FILED JEFFREY S. CHIESA ATTORNEY GENERAL OF NEW JERSEY Division of Law, 5th Floor guum"-cmwmamam 124 Halsey Street I Newar Jerse 07102 By: Jeri L. Warhaftig Deputy Attorney General STATE OF NEW JERSEY DEPARTMENT OF LAW PUBLIC SAFETY DIVISION OF CONSUMER AFFAIRS IN THE MATTER OF Administrative Action CVS Pharmacy, Inc. and ORDER of ENTRY New Jersey CVS Pharmacy, L.L.C. Assurance of Voluntary Compliance in Lieu of Civil Enforcement This Assurance of Voluntary Compliance in Lieu of Civil Enforcement between the State of New Jersey, Division of Consumer Affairs (the "Division") and CVS Pharmacy, Inc., and New Jersey CVS Pharmacy, L.L.C. (collectively, is hereby filed and entered. Date: 2 Z0 )7 Eric T. Kanefsky Acting Director New Jersey Division of Consumer Affairs JEFFREY S. CHIESA ATTORNEY GENERAL OF NEW JERSEY Division of Law, 5th Floor 124 Halsey Street Newar Jerse 07102 By: Jeri L. Warhaftig Deputy Attorney General STATE OF NEW JERSEY DEPARTMENT OF LAW PUBLIC SAFETY DIVISION OF CONSUMER AFFAIRS IN THE MATTER OF CVS Pharmacy, Inc. and New Jersey CVS Pharmacy, LOLOCI Administrative Action Assurance of Voluntary Compliance in Lieu of Civil Enforcement This Assurance of Voluntary Compliance in Lieu of Civil . UL Enforcement is made and entered into this?2Zl_day of 2013 by and between the State of New Jersey, Division of Con umer Affairs (the "Division") and CVS Pharmacy, Inc., and New Jersey CVS Pharmacy, L.L.C. (collectively, Enforcement Investigation 1. Eric T. Kanefsky, Acting Director of the New Jersey Division of Consumer Affairs (the "Acting Director") has authority over the conduct of CVS pharmacies in the State of New Jersey based upon his mandate to protect the citizens of New Jersey as well as his specific duty to administer the provisions of the Controlled Dangerous Substances Act, N.J.S.A. 24:21 gt as head of the Drug Control Unit.l 2. This matter was first opened to the former Director of the Division, Thomas Calcagni (the "Former Director"), upon receipt of information that a CVS pharmacy located at 471 Main Street, Chatham, New Jersey (Store #1279) had improperly dispensed prescription containers containing commingled medications to its customers. In response to receipt of this information, which is discussed more fully below, the Former Director commenced an investigation to assess the risk to the public, the extent to which procedures within the pharmacy gave rise to the commingling error, the remediation undertaken by CVS and the reflection of these events on the ability of CVS to safely handle Prescription Legend Drugs and Controlled Dangerous Substances. That investigation has now concluded and the Acting Director intends to address in detail this matter through the entry of this Assurance of Voluntary Compliance in Lieu of Civil Enforcement 1 In addition to the Division's authority, the New Jersey State Board of Pharmacy has jurisdiction over the conduct of its individual licensees and registrants under N.J.S.A. 45:l--l4 gt seq., N.J.S.A. 45:14-40 gt seg., and related administrative regulations, and will undertake review of its licensees' and registrants' conduct upon entry of this Assurance of Voluntary Compliance in Lieu of Civil Enforcement, subject to paragraphs 12 and 13 of this AVC. a. According to CVS, between December 1, 2011 and January 30, 2012, fifteen prescription containers dispensed by the Chatham CVS pharmacy intended to contain pediatric chewable fluoride also erroneously contained varying amounts of Tamoxifen, a breast cancer treatment drug. b. On March 2, 2012, the Former Director issued an Order reflecting his concerns about potential violations of New Jersey Statutes and Regulations implicated by the commingling errors, and his concern that the alleged error could adversely reflect on CVS Pharmacy's reliability and integrity with respect to the maintenance and control of Prescription Legend Drugs and Controlled Dangerous Substances. Therefore, the Former Director ordered CVS to produce a large body of information pertinent to the operations of the pharmacy at the Chatham location, reports of any other commingling instances in New Jersey during the preceding twelve months, and other relevant items. The Former Director also ordered CVS to appear and give testimony at an investigative inquiry held on March 9, 2012. (The Order is attached hereto as Exhibit A). c. Subsequent to receipt of the Former Director's Order, CVS produced documents and provided information through testimony and attorney proffer regarding the Chatham commingling incident. In response to the Division's inquiry, and in accordance with its existing protocol, CVS also conducted an internal investigation and assessment of the events that gave rise to the Chatham commingling error. d. During the course of the Division's inquiry into the Chatham incident, CVS advised the Division and the Board of Pharmacy of dispensing errors that occurred in four other New Jersey locations subsequent to the Chatham error: i. On or about March 3, 2012 prescription containers dispensed to customers from the CVS pharmacy at 600 North Kings Highway, Cherry Hill, New Jersey (Store #2235) contained erroneously commingled medications. Containers intended to contain Metoprolol, used to treat high blood pressure, contained both that drug and Risperidone, which treats schizophrenia. Three commingled containers were received by customers while others were detected and corrected before they were dispensed by the pharmacy. ii. On or about March 7, 2012, the CVS pharmacy at 255 Route 46, Budd Lake, New Jersey (Store #2092) had a single dispensing error in which a patient was incorrectly dispensed Pravastatin, a cholesterol medication, in lieu of Metformin, a medication for diabetes. The patient consumed the wrong medication and was seen in an emergency room. On or before March 24, 2012, approximately thirty prescriptions dispensed to customers from the CVS pharmacy located at 514 Park Avenue, Scotch Plains, New Jersey (Store #1956) had been filled from an automated filling machine found to contain commingled tablets of Atorvastatin, a cholesterol drug, and Losartan, a blood pressure medication. Thirty-eight prescription containers were filled from the machine prior to discovery of the commingled drugs. Of these thirty--eight, approximately thirty containers were dispensed to customers. There is no indication that any incorrect medication was consumed. iv. On March 11, 2012, a CVS pharmacy in Rahway, New Jersey filled a prescription calling for 120 tablets of Coreg 20 mg, a high blood pressure medication, with a mixture of 90 Coreg 20 mg tablets and 30 Coreg 80 mg tablets. Investigation by CVS indicated that this error occurred when pharmacy personnel bypassed the computer accuracy scan function, which is used to verify that a stock bottle corresponds to the type and dosage of prescribed medication. There is no indication that the incorrect medication was consumed. e. Except as outlined above, the Division of Consumer Affairs and the New Jersey State Board of Pharmacy are unaware of any other consumer harm arising from the above referenced incidents. f. In response to the above incidents, CVS notified all potentially affected customers of the dispensing errors, and remedial steps were taken by CVS to substitute accurate prescriptions for the commingled containers and to direct customers to appropriate medical resources. The Division and the Board of Pharmacy were also notified. g. Through the investigations conducted by the Division and CVS, certain enhancements and improvements to CVS's then--existing practices and procedures have been identified which the parties agree are intended to remediate the issues that gave rise to the commingling errors and protect the public by avoiding future commingling errors. The Division notes that throughout this process CVS displayed a commitment to the development and implementation of enhancements to address these issues{ This AVC arises out of the parties' joint commitment to public safety and desire to take the necessary steps to avoid future commingling errors at CVS to the extent possible. h. The Acting Director believes that this AVC will serve to address commingling errors that have arisen in New Jersey CVS pharmacies. The Acting Director intends for this AVC to serve to educate both the regulated community and the citizens of New Jersey about the critical role individuals play in assuring that prescriptions dispensed to the public are accurate and that medications are safe for consumption. Finally, the Acting Director expects that the practices and procedures set forth in this AVC and undertaken by CVS will serve as a model for use by other pharmacies in this State. i. The investigation of the dispensing incidents included discussions with CVS personnel and counsel, review of the CVS internal investigation, receipt of reports of inspections conducted in the CVS--Chatham pharmacy and other CVS locations in New Jersey by the Enforcement Bureau of the Division of Consumer Affairs, and consultation with the Board of Pharmacy, which has independent jurisdiction to license and oversee pharmacists and register and oversee pharmacy technicians. j. Ultimately, the inquiry revealed two primary types of pharmacy dispensing errors which had occurred in the five New Jersey CVS pharmacies. The first type of error arose from the pharmacy staff's incorrect filling of individual prescription containers from manufacturers' stock bottles. The commingling errors that occurred in Chatham, Budd Lake and Rahway were of this type. The second type of error arose from the improper filling of individual prescription containers by an automated filling machine. The commingling errors in the Cherry Hill and Scotch Plains CVS stores were of this second type. Both types were caused by human error. k. With respect to the first type of error, CVS has longstanding protocols, consistent with industry standards, dealing with prescription containers that are prepared for a customer, but never actually claimed and purchased by that customer. After a given period of time, the medications in those containers (which never leave CVS's possession) are returned to pharmacy stock through a "Return to Stock" procedure to be re--sold. Pursuant to CVS policy, unclaimed prescription containers are returned to store shelves in close proximity to the original stock bottle of medication. Those containers must remain clearly labeled and should be used in the filling of the next prescription issued for that medication. Under CVS protocol, the medication from unclaimed prescription containers is not supposed to be poured back into the stock bottle. 1. Investigation has determined that the commingling error in Chatham likely occurred when one or more members of the pharmacy staff (which consists of licensed pharmacists and registered pharmacy technicians) failed to follow CVS RTS procedures. It is most likely that the commingling occurred during a return to stock when a CVS staff member poured unsold prescriptions (in contravention to CVS policy) into the wrong stock bottle on the shelf. In part, this was revealed by the presence of stock bottles containing more tablets than are normally contained in a new bottle. This error was apparently detected when individuals' prescription containers were later filled by the pharmacy from those stock bottles. This dispensing error occurred despite the fact that CVS procedure requires that a pharmacist physically inspect a portion of the contents of every prescription container prior to dispensing to the patient to confirm the right medication is being dispensed. At the time of these incidents, CVS performed this check by pouring a few tablets into the lid of the container for examination before dispensing. m. Investigation of the Budd Lake incident indicated that the commingling error there occurred when the pharmacist filled a prescription calling for 360 tablets (90 day supply) of metformin, a generic diabetic medication, by using four stock bottles. The pharmacist retrieved three stock bottles of the correct medication but accidentally pulled a stock bottle of pravastatin, a generic cholesterol medication. According to CVS, the fact that the containers and labels of the two medications were similar in appearance and the fact that the medications themselves look alike contributed to the error. n. The Cherry Hill and Scotch Plains commingling errors involved automated prescription filling machines. These machines are used in many CVS pharmacies to fill high volume prescriptions (those that are most frequently ordered by that pharmacy's customers). Automated filling machines contain numerous bins or "cells" which are stocked by pharmacy staff from the stock bottles of medications. Although the use of an automated filling machine can decrease errors, it is crucial that pharmacy staff follow correct procedures to maintain the safety and integrity of the cells of medications within the machine. 0. In both Cherry Hill and Scotch Plains, a cell within the machine was found to contain two different medications. It appears likely that the error in Scotch Plains originated when errors occurred during the above 10 described RTS procedure. A stock bottle which improperly contained two medications was used to fill a cell in the machine from which commingled prescription containers were prepared. In the Cherry Hill store, however, the commingling of two medications within a single cell resulted from the filling of the cell by a pharmacy technician who failed to follow CVS's procedures. Specifically, at the time of replenishment, the pharmacy technicians likely failed to scan the bar code of each stock bottle added to the automatic dispensing cell. Failures such as those that occurred in the Cherry Hill and Scotch Plains CVS pharmacies can result in an erroneous and potentially dangerous mixture of two drugs being delivered to a significant number of customers. p. Automated filling machines frequently contain both Prescription Legend Drugs and Controlled Dangerous Substances since the machines' contents are influenced by the frequency with which particular drugs are prescribed by physicians to CVS customers in that pharmacy's service area. Thus, commingling errors present the risk that Controlled Dangerous Substances will be added to erroneously filled prescription containers. Improper handling of Controlled Dangerous Substances presents a serious risk of harm to the public so the Acting Director 11 is even more vigilant about any procedures which could cause errors in the handling of these medications. q. Finally, in addition to the information developed in the course of the above--referenced investigation of this matter, trained pharmacy inspectors from the Enforcement Bureau of the Division of Consumer Affairs performed physical inspections of the CVS pharmacies in Chatham, Cherry Hill, Scotch Plains, and Budd Lake.2 3. CVS also has conducted an investigation and, without admission of liability, also desires to resolve this matter through the entry of this AVC. NOW THEREFORE, the Parties hereto agree as follows: Voluntary Remediation 4. CVS will take certain remediation steps as detailed below to address the issues identified during the course of this investigation. CVS has already implemented many of these steps while others will be implemented in accordance with this AVC. 5. The Division expects that during the twenty--four month time period for which this AVC is in effect, CVS may develop innovations further improving consumer safety beyond those measures set forth in this AVC. The Division does not intend 2 The Division was not informed of the incident at the Rahway store until four months after it occurred. Thus a physical inspection was not performed. 12 this AVC to stifle such innovations, and the implementation of new or different procedures and/or processes to further improve patient safety and quality are permitted under this AVC. The parties will meet on or about twelve months from the entry of this AVC to discuss the progress of CVS in its implementation of consumer safety measures. At this juncture, the remediation to be undertaken includes the following actions: a. CVS has undertaken retraining of all retail pharmacy personnel in New Jersey involved in the procedures followed when unclaimed prescriptions are returned to pharmacy stock. Although its prior written procedures may have been adequate to safely handle the return to stock process, those procedures had been overlooked or circumvented by certain pharmacy employees. Since the incidents outlined above, all retail pharmacy personnel have been retrained. b. CVS procedure previously restricted the use of the automated filling machines to "specialists" who are registered pharmacy technicians and to licensed pharmacists. The "specialists" receive training in all aspects of the machine's operation and security. On March 29, 2012, CVS halted the use of automated filling machines throughout New Jersey while undertaking a program of retraining for all New Jersey pharmacy personnel who 13 were previously designated as "specialists" and authorized to fill the cells of the machine and to dispense prescriptions therefrom. The program of retraining users of the automated filling machines has been taking place throughout New Jersey and all authorized personnel within each pharmacy have been re--trained as a pre--requisite to the resumption of use of the automated filling machines. c. CVS will implement and enforce enhanced procedures for stocking the automated filling machines. These enhanced procedures are included in the retraining described in paragraph above. These enhanced procedures include the following: i. The pharmacist is required to visually check every pill before refilling a cell with a vial that has been returned to stock and visually verify all RTS pills against a pill image that is seen on a computer screen when refilling that cell. In order to assure that the individuals performing these functions are accountable for following this enhanced procedure, the computer now also tracks the credentials of every "specialist" and pharmacist who participates in refilling a particular cell. ii. Routine refilling of all machines will be scheduled to take place only during specific "down 14 time" in the store so that this critical function can be achieved during less pressured business hours. However, CVS may replenish cells in automated filling machines if the cells become empty during the course of a work day. CVS's quality assurance policy will continue to hold store pharmacists responsible for maintaining the security of the key to the automated filling machine and overseeing the replenishment procedure. iv. CVS will continue to adhere to its longstanding policy that RTS medications are never to be poured back into manufacturers' stock bottles. RTS medications will continue to be kept in separate containers which will be placed next to corresponding manufacturers' stock bottles. Where appropriate, the separate containers will be rubber banded to the stock bottles. d. As has been its policy in New Jersey, CVS will continue to employ only State registered pharmacy technicians (or those in the process of obtaining state registration). e. Commencing immediately, quality assurance reviews in stores throughout New Jersey, which are conducted by the Registered Pharmacists in Charge of each store, will occur 15 at least once every month and will be conducted with a particular focus on medication safeguards. These medication safeguards include, but are not limited to, reviews of accountability for dispensing accuracy, adherence to return to stock procedures, adherence to CVS's accuracy scan process, and, in pharmacies where CVS uses automated filling machines, adherence to CVS procedures relating to those machines. Additionally, CVS has always required store visits by district pharmacy supervisors and will continue to do so going forward. Among the issues addressed by store visits are quality assurance reviews of compliance. Store visits previously occurred at least every eight weeks, and, commencing immediately, will now occur at least once every month. District supervisors will remain vigilant in looking for indicators that CVS procedures need reinforcement or that specific individuals need retraining and will ensure that frequent assessment of employees' compliance with procedures and any necessary retraining is undertaken. f. Throughout New Jersey, pharmacy supervisors will specifically advise CVS employees that noncompliance with CVS policy and procedures will have employment consequences proportionate to the conduct. g. CVS prescription labels currently contain a written description of the medication contained in a l6 prescription container. CVS will also now make available to the public pill images and clinical information about medications through the CVS website In addition, each CVS customer will be able to view his or her own personalized prescription profile online with both color images of medications and clinical information. This will give the public an additional resource to check the accuracy of dispensed medication. h. As part of CVS's efforts to educate its patients about prescription safety, and as another way to prevent consumption of erroneously dispensed medications, within sixty (60) days after the Effective Date, CVS will display posters and provide single-page pamphlets in its New Jersey retail pharmacies to remind patients to compare the written description of their prescription on the label to the contents of their prescription vials. As an alternative to the display of posters and provision of pamphlets, CVS may develop and implement a comparable method of disseminating this information. Such dissemination will occur at or near the point of sale of medication to CVS's customers. i. CVS will continue its use of auxiliary labels which are placed on pharmacy containers to notify a consumer of a change in the appearance of his or her medication. This typically occurs when the manufacturer l7 has re-formulated a medication which has been previously dispensed to a patient. This feature will also be described in the CVS educational pamphlet available for distribution to consumers at CVS registers. 6. Within three business days after CVS's Quality Assurance department becomes aware that a commingling error has occurred at a CVS pharmacy in New Jersey, CVS will notify the Division and the Board of Pharmacy of the occurrence. CVS will then make a full report to both the Division of Consumer Affairs (through the Attorney General) and the Board of Pharmacy within ten business days after the Quality Assurance department becomes aware of the occurrence. That report will include a summary of the investigation undertaken by CVS and an assessment of the source of the error. To ensure the privacy of CVS customers and compliance with federal laws, the information provided in the reports will not include information identifying any patients. The parties anticipate that these reports, if necessary, will be made in a spirit of improving the provision of pharmaceutical medications to New Jersey citizens and will be made without prejudice to the Division of Consumer Affairs' and the Board of Pharmacy's ability to oversee licensed practice in New Jersey and to take appropriate disciplinary steps in the event that violations of State statutes and regulations have occurred. 18 7. As of December 31, 2012, CVS provided its pharmacists in New Jersey with computer access in the workplace to the New Jersey Prescription Monitoring Program which will enable pharmacists to access the PMP where appropriate, in the exercise of their professional judgment. CVS will join with the Division to encourage all CVS pharmacists to enroll in the PMP by sending the letter attached hereto as Exhibit to all pharmacists employed in CVS retail stores in New Jersey. The letter shall issue from CVS within 60 days of the effective date of this AVC. Educational and Enforcement Initiative Funding 8. The Division of Consumer Affairs directs a number of initiatives as part of its ongoing efforts to educate the public about the risks inherent in prescription medications as well as prescription drug abuse. One existing component of the Division's efforts in this area is demonstrated by the New Jersey Prescription Monitoring Program, a statewide database that collects prescription data on Controlled Dangerous Substances and Human Growth Hormones dispensed in outpatient settings in New Jersey and by out--of--state pharmacies dispensing into New Jersey. This database, which can be consulted when prescribers or pharmacists are concerned that a current or prospective patient appears to have a substance abuse problem or appears to be inappropriately obtaining Controlled Dangerous 19 Substances or Human Growth Hormones, has already proven to be an important tool in informing and protecting the public. Another initiative is the Division's website for consumers, which displays listings of current drug prices and information on common medications. Additionally, the Division is helping to remove unwanted prescription drugs from NJ households by placing secure drug "drop boxes" throughout the State, where consumers can dispose of unwanted or leftover medications. The Division, through its Enforcement Bureau, also investigates cases of suspected prescription drug diversion. These efforts, and others, demonstrate the State's commitment to consumer education, outreach, and enforcement in the area of prescription drugs awareness. The citizens of New Jersey need to be current and informed about the information available to them, by which they can help ensure the safety of themselves and their loved ones, and the Division must remain vigilant in educating New Jersey's citizens and in combating diversion. 9. The Acting Director intends to continue the Division's efforts outlined above in paragraph 8 and mount a new widely disseminated public education campaign directed at the citizens of New Jersey to advise them of the need to carefully monitor the appearance of their medication, to question pharmacists (or their physicians) when they have concerns about medications, and to check available resources to obtain information about their 20 prescriptions (the "Division's Education and Enforcement Campaign"). In addition to directly providing information about medication safety, the Division's Education and Enforcement Campaign will allow the Division to continue to protect the public from prescription drug diversion, provide consumers with additional educational resources such as sources for color images and descriptions of various frequently prescribed medications, and include a program of outreach to senior citizens and homecare providers who are in a position to detect medication errors. This Campaign will operate cooperatively with existing Division of Consumer Affairs Campaigns to ensure that prescription medications are dispensed accurately, handled safely and disposed of properly. 10. In support of the Division's Education and Enforcement Campaign, CVS agrees to pay the Division the sum of Six Hundred and Fifty Thousand Dollars This payment will reimburse the Division for attorney's fees and investigative costs and the remainder will be applied toward the funding of the Division's Education and Enforcement Campaign. The Parties acknowledge and agree that the payment described herein is not a fine or penalty, or payment in lieu thereof. 11. The payment shall be made within thirty days of the execution of this AVC by both parties and may be paid by wire 21 transfer, pursuant to wire instructions to be provided by the Division. Release 12. Subject to paragraph 13 below, this AVC resolves all matters known to the Division of Consumer Affairs on behalf of the State of New Jersey (including on behalf of the New Jersey Board of Pharmacy) and arising from the dispensing errors in late 2011 and in 2012 at the Chatham, Cherry Hill, Scotch Plains, Budd Lake, and Rahway CVS pharmacies (the "Covered Conduct"). By its execution of this AVC, the Division releases and discharges CVS, CVS Rx Services, Inc., and their officers, employees (with the exception of NJ licensed pharmacists and pharmacy technicians involved with the Covered Conduct, as referenced in paragraph 13 below), agents, other workforce members, affiliates, merged or acquired entities, parent or controlling entities, wholly--owned subsidiaries, and all of its past and present subsidiaries, affiliates, and predecessors from all civil administrative claims or other civil causes of action, damages, restitution, costs, attorney fees, fines and civil penalties that the Division could have brought or asserted based upon the Covered Conduct that occurred prior to the Effective Date of this AVC. 13. Notwithstanding any other term of this AVC, this AVC does not preclude any potential investigation and disciplinary 22 action by the New Jersey State Board of Pharmacy against individual pharmacists and pharmacy technicians who are its licensees and registrants pursuant to the New Jersey Pharmacy Practice Act, N.J.S.A. 45:14-40 et seg., the New Jersey Uniform Enforcement Act, N.J.S.A. 45:l--14 gt and administrative regulations promulgated under those Acts. Additional Provisions 14. This AVC represents the full and complete terms of the settlement entered into by the Parties hereto. In any action undertaken by the Parties, no prior versions of this AVC and no prior versions of any of its terms may be introduced for any purpose whatsoever. 15. This AVC shall not be construed or used as a waiver or limitation of any defense otherwise available to CVS in any action, or of right to defend itself from, or make any arguments in, any private individual, regulatory, governmental, or class claims or suits relating to the subject matter or terms of this AVC. This AVC is made without trial or adjudication of any issue of fact or law, or any finding or admission of liability of any kind and shall have no preclusive or res judicata effect against CVS in any other proceeding. Notwithstanding the foregoing, the Division may file an action to enforce the terms of this AVC. 23 16. No part of this AVC shall create a private cause of action or confer any right to any third party for violation of any federal or state statute except that the Division may file an action to enforce the terms of this AVC. It is the intent of the Parties that this AVC not be admissible in other cases or binding on CVS in any respect other than in connection with the enforcement of this AVC or the actions of the Board of Pharmacy allowed for in paragraphs 12 and 13. 17. Should the Division receive any requests from third parties pursuant to the New Jersey Open Public Records Act or other lawful demand for access to documents or information it receives from CVS pursuant to this AVC, it will notify CVS so that CVS may have a reasonable opportunity to object to the disclosure of such information or documents. This paragraph shall survive the expiration of this AVC. 18. Any notices, statements, or other written documents required by this AVC shall be provided by first class mail to the intended recipient at the address set forth below, unless a different address is specified in writing by the party Qhanging such address: For the Division: For CVS: .Acting Director Eric T. CVS Pharmacy, Inc. Kanefsky Attn: Corporate Secretary NJ Division of Consumer One CVS Drive Affairs Woonsocket, RI 02895 124 Halsey Street Newark, NJ 07102 - and -- 24 CVS Pharmacy, Inc. Attn: Chief Compliance Officer One CVS Drive Woonsocket, RI 02895 19. This AVC will take effect on the date on which all parties have executed this AVC (the "Effective Date"). Unless otherwise agreed by the Parties, this AVC will expire two years after the Effective Date. 20. The Parties represent that an authorized representative of each has signed this AVC with full knowledge, understanding, and acceptance of its terms and that this person has done so with the authority to legally bind the respective Parties. 21. This AVC may be executed in counterparts, and a facsimile or PDF signature shall be deemed to be, and shall have the same force and effect as, an original signature. so AGREED ON THIS DAY OF . 2013: fl CVS Pharmacy, Inc. and New Jerse CVS Pharmacy, L.L.C. Thomas S. Moffatt Vice President, Assistant General Counsel, Corporate Secretary and President, New Jersey CVS Pharmacy, L.L.C. 25 Jeffrey S. Chiesa Attorney General of New Jersey 26