior to a transaction in a penny stock not otherwise exempt from the rules, to deliver a standardized risk disclosure document that provides information about penny stocks and the risks in the penny stock market. The broker-dealer must also provide the customer with current bid and offer quotations for the penny stock, the compensation of the broker-dealer and its salesperson in the transaction, and monthly account statements showing the market value of each penny stock held in the customer’s account. In addition, the penny stock rules generally require that prior to a transaction in a penny stock the broker-dealer make a special written determination that the penny stock is a suitable investment for the purchaser and receive the purchaser’s written agreement to the transaction. These disclosure requirements may have the effect of reducing the level of trading activity in the secondary market for a stock that becomes subject to the penny stock rules.  The Securities are subject to the penny stock rules, and investors may find it more difficult to sell their securities.

  

  

  

 

7.           Indemnification.  The Subscriber agrees to indemnify and hold the Company and any person, if any, who controls the Company, within the meaning of Section 15 of the Act, and the Company’s officers, directors, agents, attorneys, and affiliates harmless from and against all damages, losses, costs and expenses, including reasonable attorneys’ fees and expenses reasonably incurred in the investigation or preparation in defense of any litigation commenced or threatened or any claim whatsoever, which they may incur by reason of the failure by the Subscriber to comply with the terms and conditions of this Subscription Agreement, or by reason of any misrepresentation or breach of any warranty or covenant made by the Subscriber herein, or in any document provided by the Subscriber to the Company in connection with the Subscriber’s investment in the Securities.  The Subscriber further agrees that the provisions of this Section shall survive (a) the sale, transfer or any attempted sale or transfer of all or a portion of the Securities, and (b) the death of the Subscriber.

8.           Termination, Cancellation or Revocation.  The Subscriber agrees that it may not cancel, terminate, or revoke this Subscription Agreement or any agreement made by it hereunder and that this Subscription Agreement shall survive the death or disability of the Subscriber and shall be binding upon the Subscriber’s heirs, executors, administrators, successors, and assigns, who shall execute a substantially similar agreement.

9.           Modification.  Neither this Subscription Agreement nor any provisions hereof shall be modified, discharged or terminated except by an instrument in writing signed by the party against whom any modification, discharge or termination is sought.

10.           Notices.  Any notice, demand or other communication that any party hereto may be required, or may elect, to give to anyone interested hereunder shall be deemed given (a) three (3) business days after mailing if sent by registered or certified mail, return receipt requested, addressed to such address as may be given herein, (b) immediately if delivered personally at such address, including by overnight delivery service, or (c) immediately if communicated by facsimile to the person entitled to such notice, provided, however, that acknowledgment of the receipt of such facsimile notice is returned to the person giving notice, it being understood that such acknowledgment shall not be unreasonably withheld.

11.           Payment of Expenses.  Subject to the provisions of this Subscription Agreement, the Company, on the one hand, and the Subscriber, on the other hand, will pay all fees and expenses (including, without limitation, legal fees and expenses) incurred by them in connection with the transactions contemplated hereunder.

12.           Counterparts.  This Subscription Agreement may be executed through the use of separate signature pages (including by facsimile) or in any number of counterparts, and each of such counterparts shall, for all purposes, constitute one agreement binding on all the parties, notwithstanding that all parties are not signatories to the same counterpart.

13.           Binding Effect.  Except as otherwise provided herein, this Subscription Agreement shall be binding upon and inure to the benefit of the parties and their heirs, executors, administrators, successors, legal representatives and assigns.  The obligation of the Subscriber and the agreements, representations, warranties and acknowledgments herein contained shall be deemed to be made by and be binding upon the Subscriber and the heirs, executors, administrators and successors of the Subscriber.

14.           Entire Agreement.  This instrument, including all appendices, exhibits and schedules attached hereto which have been incorporated by reference into this Subscription Agreement, contain the entire agreement of the parties with respect to the subject matter of this Subscription Agreement, and there are no representations, covenants or other agreements except as stated or referred to herein.

15.           Assignability.  This Subscription Agreement is not transferable or assignable by the Subscriber except as provided herein.

16.           Applicable Law.  This Subscription Agreement shall be governed by and construed in accordance with the laws of the State of Nevada as applied to residents of that state entering into contracts wholly to be performed in that state, without regards to conflicts of laws principles.  The Subscriber hereby agrees that any suit, action, or proceeding arising out of or relating to this Subscription Agreement, any amendments or any replacements hereof, and any transactions or agreements relating hereto shall be brought in the courts of, or the Federal courts in, the State of Nevada, County of Washoe, and the Subscriber hereby irrevocably consents and submits to the jurisdiction of such courts for the purposes of any such suit, action or proceeding, and the Subscriber agrees that service of process on the Subscriber in such suit, action or proceeding may be made in the same way as is prescribed by this Subscription Agreement for other notices.  The Subscriber hereby waives, and agrees not to assert against the Company or any assignee thereof, by way of motion, as a defense, or otherwise, in any such suit, action or proceeding, (a) any claim that he or she is not personally subject to the jurisdiction of the above-named courts or that his or her property is exempt or immune from setoff, execution or attachment, either prior to judgment or in execution thereof, and (b) to the extent permitted by applicable law, any claim that such suit, action or proceeding is brought in an inconvenient forum or that the venue of suit, action or proceeding is improper or that this subscription agreement or any amendments or any replacements hereof may not be enforced in or by such courts.  Venue for such actions as set forth above is intended to be inclusive.

17.           Waiver of Jury Trial.  The parties to this Subscription Agreement hereby waive any right that they may otherwise have to a trial by jury in any suit, action, or proceeding that arises out of or relates to this Subscription Agreement, any amendments to or any replacements of this Subscription Agreement, and any transactions or agreements relating to this Subscription Agreement.  The parties understand that, as a result of this waiver, the facts relating to any dispute that is covered by this waiver will be tried, if necessary, to a judge rather than to a jury.

18.           Severability.  If any provision or portion of this Subscription Agreement is held to be unenforceable or invalid for any reason, the remaining provisions and portions of this Subscription Agreement shall be unaffected by such holding.

[REMAINDER OF PAGE INTENTIONALLY LEFT BLANK]

SUBSCRIPTION AGREEMENT SIGNATURE PAGE

In addition to the foregoing, the Subscriber hereby certifies that it (a) agrees to all the terms and conditions of this Subscription Agreement, (b) meets the suitability standards set forth in this Subscription Agreement, and (c) is a resident of the jurisdiction indicated below.

	
I. NUMBER OF SUBSCRIBED UNITS.  Subscriber subscribes to purchase 595,238 Units (at $0.84 per Unit) of the Company (“Units”). Each Unit Consists of one Share and one Warrant.

 

II. PURCHASE PRICE.  The total purchase price of the Units (the number of Units multiplied by price per Unit) is $500,000 (the “Purchase Price”).

 

III. WARRANTS. The attached Warrants entitle the Subscriber to purchase 595,238 additional shares of Common Stock, at an exercise price of $1.26 for a period of 3 years from the date the Warrant is issued.

The Subscriber directs the Company to issue, register and deliver the certificates representing the Shares as follows:

	
REGISTRATION INSTRUCTIONS:

	
DELIVERY INSTRUCTIONS:

	
 

Name to appear on certificate

 

 

Tax ID / Corporate ID # / Cert. Incorporation #

 

 

Address

 

 

	
 

Name and account reference, if applicable

 

 

Contact name

 

 

Address

 

 

Telephone number

 

	
EXECUTED by the Subscriber this _______ day of__________, _____. By executing this Agreement, the Subscriber certifies that the Subscriber is resident in the jurisdiction shown as the “Address of the Subscriber”. The address of the Subscriber will be accepted by the Company as a representative as to the address of residency for the Subscriber.

 

	
WITNESS:

	
EXECUTION BY SUBSCRIBER:

	
 

Signature of witness

 

 

Name of witness

 

 

Address of witness

 

 

	
 

 

X                                                                

Authorized signatory

 

 

 

Name of authorized signatory (please print)

	
ACCEPTED this _______ day of ___________, _____.

AMERICAN POWER CORP.

Per:

 

Authorized signatory

	
 

 

Address of Subscriber (residence)

 

 

Telephone number and e-mail addresss5967wpi.htm

Back to Form 8-K

Exhibit 10.1

CONTRACT WITH APPROVED ENTITY PURSUANT TO SECTIONS 1860D-1 THROUGH 1860D-42

OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF

A VOLUNTARY MEDICARE PRESCRIPTION DRUG PLAN

 

CONTRACT (S5967)

 

Between

 

Centers for Medicare & Medicaid Services (hereinafter referred to as "CMS")

 

And

 

WELLCARE PRESCRIPTION INSURANCE, INC. 

(a Prescription Drug Plan Sponsor, hereinafter referred to as the "PDP Sponsor")

 

CMS and the PDP Sponsor, an entity that has been determined eligible to operate a Voluntary Medicare Prescription Drug Plan by the Administrator of CMS under 423 CFR §423.503, agree to the following for the purposes of sections 1860D-1 through 1860D-43 (with the exception of sections 1860D-22(a) and 1860D-31) of the Social Security Act (hereinafter referred to as "the Act.")

 

S5967

  

  

  

Article I 

Medicare Voluntary Prescription Drug Benefit

 

A.    PDP Sponsor agrees to operate one or more Medicare Voluntary Prescription Drug Plans (hereinafter referred to as a "PDP"), as described in its application and related materials, including but not limited to all the attestations contained therein and all supplemental guidance, for Medicare approval and in compliance with the provisions of this contract, which incorporates in its entirety the Solicitation For Applications for New Prescription Drug Plan (PDP) Sponsors released on January 5, 2010 (hereinafter collectively referred to as "the contract"). The PDP Sponsor also agrees to operate in accordance with the regulations at 42 CFR Part 423 (with the exception of Subparts Q, R, and S), sections 1860D-1 through 1860D-43 (with the exception of sections 1860D-22(a) and 1860D-31) of the Social Security Act, and the solicitation, as well as all other applicable Federal statutes, regulations, and policies. This contract is deemed to incorporate any changes that are required by statute to be implemented during the term of this contract and any regulations or policies implementing or interpreting such statutory provisions.

 

B.    CMS agrees to perform its obligations to the PDP Sponsor consistent with the regulations at 42 CFR Part 423 (with the exception of Subparts Q, R and S), sections 1860D-1 through 1860D-43 of the Social Security Act (with the exception of sections 1860D-22(a) and 1860D-31) and the solicitation, as well as all other applicable Federal statutes, regulations, and policies.

 

C.    CMS agrees that it will not implement, other than at the beginning of a calendar year, regulations under 42 CFR Part 423 that impose new, significant regulatory requirements on the PDP Sponsor. This provision does not apply to new requirements mandated by statute.

 

D.    This contract is in no way intended to supersede or modify 42 CFR, Part 423. Failure to reference a regulatory requirement in this contract does not affect the applicability of such requirements to the PDP Sponsor and CMS.

 

Article II 

Functions to be Performed by the PDP Sponsor

 

A.    ENROLLMENT

 

1.     PDP Sponsor agrees to accept new enrollments, make enrollments effective, process voluntary disenrollments, and limit involuntary disenrollments, as described in 42 CFR, Part 423, Subpart B.

 

2.     PDP Sponsor agrees to comply with the prohibition in 42 CFR 423.104(b) on discrimination in beneficiary enrollment.

 

3.     For contract year 2011, the PDP Sponsor shall not conduct Part D-related marketing activities prior to October 1, 2010 and shall not process enrollment applications prior to November 15, 2010. PDP Sponsor shall begin delivering prescription drug benefit services on January 1, 2010. For contract year 2012 and succeeding years, the PDP sponsor shall conduct Part D-related marketing and enrollment activities between October 15 and December 7 of the year prior to the contract year.

 

4.     The PDP Sponsor shall accept enrollment applications during the first 45 days of a contract year from beneficiaries who have elected to disenroll from a Medicare Advantage plan and enroll in the Medicare fee-for-service program.

 

B.    PRESCRIPTION DRUG BENEFIT

 

1.     PDP Sponsor agrees to provide the basic prescription drug coverage as defined under 42 CFR §423.100 and, to the extent applicable, supplemental benefits as defined in 42 CFR §423.100 and in accordance with Subpart C of 42 CFR Part 423. PDP Sponsor also agrees to provide Part D benefits as described in the PDP Sponsors bid(s) approved each year by CMS (as referenced in Attachment A, to be replaced each year upon renewal of the contract to reflect the Sponsors approved bids for the succeeding contract year).

 

2.     PDP Sponsor agrees to calculate and collect beneficiary premiums in accordance with 42 CFR §§423.286 and 423.293.

 

S5967

  

  

  

 

3 .    PDP Sponsor agrees to administer for its prescription drug plan members at point-of-sale the Medicare Coverage Gap Discount authorized by section 1860D-14A of the Social Security Act ("the Act").

 

C.    DISSEMINATION OF PLAN INFORMATION

 

        1.     PDP Sponsor agrees to provide the information required in 42 CFR §423.48.

 

2.     PDP Sponsor agrees to disclose information to beneficiaries in the manner and the form specified by CMS under 42 CFR §§423.128, 423 Subpart V and in the "Marketing Materials Guidelines for Medicare Advantage-Prescription Drug Plans (MA-PDs) and Prescription Drug Plans (PDPs)," and to comply with requirements in 42 CFR 423 Subpart V requiring approval of certain marketing materials prior to distribution.

 

3.     PDP Sponsor certifies that all materials it submits to CMS under the File and Use Certification authority described in the Marketing Materials Guidelines are accurate, truthful, not misleading, and consistent with CMS marketing guidelines.

 

D.    QUALITY ASSURANCE/UTILIZATION MANAGEMENT

 

PDP Sponsor agrees to operate quality assurance, drug utilization management, and medication therapy management programs, and to support electronic prescribing in accordance with Subpart D of 42 CFR Part 423.

 

E.     APPEALS AND GRIEVANCES

 

PDP Sponsor agrees to comply with all requirements in Subpart M of 42 CFR Part 423 governing coverage determinations, grievances and appeals, and formulary exceptions.

 

F.     PAYMENT TO PDP SPONSOR

 

1.     PDP Sponsor and CMS agree that payment under this contract will be governed by the rules in Subpart G of 42 CFR Part 423.

 

2.     PDP Sponsor agrees that it is bound by all applicable federal laws and regulations, guidance, and authorities pertaining to claims and debt collections. In the event that the government determines that the PDP Sponsor has been overpaid, the PDP Sponsor agrees to return those overpaid monies back to the federal government.

 

G.    BID SUBMISSION AND REVIEW

 

If the PDP Sponsor intends to participate in the Part D program for the next program year, PDP Sponsor agrees to submit the next years bid, including all required information on premiums, benefits, and cost-sharing, by the applicable due date, as provided in Subpart F of 42 CFR Part 423 so that CMS and the Part D plan sponsor may conduct negotiations regarding the terms and conditions of the proposed bid and benefit plan renewal.

 

H.    STATE LAW AND LICENSURE REQUIREMENTS

 

1.     PDP Sponsor agrees to comply with State law to the extent that it is not preempted by Federal law as described in Subpart I of 42 CFR Part 423.

 

2.     PDP Sponsor agrees that where it is operating in a State using a waiver granted pursuant to 42 CFR §423.410, such waiver shall be valid for three consecutive program years. PDP Sponsor agrees that expiration of the licensure waiver (and the failure to obtain a license from the relevant State) may be the basis for CMS deleting from the PDP Sponsors service area those PDP Regions affected by the waiver expiration. CMS may terminate or non-renew the PDP Sponsors contract where the expiration of the waiver results in the PDP Sponsor not being qualified to offer a PDP plan in any PDP Region.

 

3.     PDP Sponsor agrees that where it is operating in a State using a waiver granted pursuant to 42 CFR §423.415, such waiver shall be valid for the period that the Secretary of the Department of Health and Human Services determines is appropriate for timely processing of the PDP Sponsors license application by the State, but in no case for more than one year only, beginning on January 1 of the contract year for which CMS granted the waiver.

 

S5967

  

  

  

I.      COORDINATION WITH OTHER PRESCRIPTION DRUG COVERAGE

 

1.     PDP Sponsor agrees to comply with the coordination requirements with State Pharmacy Assistance Programs (SPAPs) and plans that provide other prescription drug coverage as described in Subpart J of 42 CFR Part 423.

 

2.     PDP Sponsor agrees to comply with Medicare Secondary Payer procedures as stated in 42 CFR §423.462. 

J.      SERVICE AREA AND PHARMACY ACCESS

 

1.     The PDP Sponsor agrees to provide Part D benefits in the service area for which it has been approved by CMS utilizing a pharmacy network and formulary approved by CMS that meet the requirements of 42 CFR §423.120.

 

2.     The PDP Sponsor agrees to provide Part D benefits through out-of-network pharmacies according to 42 CFR §423.124.

 

3.     PDP Sponsor agrees to provide benefits by means of point of service systems to adjudicate prescription drug claims in a timely and efficient manner in compliance with CMS standards, except when necessary to provide access in underserved areas, I/T/U pharmacies (as defined in 42 CFR §423.100), and long-term care pharmacies (as defined in 42 CFR §423.100).

 

4.     PDP Sponsor agrees to contract with any pharmacy that meets the PDP Sponsors reasonable and relevant standard terms and conditions.

 

K.    COMPLIANCE PROGRAM/PROGRAM INTEGRITY

 

1.     PDP Sponsor agrees that it will develop and implement a compliance program that applies to its Part D-related operations, consistent with 42 CFR §423.504(b)(4)(vi).

 

2.     The PDP sponsor agrees to provide notice based on best knowledge, information, and belief to CMS of any integrity items related to payments from governmental entities, both federal and state, for healthcare or prescription drug services that would have been reported as part of Table A. of the Business Integrity section of the PDP application. These items include any investigations, legal actions or matters subject to arbitration brought involving the sponsor (or sponsor's firm if applicable) and its subcontractors (excluding contracted network providers), including any key management or executive staff, or any major shareholders (5% or more), by a government agency (state or federal) on matters relating to payments from governmental entities, both federal and state, for healthcare and/or prescription drug services. In providing the notice, the sponsor shall keep the government informed of when the integrity item is initiated and when it is closed. Notice should be provided of the details concerning any resolution and monetary payments as well as any settlement agreements or corporate integrity agreements.

 

3.     The PDP Sponsor agrees to provide notice based on best knowledge, information, and belief to CMS in the event the Sponsor or any of its subcontractors is criminally convicted or has a civil judgment entered against it for fraudulent activities or is sanctioned under any Federal program involving the provision of health care or prescription drug services.

 

L.     LOW-INCOME SUBSIDY

 

PDP Sponsor agrees that it will participate in the administration of subsidies for low-income individuals according to Subpart P of 42 CFR Part 423.

 

M.   COMMUNICATION WITH CMS

 

PDP Sponsor agrees that it shall maintain the capacity to communicate with CMS electronically in accordance with CMS requirements.

 

N.    BENEFICIARY FINANCIAL PROTECTIONS

 

S5967

  

  

  

The PDP Sponsor agrees to afford its enrollees protection from liability for payment of fees that are the obligation of the PDP Sponsor in accordance with 42 CFR §423.505(g).

 

O.    RELATIONSHIP WITH FIRST TIER, DOWNSTREAM, AND RELATED ENTITIES

 

1.     The PDP Sponsor agrees it maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions of this contract with CMS.

 

2.     The PDP Sponsor shall ensure that any contracts or agreements with first tier, downstream, and related entities performing functions on the PDP Sponsors behalf related to the operation of the Part D benefit are in compliance with 42 CFR §423.505(i).

 

3.     The PDP Sponsor agrees to act in accordance with 45 CFR Part 76 and agrees that it will not contract with or employ entities or individuals that are excluded by the Department of Health and Human Services, Office of the Inspector General or included on the Excluded Parties List System maintained by the General Services Administration.

 

P.     CERTIFICATION OF DATA THAT DETERMINE PAYMENT

 

PDP Sponsor must provide certifications in accordance with 42 CFR §423.505(k).

 

Q.    ENROLLMENT RELATED COSTS

 

PDP Sponsor agrees to payment of fees established by CMS for cost sharing of enrollment related costs in accordance with 42 CFR §423.6.

 

R.    PDP SPONSOR REIMBURSEMENT TO PHARMACIES

 

1.     If a PDP Sponsor uses a standard for reimbursement of pharmacies based on the cost of a drug, PDP Sponsor will update such standard not less frequently than once every 7 days, beginning with an initial update on January 1 of each year, to accurately reflect the market price of the drug.

 

2.     PDP Sponsor will issue, mail, or otherwise transmit payment with respect to all claims submitted by pharmacies (other than pharmacies that dispense drugs by mail order only, or are located in, or contract with, a long-term care facility) within 14 days of receipt of an electronically submitted claim or within 30 days of receipt of a claim submitted otherwise.

 

3.     PDP Sponsor must ensure that a pharmacy located in, or having a contract with, a long-term care facility will have not less than 30 days (but not more than 90 days) to submit claims to PDP Sponsor for reimbursement.

 

Article III 

Record Retention and Reporting Requirements

 

A.    RECORD MAINTENANCE AND ACCESS

 

Sponsor agrees to maintain records and provide access in accordance with 42 CFR §§ 423.505 (b)(10) and 423.505(i)(2).

 

B.    GENERAL REPORTING REQUIREMENTS

 

The PDP Sponsor agrees to submit information to CMS according to 42 CFR §§423.505(f), 423.514, and the "Final Medicare Part D Reporting Requirements," a document issued by CMS and subject to modification each program year.

 

C.    LICENSURE-RELATED REPORTING REQUIREMENTS

 

1.     If the PDP Sponsor is operating under a CMS-granted licensure waiver in any State, the PDP Sponsor agrees to notify CMS in writing of the States disposition of the Sponsors license application within ten business days of the date that it receives notice of the States action.

 

S5967

  

  

  

2.     For those States where the PDP Sponsor is operating under a risk-bearing license, the Sponsor agrees to provide written notice to CMS of the States non-renewal of the Sponsors license within ten days of receiving notice of the States action.

 

3.     In the event that a State regulator imposes a sanction against the PDP Sponsor or requires the implementation of a corrective action plan, the Sponsor agrees to provide written notice to CMS of such sanction or corrective action requirement (including basis for the sanction and/or timeline for corrective action) within ten days of receiving notice of the States action.

 

4.     In the event that there is a change in the status of the PDP Sponsors risk-bearing license in any State (e.g., suspension, revocation), the Sponsor agrees to provide written notice to CMS of the change in status (including basis for the change in status and effective date) within ten days of receiving notice of the States action.

 

5.     If the PDP Sponsor is operating a Part D benefit under a CMS-granted waiver in every State in its service area, and the Sponsor is terminating or reducing the amount of an existing letter of credit obtained for the purposes of funding projected losses, the Sponsor shall provide written notice to CMS of such action 30 days prior to its effective date. The PDP Sponsor agrees that it must obtain CMS approval prior to terminating or reducing the amount of a letter of credit obtained for the purposes of funding projected losses under Appendix IV of the PDP Solicitation.

 

D.    CMS LICENSE FOR USE OF PLAN FORMULARY

 

PDP Sponsor agrees to submit to CMS each plan's formulary information, including any changes to its formularies, and hereby grants to the Government, and any person or entity who might receive the formulary from the Government, a non-exclusive license to use all or any portion of the formulary for any purpose related to the administration of the Part D program, including without limitation publicly distributing, displaying, publishing or reconfiguration of the information in any medium, including www.medicare.gov, and by any electronic, print or other means of distribution.

 

Article IV 

HIPAA Provisions

 

HIPAA TRANSACTIONS/PRIVACY/SECURITY

 

A.    PDP Sponsor agrees to comply with the confidentiality and enrollee record accuracy requirements specified in 42 CFR §423.136.

 

B.     PDP Sponsor agrees to enter into a business associate agreement with the entity with which CMS has contracted to track Medicare beneficiaries true out-of- pocket costs.

 

Article V 

Requirements of Other Laws and Regulations

 

The PDP Sponsor agrees to comply with (a) applicable Federal laws and regulations designed to prevent fraud, waste, and abuse, including, but not limited to applicable provisions of Federal criminal law, the False Claims Act (31 U.S.C. §§3729 et seq.), and the anti-kickback provision of section 1128B of the Act; (b) applicable HIPAA Administrative Simplification Security and Privacy rules at 45 CFR parts 160, 162, and 164; and (c) all other applicable Federal statutes and regulations. Requirements of Other Laws and Regulations

 

Article VI 

Contract Term and Renewal

 

A.    TERM OF CONTRACT

 

This contract is effective from the date of CMS authorized representatives signature through December 31, 2011. This contract shall be renewable for successive one-year periods thereafter according to 42 CFR §423.506.

 

S5967

  

  

  

B.    QUALIFICATION TO RENEW A CONTRACT

 

1.     In accordance with 42 CFR §423.507, the PDP Sponsor will be determined qualified to renew its contract annually only if:

 

(a)      The PDP Sponsor has not provided CMS with a notice of intention not to renew in accordance with Article VII of this contract, and

 

                (b)      CMS has not provided the PDP Sponsor with a notice of intention not to renew.

 

2.     Although PDP Sponsor may be determined qualified to renew its contract under this Article, if the PDP Sponsor and CMS cannot reach agreement on the bid under Subpart F of 42 CFR Part 423, no renewal takes place, and the failure to reach agreement is not subject to the appeals provisions in Subpart N of 42 CFR Part 423.

 

Article VII 

Nonrenewal of Contract

 

A.    NONRENEWAL BY THE PDP SPONSOR

 

1.     The PDP Sponsor may elect not to renew its contract with CMS, effective at the end of the term of the contract for any reason as long as PDP Sponsor provides proper notice of the decision according to the required timeframes.

 

        2.      If the PDP Sponsor does not intend to renew its contract, it must notify:

 

                (a)      CMS in writing by the first Monday of June in the year in which the current contract period ends;

 

(b)      Each Medicare enrollee, at least 90 days before the date on which the nonrenewal is effective. The PDP sponsor must provide, to enrollees, through this notice or outbound telephone calls, information on alternatives available for obtaining qualified prescription drug coverage within the PDP region, including Medicare Advantage-Prescription Drug plans, Medicare cost plans offering a Part D plan, and other PDPs, and must receive CMS approval of notices or scripts prior to their use.

 

3.     If the PDP Sponsor does not renew a contract CMS cannot enter into a contract with the organization for 2 years unless there are special circumstances that warrant special consideration, as determined by CMS.

 

4.     If the PDP Sponsor does not renew a contract, it must ensure the timely transfer of any data or files in accordance with CMS instructions.

 

B.    NONRENEWAL BY CMS

 

1.     CMS may determine that the PDP Sponsor is not qualified to renew its contract for any of the following reasons:

 

                (a)      The reasons listed in 42 CFR §423.509(a) that also permit CMS to terminate the contract.

 

(b)      The PDP Sponsor has committed any of the acts in 42 CFR §423.752 that support the imposition of intermediate sanctions or civil money penalties under 42 CFR §423.750.

 

        2.     CMS will provide notice of its decision if the PDP Sponsor is not qualified to renew its contract as follows:

 

                (a)      To the PDP Sponsor by August 1 of the current contract year.

 

(b)      If CMS decides that the PDP Sponsor is not qualified to renew its contract, to the PDP Sponsors Medicare enrollees by mail at least 90 days before the end of the current calendar year.

 

(c)      CMS will provide the notice described in (B)(2)(ii) of this Article where a non-renewal results because CMS and the PDP Sponsor are unable to reach agreement on the bid under 42 CFR Part 423, Subpart F.

S5967

  

  

  

3.     CMS shall give the PDP Sponsor written notice of its right to appeal the decision that the sponsor is not qualified renew its contract in accordance with 42 CFR §423.642(b).

 

Article VIII 

Modification or Termination of Contract

 

A.    CONTRACT MODIFICATION OR TERMINATION BY MUTUAL CONSENT

 

        1.     This contract may be modified or terminated at any time by written mutual consent of the parties.

 

2.     If this contract is terminated by mutual consent, the PDP Sponsor must provide notice to its Medicare enrollees and the general public in accordance with CMSs instructions.

 

3.     If the contract is modified by mutual consent, the PDP Sponsor must notify its Medicare enrollees of any changes that CMS determines are appropriate for notification according to the process and timeframes specified by CMS.

 

4.     If a contract is terminated under section A of this Article, the PDP Sponsor must ensure the timely transfer of any data or files.

 

5.     If a contract is terminated under section A of this Article, CMS cannot enter into a contract with the organization for a period of up to 2 years unless there are special circumstances that warrant special consideration, as determined by CMS.

 

B.    TERMINATION OF CONTRACT BY CMS

 

CMS may terminate the contract in accordance with 42 CFR §423.509. C. TERMINATION OF CONTRACT BY THE PDP SPONSOR

 

The PDP Sponsor may terminate the contract only in accordance with 42 CFR §423.510.

 

Article IX 

Intermediate Sanctions

 

Consistent with Subpart O of 42 CFR Part 423, the PDP Sponsor shall be subject to sanctions and civil money penalties.

 

Article X 

Severability

 

Severability of the contract shall be in accordance with 42 CFR 423.504(e).

 

Article XI 

Miscellaneous

 

A.    DEFINITIONS

 

Terms not otherwise defined in this contract shall have the meaning given to such terms in 42 CFR Part 423.

 

B.    ALTERATION TO ORIGINAL CONTRACT TERMS

 

The PDP Sponsor agrees that it has not altered in any way the terms of the PDP contract presented for signature by CMS. PDP Sponsor agrees that any alterations to the original text the PDP Sponsor may make to this contract shall not be binding on the parties.

 

S5967

  

  

  

C.    ADDITIONAL CONTRACT TERMS

 

The PDP Sponsor agrees to include in this contract other terms and conditions in accordance with 42 CFR §423.505(j).

 

D.    CMS APPROVAL TO BEGIN MARKETING AND ENROLLMENT ACTIVITIES

 

PDP Sponsor agrees that it must complete CMS operational requirements prior to receiving CMS approval to begin Part D marketing and enrollment activities. Such activities include, but are not limited to, establishing and successfully testing connectivity with CMS systems to process enrollment applications (or contracting with an entity qualified to perform such functions on PDP Sponsors behalf) and successfully demonstrating capability to submit accurate and timely price comparison data. To establish and successfully test connectivity, the PDP Sponsor must, 1) establish and test physical connectivity to the CMS data center, 2) acquire user identifications and passwords, 3) receive, store, and maintain data necessary to perform enrollments and send and receive transactions to and from CMS, and 4) check and receive transaction status information.

 

E.     Pursuant to section 13112 of the American Recovery and Reinvestment Act of 2009 (ARRA), the PDP Sponsor agrees that as it implements, acquires, or upgrades its health information technology systems, it shall utilize, where available, health information technology systems and products that meet standards and implementation specifications adopted under section 3004 of the Public Health Service Act, as amended by section 13101 of the ARRA.

 

S5967

  

  

  

In witness whereof, the parties hereby execute this contract.

 

This document has been electronically signed by:

 

FOR THE PDP SPONSOR

 

Thomas Tran

	 	 

 

Contracting Official Name

 

 

8/31/2010 11:16:53 AM

	 	 

 

Date

 

	 WELLCARE PRESCRIPTION INSURANCE, INC.	 	
 8735 Henderson Rd, Renaissance 2 

Tampa, FL 33634

	 
	 	 	 	 
	
 

Organization

	 	
 

Address

	 

 

 

FOR THE CENTERS FOR MEDICARE & MEDICAID SERVICES

 

	/s/ Cynthia Tudor	 	
 10/4/2010 11:08:39 AM

	 
	 	 	 	 
	

 

Cynthia Tudor, PhD

Director

Medicare Drug Benefit

and C & D Data Group,

Center for Medicare

	 	
 

Date

	 

 

S5967

  

  

  

Prescription Drug Plan Attestation of Benefit Plan

WELLCARE PRESCRIPTION INSURANCE, INC.

S5967

 

I attest that I have examined the Plan Benefit Packages (PBPs) identified below and that the benefits identified in the PBPs are those that the above-stated organization will make available to eligible beneficiaries in the approved service area during program year 2011. I further attest that we have reviewed the bid pricing tools (BPTs) with the certifying actuary and have determined them to be consistent with the PBPs being attested to here.

 

I further attest that these benefits will be offered in accordance with all applicable Medicare program authorizing statutes and regulations and program guidance that CMS has issued to date and will issue during the remainder of 2010 and 2011, including but not limited to, the 2011 Call Letter, the 2011 Solicitations for New Contract Applicants, the Medicare Prescription Drug Benefit Manual, the Medicare Managed Care Manual, and the CMS memoranda issued through the Health Plan Management System (HPMS).

 

	
Plan 

ID

	
Segment 

ID

	Version	Plan Name	Plan Type	
Transaction 

Type

	
Part D 

Premium

	
CMS Approval 

Date

	
Effective 

Date

	

035

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

43.80

	

09/03/2010

	

01/01/2011

	

036

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

53.50

	

09/03/2010

	

01/01/2011

	

037

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

58.20

	

09/03/2010

	

01/01/2011

	

038

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

56.10

	

09/03/2010

	

01/01/2011

	

039

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

53.90

	

09/03/2010

	

01/01/2011 

	

040

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

55.70

	

09/03/2010

	

01/01/2011

	

041

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

58.70

	

09/03/2010

	

01/01/2011 

	

042

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

59.10

	

09/03/2010

	

01/01/2011

	

043

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

61.50

	

09/03/2010

	

01/01/2011 

	

044

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare 

Prescription 

Drug Plan

	

Renewal

	

56.90

	

09/03/2010

	

01/01/2011

	

045

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

48.30

	

09/03/2010 

	

01/01/2011 

	

046

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

61.60

	

09/03/2010

	

01/01/2011 

	

047

	

0

	

5

	  	  	

Renewal

	

54.90

	

09/03/2010

	

01/01/2011

 

S5967

  

  

  

	
Plan 

ID

	
Segment

ID

	Version	Plan Name	Plan Type	
Transaction

Type

	
Part D 

Premium

	
CMS 

Approval

 Date

	
Effective 

Date

	  	  	  	

Well Care

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	  	  	  	  
	

048

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

56.00

	

09/03/2010

	

01/01/2011 

	

049

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

59.30

	

09/03/2010

	

01/01/2011

	

051

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

54.40

	

09/03/2010

	

01/01/2011 

	

052

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

58.70

	

09/03/2010

	

01/01/2011

	

053

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

57.60

	

09/03/2010

	

01/01/2011

	

054

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

62.30

	

09/03/2010

	

01/01/2011 

	

055

	

0

	

6

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

60.90

	

09/03/2010

	

01/01/2011 

	

056 

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

53.30

	

09/03/2010

	

01/01/2011 

	

057

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare 

Prescription 

Drug Plan

	

Renewal

	

59.60

	

09/03/2010

	

01/01/2011 

	

058

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare 

Prescription 

Drug Plan

	

Renewal

	

57.20

	

09/03/2010

	

01/01/2011 

	

059 

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

62.50

	

09/03/2010

	

01/01/2011 

	

060 

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

43.80

	

09/03/2010 

	

01/01/2011 

	

061

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

57.30

	

09/03/201

	

01/01/2011

	

062

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

50.30

	

09/03/2010

	

01/01/2011 

	

063

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

53.20

	

09/03/2010

	

01/01/2011 

	

064

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare 

Prescription 

Drug Plan

	

Renewal

	

61.30

	

09/03/2010

	

01/01/2011 

	

065

	

0

	

6

	  	  	

Renewal

	

68.60

	

09/03/2010

	

01/01/2011

 

S5967

  

  

  

	
Plan 

ID

	
Segment 

ID

	Version	Plan Name	Plan Type	
Transaction 

Type

	
Part D 

Premium

	
CMS 

Approval 

Date

	
Effective 

Date

	  	  	  	

Well Care

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	  	  	  	  
	

066

	

0

	

5

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

52.20

	

09/03/2010

	

01/01/2011 

	

067

	

0

	

6

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

52.80

	

09/03/2010

	

01/01/2011 

	

068

	

0

	

6

	

WellCare

Signature

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

60.00

	

09/03/2010

	

01/01/2011

	

138

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

28.50

	

09/03/2010

	

01/01/2011 

	

139

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

35.20

	

09/03/2010

	

01/01/2011 

	

140

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

33.40

	

09/03/2010

	

01/01/2011 

	

141

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

45.00

	

09/03/2010

	

01/01/2011 

	

142

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

33.60

	

09/03/2010

	

01/01/2011

	

143

	

 
0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

31.80

	

09/03/2010

	

01/01/2011

	

144

	

0

	

4

	

WellCare

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

33.50

	

09/03/2010

	

01/01/2011 

	

145 

	

0

	

4

	

WellCare 

Classic

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

34.90

	

09/03/2010

	

01/01/2011 

	

146

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

35.20

	

09/03/2010 

	

01/01/2011 

	

147

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

29.40

	

09/03/2010

	

01/01/2011 

	

148

	

 
0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

30.90

	

09/03/2010 

	

01/01/2011 

	

149

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

32.70

	

09/03/2010 |

	

01/01/2011 

	

150

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare 

Prescription  

Drug Plan

	

Renewal

	

35.30

	

09/03/2010 

	

01/01/2011

	

151

	

0

	

4

	  	  	

Renewal

	

31.40

	

09/03/2010 

	

01/01/2011

 

S5967

  

  

  

 

	
Plan 

ID

	
Segment 

ID

	Version	Plan Name	Plan Type	
Transaction 

Type

	
Part D 

Premium

	
CMS 

Approval 

Date

	
Effective 

Date

	  	  	  	

WellCare 

Classic

(PDP)

	

Medicare

Prescription

Drug Plan

	  	  	  	  
	

152

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

36.00

	

09/03/2010

	

01/01/2011 

	

154

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

32.40

	

09/03/2010

	

01/01/2011 

	

155

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

37.40

	

09/03/2010

	

01/01/2011 

	

156

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

29.20

	

09/03/2010

	

01/01/2011 

	

157

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

32.40

	

09/03/2010

	

01/01/2011

	

158

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

33.40

	

09/03/2010

	

01/01/2011

	

159

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

28.00

	

09/03/2010

	

01/01/2011 

	

160

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

34.50

	

09/03/2010

	

01/01/2011

	

161

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

36.60

	

09/03/2010

	

01/01/2011

	

162

	

0

	

4

	

WellCare 

Classic

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

36.20

	

09/03/2010

	

01/01/2011

	

163

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

23.30

	

09/03/2010

	

01/01/2011

	

164

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

32.50

	

09/03/2010

	

01/01/2011

	

165

	

 
0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

23.80

	

09/03/2010

	

01/01/2011 

	

166

	

0

	

4

	

WellCare

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

34.40

	

09/03/2010

	

01/01/2011 

	

167

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

34.80

	

09/03/2010

	

01/01/2011 

	

168

	

0

	

4

	

WellCare 

Classic 

(PDP)

	

Medicare 

Prescription 

Drug Plan

	

Renewal

	

39.60

	

09/03/2010

	

01/01/2011 

	

169

	

0

	

4

	  	  	

Renewal

	

31.50

	

09/03/2010

	

01/01/2011

 

S5967

  

  

  

	
Plan

ID

	
Segment

ID

	Version	Plan Name	Plan Type	
Transaction

Type

	
Part D

Premium

	
CMS 

Approval 

Date

	
Effective 

Date

	  	  	  	

WellCare Classic (PDP)

	

Medicare

Prescription

Drug Plan

	  	  	  	  
	

170

	

0

	

5

	

WellCare Classic (PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

37.60

	

09/03/2010

	

01/01/2011 

	

171

	

 
0

	

4

	

WellCare Classic (PDP)

	

Medicare

Prescription

Drug Plan

	

Renewal

	

37.00

	

09/03/2010

	

01/01/2011 

 

S5967

  

  

  

 

 

	 Thomas Tran	 	
8/31/2010 11:16:53 AM

	 
	 	 	 	 
	
 

Contracting Official Name

	 	
 

Date

	 

 

 

 

	WELLCARE PRESCRIPTION INSURANCE, INC.	 	
8735 Henderson Rd, Renaissance 2 

Tampa, FL 33634

	 
	 	 	 	 
	

 

Organization

	 	
 

Address

	 

S5967

  

  

  

DATA USE ATTESTATION

 

The sponsor shall restrict its use and disclosure of Medicare data obtained from CMS information systems (listed in Attachment A) to those purposes directly related to the administration of the Medicare managed care and/or outpatient prescription drug benefits for which it has contracted with the Centers for Medicare & Medicaid Services (CMS) to administer. The sponsor shall only maintain data obtained from CMS information systems that are needed to administer the Medicare managed care and/or outpatient prescription drug benefits that it has contracted with CMS to administer. The sponsor (or its subcontractors or other related entities) may not re-use or provide other entities access to the CMS information system, or data obtained from the system, to support any line of business other than the Medicare managed care and/or outpatient prescription drug benefit for which the sponsor contracted with CMS.

 

The sponsor further attests that it shall limit the use of information it obtains from its Medicare plan members to those purposes directly related to the administration of such plan. The sponsor acknowledges two exceptions to this limitation. First, the sponsor may provide its Medicare members information about non-health related services after obtaining consent from the members. Second, the sponsor may provide information about health-related services without obtaining prior member consent, as long as the sponsor affords the member an opportunity to elect not to receive such information.

 

CMS may terminate the sponsors access to the CMS data systems immediately upon determining that the sponsor has used its access to a data system, data obtained from such systems, or data supplied by its Medicare members beyond the scope for which CMS has authorized under this agreement. A termination of this data use agreement may result in CMS terminating the sponsors Medicare contract(s) on the basis that it is no longer qualified as a Medicare sponsor. This agreement shall remain in effect as long as the sponsor remains a Medicare managed care organization and/or outpatient prescription drug benefit sponsor. This agreement excludes any public use files or other publicly available reports or files that CMS makes available to the general public on our website.

 

S5967

  

  

  

Attachment A

 

The following list contains a representative (but not comprehensive) list of CMS information systems to which the Data Use Attestation applies. CMS will update the list periodically as necessary to reflect changes in the agencys information systems

 

Automated Plan Payment System (APPS)

Common Medicare Environment (CME)

Common Working File (CWF)

Coordination of Benefits Contractor (COBC)

Drug Data Processing System (DDPS)

Electronic Correspondence Referral System (ECRS)

Enrollment Database (EDB)

Financial Accounting and Control System (FACS)

Front End Risk Adjustment System (FERAS)

Health Plan Management System (HPMS), including Complaints Tracking and all other modules

HI Master Record (HIMR)

Individuals Authorized Access to CMS Computer Services (IACS)

Integrated User Interface (IUI)

Medicare Advantage Prescription Drug System (MARx)

Medicare Appeals System (MAS)

Medicare Beneficiary Database (MBD)

Payment Reconciliation System (PRS)

Premium Withholding System (PWS)

Prescription Drug Event Front End System (PDFS)

Retiree Drug System (RDS)

Risk Adjustments Processing Systems (RAPS)

 

S5967

  

  

  

This document has been electronically signed by:

 

Thomas Tran

	 	 

 

Contracting Official Name

 

 

8/31/2010 11:16:53 AM

	 	 

 

Date

 

WELLCARE PRESCRIPTION INSURANCE, INC.

	 	 

 

Organization

 

8735 Henderson Rd, Renaissance 2 

Tampa, FL 33634

	 	 

 

Address

 

S5967

  

  

  

SIGNATURE ATTESTATION

 

Contract ID: S5967

Contract Name: WELLCARE PRESCRIPTION INSURANCE, INC.

 

I understand that by signing and dating this form, I am acknowledging that I am an authorized representative of the above named organization and that I am the contracting official associated with the user ID used to log on to the Health Plan Management System (HPMS) to sign the 2011 Medicare contracting documents. I also acknowledge that in accordance with the HPMS Rules of Behavior, sharing user IDs is strictly prohibited.

 

This document has been electronically signed by:

 

Thomas Tran

	 	 

 

Contracting Official Name

 

 

8/31/2010 11:16:53 AM

	 	 

 

Date

 

 

WELLCARE PRESCRIPTION INSURANCE, INC.

	 	 

 

Organization

 

8735 Henderson Rd, Renaissance 2 

Tampa, FL 33634

	 	 

 

Address

S5967

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00179-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00179-of-00352.parquet"}]]