Request for Proposal for Fully Insured, Minimum Premium ... · Fully Insured, Minimum Premium, and Administrative ... Minimum Premium, and Administrative Services ... both in- and

Proposal No. P14/9833

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Request for Proposal for Fully Insured, Minimum Premium, and Administrative Services Only

Medical Plans Self-Funded Pharmacy Benefit Management Services

Pima County Community College District (“College” or “District”) is seeking proposals from qualified firms for Employee Medical Benefit Plan (Fully Insured, Minimum Premium, and Administrative Services Only) and Pharmacy Benefit Management Services. The deadline for receipt of sealed proposals is: January 8, 2014 at 3:00 PM (Arizona Time). Sealed proposals must be received by this deadline at the following location:

Pima County Community College District District Finance Office-Purchasing 4905D East Broadway, Room D-232 Tucson, Arizona 85709-1420

Any proposal received after the date and time listed above will be returned and will not be considered. Questions pertaining to this Request for Proposal (RFP) must be communicated in writing and be received via email by December 16, 2013 at 3:00 PM (Arizona Time). Questions must be sent to the email address below and should include the specified Buyer’s name and proposal number, and any question(s) should include a reference to the appropriate page and section number of the RFP. Questions and answers will be posted on the Pima Community College webpage listed below by December 20, 2013 at 5:00 PM (Arizona Time):

Linda Ellis, CPPB Senior Buyer

[email protected] Copies of the Request for Proposal, questions, and answers, and any related documents are available on the Pima Community College Website: http://www.pima.edu/administrative-services/purchasing/current-requests-for-proposals-bids-quotes.html Thomas E. Harrington, C.P.M. Purchasing Director Pima County Community College District District Finance Office-Purchasing 4905 East Broadway, Room D-232 Tucson, Arizona 85709-1420

mailto:[email protected]

http://www.pima.edu/administrative-services/purchasing/current-requests-for-proposals-bids-quotes.html

http://www.pima.edu/administrative-services/purchasing/current-requests-for-proposals-bids-quotes.html


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Table of Contents

Section 1 Project Summary Section 2 Scope of Work Section 3 Proposal Preparation and Submittal Section 4 Selection and Contract Award Section 5 Proposal Form Attachment A Insurance Attachment B Terms and Conditions Attachment C List of Vendor Exhibits Exhibit 1 - Intent to Propose Exhibit 2 - Scope of Work Exhibit 3 - Confidentiality Agreement Exhibit 4 - Prior and Pending Lawsuits Exhibit 5 - Fees/Rates Certification Exhibit 6 - Confidential and Proprietary Submittals Exhibit 7 – Deviations

Exhibit 8 – Vendor Information Form Attachment D Benefit Handbook Plan Description Attachment E Open Enrollment Guide Attachment F Census and Claims (Medical and Pharmacy) Experience* Attachment G Financial Workbook (includes provider disruption with tax IDs) Attachment H Cigna Plan Documents and Riders A census file, two claims experience files and the financial workbook have not been included. These documents will be provided to vendors after completion and submission of the Confidentiality Agreement contained as Exhibit 3 in this RFP. The completed and signed agreement should be emailed to Linda Ellis, CPPB, Senior Buyer, at [email protected]. Vendors will then receive the census file via secure email from the College’s consultant, Segal Company.




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Section 1 Project Summary

1. Request for Proposal Summary

Pima County Community College District (“College” or “District”) is seeking proposals from qualified firms for Employee Medical Benefit Plans (Fully Insured, Minimum Premium, and Administrative Services Only) and Self-Funded Pharmacy Benefit Management Services in accordance with the Scope of Work specified in this Request for Proposal (RFP).

2. Entity Submitting RFP. The terms “vendor”, “proposer”, “offerer”, “firm”, “consultant”, “company” or “contractor” used in this RFP or any subsequent documents or communications related to this RFP are interchangeable and mean the entity submitting a proposal and seeking to enter into a contract for the goods and/or services requested in this RFP.

3. Description of Pima County Community College District Pima County Community College District, located in Tucson, Arizona, is one of the ten largest multi-campus, multi-site Community Colleges in the United States. The College is a two-year institution offering both occupational and traditional college courses, and awards many different degrees and certificates. The College’s comprehensive curriculum includes credit courses, workforce development programs (Center for Training and Development), adult education special programs (GED), as well as corporate and community based non-credit instruction. Students attend classes at six major campuses including the Community Campus, which itself holds classes at over 70 locations in Southern Arizona. The College employs more than 1,400 regular employees, approximately 1,500 adjunct faculty and 500 part-time personnel. More than 70,000 students attend credit and non-credit classes annually. The population for the Tucson metro area is approximately 1 million people. The College is accredited by the Commission on Institutions of Higher Education of the North Central Association of Colleges and Schools.


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Section 2 Scope of Work

PROJECT SCOPE It is the intention of the College to continue to offer the current plan designs for the July 1, 2014 through June 30, 2015 plan year. In addition, The College plans to continue to self-fund the prescription drug benefit plan whether it is bundled with the Medical provider or under a separate contract with a Pharmacy Benefit Manager. There is interest in reviewing the possibility of adding a High Deductible Health Plan effective July 1, 2014, which is included as part of this RFP. The College is seeking proposals for the following scenarios:

Fully-Insured Medical/Vision* Plans Fully-Insured Minimum Premium Medical/Vision* Plans Administrative Services Only Medical/Vision*, Stop-Loss, and Prescription Drug

Plans Self-Funded Pharmacy Benefit Management Services

*Vision Plan applies only to the OAPIN participants and their dependents. OAPIN is CIGNA’s name for an in-network only PPO/POS. OAP stands for Open Access Plus PPO/POS network. Vendors may choose to submit a proposal for the Medical/Vision Plans only, the Prescription Drug Plan only, or both. In each case, it is the College’s intent to keep the Pharmacy portion of their program self-funded. If you are proposing to bundle the Prescription Drug Benefit under the Fully-Insured and Minimum Premium scenarios, it should be as an option. In each of these four scenarios, vendors should duplicate the benefits currently offered in the OAPIN, OAP, Vision, and Prescription Drug plans. However, The College would also like the Vision plan to be offered to OAP (PPO/POS) plan participants as well. The College intends to change the Pharmacy pricing from Traditional to Transparent pricing as of July 1, 2014. This change should be taken into consideration when submitting your proposal. The College does not anticipate any other changes for July 1, 2014, except those required by Health Care Reform. The College is also interested in Wellness Programs such as onsite flu shots, biometrics, dedicated wellness resources, a wellness budget funded by the vendor, and health reimbursement arrangements (see Page 8, Special Programs, for a description of the HRA). In addition, your proposal should include the administration of a third medical plan incorporating a High Deductible Health Plan with an Health Savings Account should the College decide to implement one July 1, 2014. Fully-Insured Medical/Vision Plan The following components should be included in your response to this section of the RFP:

Assume duplication of the current Medical/Vision benefit plans.


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If you are proposing to bundle the Prescription Drug benefit, it should be optional and on a self-funded basis, and assume current benefits and contract provisions, with the exception of the change to Transparent pricing.

If a separate PBM vendor is selected, the Medical/Vision vendor will be required to accept claim data from the PBM vendor and include those claims in the true out-of-pocket maximum required by Health Care Reform.

The Medical contract is to be underwritten on an experience-rated, non-retention accounting basis.

Claims should be pooled at $150,000. For purposes of determining whether the pooling point has been attained, the proposed

contract should include medical claims only. If any disease management programs are available and included in your proposal, they

must be proposed on an opt-out basis. Provide online access to reporting for both the College and the designated consultant.

Minimum Premium Medical/Vision Plans

Assume duplication of the current Medical/Vision benefit plans. Funding should be on a Minimum Premium (an insured contract as defined by the

Department of Insurance) basis for Medical and Vision. The College is not interested in a Minimum Premium “look-alike” (aka ‘self-funded with a low aggregate corridor).

If you are proposing to bundle the Prescription Drug benefit, it should be optional and on a self-funded basis, and assume current benefits and contract provisions, with the exception of the change to Transparent pricing.

If a separate PBM vendor is selected, the Medical/Vision vendor will be required to accept claim data from the PBM vendor and include those claims in the true out-of-pocket maximum required by Health Care Reform.

Claims should be pooled at $150,000. The College would like the opportunity to hold its own reserves. If any disease management programs are available and included in your proposal, they


Administrative Services Only and Stop-Loss Insurance Medical/Vision* Plans

Assume duplication of the current Medical/Vision and Prescription drug benefit plans. It is the College’s intention that if an Administrative Services Only contract for Medical

and Vision is implemented, it will be with a single vendor. If a separate PBM vendor is selected, the Medical/Vision vendor will be required to

accept claim data from the PBM vendor and include those claims in the true out-of-pocket maximum required by Health Care Reform.

The Prescription Drug program should include the change to Transparent pricing. Include Specific Stop-Loss with a $150,000 deductible and Aggregate Stop-Loss with a

125% attachment factor. Your Stop-Loss proposal should assume claims for medical only, as an alternative

include prescription drugs. Vendor will be responsible for all three levels of claim appeals. If any disease management programs are available and included in your proposal, they



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A 10 business day grace period to submit claim payment to the administrator. Self-Funded Pharmacy Benefit Management Services

Assume duplication of the current benefits and contract provisions with the exception of the change to Transparent pricing.

If proposing only on the PBM portion of this RFP, assume that the vendor will be required to submit prescription drug data to the Medical/Vision vendor on a daily basis.

Please refer to the PBM portion of this RFP. Vendor will be responsible for all three levels of claim appeals. A 10 business day grace period to submit claim payment to the PBM. Vendor will be responsible for all three levels of claim appeals. Provide online access to reporting for both The College and consultant.

UNDERWRITING INFORMATION Pima County Community College District currently offers medical and prescription drug benefits to 1,349 employees. Plan Designs The College offers two medical plan options: (1) Open Access Plus (OAPIN) - Plan with in-network benefits only, including copays and a

Vision Plan. (2) Open Access Plus (OAP) – Plan with a $500 Deductible, with coinsurance and copays

for some services, both in- and out-of-network benefits, and a Health Reimbursement Account (HRA).

Both of the Medical plans have been underwritten by Cigna on a fully-insured basis since July 1, 2009. The plans contain a $150,000 pooling level. The current Plan Designs are explained in detail in both the Plan Document and Open Enrollment Guide contained in this RFP. The plan design changes that have been implemented during the last three years are as follows: July 1, 2013: OAP Plan changes were as follows:

Calendar year deductible increased from $250/$500 to $500/$1,000 Increased Specialist Copay from $20 to $35 per visit Urgent Care Copay increased from $35 to $50 per visit Emergency Room Copay increased from $75 to $125 per visit Outpatient Therapy Copay increased from $20 to $35 per visit Behavioral Health Copay increased from $20 to $35 per visit Women’s contraceptive and reproductive counseling will be offered at no cost


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July 1, 2013 OAPIN Plan changes were as follows:

Increased PCP Copay from $15 to $20 per visit Increased Specialist Copay from $30 to $35 per visit Increased Copay for Convenience Care Clinics from $15 to $20 per visits Urgent Care Copay increased from $35 to $50 per visit Emergency Room Copay increased from $75 to $125 per visit Outpatient Therapy Copay increased from $20 to $35 per visit Behavioral Health Copay increased from $20 to $35 per visit Behavioral Health Outpatient Facility Copay increased from $20 to $35 per visit Women’s contraceptive and reproductive counseling will be offered at no cost

There was one benefit change to the Medical plan July 1, 2012:

The College made all colonoscopies at no cost to members, including those with a diagnosis.

July 1, 2011 OAP and OAPIN Plan changes were as follows:

The College implemented changes relative to the ACA by including enhanced preventive services at no cost to the member; no lifetime maximums; and eligibility for children up to age 26 regardless of student, marital or tax-dependent status.

The Prescription Drug program has been self-funded through ESI (Express Scripts Incorporated, formerly Medco) since July 1, 2003 and uses Traditional Pricing (although, as stated earlier, The College desires the program to use Transparent Pricing from July 1, 2014 forward). The plan design changes that have been implemented during the past three years are as follows: July 1, 2013 PBM Plan changes:

Implemented prior authorization and quantity management procedures:

Prior Authorization targets the utilization of drugs for which there are multiple FDA-approved uses or guidelines to encourage safe and effective usage.

Drug Quantity Limits are determined based on clinical guidelines and may limit

medication quantities for safety and effectiveness reasons.

Changed from a $5 Generic and $25 Brand copay structure to a $5 Generic, $25 Preferred Brand, and $40 Non-Preferred Brand copay structure.

There were no changes to the prescription drug benefits for July 1, 2011 or July 1, 2012.


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If the College implements a High Deductible Health Plan, the following provides an outline of the anticipated benefit design:

$1,500 individual deductible $3,000 family deductible Coinsurance: 80%/20% In-Network, 60%/40% Out-of-Network Out-of-Pocket max including deductible: $5,000 individual/ $10,000 family (In-Network),

$10,000 individual/ $20,000 family (Out-of-Network) Preventive Care covered at 100% The College will fund the Health Savings Account (HSA) at an amount yet to be

determined. The remainder of the plan design should be consistent with the current OAP plan. (Note: Office Visit and other copays would not apply under this plan). Special Programs Plan Design The College has arranged other Special Programs in conjunction with the Cigna medical plans of which you should be aware. It is the intention of the College to maintain these programs. Healthy Reimbursement Account (HRA): The College funds a HRA known to members as a Healthy Awards Account for each employee that enrolls in the OAP plan. The Healthy Awards dollars are not included in the Cigna rates as they are totally funded by the College. Employees are reimbursed tax-free for qualified medical expenses such as co-pays, deductibles, and co-insurance incurred under their Cigna coverage. A pre-set award amount, which is based on the level of plan coverage, is deposited into a Cigna account. The amount of the deposit depends on the employee’s enrollment tier, as follows:

Rate Tier Health

Reimbursement Amount*

Employee Only $200 Employee + Spouse $500 Employee + Child(ren) $500 Employee + Family $750

*The amount is pro-rated for employees who become covered after The beginning of the plan year (new hires, special enrollment, etc.)

There are no forms or claims to file. When an eligible expense is incurred, Cigna uses the money in the participant’s Account to reimburse the expense. A reimbursement check is then mailed along with the Explanation of Benefits statement. The College reserves the right to change the HRA amounts. Health Insurance Waiver: Employees are allowed to waive medical coverage if they can provide proof of coverage in another qualified group health plan and complete the necessary form. Those employees who qualify for the waiver can receive up to $2,400 per plan year (pro-rated for effective dates after the beginning of the plan year) deposited into the Flexible


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Spending Account sponsored by the College. They can use all of it in the Health Care Spending Account or Dependent Care Spending Account, or split the amount (50%/50%). This program is administered internally by the College. Currently 182 Employees have waived coverage. Reimbursement for Inpatient and Outpatient Hospital Costs: Employees participating in the Medical/Rx coverage participate in this program. The College reimburses a portion of each inpatient hospital and outpatient hospital cost, including co-pay(s), deductible or coinsurance(s) incurred during the Plan Year for themselves and/or their covered dependents. This program is administered internally by the College. The maximum reimbursement for the OAP plan is $550 for each inpatient expense and/or outpatient service incurred, less any Healthy Awards HRA reimbursements. The maximum reimbursement for the OAPIN plan is $350 for each inpatient cost and $150 for each outpatient cost, adjusted for any discounts by the medical facility. However, under no circumstance will the College reimburse the employee for 100 percent of their financial responsibility for the hospital service received. The minimum responsibility the employee must pay for an inpatient hospital stay is $150 and for an outpatient hospital visit is $100. Emergency Room co-pays/visits are excluded from this program. The table below reflects the total amount reimbursed to employees during the last three plan years.

Plan Year Inpatient and

Outpatient Hospital

Reimbursement 2012-2013 $23,420 2011-2012 $31,912 2010-2011 $30,783

Eligibility Eligible Employees are defined as follows:

Full-time regular classified employees and administrators Regular faculty working at least 30 hours per week Regular faculty who, by prior approval, have up to 2/5 unpaid release time for sabbatical Faculty on a one-year administrative appointment Probationary employees

Temporary employees and adjunct faculty are not currently benefit eligible. However, the College is currently reviewing its policies to comply with the Affordable Care Act. Eligible dependents are defined as the legal spouse, domestic partners, and dependent children up to age 26 regardless of student, marital, or tax-dependent status. A domestic partner’s dependent children can participate, but only to the extent that the domestic partner participates. Employees have 30 days from their date of hire to enroll. Coverage begins the first day of the month following the date enrollment forms are submitted to the Benefits Office.


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The College currently transmits an annual eligibility and enrollment file to the carrier. The College benefit staff makes mid-year elections, changes, and updates via access to the vendor’s web portal for the employer. The vendor is required to provide ID cards with the College’s name and/or logo in addition to an electronic copy of the ID card. Enrollment The current enrollment breakdown by plan and coverage tier is as follows:

Enrollment Tier OAPIN OAP Combined

Employee Only 391 395 786

Employee + Spouse 65 69 134

Employee + Child(ren) 50 72 122

Employee + Family 28 97 125

Total 534 633 1,167

Claims Experience (Medical and Pharmacy) 36 months of medical paid claims and enrollment including large claims information and pharmacy claims will be provided to vendors after completion and submission of the Confidentiality Agreement contained as Exhibit 3 in this RFP. Paid claims reflect amounts in excess of the pooling point ($150,000). Non-network claims are paid at 110% of Medicare. Enrollment History The enrollment history for the three prior years is included in the attachments. History of Rates The rate history for the two medical plans and the vision plan offered to OAPIN participants is shown below. These are the fully insured rates paid to Cigna and do not include prescription drug coverage or the HRA contribution from the College. The College intends to maintain the current ratio for Fully Insured and Minimum Premium Rates (1.0 Employee, 2.0 Employee & Spouse, 1.8 Employee & Child(ren), and 2.85 Employee & Family).

Plan/Rate Tier 2013-2014 2012-2013 2011-2012

OAPIN

Employee Only $ 506.52 $ 471.17 $ 415.49

Employee + Spouse $1,013.04 $ 942.35 $ 830.99

Employee + Child(ren) $ 911.74 $ 848.11 $ 747.89

Employee + Family $1,443.58 $1,342.83 $1,180.01


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Plan/Rate Tier 2013-2014 2012-2013 2011-2012

OAP Employee Only $ 460.63 $ 428.45 $ 393.81 Employee + Spouse $ 921.26 $ 856.90 $ 787.64 Employee + Child(ren) $ 829.13 $ 771.21 $ 708.88 Employee + Family $1,312.79 $1,221.08 $1,118.44

VISION (OAPIN Only)

Employee Only $0.92 $0.92 $0.83

Employee + Spouse $1.83 $1.83 $1.64

Employee + Child(ren) $1.85 $1.85 $1.66

Employee + Family $2.92 $2.92 $2.62

Contributions For the July 1, 2013 plan year, the College contribution strategy is as follows:

OAP Plan: The College is paying the full cost of employee coverage and between 45 percent and 55 percent of the cost for dependents, based on the rate tier in which the employee enrolls. This does not include any deposits into the (HRA) Healthy Awards Account, which is fully-funded by the College in addition to the contribution towards the Medical plan.

OAPIN Plan: The College pays all but 4.3 percent of the cost of employee coverage for

those who choose to enroll in the OAPIN plan and approximately 40 percent of the cost of coverage for dependents.

Census A census file has not been included. This document will be provided to vendors after completion and submission of the Confidentiality Agreement contained as Exhibit 3 in this RFP. The completed and signed agreement should be emailed to Linda Ellis, CPPB, Senior Buyer, at [email protected]. Vendors will then receive the census file via secure email from the College’s consultant, Segal Company. Medical Network Discounts Medical network discounts are a key part of this RFP evaluation process. This RFP will make use of discount information collected as part of the Uniform Data Submission (UDS) Task Force, a group of major carriers and consulting firms that have come together to simplify the collection of data for discount analysis so that all participating vendors provide the requested data in the same format. If your firm is not a part of this task force, you should contact our consulting firm Segal (Jeanna Carlton at [email protected] ) for data requirements and data record layout specifications.




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Fee/Rate Structure Proposed fees/rates must be valid for 120 days from the date your proposal is submitted. Fees/Rates must be guaranteed from year to year as quoted. No commissions are to be added to fees. All start-up costs, travel, supplies, training, and administration costs should be included in your fees/rates.


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Section 3

Proposal Preparation and Submittal

Proposals must conform to all requirements stated below, and elsewhere in this RFP. Disregarding these requirements may result in disqualification of the proposal. Before submitting a proposal, each firm shall familiarize itself with the entire RFP, including Scope of Work, contract form and all laws, regulations and other factors affecting contract performance. The firm shall be responsible for fully understanding the requirements of a subsequent contract and otherwise satisfy itself as to the expense and difficulties accompanying the fulfillment of contract requirements. The submission of a proposal will constitute a representation of compliance by the firm. There will be no subsequent financial adjustment for lack of such familiarization. All proposal materials must be placed in a sealed package (envelope, box, etc.) clearly marked with the proposal name and number and the firm’s name. It is the responsibility of the firm to ensure that proposals are received in the Office of the Purchasing Director by the due date and time stated on page 1 of this RFP. The firm is responsible for delivery of their proposal by the deadline notwithstanding any claims of error or failure to perform by a mail, courier, or package delivery service. No proposals or proposal modifications may be submitted orally, electronically, or via telephone, facsimile, electronic mail (email) or telegraph. All proposals must be typewritten on standard paper size (8½ x 11 inches) and shall be in the required format incorporating the forms provided in this RFP package, if any. It is permissible to copy these forms as required. The authorized person signing the proposal shall initial erasures, interlineations or other modifications on the proposal. The firm’s proposal should be organized in sections as outlined below:

1. Cover Letter

All proposals must include a cover letter submitted under the firm’s name on the firm’s letterhead containing the signature and title of a person or an official of the firm who is authorized to commit the firm to a potential contract with the College. The cover letter must also identify the primary contact for this proposal and include the College’s RFP number found within this RFP. The cover letter should express the firm’s interest and serve as an executive summary of the proposal.

2. Proposal Form

All proposals must include the complete Proposal Form signed by a person or an official authorized to commit the firm to a contract with the College. Your proposal must include the following documents with signature where required: Proposal Form (located in section 5 of this RFP) Scope of Work Table (Exhibit 2) Prior and Pending Lawsuits (Exhibit 4) Fees/Rates Certification Form (Exhibit 5)


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Confidential and Proprietary Submittals Form (Exhibit 6) Deviations and Exceptions Form (Exhibit 7) Vendor Information Form (Exhibit 8) Medical/Vision Questionnaire PBM Questionnaire Financial Workbook (Attachment G) Sample Contract Sample Report Package The College also requests an electronic copy of your Pima County PPO/POS network provider directories. The directories should be based on the following file specifications: Acceptable File Format: Excel (Preferred) Access Required Fields • Provider last name (Please do not put generation indicator i.e. Jr. III…or designation

such as MD or DC, etc. in this field) • Provider first name (Please do not combine first and last names in the same field) • Middle Initial • TIN (Preferred) or NPI • Street address (Only include physical locations not billing addresses such as P.O. Box) • City • State • 5-digit zip code (Some zip codes start with 0. Please do not use number format which

deletes the 0) • Network Indicator (PPO/POS) • Type of provider (primary care, chiropractor, hospital, etc.) • Degree (MD, DO, DPM) – The College will use this field to specifically evaluate the

number of doctors in your network Inpatient facilities and Outpatient facilities should be shown in separate lists from professional providers. You may also include any other fields that are in your data files, but only the fields listed above are required. Note: be careful not to send duplicate records. Our experience dealing with electronic provider listings is that we very often receive two or more records for the same provider (e.g. “John Smith” & “John A. Smith” with the same address).


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3. Proposal Copies

The firm must submit one (1) original copy of the proposal, clearly marked “Original”, one (1) copy of the proposal, clearly marked “Copy” and one (1) digital PDF copy (except certain exhibits noted below should be provided in native format) of the proposal on media suitable for copying and distributing electronically. Your proposal must also include a flash drive or CD with the requested Excel exhibits and Word questionnaire in their native format (not PDF). Vendor should be aware that failure to submit the proposal is the requested format may be rejected, subject to College review.

4. Qualifications Please refer to the Questionnaire for specific questions regarding your qualifications.

5. Response Responses must be clear and thorough, but concise, and written in plain, easy to understand language. Responses must follow the numbering format used in this Request For Proposal.

6. Exceptions Requested

Any exceptions to the requirements of this RFP that the firm requests the College to consider must be placed in this section using the Deviations Exhibit (Exhibit 7). Each alternate or exception should be addressed separately with specific reference to the requirement. If there are no proposed alternates or exceptions, a statement to that effect must be included in this section of the proposal. Any exceptions requested from the Contract Documents must also be included in this section. Exceptions that are not requested as part of the bid shall not be considered. Any proposed additional or alternate terms and conditions, contracts, waivers, licenses or agreements required by the firm should be included here with a brief explanatory introduction.

7. PROPRIETARY INFORMATION In the event any proposer shall include in the proposal any information deemed "proprietary" or "protected," such information shall be separately packaged from the balance of the proposal and clearly marked as to any proprietary claim. The College discourages the submission of such information and undertakes to provide no more than reasonable efforts to protect the proprietary nature of such information. The College, as a public entity, cannot and does not warrant that proprietary information will not be disclosed. The College shall have the right to use any and all information included in the proposals submitted unless the information is expressly restricted by the proposer. Firms wishing to be considered in the selection process who provide confidential or proprietary information must indicate such information in Exhibit 6 marked Confidential/Proprietary information.


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8. Cost Proposal The Cost Proposal should be reflected in the appropriate Excel Workbook (Attachment G – Financial Workbook) that accompanies this RFP. The Cost Proposal is required to be included with the original proposal. a. Prices shall be shown by item and individually extended, unless otherwise indicated. In

case of a conflict between unit price and extension, unit price prevails. b. The College is not exempt from paying State and local transaction privilege tax (sales

tax). i. Proposals that include equipment or materials should include itemized sales tax in

the amount of your proposal. ii. Proposals for services only, are not taxable.

c. Provide detailed explanations of any assumptions that the proposer made in calculating the project costs in order to provide sufficient information for the College to be able to prepare a detailed cost analysis and comparison.

d. Identify when the proposer proposes to bill the College (e.g. progress payments, in advance, milestone, weekly, monthly, etc.)

e. Indicate if any items are optional and specify them in a separate section(s). f. Underwriting caveats

Pima Community College expects that all costs are included in the overall fee for services proposed, and that there will be no additional expenses billed to the College for any reason. 9. Award

The initial term of the contract shall be for one year. Four, one-year extensions of the contract may be effected by Purchase Order or an amendment to this Agreement approved by both parties.

10. Appendix The Proposal Appendix must include: a. All documents or forms required by the College to be completed by the firm including the

required documents specified in the Appendix of this RFP.

b. Details of any past or pending litigation your company or any of its subsidiaries or affiliates has had in the past five years relate to the performance of services provided by your firm. Vendors to complete Exhibit 4 detailing information related to Pending or Past litigation.

c. If a firm has had any previous contracts canceled or is currently debarred, suspended, or proposed for debarment by any government entity, the current status must be documented in this proposal. The firm agrees to notify the College of any change in this status. If any customer has stopped using the product(s) or service(s) you are proposing, provide details including customer name, date when product was installed, date when product was discontinued (usage) and reason for discontinuation, including contact details of the customer.


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d. If the firm intends to use any cooperative, subcontract, third party agreement, or the like

to perform under their proposal, the firm must supply the name, address, qualifications, and criteria used by the firm for selection of any third party, and the intended services to be performed. The services provided under the scope of work proposed, in part or in whole, shall not be subcontracted our assigned without prior written permission of the College, except that the contractor may, without prior approval and without being released from any of its responsibilities hereunder, assign the contract to any affiliate or wholly-owned subsidiary of the contractor.

e. Samples of any documentation or form that proposer will require the College to sign.

11. General a. Cost of Proposal Preparation – The College shall not reimburse the cost of

developing, presenting or providing any response to this solicitation; offers submitted for consideration should be prepared simply, and economically, providing adequate information in a straightforward and concise manner.

b. Certification – By signature on the Proposal Form included herein, the vendor certifies

that the submission of the proposal did not involve collusion or other anti-competitive practices. The vendor has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service to a public servant in connection with the submitted proposal. In addition, vendor certifies whether or not an employee of the College has, or whose relative has, a substantial interest in any agreement subsequent to this document. Vendor also certifies their status with regard to debarment, or suspension by any governmental entity. Failure to provide a valid signature affirming the stipulations required by this clause shall result in the rejection of the submitted proposal and, if applicable, any resulting agreement. Signing the certification with a false statement shall void the proposal and, if applicable, any resulting agreement. Any resulting agreement may be subject to legal remedies provided by law. Vendor agrees to promote and offer to the College only those services and/or materials as stated in and allowed for under resulting agreement(s). A valid signature is defined as an officer or other individual with the ability to bind the contract on behalf of the vendor.


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Section 4

Selection and Contract Award

Proposals shall be evaluated based on the requirements set forth in the RFP. Selection of the firm(s) will be at the discretion of the College and will be based on the proposal that the College deems to be the most responsive, responsible and serves the best interests of the College. It is the intent of the College to negotiate and enter into a contract with the selected firm following a Notice of Intent of Selection. The initial term of the contract shall be for one year. Four, one-year extensions of the contract may be effected by Purchase Order or an amendment to this Agreement approved by both parties. Selected proposer(s) may be required to make on-site oral and visual presentations or demonstrations at the request of the College. The College will schedule the time and location for any presentations. Costs and equipment for such presentations are the responsibility of the proposer. Best and Final offers may be solicited from the pool of finalists prior to selection of the successful firm. Fully Insured, Minimum Premium and ASO Medical and Vision proposals will be reviewed by a selection committee and will be evaluated based on the following criteria, listed in order of importance:

A. Responsiveness of the proposal in clearly stating and understanding the scope of work, and in meeting the requirements of the RFP including matching the requested plan designs, and meeting the contractual requirements.

B. Network size and disruption.

C. College’s assessment of the Offeror’s abilities to meet and satisfy the needs of the College, taking into consideration proposed services, or expertise offered, that exceed the requirements, or the vendor’s inability to meet some of the requirements of the specifications.

D. Qualifications of the Offeror, financial and otherwise, to provide the College with these

services for the required period of time, provide appropriate staffing, provide necessary resources and show a history of demonstrated competence.

E. Cost, including network discounts (based on the results of the Uniform Data Submission

[UDS] analysis) – While cost is a significant factor in considering the placement of the awards, it is not the only factor. The award will not be based on price alone, nor will it be based solely upon the lowest fees/rates submitted.

F. Information obtained by the College from Offeror’s references or other clients.

G. Reporting Capabilities.

H. Performance Guarantees.


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Self-Funded Pharmacy Benefit Management proposals will be reviewed by a selection committee and will be evaluated based on the following criteria:

A. Overall Costs to the Client and its members B. Strength of Pharmacy Network and Formulary Management Programs (including Limited

Network)

C. Administrative, Member, Account Service Capabilities (that are not limited to services already included) and Flexibility

D. Clinical Support to the College

E. Demonstrated Ability to Manage Drug Mix

F. Organizational Strength and Stability

G. Advancing Patient Safety and Population Health

If a contractor receives a proposal award, a purchase order is issued, and contractor is unable to meet the delivery requirements, meet service requirements, or material that meets the College’s needs as outlined in this Request for Proposal, or is unable to hold proposal price, or fails to provide product or service within a reasonable period of time, AND/OR fails to provide product complying with proposal specifications, as determined by the College, the College reserves the right to go to the next lowest proposal price of equal quality which meets proposal specifications.


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Section 5

Proposal Form

Date __________________________________ Proposal of ___________________________________________________________________, (Name) a corporation organized and existing under the laws of the State of ______________________; a partnership consisting of ________________________________________; an individual trading as _______________________________________________________________. (Name) Request for Proposal: ______________________________________ [provide title or brief description] To: Pima County Community College District (“College”) 1. In compliance with your Request for Proposal No. __________, the undersigned hereby offers to furnish the services designated in the RFP, in strict accordance with the RFP, upon written notice of acceptance of this Proposal at any time within thirty (30) days after the date of opening of the Proposals, and to execute the Contract in accordance with the Proposal as accepted within five (5) days after the Contract is presented for signature. 2. The undersigned Proposer hereby acknowledges receipt of the following Addenda, if any: Addendum No. Date ____________________ _____________________ ____________________ _____________________ ____________________ _____________________ ____________________ _____________________ ____________________ _____________________ ____________________ _____________________ 3. The undersigned Proposer understands that the College reserves the right to reject any or all Proposals or to waive any formality or technicality, as determined by the College in its sole discretion, in any Proposal in the interest of the College. 4. The undersigned Proposer hereby certifies and affirms that this Proposal is genuine and not a sham or collusive, nor made in the interest or behalf of any person not herein named, and that the undersigned Proposer has not directly or indirectly induced or solicited any other Proposer to put in a sham bid, or any other person, firm, or corporation to refrain from bidding, and that the Proposer has not in any manner sought by collusion to secure for itself an advantage over any other Proposer.


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5. The undersigned certifies that to the best of his/her knowledge: (check only one)

( ) There is no officer or employee of Pima Community College who has, or would have, or whose relative has, or would have, a substantial interest in any contract resulting from this request. ( ) The names of any and all public officers or employees of Pima Community College who have, or would have, or whose relative has, or would have, a substantial interest in any contract resulting from this request, and the nature of the substantial interest, are included below or as an attachment to this Proposal.

_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 6. The Proposer certifies, to the best of its knowledge and belief, that: (i) The Proposer and/or any of its Principals or Owners:

(A) (check one) are ( ) or are not ( ) presently debarred, suspended, proposed for debarment, or declared ineligible for the award of contracts by any governmental agency. (B) (check one) have ( ) or have not ( ), within a three year period preceding this offer, been convicted of or had a civil judgment rendered against them for: commission of fraud or a criminal offense in connection with obtaining, attempting to obtain or performing a public (federal, state or local) contract or subcontract; violation of federal or state antitrust statutes, rules or regulations relating to the submission of offers; or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion; or receiving stolen property; and (C) (check one) are ( ) or are not ( ) presently indicted for, or otherwise criminally or civilly charged by a governmental entity with, commission of any other of the offenses enumerated in paragraph (i)(B) of this provision.

(ii) The Proposer (check one) has ( ) or has not ( ), within a three year period preceding this offer, had one or more contracts terminated for default by any governmental agency.


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“Principals,” for the purposes of this Proposal, means officers, directors, owners, partners and persons having primary or substantial management or supervisory responsibilities within a business entity.

7. The certifications in paragraphs 4, 5 and 6 of this Proposal are material representations of fact upon which reliance will be placed when making an award. If it is later determined that the Proposer knowingly rendered an erroneous certification, in addition to other remedies available to the College, the College may terminate the contract resulting from this solicitation for default. ______________________________________ (Official Name of Firm)

SEAL - If Bidder is a Corporation ______________________________________ (Signature) ______________________________________ (Print Name) ______________________________________ (Title) _______________________________________ (Complete Business Address) _______________________________________ (Email Address) _______________________________________ (Federal Taxpayer ID Number)


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Attachment A INSURANCE

1. Insurance Requirements

The Vendor, at Vendor’s own expense, shall purchase and maintain the herein stipulated minimum insurance with companies duly licensed to do business in the State of Arizona with policies and forms satisfactory to the College and possessing a current A.M. Best, Inc. Rating of B++6.

All insurance required herein shall be maintained in full force and effect until all work required to be performed under the terms of the agreement is satisfactorily completed and formally accepted; failure to do so may, at the sole direction of the College, constitute a material breach of the agreement.

The Vendor’s insurance shall be primary insurance, and any insurance or self-insurance maintained by the College shall not contribute to it.

Any failure to comply with the claim reporting provisions of the policies or any breach of an insurance policy warranty shall not affect coverage afforded under the policy to protect the College.

All policies, except Workers’ Compensation, shall contain a waiver of transfer rights of recovery (subrogation) against the College, its agents, representatives, directors, officers, and employees for any claims arising out of the Vendor’s work or service.

The insurance policies may provide coverage which contains deductibles or self-insured retentions. Such deductible and/or self-insured retentions shall not be applicable with respect to the coverage provided to the College under such policies. The Vendor shall be solely responsible for deductible and/or self-insured retention and the College, at its option, may require the Vendor to secure the payment of such deductible or self-insured retentions by a surety bond or an irrevocable and unconditional letter of credit.

The College reserves the right to request and to receive, within 10 working days, certified copies of any or all of the herein required insurance policies and/or endorsements. The College shall not be obligated, however, to review same or to advise Vendor of any deficiencies in such policies and endorsements, and such receipt shall not relieve Vendor from, or be deemed a waiver of the College’s right to insist on, strict fulfillment of Vendor’s obligations under the agreement.

The insurance policies, except Workers’ Compensation, required by the agreement shall name the College, its agents, representatives, officers, directors, officials, and employees as Additional Insureds.


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REQUIRED COVERAGE

General Liability

Vendor shall maintain Commercial General Liability insurance with a limit of not less than $2,000,000 for each occurrence with a $2,000,000 Products and Completed Operations Aggregate and $2,000,000 General Aggregate Limit. The policies shall include coverage for bodily injury, broad form property damage, personal injury, products/completed operations and blanket contractual coverage including, but not limited to, the liability assumed under the indemnification provisions of the agreement, which coverage will be at least as broad as Insurance Service Office, Inc. Policy Form CG 000211093 or any replacement thereof. The coverage shall not exclude X, C, U.

Such policies shall contain a severability of interest provision, and shall not contain a sunset provision or commutation clause, or any provision that would serve to limit third party action over claims.

The Commercial General Liability additional insured endorsement shall be at least as broad as the Insurance Service Office, Inc’s, Additional Insured, Form B CG20101185, and shall include coverage for Vendor’s operations and products and completed operations.

CERTIFICATES OF INSURANCE

Prior to commencing Services under the agreement, Vendor shall furnish the College with Certificates of Insurance, or formal endorsements as required by the agreement, issued by Vendor’s insurer(s), as evidence that policies providing the required coverages, conditions and limits required by the agreement are in full force and effect.

In the event any insurance policy(ies) required by the agreement is(are) written on a “claims made” basis, coverage shall extend for two years past completion and acceptance of the Vendor’s work or services and as evidenced by annual Certificates of Insurance.

If a policy does expire during the life of the agreement, a renewal certificate must be sent to the College thirty (30) days prior to the expiration date.

All Certificates of Insurance required by the agreement shall be identified with a bid serial number and title.

CANCELLATION AND EXPIRATION NOTICE

Insurance evidenced by these certificates shall not expire, be canceled, or materially changed without thirty (30) days prior written notice to the College.


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Automobile Liability

Vendor shall maintain and cause any subcontractors to maintain Commercial/Business Automotive Liability insurance with a combined single limit for bodily injury and property damage of not less than $1,000,000 each occurrence with respect to the Vendor’s owned, hired, and non-owned vehicles assigned to or used in performance of the Vendor’s work. Coverage will be at least as broad as coverage code 1, “any auto”, (Insurance Service Office, Inc. Policy Form CA 00011293, or any replacements thereof). Such insurance shall include coverage for loading and offloading hazards. If hazardous substances, materials, or wastes are to be transported, MCS 90 endorsement shall be included and $5,000,000 per accident limits for bodily injury and property damage shall apply.

Professional Liability

Professional liability insurance with minimum limits of $1,000,000 per occurrence and requiring notice to the College at least thirty (30) days prior to cancellation or restriction of coverage. Coverage shall be afforded on a form acceptable to the College. Vendor shall maintain such professional liability insurance until at least three (3) years after completion of all services required under this agreement.

Workers’ Compensation

This Vendor shall carry Workers’ Compensation insurance to cover obligations imposed by federal and state statutes having jurisdiction of Vendor’s employees engaged in the performance of the work; and, Employer’s Liability insurance of not less than $2,000,000 for each accident, $1,000,000 disease for each employee, and $1,000,000 disease policy limit.

In case any work is subcontracted, the Vendor will require the Subcontractor to provide Workers’ Compensation and Employer’s Liability to at least the same extent as required of the Vendor.


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Attachment B Terms and Conditions

1. Legal Remedies – All claims and controversies shall be subject to the Pima County

Community College Policy regarding Formal Protests and Appeals.

2. Agreement –The Agreement shall contain the entire agreement between the College and the Vendor relating to this requirement and shall prevail over any and all previous agreements, contracts, proposals, negotiations, purchase orders or master agreement in any form.

3. Agreement Amendments – The Agreement shall be modified only by a written amendment signed by persons duly authorized to enter into agreements on behalf of the College and the Vendor.

4. Provisions Required by Law – Each and every provision of law and any clause required by law to be in the Agreement shall be read and enforced as though it were included herein, and if through mistake or otherwise any such provision is not inserted, or is not correctly inserted, then upon the application of either party the Agreement shall forthwith be physically amended to make such insertion or correction.

5. Severability – The provisions of the Agreement are severable to the extent that any

provision or application held to be invalid shall not affect any other provision or application of the Agreement which may remain in effect without the invalid provision or application.

6. Records – Pursuant to provisions of title 35, chapter 1, article 6 A.R.S. §35-215 the Vendor shall retain, and shall contractually require each subcontractor to retain, all books, accounts, reports, files and other records relating to the acquisition and performance of the Agreement for a period of five (5) years after the completion of the Agreement. All such documents shall be subject to inspection and audit at reasonable times. Upon request, a legible copy of any or all such documents shall be produced at the offices of the Auditor General, the Attorney General or the College Purchasing Office.

7. Advertising – Contractor shall not advertise or publish information concerning the Agreement, without prior written consent of the College.

8. Preparation of Specifications by Persons Other than College Personnel – All specifications shall seek to promote overall economy for the purposes intended and encourage competition and not be unduly restrictive in satisfying the College’s needs. No person preparing specifications shall receive any direct or indirect benefit from the utilization of specifications, other than fees paid for the preparation of specifications.

9. Americans With Disabilities Act – The Vendor shall comply with all applicable provisions of the Americans With Disabilities Act and applicable federal regulations under the act.


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10. Conflict of Interest – The College may, within three years after its execution, cancel

the agreement without penalty or further obligation if any person significantly involved in negotiating, drafting, securing or obtaining the agreement for or on behalf of the College becomes an employee of or a vendor in any capacity to any other party to the agreement with reference to the subject matter of the Agreement while the Agreement or any extension thereof is in effect or as otherwise provided by A.R.S. § 38-511..

11. Drug Free Workplace – The Vendor agrees that in the performance of the Agreement,

neither the Vendor nor any employee of the Vendor shall engage in the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance in conducting any activity covered in the Agreement. The College reserves the right to request a copy of the Vendor Drug Free Workplace Policy. The Vendor further agrees to insert a provision similar to this statement in all subcontracts for services required.

12. Equal Opportunity – The provisions of Section 202 of Executive Order 11246.41 C.F.R. Sec. -0-1.4.41 Sec. 60-250.4 and 41 C.F.R. Sec. 60-741.4 are incorporated herein by reference and shall be applicable to the Agreement unless the Agreement is exempted under the rules, regulations or orders of the U.S. Secretary of Labor.

13. Federal, State and Local Taxes, Licenses and Permits – Vendor is solely responsible for complying with all laws, ordinances, and regulations on taxes, registrations, licenses and permits, as they may apply to any matter under this document. The Vendor must demonstrate that they are duly licensed by whatever regulatory body may so require during the performance of the Agreement. Prior to the commencement of Agreement, the Vendor shall be prepared to provide evidence of such licensing as may be requested by the College. Vendor shall, at no expense to the College, procure and keep in force during the entire period of the Agreement all such permits and licenses.

14. Gratuities – The College may, by written notice to the Vendor, cancel the agreement if it is found by the College that gratuities, in the form of entertainment, gifts or otherwise were offered or given by the Vendor or any agent or representative of the contractor, to any officer or employee of the College with a view toward securing an agreement or securing favorable treatment with respect to the performing of such agreement.

15. Liens – Each Vendor shall keep the College free and clear from all liens asserted by any person or entity for any reason arising out of the furnishing of services or materials by or to the Vendor.

16. Sales and Use Tax – The College is not exempt from state sales and use tax.

17. Sexual Harassment – Federal law and the policies of the College prohibit sexual harassment of College employees or students. Sexual harassment includes any unwelcome sexual advance toward a College employee or student, any request to a sexual favor from a College employee or student, or any other verbal or physical conduct of a sexual nature that is so severe or pervasive as to create a hostile or offensive working or educational environment for College employees or students. Vendor, subcontractors and suppliers for this project are required to exercise control over their employees so as to prohibit acts of sexual harassment of College employees and students. The employer of any person whom the College, in its reasonable judgment,


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determines has committed an act of sexual harassment agrees as a term and condition of the Agreement to cause such person to be removed from the project site and from College premises and to take such other action as may be reasonably necessary to cause the sexual harassment to cease.

18. Smoking – All facilities of the College are smoke free. Smoking is permitted only inside designated smoking areas. The Vendor is required to comply with this smoke free policy.

19. Confidentiality – The parties shall comply with 20 USC Section 1232(g), the Buckley Amendment to the Family Educational Right and Privacy Act of 1974. Therefore, Contractor shall not be entitled to receive Employee or Student information directly from the College, other than public information available in any College directory which is not protected by federal or state privacy or confidentiality statutes or regulations. Contractor may solicit Employee and Student information directly from Employees and Students subject to prior disclosures by Contractor of all intended uses of such information. Regardless of the Employee or Student personal information, even if such information is publicly available via directories, Contractor shall under no circumstances sell, duplicate, market, or give to any person or persons, entities or other companies a list or other personal information of any or all Employees or Students. All Employee and Student identities and personal information shall remain confidential. Disclosure by Contractor occurring without the express prior written consent of the Employee or Student shall result in the immediate termination of this agreement.

20. Assignment-Delegation – No right or interest in the Agreement shall be assigned or

delegated by Vendor without the prior written permission of the College. Any attempted assignment or delegation by Vendor shall be wholly void and totally ineffective for all purposes unless made in conformity with this paragraph.

21. Force Majeure – Neither party shall be liable in damages of have the right to terminate this Agreement for any delay or default in performing under the Agreement if such delay or default is caused by conditions beyond its reasonable control including, but not limited to wars, insurrections, fires, floods, governmental restrictions and/or any other cause beyond the reasonable control of the party whose performance is affected.

22. Intellectual Property Rights – It is understood and agreed that ownership of intellectual property developed as a result of fulfilling the requirements of this Agreement belongs solely and exclusively to the College. Documents provided in connection with the Agreement belong to the College and are being used with permission. Intellectual property, as used herein, means all forms of legally protectable intellectual property, including copyrights, trademarks, inventions, patent applications, patents and mask works, drawings and/or blueprints. It is also understood and agreed that any intellectual property created as a result of Vendor’s performance of this Agreement is considered a work for hire under the U.S. copyright laws and as such, the College will own the copyright.

23. Laws and Regulations – Vendors are solely responsible for keeping themselves fully

informed of and faithfully observing all laws, ordinances, and regulations affecting the


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rights of their employees, and shall protect and indemnify the College, its officers and agents against any claims of liability arising from or based on any violation thereof.

24. Payment Terms – Payments by the College shall be subject to the provision of Title 35 of Arizona Revised Statutes, relating to time and manner of submission of claims. The College’s obligation is payable only and solely from funds appropriated for the purpose of the Agreement. Unless otherwise stated herein, the payment terms for the Agreement are Net 30 days.

25. Price Adjustment – Price changes will normally only be considered at the end of one Agreement period and the beginning of another. Price change requests shall be in writing, submitted 180 days prior to the end of the current Agreement period, and shall be supported by written evidence of increased costs to the Vendor. The College will not approve unsupported price increases that will merely increase the gross profitability of Vendor at the expense of the College. Price change requests shall be a factor in the Agreement extension review process. The College shall, in its sole opinion, determine whether the requested price increase or an alternate option is in the best interest of the College.

26. Prior Course of Dealings – No trade usage, prior course of dealing, or course of performance under other agreements shall be a part of this Agreement resulting from this RFP, nor shall such trade usage, prior course of dealing or course of performance be used in the interpretation or construction of such resulting agreement.

27. Right to Offset – The College shall be entitled to offset against any sums due the Vendor, any expenses or costs incurred by the College, or damages assessed by the College concerning the Vendor’s non-conforming performance or failure to perform the Agreement, or any other debt owing the College.

28. Insolvency – The College shall have the right to terminate the Agreement at any time in the event Vendor files a petition in bankruptcy; or is adjudicated bankrupt; or if a petition in bankruptcy is filed against Vendor and not discharged within thirty (30) days; or if Vendor becomes insolvent or makes an assignment for the benefit of its creditors or an arrangement pursuant to any bankruptcy law; or if a receiver is appointed for Vendor or its business.

29. Lack of Funding – The Agreement may be canceled without further obligation on the part of the College in the event that sufficient appropriated funding is unavailable to assure full performance of the terms. The Vendor shall be notified in writing of such non-appropriation as soon as reasonably possible. No penalty shall accrue to the College in the event this cancellation provision is exercised. This cancellation provision shall not be construed so as to permit the College to terminate the Agreement in order to acquire similar equipment, material, supplies or services from another party.

30. Stop Work Order – The College may at any time, by written order to the Vendor, require the Vendor to stop all or any part of the work called for by the Agreement for a period of up to ninety (90) days after the order is delivered to the Vendor, and for any further period to which the parties may agree. The order shall be specifically identified as the Stop Work Order issued under this provision. Upon receipt of the order, the Vendor shall immediately comply with its terms and take all reasonable steps to minimize the


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incidence of costs allocable to the work covered by the order during the period of work stoppage. If a Stop Work Order issued under this provision is canceled or the period of the order or any extension expires, the Vendor shall resume work. The College shall make an equitable adjustment in the delivery schedule or Agreement price, or both, and the Agreement shall be amended in writing accordingly.

31. Suspension or Debarment – The College may by written notice to the Vendor immediately terminate the Agreement if the College determines that the Vendor has been debarred, suspended, or otherwise lawfully prohibited from participating in any public procurement activity, including but not limited to, being disapproved as a subcontractor or Contractor of any public procurement unit or other governmental body.

32. Continuation of Performance Through Termination – The Vendor shall continue to perform, in accordance with the requirements of Agreement, up to the date of termination, as directed in the termination notice.

33. Federal Immigration Laws and Regulations – Vendor warrants that it complies with all Federal Immigration laws and regulations that relate to its employees and complies with A.R.S. § 23-214(a) and that it requires the same compliance of all subcontractors under the agreement. Vendor acknowledges that pursuant to A.R.S. § 41-4401 and effective September 30, 2008, a breach of this warranty is a material breach of the agreement subject to penalties up to and including termination of the agreement. The College retains the legal right to audit the records of the Vendor and inspect the papers of any employee who works for the Vendor to ensure compliance with this warranty and the Vendor shall assist in any such audit. The Vendor shall include the requirements of this paragraph in each contract with subcontractors under the agreement. If the Vendor or subcontractor warrants that it has complied with the employment verification provisions prescribed by sections 274(a) and 274(b) of the Federal Immigration and Nationality Act and the E-verify requirements prescribed by A.R.S. § 23-214(A)the Vendor or subcontractor shall be deemed to be in compliance with this provision. The College may request proof of such compliance at any time during the term of the Agreement by the Vendor and any subcontractor.

34. Extended Contract The College is an active member of the Strategic Alliance for Volume Expenditures (S.AV.E.) Cooperative agreement. Under this Cooperative Purchasing Agreement, and with the concurrence of the successful Proposer, other members of this organization may access any subsequent agreement/contract resulting from this solicitation. If the Proposer does not want to grant such access, it must be stated in their Proposal. In the absence of a statement to the contrary, the college will assume that access is granted by the Proposer to any subsequent agreement/contract.


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ATTACHMENT C VENDOR EXHIBITS

Vendors submitting proposals should complete and sign all of the following documents:

Exhibit 1 Intent to Propose

Exhibit 2 Scope of Work

Exhibit 3 Confidentiality Agreement

Exhibit 4 Prior and Pending Lawsuits

Exhibit 5 Fees/Rates Certification

Exhibit 6 Confidential and Proprietary Submittals

Exhibit 7 Deviations

Exhibit 8 Vendor Information Form


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Exhibit 1 INTENT TO PROPOSE

Due Date: December 20, 2013

Email: [email protected] Attn: Ms. Linda Ellis, CPPB, Senior Buyer RE: Pima County Community College District

Request for Proposal No. P14/9833

We are in receipt of the above referenced RFP and will/will not be quoting the following service:

Services

Respond (mark x if you will submit a proposal)

Name of Medical Network You Will Propose (Required for UDS Database Analysis)

Decline (mark x if you will NOT submit a proposal)

Reason for Decline

Fully-Insured Medical/Vision Plan

Minimum Premium Medical/Vision Plan

ASO Medical/Vision/Stop-Loss Plan

Pharmacy Benefit Management N/A

Name of Company Address

Phone Number

Email Address

Signature



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Exhibit 2 Scope of Work

(See Pages 4 through 11 for Scope of Work)

Scope of Work Included

Vendor Name:

Account Management

• Designated LOCAL (Arizona based) Account Manager and Account Management Team

• Attend College Meetings as requested

Customer Service • Customer service to answer inquiries on claims, eligibility, provider network,

services, coverage, or other inquiries from participants Monday through Friday from 8:00 AM to 6:00 PM (AZ time)

Open Enrollment Support

• Prepare and provide Benefit Presentations in collaboration with the College

• Attend Annual Open Enrollment Meetings

Plan Document/SPD/Identification Cards

• Prepare Summary of Benefit Coverage documents

• Preparation of plan documents and booklets

• Production (including printing) of ID Cards

Claims Administration

• Claims forms

• Receive claims and process payments of benefits in accordance with the plan designs for all claims incurred

• Correspond with participants and providers if additional information is necessary to complete the processing of claims

• Determine, based on the College’s medical necessity guidelines, benefits payable under the Plan, pursuant to the terms and conditions of the College’s Benefit Plan booklets

• Coordinate benefits payable under the Plan and with other benefit plans, if applicable


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Vendor Name:

• Notice to the Participants regarding the reason(s) for denial of benefits (which are denied) and provide for the review of such denied claims

• Explanation of benefits for claims transactions sent to Participants

• Preparation and mailing of 1099 forms

• Perform Recovery of Overpayments/Erroneous Payments

• Administer a Fraud and Abuse Detection Program

• Level I, II, and III Claim Appeal Services • Administration of the College’s Health Reimbursement Accounts for

PPO/POSparticipants (described in the Scope of Work as “Healthy Awards”)

• Administration of the College’s Health Savings Account should the College implement a High Deductible Health Plan.

Eligibility/Enrollment Administration/Notices

• Administer eligibility based on the College’s eligibility criteria

• HIPAA Certificates of Creditable Coverage

Pharmacy Benefit Management

• Pricing is being provided on a transparent basis.

• ID cards (initial, duplicate, additional and replacement cards), online provider directories, and formulary lists, separate cards if multiple vendors

• PBM integration with Claims, Disease Management, Utilization Management Administrators

• Claims adjudication

• Standard Systems Edits (must include “too early refill” edit)

• Network Pharmacy Management

• Formulary Management and Rebate Sharing

• Eligibility Verification and Maintenance

• MAC pricing program administration

• Data Reporting

• Customer Service including toll free telephone and internet access

• Provider Management and Education


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Vendor Name:

• Patient Education

• Data Requests

• Online Systems for the employer, members, and the College’s consultant

• Ad-Hoc Reporting

Specific Stop Loss

• Specific Stop-Loss with a deductible of $150,000

• A 12/15 month contract covering claims incurred during the contract period and paid during the plan year and the 3 months following

• Includes claims incurred and paid under both the medical and prescription drug program or medical only (optional)

Interface/Coordination with the College’s PBM Vendor (if a separate provider selected)

• Receive claims data from the PBM on a daily basis

• Accept eligibility from the College.

• Coordinate data and reporting with stop loss vendor

• Coordinate data with the PBM for cross accumulation of the true out-of-pocket maximum

PBM Coordination with the Medical Administrator

• Receive data from the medical vendor

• Accept eligibility from the College.

• Coordinate data and reporting with the medical TPA for stop loss purposes

• Coordinate data with the medical administrator for cross accumulation of the true out-of-pocket maximum

Reporting Requirements • Timely management reports or internet access to monitor financial and service

level performance as described in the Reporting Chart in the Questionnaire.

Secure Internet Access

• Access to Enrollment/Eligibility Administration Portal for Employer

• Access to Claims Administration Portal for Employee


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Vendor Name:

• Employer and/or Designated Consultant access to Claims Data Reporting Portal

• Access to Online Wellness Portal

UTILIZATION MANAGEMENT SERVICES

• Provide prospective, concurrent, and retrospective medical utilization review services

• Provide case management services based on internal criteria including:

o Early case identification

o Initial assessment

o Development of a case management plan

o Implementation and coordination of alternative treatment plans

o Ongoing progress assessment of alternative treatment plans

o Additional case activities necessary to complete recommendations

• Discharge planning

• Inpatient/Outpatient Surgical Review

• Medical necessity review

• Pre-service claim appeals

• Access to Medical Director and physician panels

• Provide quarterly reports included in firms standard reporting package

• Provide sample Plan utilization management language for review and revision by the College, as requested

• 24-hour nurse hotline

• Maternity Management Services


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Vendor Name:

PPO/POS NETWORK ACCESS (INSIDE AND OUTSIDE ARIZONA)

Access to provider directories

Access to in-network providers inside the State of Arizona

Access to nationwide in-network providers.

Repricing of network claims submitted by plan participants

DISEASE MANAGEMENT PROGRAMS

Include standard disease management programs on an Opt-Out basis.

WELLNESS RESOURCES

Annual Onsite Flu Shot Clinics

Biometric Screening Program

Dedicated Wellness Resources to provide management for the College Wellness program under the direction of the Employee Service Center. This may be accomplished by funding a College-hired wellness coordinator, or significant access to a vendor to provide wellness expertise. Duties would include:

Create a culture of wellness throughout the College Serve as a central point for communication of the College’s wellness program Develop and implement an integrated wellness plan with employee involvement, education, incentives and programming.

Vendor Funded Wellness Budget

COMMENTS (for use in providing additional comments/caveats to any section of the Scope of Work)


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Exhibit 3 CONFIDENTIALITY AGREEMENT

To Be Used by Entities Responding to the RFP Prepared by The Segal Company

Date:

Name:

Job Title:

Company Name: Business Address: This confidentiality agreement is between The Segal Group, Inc., the parent of The Segal Company, on behalf of The Segal Company operating subsidiaries, (hereafter “Segal”) and _________________________, on behalf of itself and all of its subsidiaries and affiliates, (hereafter “Bidder”) and is executed in connection with a bid that Bidder intends to submit to Segal in response to an RFP prepared by Segal on behalf of its Clients (each hereafter “Client.”). In order to prepare a responsive bid, Bidder needs to receive certain Client health plan information and data, including individually identifiable health information pertaining to Client health plan participants and beneficiaries, as well as other Segal Proprietary Information consisting of the RFP questionnaire/RFI specifications and any associated financial spreadsheets (collectively “Segal’s Proprietary Information”). Segal and Bidder agree that the term “individually identifiable health information” refers to any health information that is not “de-identified,” as defined in 45 C.F.R. Section 164.514(b)(2). In addition, in order to evaluate the bids submitted by Bidder, Segal and Client may need to receive certain proprietary information from Bidder including, but not limited to provider-specific network allowances or provider-specific reimbursement arrangements and Maximum allowable Cost (“MAC”) list, including corresponding MAC pricing (“Bidder’s Proprietary Information”). Segal’s Proprietary Information and Bidder’s Proprietary Information are collectively referred to as “Proprietary Information.” Segal and Bidder agree to provide the necessary Proprietary Information in connection with the RFP and the parties agree as follows: 1. Bidder will use Segal’s Proprietary Information only for the purpose of preparing Bidder’s

bid/response to the RFP and subject to paragraph 5 of this Agreement. Segal will use Bidder’s Proprietary Information only for the purpose of evaluating the bid/response submitted by Bidder and subject to paragraph 5 of this Agreement.


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2. Bidder and Segal agree that only those individuals employed by Bidder or Segal (respectively) who have a need to know Proprietary Information to prepare the bid/response or evaluate the bid/response and have been made aware of the terms of this Agreement and have agreed to abide by its terms will have access to Proprietary Information of the other party (“Bidder’s Representatives” and “Segal’s Representatives”).

3. Neither Bidder nor any of its Representatives will disclose Segal’s Proprietary Information to

any person or entity outside of Bidder, unless such a disclosure is: (a) necessary to prepare the bid/response, Bidder obtains Segal’s prior written consent to the disclosure, which consent shall not be unreasonably withheld, and the recipient first executes a confidentiality agreement with provisions substantially equivalent to this one; or (b) required by law. Neither Segal nor any of its Representatives will disclose Bidder’s Proprietary Information to any person or entity outside of Segal (other than Client), unless such a disclosure is: (a) necessary to evaluate the bid/response, Segal obtains Bidder’s prior written consent to the disclosure, which consent shall not be unreasonably withheld, and the recipient first executes a confidentiality agreement with provisions substantially equivalent to this one; or (b) required by law.

4. Bidder and Segal agree to use commercially reasonable efforts to maintain the security of the Proprietary Information of the other party.

5. Each party will return the other party’s Proprietary Information to the other party or destroy it upon completion of the RFP process if such return or destruction is feasible, except that each party may retain an archival copy of the other party’s Proprietary Information for its files, subject to its continued compliance with its obligations under this Agreement. If a party determines that return or destruction of some or all of the other party’s Proprietary Information is not feasible, such party agrees to: (a) extend the protections of this Agreement to any retained information for as long as the party retains it; and (b) limit further uses or disclosures to those that make the return or destruction infeasible.

6. Each party will report to the other party any use and/or disclosure of the other party’s Proprietary Information that is not permitted by this Agreement.

7. Each party shall regard and preserve as confidential all of the other party’s Proprietary Information that has been or may be obtained by such party during the course of the RFP process, whether Bidder or Segal has such information in memory, or in writing or in other physical form. Neither party shall, without written authority from the other party, use for such party’s benefit or purposes, either during the RFP process or thereafter, any Proprietary Information of the other party except as permitted herein.

8. With respect to the RFP and the Proprietary Information exchanged in connection therewith,

the obligations assumed by the parties in this Agreement shall continue beyond completion of the RFP process.


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9. Bidder shall and does hereby indemnify, defend and hold harmless Segal and their respective officers, directors, employees and shareholders from and against any and all claims, demands, losses, costs, expenses, obligations, liabilities, damages, recoveries, and deficiencies, including interest, penalties, and reasonable attorney fees and costs, that Segal may incur or suffer and that result from, or are related to, any breach or failure of Bidder and Bidder’s Representatives to perform any of the representations, warranties and agreements contained in this Agreement that pertain to individually identifiable health information.

10. Bidder recognizes that any breach of the covenants contained in this Agreement would irreparably injure Segal. Accordingly, Segal may, in addition to pursuing its other remedies, seek an injunction from any court having jurisdiction of the matter restraining any further violation and no bond or other security shall be required in connection with such injunction.

11. If any of the provisions herein become invalid or are declared invalid, such determination of

invalidity as to the clause(s) shall not affect the other provisions of this Agreement. If any provision of this Agreement should be held invalid or unenforceable, the remaining provisions shall be unaffected by such a holding. If any provision is found inapplicable to any person or circumstance, it shall nevertheless remain applicable to all other persons and circumstances.

12. This Agreement shall be binding upon Segal and Bidder and their respective successors, assigns, heirs, executors and administrators.

13. This Agreement contains the entire understanding of the parties hereto and supersedes all previous communications, representations, or agreements, oral or written, with respect to the subject matter hereof. No failure to exercise nor any delays in exercising any right or remedy hereunder shall operate as a waiver thereof; nor shall any single or partial exercise of any right or remedy hereunder preclude any other or further exercise thereof or the exercise of any other right or remedy. Neither this Agreement nor any of its provisions may be amended, supplemented, changed, waived or rescinded except by a written instrument signed by the party against whom enforcement thereof is sought. No waiver of any right or remedy hereunder on any one occasion shall extend to any subsequent or other matter.

14. This Agreement shall be governed by and construed in accordance with the laws of the State of New York applicable to contracts made on and performed within the State of New York.


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Intending to be legally bound, the Parties have executed this Agreement.

The Segal Group, Inc. Bidder

Signed: Signed: Print Name:

Print Name:

Title: Title:

Date: Date:


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Exhibit 4 PRIOR AND PENDING LAWSUITS

Name of Company: Signature: Date: _____________________ Describe any pending or closed lawsuits against your organization in the past five (5) year

Authorized Signature

Firm Name

Date


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Exhibit 5

FEES/RATES CERTIFICATION

The fees/rates charts (and any attached fee pages) have been checked and rechecked for

accuracy and are now submitted to Pima County Community College District on this ________

day of January, 2014.

Questions specifically related to these fees/rates should be addressed to:

Name: _________________________________________

Title:___________________________________________

Email address: ___________________________________

Telephone: ______________________________________


Firm Name

Date


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Exhibit 6

CONFIDENTIAL/PROPRIETARY SUBMITTALS Confidential/Proprietary Submittals (mark one): __________ No confidential/proprietary materials have been included with this offer __________ Confidential/Proprietary materials included. Offerors should identify below any portion of their offer deemed confidential or proprietary. Identification in this section does not guarantee that disclosure will be prevented but that the item will be subject to review by the Offeror and the College representative prior to any public disclosure. Requests to deem the entire offer or price as confidential will not be considered.

Firm Name



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Exhibit 7 - DEVIATIONS Directions: Indicate all areas where your proposal may differ from the requested services or contract and insurance language (Attachments A and B). In particular, clearly list all plan benefit features that you cannot administer with the current plan design or any contract or insurance deviations. Do not say “see proposal” or include your standard benefit summary and expect the College to determine where differences exist. Do not indicate that “your standard contractual provisions will apply beyond basic plan design features” without indicating differences. The College needs to thoroughly understand any differences you are proposing. If you do not have any deviations please mark N/A. If nothing is indicated on this form, then it will be assumed your proposed benefits match the current benefits exactly even if you include a benefit summary that states differently. Use additional pages as necessary. Name of Company:

Signature:

Date:

DEVIATIONS FROM SPECIFICATIONS 1.


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Exhibit 8 – Vendor Information Form Organization Name:

Contact Person’s Name

Title

Address

City/State

Phone Number

E-mail Address

Fax Number Please provide references for each type of funding you are proposing: References – FULLY INSURED

CURRENT PUBLIC SECTOR REFERENCES

Name Contact Name Phone Number and

Client Location Number of Members

Contract Start Date

RECENTLY TERMINATED PUBLIC SECTOR CLIENT REFERENCES

Name Contact Name Phone Number Termination

Reason Termination

Date



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References – MINIMUM PREMIUM




Contract Start Date



Reason Termination

Date

References – SELF-FUNDED/ASO




Contract Start Date



Reason Termination

Date

_____________________________________ Authorized Signature


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QUESTIONNAIRE

Pages 49 through 90 contain the questions related to the Medical Plans. Please refer to pages 91 through 127 for the Pharmacy Benefit

Management Section of this RFP.


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Instructions to Vendors:

***DO NOT ALTER THE QUESTIONS OR QUESTION NUMBERING***.

Provide answers to the questionnaires in MS Word format. The questionnaire contains different types of formats: Yes or No (with and without

narrative) and Narrative. For the Yes or No questions (without narrative), DO NOT provide narrative in your response, except to refer the reader to an appendix or location where additional information is provided, if necessary.

Provide an answer to each question even if the answer is “not applicable” or “unknown.” Answer the question as directly as possible.

• If the questions asks “How many…” provide a number

• If the question asks, “Do you…” indicate Yes or No first, followed by your additional narrative explanation.

Lengthy responses may be truncated when displayed…to avoid this, be concise in your response. Use bullet points as appropriate. Reconsider how to word any response that exceeds 200 words in length so that the response contains the most important points you want displayed. Refer the reader to an appendix/attachment for further information.

Where you desire to provide additional information to assist the reader in more fully understanding a response, refer the reader of your RFP response to your appendix/attachments.

Vendor will be held accountable for accuracy/validity of all answers. RFP responses to the questionnaire will become part of the contract between the winning

Vendor and the College.

NOTE: Answers to the questions must be provided in hard copy and MS Word format on CD or Flash Drive.

DO NOT PDF or otherwise protect the CD or Flash Drive.


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Complete this form and include it with your response. Indicate “yes” or “no” to your organization’s ability to meet the general requirements. Vendor will be held accountable for accuracy/validity of all answers.

MINIMUM REQUIREMENTS YES NO

1. Does your contract have a length of one (1) year with the option to renew four (4) additional one year periods?

2. Do you agree to provide notice of your renewal a minimum of 180 days in advance of the July 1 effective date?

3. Are all fees guaranteed for a minimum of 12 months?

4. Are your proposed fees and contract terms guaranteed for at least 120 days from the date your proposal is submitted?

5. If you have submitted a proposal for more than one service contained in this RFP, have you proposed pricing reflective of a freestanding contract for each service as requested in this RFP?

6. Do you agree to provide local account management (Arizona based) throughout the term of this contract?

7. Do you agree to provide Annual Onsite Flu Shot Clinics?

8. Do you agree to provide Biometric Screenings?

9. Do you agree to provide Health Risk Assessments?

10. Do you agree to provide wellness media, (PSA, white papers) easily modified to College brand?

11. Do you agree to offer wellness education services, on-site and via media?

12. Do your proposed rates/fees assume that your firm will administer an HDHP Plan with an HSA in addition to the two plans in place if the College decides to add the third option July 1, 2014 without any change in your quoted fees?

13. Do you agree that your proposal is not contingent on acceptance of other coverage or services outside the Scope of this RFP?

14. Does your self-funded proposal include a 10 business day grace period for payment of claims?

15. Are your fees/rates net of commissions?

16. Do you agree to handle All Levels (I, II, & III) of claim appeals?


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MINIMUM REQUIREMENTS YES NO

If you answered “No” to any of the questions above, please provide an explanation below:

Requirement No. Explanation

CONTRACTUAL If your response differs by the type of funding and/or

network you are proposing, provide the appropriate response for each approach

Yes or No

Explain any “No” response

1. Termination Provisions: The College may terminate the contract at any time by giving 30 days written notice. The successful bidder may only terminate the contract by giving notice 120 days in advance. The College can terminate the contract without cause or financial penalty at any time during the duration of the contract.

2. Upon the termination of the agreement with the College, you will cooperate fully with the College and/or its subsequent service provider in order to effect an orderly transition of services from your organization to a subsequent service provider, at no added fee.

3. Size Variance Provision: Any provisions, references, or guidelines relating to reevaluation of proposed fees due to variation in enrollment in the plan must not be less than 20% of the enrollment at the beginning of each plan year.

4. Right to Audit: The College reserves the right to an independent audit by an auditor of their choice. Bidder agrees to not charge for any expense incurred by the bidder for time necessary to prepare claim files. The cost of the third party to audit will be the responsibility of the College.


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Yes or No


5. Subcontracting:

a. List any services related to the Scope of Work of this RFP that you currently subcontract (or plan to subcontract for this contract) and the name of the vendor(s) to whom you subcontract.

b. Do you agree to provide advanced written notice to the College if you decide to subcontract for any services related to the Scope of Work?

c. Do you understand that if you use subcontractors in the delivery of your services under this proposal your firm is responsible for the timeliness, accuracy, privacy, comprehensiveness, and reporting components of the subcontractor’s services?

d. Explain any of your current contractual relationships with a third-party firm in which the third party firm will be paid by the College either directly or indirectly during the course of the contract with the College (e.g. % of savings).

6. Do you agree that you will not assign or transfer the rights or obligations of the contract or any portion thereof, without the prior written approval of the College?

7. Do you agree to maintain proper licensure as required by any state law where it relates to the services that you will be performing for the College?

8. Do you agree that the College will determine eligibility for coverage?

9. Do you agree that your contract includes an indemnification/hold harmless clause to protect the College from negligence of your employees?


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Yes or No


10. HIPAA Compliance: All bidder systems and services must comply with current HIPAA EDI, Privacy, and Security regulations at all times. Do you agree to maintain adherence to federal HIPAA Privacy and Security regulations as it relates to the personal health information you receive about the College’s plan participants during the proposal, implementation, contract, and post-contract periods?

11. Are you willing to sign a contract with the College that indicates your firm will pay fines the College may be assessed as a result of your firm's noncompliance with HIPAA EDI, Privacy and Security regulations and pay costs associated with remedy of any breach your firm initiates?

12. If you participate in the Federal Employees Health Benefits Program, and were awarded this contract, please confirm that Pima County Community College District would not be considered a peer group of the Federal program. (A Yes answer would confirm that they would not be considered a peer group, and a No response would mean that you do not agree and they would be considered a peer group. If you mark no, please provide a more detailed response.)


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NOTE: This section must be completed in a “yes” or “no” format. You may enter any N/A response in the NO column. If additional details are required, include in a separate attachment to your response labeled “Questionnaire Appendix” in MS Word format. Please be sure to read the Instructions at the beginning of the Questionnaire section before completing this section.

YES NO

ADMINISTRATION SERVICES If your response differs by the type of funding and/or network you are proposing,

provide the appropriate response for each approach

INDICATE TO THE RIGHT THE NAME OF THE NETWORK YOUR RESPONSE IS BEING PROVIDED FOR:

1. When participants call your customer service number and ask questions about the PPO/POS network, do the representatives: a. Provide direct answers to all issues? b. Provide a separate number to call for further assistance with

network questions? c. Provide a warm direct transfer, without interruption, to experts

who then provide answers to network questions?

2. Can you accept eligibility files in electronic format?

3. Do you have a secure web-based eligibility system the College’s staff may use to upload eligibility?

4. Will the College have online access to address additions, terminations, and status changes?

5. Does your system support on line real time eligibility inquiries by the College?

6. Have you noted on the Deviations Form any provisions of the current benefit plan that you are not able to administer? Please be specific and do not refer the reader to “see our proposal” etc.

CLAIMS PROCESSING AND CAPABILITIES

1. Does your EOB include:

a. Specific instructions on exactly how to appeal?

b. Specific information on the timeframes for appealing?

2. Do you have an automated method to identify and recover overpayments?


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YES NO

3. Do you use a subcontracted vendor to identify and recover overpayments?

If yes: a. Is the cost borne by the College? b. Is the cost a part of your administration fee? c. How far back do you go to recover overpayments?

4. Do you have the ability to administer claims based on the College’s current plan design(s) and will not ask the College to alter any of their plan of benefits in order to accommodate your computer system?

5. Are you planning to implement a new claim system in the next 24 months?

6. Do you anticipate any major enhancements to your claim system in the next 12 months?

7. Has your claim system been updated to comply with HIPAA 5010 conversion?

8. Do you capture/store the following data in your claim system:

a. Group policy number?

b. Employer ID number?

c. Employee ID Number or other unique identifier?

d. Claimant ID Number or other unique identifier?

e. Claimant relationship: employee, spouse, child?

f. Claimant gender?

g. Claimant date of birth?

h. Separate claims data for COBRA participants?

i. Provider name?

j. Provider ID number (TIN or NPI)?

k. Provider/service address, city, state, zip code?

l. Type of service?

m. Billed amount? n. Allowed amount?

o. Deductible, coinsurance, copay amounts?


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YES NO

p. Discount amount?

q. Ineligible amount?

r. Paid amount?

s. Claim processed/date paid?

9. Does your proposal include administration of the College Health Reimbursement Account program for PPO/POS participants?

10. Does your proposal include administration of a Health Savings Account should the College implement a High Deductible Health Plan?

ARIZONA NETWORK If your response differs by the type of funding and/or network you are proposing, provide the appropriate response for each approach

1. Does your organization contract directly with providers:

a. Inside Arizona?

b. Outside Arizona?

2. Does your organization contract indirectly with providers through another organization:

a. Inside Arizona?

b. Outside Arizona?

3. Are any fees associated with contracting with another organization ever billed to the College?

4. Do you offer reciprocity arrangements for members who travel outside the service area and need:

a. Emergency treatment?

b. Non- Emergency treatment?

5. Can your network providers deliver services for the following specialized treatment conditions:

a. Major burns?

b. Organ transplants?

c. Bone marrow transplants?

d. Specialized cancer treatments such as Proton Beam Radiation?

e. Neonatal care?

f. Fertility treatments?


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YES NO

g. Hemophilia treatment?

6. Are the following providers in your network:

a. Arizona Mayo Clinic (Physicians)?

b. Arizona Mayo Hospital?

c. Mayo Clinics (Physicians) outside Arizona?

d. Mayo Hospital outside Arizona?

e. Cancer Treatment Centers of America?

f. Arizona Hemophilia and Thrombosis Center at Arizona Sciences Center, Tucson?

g. Arizona Hemophilia and Thrombosis Center at Phoenix Children's Hospital?

7. Does your network contract with Centers of Excellence for organ transplants?

8. Do you anticipate a change in the size or location of your network in the next year that would affect the College’s population?

9. Are there any penalties incurred by the College when claims payments do not occur within a certain number of days (i.e., the discount is not valid if claims are not paid within 30 days of being submitted)?

OUTSIDE ARIZONA If your response differs by the type of funding and/or network you are proposing, provide the appropriate response for each approach

1. Does your organization contract directly with providers?

2. Does your organization contract indirectly with providers through another organization?

3. Are any fees associated with contracting with another organization ever billed to the College?

4. Can your network providers deliver services for the following specialized treatment conditions:

a. Major burns?

b. Organ transplants?

c. Bone marrow transplants?

d. Specialized cancer treatments such as Proton Beam Radiation?

e. Neonatal care?


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YES NO

f. Fertility treatments?

g. Hemophilia treatments?

5. Are the following providers in your network:

a. Mayo Clinics (Physicians) outside Arizona?

b. Mayo Hospital outside Arizona?

c. Cancer Treatment Centers of America outside Arizona?

6. Does your network contract with Centers of Excellence for organ transplants?

7. Do you anticipate a change in the size or location of your network in the next year that would affect the College’s population?

8. Are there any penalties incurred by the College when claims payments do not occur within a certain number of days (i.e., the discount is not valid if claims are not paid within 30 days of being submitted)?


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NOTE: This portion of the Questionnaire is for narrative responses. Please be sure to read and follow the Instructions at the beginning of the Questionnaire before completing.

GENERAL INFORMATION If your response differs by the type of funding and/or network you are proposing, provide the

appropriate response for each approach VENDOR RESPONSE

1. Organization background:

a. Organization’s name

b. Corporate headquarters address c. City & State that will service the

College’s account

d. Does your firm have a local office? e. Date your firm became operational f. Date your firm became operational for

the services requested in this RFP

g. Ownership of your firm

2. Indicate your firm’s latest ratings by all of the following agencies: Rating

Date of Rating Review

A.M. Best

Standard and Poor’s (S&P)

Fitch

Moody’s

Weiss

3. Implementation:

a. What is the minimum amount of implementation lead-time needed to initiate the proposed services?

b. List any transition issues the College should consider.

c. List any specific administrative procedures or information your firm will need from the College in order to implement your services?


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GENERAL INFORMATION If your response differs by the type of funding and/or network you are proposing, provide the

appropriate response for each approach VENDOR RESPONSE 4. Complete the following information about

the individual from your organization who will be assigned as the OVERALL ACCOUNT MANAGER for this client:

Name: Title: City/State: Length of Time in Current Position: 5. Complete the following information about

the individual from your organization who will be assigned as the PRIMARY DAY TO DAY CONTACT for this client:

Name: Title: City/State: Length of Time in Current Position: 6. Describe all tools that are available on

your website to consumers, such as network provider quality, treatment estimates, deductible and out-of-pocket accumulators, etc.

7. Please provide a temporary login password to allow the selection committee to evaluate the tools.

8. With which PBM’s do you currently work with for other clients under your self-funded arrangements?

9. Would there be any additional charges to the College to establish a relationship with a PBM should the College decide to continue to unbundle the Medical and PBM contracts? If so, please describe.


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CUSTOMER SERVICE OPERATIONS If your response differs by the type of funding and/or

network you are proposing, provide the appropriate response for each approach VENDOR RESPONSE

1. Will there be a designated team of customer service representatives for the Client?

a. Will you provide a toll-free customer service number for claim and benefit inquiries?

b. Are questions regarding provider billing, benefits, or member grievances covered by the same phone number?

c. If not, please explain.

2. What hours and days are live customer service representatives available (indicate using AZ time)?

3. Are your customer service representatives in the continental US?

4. What alternative services do you provide? (i.e., Assistance for the hearing impaired, 24-hour toll-free automated benefits and eligibility, customer service accessible via the internet, etc.)

5. Please provide the following statistics for 2012 and 2013 YTD:

a. Average speed to answer: ___% within 30 seconds

b. Busy rate: ___ seconds

c. Abandonment Rate : ___%


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CUSTOMER SERVICE OPERATIONS If your response differs by the type of funding and/or

network you are proposing, provide the appropriate response for each approach VENDOR RESPONSE

6. Are plan participants able to access a web portal for:

a. Status of claims b. Benefit brochure c. ID cards

7. What kind of web tools do you have for consumer engagement such as:

a. Network provider quality

b. Treatment estimator

c. Deductible/out-of-pocket accumulator

d. Modeling of plan options for members?

e. Please provide a temporary login and password so the College can evaluate your tools.

8. What methods does your organization use to measure customer satisfaction?

9. Provide a copy of your most recent customer satisfaction survey statistics.


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REPORTING

Do you have the ability to generate all available reports by Entity, by Plan Option (up to 3 medical plans and 1 vision plan) as described in Section 1, Background (Yes or No)?

Report Type Month Quarter Annual Vendor

Response (Y or N)

Online Access (Y or N)

Excel

(Y or N)

Enrollment by coverage tier X

Paid Claims

By Type (fee for service, capitated) X

By Status (Active, COBRA) X

By Member Cost-Sharing by plan option

X

Overpayments X

Large Claim Report - $25,000 with diagnosis

By Status (Active, COBRA) X

Other Claims Reports

Claims Lag X

Network Utilization

In-Network X

Out-of-network X

Out-of-State X

Utilization (benchmark) Reports to the College in October each year

X

Ad Hoc Reporting Capabilities

Ability for the College to generate Ad Hoc Reports

Determined by the College

Does the information provided allow drill down on the data?

Indicate if any reports are different or unavailable based on funding type.

HRA ADMINISTRATION VENDOR RESPONSE


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If your response differs by the type of funding and/or network you are proposing, provide the appropriate

response for each approach 1. Does your proposal assume administration of

the College’s Health Reimbursement Account program?

2. Are you able to provide automatic reimbursement of HRA fund to cover the participant’s out-of-pocket costs as a part of the claim adjudication process?

3. Are you able to administer a debit card as part of the HRA program?

4. Please detail the reports you will provide to the College and their employees.

HDHP/HSA ADMINISTRATIVE SERVICES If your response differs by the type of funding and/or network you are proposing, provide the appropriate

response for each approach

VENDOR RESPONSE

1. Are you a qualified HSA Administrator?

2. Do you provide a call center available to answer questions?

3. Is a debit card available to plan participants?

4. Please detail the reports you will provide to the College and their employees.

UTILIZATION MANAGEMENT If your response differs by the type of funding and/or network you are proposing, provide the appropriate


VENDOR RESPONSE

1. Does your precertification program include analysis and determinations of:

a. Appropriate level of care? b. Reasonable length of stay? c. Actual medical necessity? d. Appropriateness of the surgery or

service being requested?


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VENDOR RESPONSE

e. Necessity for a proposed pre-operative hospital day?

f. Necessity for proposed 23-hour observation stays following outpatient surgery?

2. Do you review the following under pre-service review:

a. Elective inpatient medical/surgical admissions?

b. Elective outpatient surgery? c. Diagnostic services? d. Durable medical equipment? e. Corrective appliances/prosthetics? f. Skilled nursing facility? g. Home health/home enteral, infusion

therapy? h. Physical therapy? i. Acute psychiatric admissions? j. Residential psychiatric admissions? k. Psychiatric outpatient therapy

services? l. Substance abuse? m. Chiropractic care?

n. Other services (describe)?

3. Do you agree to attempt to redirect pre-service callers to an appropriate in-network provider?

4. If unable to redirect to an appropriate in-network provider, do you agree to document why?


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VENDOR RESPONSE

5. Responsibility for obtaining a pre-service certification lies with the:

a. Member? b. Provider? c. Client?

6. If the service provider fails to obtain approval, is the member responsible?

7. Do you agree to perform telephonic concurrent review on applicable inpatient admissions, redirect to in-network providers (when possible), and refer to case management for additional follow-up?

8. During case management, do you agree to direct the patient and/or their health care providers to use in-network services?

DISEASE MANAGEMENT If your response differs by the type of funding and/or network you are proposing, provide the appropriate


VENDOR RESPONSE

1. Have you included information in your response regarding all of the Disease Management Programs that you are offering to the College?

2. Did you propose your Disease Management Program as an Opt-Out approach, as requested?

3. Are you willing to include performance guarantees based on the effectiveness of your Disease Management Program?


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FULLY-INSURED MEDICAL UNDERWRITING If your response differs by the type of funding and/or network you are proposing, provide the appropriate

response for each approach Vendor Response

1. Does your proposal reflect a contract with a $150,000 medical pooling level?

2. What credibility factor was assigned to the Client’s experience?

3. What experience period will be used for the first renewal (e.g., first 5 months)? What period will be used in second and later renewals?

4. If the group remains the same size, what credibility will be given at the time of renewal (100 percent credibility means only the claims experience of that coverage on that group will be used and 0 percent means the coverage is manually rated)?

5. How much would the group have to change in size before the credibility percentages above would vary by more than 10 percent?

6. Explain the methodology and data to be used for the renewal process. How will projected incurred claims be estimated for these plans?

7. What credibility do you anticipate assigning to the College’s experience at:

First Renewal?

Subsequent?

8. What is your standard reserve factor (as a % of mature paid claims)?

9. What maturity factor would you use to adjust Medical paid claims for the first renewal?

10. What is your current leverage trend factor for the pooling point proposed by your firm?

11. Are you willing to provide a second year rate guarantee, rate cap, or component guarantee? Describe.


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FULLY-INSURED MEDICAL UNDERWRITING If your response differs by the type of funding and/or network you are proposing, provide the appropriate

response for each approach Vendor Response

12. What is your current trend factor for the product proposed and in the client’s service area.


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FULLY-INSURED MEDICAL GENERAL If your response differs by the type of funding and/or network you are proposing, provide the appropriate

response for each approach VENDOR RESPONSE

1. Are you able to match the current medical benefits exactly?

2. If not, have you listed all deviations on the Deviations and Exceptions Exhibit contained in this RFP. (Do not refer to any other document to respond to this question.)

3. Will the client have online access to address additions, terminations, and status changes?

4. How long before notification of a new employee is the additional charge reflected on your premium billing?

5. What is your current medical trend for the greater Tucson metropolitan area for the products you are proposing for the College?

6. List the type of providers who have Contracts based on capitation.

7. If your firm uses capitation, is the charge to the client the amount you pay to the providers (in other words, do you keep a spread)?

8. How will your Patient Centered Medical Home or ACO impact or be included in your PPO/POS network proposed?


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MINIMUM PREMIUM MEDICAL UNDERWRITING



VENDOR RESPONSE

1. If your underwriting procedures allow the unrevealed claims reserves to be held by the College or maintained in a separate policyholder managed account, indicate:

a. How a reserve release would occur and what happens on termination of the policy?

b. Who is liable for claims run-out in excess of the reserve if the reserve is returned to your company at the time of policy termination?

c. If the reserve is turned over to your company and claims run-out is less than the reserve amount, is the difference returned to the College?

2. If your underwriting procedures require the incurred but unreported claims reserve be retained by your company, indicate:

a. What rate of interest will be credited on these funds?

b. Is this interest returned directly to the College or credited against the retention costs?

c. What is the amount of interest that is estimated to be credited during the first and subsequent policy years?

d. After termination, will a final accounting be done on the reserves remaining after the payment of claims run-out?


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VENDOR RESPONSE

e. Will any remaining reserves be returned to the College?

f. When would this final accounting be completed?

3. a. Does your contract include a deficit carryover provision? If so, please explain.

b. Do you charge interest on deficits in years subsequent to the deficit?

c. Would your company agree to limit the deficit recovery from future years’ surpluses to a given amount?

4. a. Is the maximum policyholder claims liability based on paid or incurred claims?

b. Will that limit be affected by either the College or your company holding the reserve?

5. Does your proposal assume a monthly policyholder maximum claims liability? Describe your method for applying this approach.

6. Does your proposal assume an annual policyholder maximum claims liability? Describe your method for applying this approach.

7. Are premium taxes and ACA Health Insurer taxes paid on the premium equivalent or only the portion of the rate remitted as premium (i.e. retention, pooling, and IBNR reserve)?

8. Would the College be required to pay any deficit that may exist upon contract termination?


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VENDOR RESPONSE

9. Is the final accounting based on incurred claims where the IBNR is derived from known run-outs plus a completion factor (if applicable) or on a factor multiplied by paid claims?

10. If the final accounting is based on a factor multiplied by paid claims, what is your standard book of business factor?

11. Are reserves reconciled upon master contract termination?

12. Is the client required to maintain a certain level of funds in the bank account?

13. Is your retention estimated or guaranteed?


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CLAIMS PROCESSING If your response differs by the type of funding and/or network you are proposing, provide the appropriate


GENERAL INFORMATION

1. Regarding your client base in the office proposed to service the College:

a. Number of clients you currently provide claim administration services at this location.

b. Number of total lives that these clients represent.

SYSTEM CAPABILITIES

2. If you use a subcontracted vendor to identify and recover overpayments, is the cost borne by the College or part of your administration fees?

3. For claims that need additional information in order to adjudicate (such as needing an operative report, ER visits notes, ambulance records, student status, etc.):

a. Do you pend those claims, or deny/ close the claims?

b. How long can a claim be listed as pending before you bring resolution to that claim?

PROCESSING TIME

4. Based on the most recent 6 months and including the time the claim is with a clearinghouse, if any), indicate:

a. Average number of calendar days to process a clean claim from date received to date a check is issued to the provider/patient.


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b. Average number of calendar days to process a claim from date received to date EOB is sent to patient.

c. What percent of all claims submitted (regardless of information provided on claim) have been processed (from date received to date EOB is issued) within 14 calendar days?

d. What percent of all claims submitted (regardless of information provided on claim) have been processed (from date received to date EOB is issued) within 30 calendar days?

REIMBURSEMENT PROCEDURE

5. If the College had specific guidelines for multiple surgical procedures that differs from your standard, can your system accommodate?

6. Describe what, if any, hospital bill audit procedures are in place to detect mischarges and inappropriate charges on hospital bills and/or the miscoding of DRGs.

7. Is your interface with UM vendors (for decisions on precertification, length of stay, case management, and UR-negotiated fee discounts) electronic or paper?

8. How do you manage Coordination of Benefits (COB):

a. Pre-payment or post-payment?

b. What procedures do you perform to determine the presence of other coverage (e.g., use claim detail, open enrollment query, annual query, etc.)?

9. How do you administer subrogation (pay and pursue or pursue and pay)?


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10. The College currently pays 100% of the cost for a colonoscopy for all plan members as appropriate, regardless of diagnosis. Are you able to identify a preventive colonoscopy (doctor ordered, not on a normal preventive schedule) versus a diagnostic colonoscopy, and support administration of each separately (e.g., one paid at 100% and one paid subject to deductible and coinsurance)?

11. Explain what system you use and how you track and document inquiries from claimants.

SELF-FUNDING GENERAL If your response differs by the type of funding and/or network you are proposing, provide the appropriate


1. Will the College have a dedicated or designated team to help with questions?

2. Indicate any minimum checking account balance you require to pay claims.

3. Please describe any banking requirements.

4. Run-Out

a. Do you agree to process the run-out upon contract termination?

b. If so, what is the fee that would be charged to the College?

c. How long would you administer run outs?


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ARIZONA NETWORK COMPOSITION If your response differs by the type of funding and/or network you are proposing, provide the appropriate


VENDOR RESPONSE

1. What is the name of your network?

2. If you directly or indirectly contract with another network inside Arizona: a. What is the network name and fee you

pay?

b. If there is a fee, is it included in your administration fee or billed to the College?

c. If billed to the College, what is the amount of the fee?

3. Provide a list of the Centers of Excellence included in your network in Arizona used for organ transplants.

4. Outline any anticipated network changes for:

i. Physicians

ii. Hospitals

5. Indicate major hospital contracts scheduled for renewal in the next 12 months for:

a. Pima County

b. Arizona (other than Pima County)

6. Indicate your self-reported discounts (using billed less ineligible as the denominator) within the College’s service area based on your book of business.


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ARIZONA NETWORK COMPOSITION If your response differs by the type of funding and/or network you are proposing, provide the appropriate


VENDOR RESPONSE

7. Based on your Geo Access report using this client’s census and criteria below, indicate the locations (city, town, state, and zip code) where your network does and does not have coverage.

a. 2 PCPs within 10 miles (include family practice, general practice, internal medicine, pediatricians and OB/GYN)

b. 2 Specialists within 10 miles

c. 1 Hospital within 20 miles

ARIZONA NETWORK CLAIMS PAYMENT If your response differs by the type of funding and/or network you are proposing, provide the

appropriate response for each approach

VENDOR RESPONSE

1. How is continuity of care maintained?

2. What penalties should the College be aware of that are included in your provider contracts related to untimely claim payment that would impact the College?

3. List all of the scenarios in which your discounts cannot be applied to bills submitted by network facilities or physicians (e.g., workers comp, third party liability, etc.).


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OUTSIDE ARIZONA NETWORK COMPOSITION



VENDOR RESPONSE

1. What is the name of your network?

2. If you directly or indirectly contract with another network:

a. What is the network name and fee you pay?

b. If there is a fee, is it included in your administration fee or billed to the College?

c. If billed to the College, what is the amount of the fee?

3. Provide a list of the Centers of Excellence included in your network used for organ transplants based on the employee zip codes outside Arizona.

4. Outline any anticipated network changes, based on the employee zip codes outside Arizona for:

a. Physicians

b. Hospitals

5. Indicate major hospital contracts scheduled for renewal in the next 12 months based on employee zip codes outside Arizona.

6. List any provider-types in your network that are compensated on a capitation basis.

7. Indicate your self-reported discounts (using billed charges less ineligible as your denominator) within the College’s service area (based on employee zip codes outside Arizona), based on your book of business.


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OUTSIDE ARIZONA NETWORK CLAIMS PAYMENT

If your response differs by the type of funding and/or network you are proposing, provide the


VENDOR RESPONSE

1. How is continuity of care maintained?

2. What penalties should the College be aware are included in your provider contracts related to untimely claim payment?


NON-NETWORK CLAIMS PAYMENT If your response differs by the type of funding and/or network you are proposing, provide the


VENDOR RESPONSE

1. Describe how you would determine reasonable and customary allowances.

2. What percent of Medicare do you propose for non-network claims?


HDHP/HSA ADMINISTRATIVE SERVICES



1. What is the name of the HSA administrator (i.e. the Medical TPA, a contracted partner)?

2. Explain the basis for your qualifications as an HSA administrator and the dates of qualification.


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HDHP/HSA ADMINISTRATIVE SERVICES If your response differs by the type of funding and/or network you are proposing, provide the


3. How long have you provided HSA administration services?

4. What information or administration services for HSA’s are available on your website?

5. Do you have a call center available to answer questions telephonically?

6. Name the qualified HSA custodians/ trustees (e.g. banks and insurers) with which you have a relationship and describe that relationship.

7. What services and reporting can the College and its employees expect from the HSA custodian/trustee?

8. Explain the payroll and transfer of funds process from the employer to the bank.

HRA ADMINISTRATIVE SERVICES If your response differs by the type of funding and/or network you are proposing, provide the


1. What is the name of the HRA administrator (i.e. the Medical TPA, a contracted partner)?

2. Explain the basis for your qualifications as an HRA administrator and the dates of qualification.

3. How long have you provided HRA administration services?

4. Explain the funding of the HRA and administration

5. What information or administration services for HRA’s are available on your website?


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HRA ADMINISTRATIVE SERVICES If your response differs by the type of funding and/or network you are proposing, provide the


6. Do you have a call center available to answer questions telephonically?

7. Name the qualified HRA custodians/ trustees (e.g. banks and insurers) with which you have a relationship and describe that relationship.

8. What services and reporting can the College and its employees expect from the HRA custodian/trustee?

9. Explain the payroll and transfer of funds process from the employer to the bank.


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UTILIZATION MANAGEMENT (UM) GENERAL ADMINISTRATION



1. What is the name of, and who owns, the UM firm you are proposing for the College?

2. Describe how your firm assures confidentiality of medical information received during the UM process.

3. Is your firm currently URAC accredited for utilization management services?

UTILIZATION MANAGEMENT PRE-SERVICE REVIEW



1. Indicate the toll-free number and minimum hours of operation of your switchboard: a. Weekdays b. Weekends c. Holidays

2. What type of system is available for receipt of pre-service calls before/after your normal working hours?

a. Answering machine with recorded message given

b. Answering machine will accept receipt of messages

c. Answering service to receive messages

d. Open 24 hours a day


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UTILIZATION MANAGEMENT PRE-SERVICE REVIEW



e. No provisions, except during normal business hours

3. Describe the method and frequency of notification from your firm to the claims administrator about the cases that have received your pre-service review and concurrent review services.

UTILIZATION MANAGEMENT (UM) CASE MANAGEMENT



1. Does your firm perform case management?

2. How do you find cases to case manage?

3. What types of cases do you identify for case management?

4. Describe the method and frequency of notification from your firm to the claims administrator about the cases that have received your case management services.

VISION NETWORK If your response differs by the type of funding and/or network you are proposing, provide the appropriate


VENDOR RESPONSE

1. Do you wholly own and operate the network you are proposing for the College?

2. Indicate the marketing name of the network you are proposing.


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VENDOR RESPONSE

3. Have you noted on the Deviations Form any provisions of the current benefit plan that you are not able to administer? Please be specific and do not refer the reader to “see our proposal” etc.

4. Is your vision care network in the College’s service area made up of retail chains only, independent opticians / ophthalmologists only, or a mixture of both?

5. What percent of the offices are private provider offices versus chain stores?

6. a. Does your organization have an association with any optical chain stores?

b. If so, please specify and explain.

7. Please provide Geo Access reports using the following access standards: Your results must be based on those employees on the census that have currently elected vision benefits. Reports should reflect city, state, zip code, and number of unique vision providers by zip, number of employees with desired access (as defined below) for each category AND locations (Zip Code and County) where access standards are not met including the number of employees without desired access.

a. Ophthalmologists:

Access criteria: 1 provider within 10 miles of home zip code

b. Optometrists:

Access criteria: 1 provider within 10 miles of home zip code


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VENDOR RESPONSE

8. For 2012 and 2013 YTD, provide the number of network participating providers that were terminated in the College’s service area:

a. By your organization

b. By the provider

9. What changes do you anticipate to your network over the next two years?

10. How does your organization measure the quality of care provided by the providers in your network?

11. How many complaints per 1,000 visits do you receive on your network providers?

12. Do any network providers include night or weekend hours?

13. How long is the average wait time to get an eye exam?

14. Do network providers pay a membership fee to your organization?

15. Do you provide services through Walmart?

16. Do you provide services through Costco?

17. Do you provide services through Sam’s Club?

18. Do you provide services through Target?

19. How do your providers recognize a patient as a participant in your vision program - voucher, ID card, electronic connection to your eligibility database, etc.? Please explain.


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WELLNESS SERVICES



VENDOR RESPONSE

1. Have you included information in your response regarding all of the Wellness Services and Programs that you are offering to the College?

2. Are you willing to include performance guarantees based on the effectiveness of your Wellness Services Program? If so, please describe.

3. Describe any Wellness Allowance you have included in your proposal.

4. Will a Wellness Allowance be provided annually? If so, how much?

5. Describe what items the College can pay for with the Wellness Allowance.

6. Do you agree to allow the College to roll over any unused funds from one year to the next?

7. Describe any type of dedicated wellness resources you are willing to offer the College.

STOP LOSS COVERAGE If your response differs by the type of funding and/or network you are proposing, provide the appropriate


1. a. Has your organization read and agreed to administer stop loss insurance in accordance with the plans as described in the attachments?

b. If no, please explain any deviations.


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2. Are your proposed rates firm?

3. Describe any underwriting contingencies.

4. Describe your renewal calculation.

5. a. Indicate which TPA’s and Medical carriers you can work with.

b. Indicate which PBM’s you can work with.

6. Do you agree to administer stop loss insurance in accordance with the plans’ experimental and medically necessary definitions, as described in the plans?

7. a. Are there any individuals being excluded from coverage, or provided different or limited coverage under your contract for medical?

b. Are there any individuals being excluded from coverage, or provided different or limited coverage under your contract for pharmacy ?

8. Does your contract allow you to limit or exclude coverage on covered persons at renewal?

9. Do you require a disclosure statement be completed at renewal?

10. If a disclosure statement is required to be completed, what is the maximum number of days in advance of the effective date it can be completed?

11. Will you accept the data from the claims payor directly?


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12. Define clearly the terms and conditions of your contract as they apply to termination.

13. After termination, what is the maximum number of days allowed for submission of a valid claim that was paid by the administrator within the contract period?

14. Does your program include access to transplant centers of excellence so the College can utilize any pre-negotiated discounts?

15. What is your current leverage trend factor for the proposed deductible level?

16. What has been your 2013/2012 average increase for your book of business for the proposed deductible level?

17. What has been your 2013/2012 average increase for your book of business for the proposed aggregate attachment factor of 125%?


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For the following categories, provide the performance standard you are willing to offer, the financial penalty (maximum dollar amount or % of administrative fees) you will agree to pay if the standard is not met, and the method of measuring the penalty for each funding type proposed.

PERFORMANCE GUARANTEES If your response differs by the type of funding and/or network you are proposing, provide the appropriate


VENDOR RESPONSE

FINANCIAL PENALTY (Maximum

Dollar Amount of % or

Administrative Fees)

1. Vendor attendance at College meetings

Attendance by vendor representatives when requested at meetings scheduled by the Client during the contract period and implementation phase.

2. Vendor call (or e-mail) return timeliness

The College or designated consultant’s calls (or e-mails) to vendor are returned within 24 clock hours.

3. Processing eligibility updates

All updates to eligibility or enrollment records will be made within 3 business days after the information is received by the vendor.

4. Telephone call availability & answering speed

90% of all calls are answered within 30 seconds, and telephone service is available between 8:00 am and 6:00 pm Arizona Time Zone on business days.

5. Telephone call on-hold (in-queue) time

An average of less than 2 minute(s) on hold before a human being answers.

6. Telephone Abandonment Rate

An abandonment rate of less than 3% is maintained during standard business hours.


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VENDOR RESPONSE




7. Claims Processing Accuracy

99% of claims dollars submitted for payment will be accurately processed and paid. Regardless of whether or not these standards of performance are satisfied, the vendor must reimburse the College for all overpayments that are not recovered from the recipient within 60 days after the overpayment is discovered. The College will assign its right to recover any such overpayments to the vendor.

8. Turnaround Time on Claims Payments

95% of all claims received will be completely processed (paid, denied, or pended for additional information) within 14 calendar days after they are received. 100% of claims will be processed within 30 calendar days of receipt.

9. Elevated Claim Issues

When the College contacts you with an elevated claim issue via telephone or email directly or through their consultant you will respond within 24 hours and provide progress reports every 48 hours until the issue is resolved.

10. Timeliness of Claim Reports

Each report the vendor will supply the College will be provided within a mutually agreed upon timeframe.

11. Claims Coding

99% of all claims will be coded with no errors.


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VENDOR RESPONSE




12. Implementation

Successful implementation as defined by key milestones. Include measurable milestones in your proposal.

13. Data Exchange

Receive and transmit the College’s data with vendors based on a frequency defined by the business needs of the College.

14. Network Discounts

Achievement of self-reported discounts (as responded to in the Network Composition section of this Questionnaire).

15. Network Size

Agree to maintain the size of the network as provided by your Geo Access report.


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THE FOLLOWING SECTION APPLIES TO THE PHARMACY BENEFIT MANAGEMENT PORTION OF THIS REQUEST FOR PROPOSAL


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General Proposal Requirements In order for your proposal to be considered and accepted, your organization must provide answers to the questions presented in this RFP. Each question must be answered specifically and in detail. Reference should not be made to a prior response, or to your contract, unless the question involved specifically provides such an option. Be sure to review this entire RFP before responding to any of the questions, so that you have a complete understanding of all of the College's requirements with respect to the proposal.

***DO NOT ALTER THE QUESTIONS OR QUESTION NUMBERING***

1. Provide an answer to each question even if the answer is “not applicable” or “unknown.”

2. Answer the question as directly as possible. • If the question asks “How many…” provide a number. • If the question asks, “Do you…” indicate Yes or No followed by any additional narrative

explanation.

3. Where you desire to provide additional information to assist the reader in more fully understanding a response, refer the reader of your RFP response to your appendix/attachments. However, direct responses to all of the RFP questions must be provided and will be looked upon favorably.

4. Bidder will be held accountable for accuracy/validity of all answers. If your proposal is different in any way (whether more or less favorable) from that indicated in this RFP, clearly indicate where and explain the difference. If you do not, the submission of your proposal will be deemed a certification that you will comply in every respect (including, but not limited to, coverage provided, funding method requested, benefit exclusions and limitations, underwriting provisions, etc.) with the requirements set forth in this RFP. If you are unable to perform any required service, indicate clearly: a) what you are currently unable to do, and, b) what steps will be taken (if any) to meet the requirement, the timetable for that process and who will be responsible for the implementation, along with that person's qualifications. All products should be priced individually. If pricing terms are provided for combining services, show the pricing terms as a separate line item. Financial Section: When displaying your proposed fees, the tables in the Financial Section included in this RFP must be used. Please note that pricing terms should be offered on a pass through (transparent) basis. Information provided in any other format will not be considered. Footnotes to the form(s) may be used to provide supplemental explanations, if necessary.


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Network Disruption: A network disruption analysis is necessary in order to award a final contract. The lack of disruption from the current network will be a major factor affecting the outcome of this proposing process. In order to be considered, your organization must provide data regarding your network and contracted pharmacies. The basis of this evaluation will include your organization’s broadest, national network offering. Minimum Contractual Requirements: The Minimum Contractual Requirement section will become part of the actual contract document. Agreement to the terms and language in this section will be a critical factor in bidder evaluation and selection and an authorized binding signature will be required.


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MINIMUM CONTRACTUAL REQUIREMENTS The following are the College’s core requirements. Bidders’ responses to this section will be heavily weighted in the selection process. Please include your responses within this form. Indicate “yes” or “no” as to your organization’s ability to comply.

MINIMUM CONTRACTUAL REQUIREMENTS YES NO 1. The College will have the right to terminate the PBM with or

without cause given a 60-day notice period after the initial 12-month period has elapsed, without penalty to the College.

2. The resulting contract will contain a provision allowing the College a 10 business day grace period to fund claims.

3. Definitions (You agree to the following contract definition) a. “Pass Through” and “Transparent” - PBM agrees to pass-

through 100% of negotiated discounts with network pharmacies at the point-of-service and to provide auditing protocol enabling tracking of individual claims back to original pharmacy network contract documents. The PBM agrees to disclose details of all programs and services generating financial remuneration from outside entities.

b. “Rebates” - Compensation or remuneration of any kind received or recovered from a pharmaceutical manufacturer attributable to the purchase or utilization of covered drugs by eligible persons, including, but not limited to, incentive rebates categorized as mail order purchase discounts; credits; rebates, regardless of how categorized; market share incentives; promotional allowances; commissions; educational grants; market share of utilization; drug pull-through programs; implementation allowances; clinical detailing; rebate submission fees; and administrative or management fees. Rebates also include any fees that PBM receives from a pharmaceutical manufacturer for administrative costs, formulary placement, and/or access.

4. The PBM agrees to a five-year contract term with a three-year pricing guarantee effective July 1, 2014, with the option to renew annually during the five-year contract.

5. The PBM agrees that no financial penalty for non-renewal will apply, even during the first year three years of the contract period.

6. The PBM contract will provide 180-days advance notice of renewal rates (after initial three-year term), which shall then be subject to negotiation and written agreement between the parties.


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MINIMUM CONTRACTUAL REQUIREMENTS YES NO 7. The College or its designee will have the right to audit, with

an auditor of its choice, with full cooperation of the selected PBM, the claims, services and pricing and/or rebates to verify compliance with all program requirements and contractual guarantees. This provision shall survive the termination of the agreement between the parties for a period of 3 years. The College or its designee will have the right to conduct an audit at any time during the year, at any time during the 3 year contract term and each renewal year (for a period of 5 years) and the selected PBM will provide all documentation necessary to perform the audit. All costs incurred by the PBM to comply with the audit (e.g., data access, evaluation) shall be the responsibility of the PBM.

8. All pricing submitted will NOT be contingent on participation in any proposed clinical management programs, group medical or behavioral health programs proposed by you or any other vendor other than programs that are requested by the College. Further, the pricing guaranteed in the Financial Section of this RFP reflects a) the PBM’s broadest national network and b) the PBM’s broadest formulary or preferred drug listing, without any drug coverage exclusions unless otherwise authorized or requested by the College.

9. All rebate revenue earned by the College will be paid to the College regardless of their termination status as a client.

10. The PBM agrees to load all current prior authorizations, open mail order refills, specialty transfer files, and accumulator files that exist for current members from the existing PBM at NO charge to the College (with no charges being deducted from the implementation allowance for file loading or IT ).

11. Brand and Minimum Generic Discount Guarantees for both mail and retail shall be defined as follows: (Aggregate Ingredient Cost/Aggregate AWP).

a. Aggregate Ingredient Cost prior to application of plan specific co-payments will be the basis of the calculation.

b. Aggregate AWP will be from a single, nationally recognized price source for all claims. Please indicate source.

c. Dispensing Fees are not included in the Aggregate Ingredient Cost.

d. Both the Aggregate Ingredient Cost and Aggregate AWP from the actual date of claim adjudication will be used.

e. Aggregate AWP will be the date sensitive, 11-digit NDC of the actual product dispensed.

f. Both non-MAC, MAC, single-source and multiple source generic products are to be included in the generic guarantee measurement.


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MINIMUM CONTRACTUAL REQUIREMENTS YES NO g. Compounds, Specialty Pharmacy Program claims, OTC

claims, zero balance claims, Usual and Customary (U&C) claims, and claims with ancillary charges will be excluded from the guarantee measurements for retail and mail order components.

h. The guarantee measurement must exclude the savings impact from DUR programs, formulary programs, utilization management programs, and/or other therapeutic interventions.

i. Any shortfall between the actual result and the guarantee will be paid, dollar-for-dollar, to the College within 60 days of the end of the measurement period.

j. Measurement will be performed annually via independent audit utilizing date-sensitive AWP derived from a single, nationally recognized price source for all claims.

12. The PBM agrees to base all guarantees on the actual package size from which the prescriptions are dispensed.

13. The College will be notified of any switch to the source of the aggregate AWP with at least a 180-day notice. In the event that a switch is made that is not price neutral, the College will have the right to terminate the contract with no penalty.

14. Each distinct pricing guarantee will be measured and reconciled on a component (e.g. retail brand, retail generic, mail order brand, mail order generic, and specialty) basis only and guaranteed on a dollar-for-dollar basis with 100% of any shortfalls recouped by the College. Surpluses in one component may not be utilized to offset deficits in another component.

15. Rebates can be passed through at the point-of-sale based on PBM’s best estimate of the expected rebate amount. The AWP discount will first be applied, less the rebate factor (expressed as a percentage of the ingredient cost), and then member’s copayment applied. Quarterly, within sixty (60) days of the quarter’s close, PBM will reconcile rebate guarantees to verify that the College is receiving the guaranteed rebates.

16. Guaranteed rebates per prescription will be based on all prescriptions dispensed, not on brand or formulary prescriptions dispensed.

17. 100% of all rebates collected will be passed through to the College.

18. Rebates are guaranteed on a minimum (i.e., not fixed) basis. 19. Rebates are guaranteed for the life of the contract as well as

any extension of the underlying agreement. Rebates will continue to be paid if earned during the contract period and up to 18 months past contract termination.


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MINIMUM CONTRACTUAL REQUIREMENTS YES NO 20. Rebates will not be withheld for execution of annual contract

amendments. The College is entering in to a multi-year agreement and needs no annual renewals/amendments signatures for payments of rebates.

21. Rebate reports listing detailed rebate utilization and calculations will be provided to the College.

22. The PBM agrees to provide Retail/Mail Order unit cost equalization to the College, meaning that Mail Order unit costs prior to member cost sharing, dispensing fees, and sales taxes charged to the College will be no greater than those at Retail. The PBM agrees to produce a date-sensitive comparison report showing unit costs charged to the College at a GCN-level, and reimburse the College on a dollar-for-dollar basis for all instances where mail order unit costs exceed retail unit’s costs. Report and reconciliation will be provided on a quarterly basis.

23. The PBM agrees to obtain the College’s approval for all member communication materials before distribution to members. The PBM will not automatically enroll the College in any programs that involve any type of communications with members or alterations of members’ medications, without express written consent from the College.

24. PBM agrees to hold the College harmless for any HIPAA Violations made by the PBM or its Network Pharmacies.

25. The PBM will agree to be claims fiduciary for clinical based determinations.

26. The PBM will agree to defend claims litigation based on its decisions to deny coverage for clinical reasons.

27. The PBM will agree to handle claims/appeals processing in accordance with the minimum requirements of ERISA as amended by PPACA for a non-grandfathered plan.

28. The PBM will agree to be responsible for selecting and contracting the external review organizations sufficient to allow the plans to comply with ERISA as amended by the Patient Protection and Affordable Care Act (PPACA).

29. PBM agrees to provide dedicated account resources including, but not limited to, an implementation manager, strategic account executive, clinical director - pharmacist, account manager, claims advocate and an underwriter/financial analyst. Please include biographies.


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MINIMUM CONTRACTUAL REQUIREMENTS YES NO 30. PBM agrees to a mid-contract-term market check to ensure

the College is receiving appropriate current pricing terms based on its volume and membership, and will improve pricing in the event that the College’s contract terms are less than current. The College will have the right to terminate without penalty if the pricing terms are not industry competitive.

31. The PBM will be responsible for collecting any outstanding member cost shares for prescriptions dispensed through the mail order facility. The PBM will not invoice The College for any uncollected member cost shares.

32. The PBM will not withhold any financial recoveries from audits performed on the contracted pharmacy network including mail order and specialty pharmacies. Any recoveries will be disclosed and credited to the College.

33. The PBM agrees to provide an Implementation Credit to the College on a Per Member basis.

34. With the exception of FDA directed market removals, the PBM agrees it will not remove a covered drug from the Formulary/Drug list, exclude coverage of a drug, or change the utilization management status (i.e., add a prior authorization, step therapy, or quantity limit) of any drug without written approval from The College.

35. The PBM will agree to fund a Pre-Implementation Audit (up to $30,000) to be conducted at least 60 days prior to the start of claims adjudication. The PBM will work with the auditor to run test claims in a test environment utilizing the College’s actual plan parameters.

36. The PBM will provide draft SPD language for any clinical programs that are to be implemented.

37. The PBM has the ability and will agree to facilitate the CMS/RDS prescription drug subsidy program.

38. The PBM must be able to administer a 90-day retail prescription drug benefit.

39. The PBM agrees to notify the College or its designee in advance of 90 days when a formulary drug is targeted to be moved to or from the preferred drug list. The PBM must provide a detailed disruption and financial impact analysis at the same time, and be responsible for communication to affected members.


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CONTRACTUAL EXPECTATIONS The following are the College’s expectations of how the topics below will be addressed in the final, executed contracts with the College. Please complete this form and include it within your response. Indicate “yes” or “no” as to your organization’s ability to comply. An explanation of your “yes” or “no” response may be requested during the proposal evaluation process.

CONTRACTUAL EXPECTATIONS YES NO 1. Definitions

a. AWP (Average Wholesale Price) is based on date sensitive, 11-digit NDC as supplied by a nationally-recognized pricing source (i.e., First DataBank, Medi-Span) for retail, mail order, and specialty adjudicated claims (Subject to outstanding litigation).

b. Member Copay - Members will pay the lowest of the following: plan copay/coinsurance, plan-negotiated discounted price plus dispensing fee, usual and customary (U&C), or retail cash price.

c. The College eligibility and claim data - All eligibility and claims records are the sole property of the College and must be made available upon request to the College and its representatives. Selling or providing of the College’s data to ANY outside entities must be approved in advance, reported on a monthly basis and all income derived must be disclosed and shared per agreement with the College. Even if PBM has not "sold" the data, it is NOT free to use the data for analyses that they publish or provide to outside industries.

d. Paid Claims - Defined as all transactions made on eligible members that result in a payment to pharmacies or members from the College or the College member copays. (Does not include reversals and adjustments.) Each unique prescription that results in payment shall be calculated separately as a paid claim.

e. Members - All eligible employees and their eligible dependents enrolled under the College prescription benefit program.

2. The College will not be held responsible for time or miscellaneous costs incurred by the PBM in association with any audit process including, all costs associated with providing data, audit finding response reports, or systems access provided to the College or its designee by the PBM during the life of the contract. Note: This includes any data required to transfer the business to another vendor and money collected from lawsuits and internal audits.

3. The PBM agrees to a 21-day turnaround time to provide its response to claims audit findings.


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CONTRACTUAL EXPECTATIONS YES NO 4. The PBM will NOT implement, administer, or allow any

program that results in the conversion from lower discounted ingredient cost drug products to higher ingredient cost drug products or increases member’s cost share without the prior written consent of the College or its designee.

5. The PBM mail order service must notify each affected individual and the College or its designee prior to substituting products that will result in higher member co-pay.

6. The College reserves the right to review, edit, or customize any communication from the PBM to its membership.

7. PBM agrees to notify the College and its members at least 60 days prior to the addition of a drug to the specialty drug list and at least 90 days prior to a deletion of a drug from the specialty drug list. The College reserves the right to approve any addition to the specialty drug list.

8. The College will have the ability to annually renegotiate and/or “carve-out” specialty drug pricing and service terms.

9. All pricing will be effective and guaranteed for the term of the agreement (excluding the renegotiated specialty pricing) and will not include adjustments for claims volume shifts amongst the various provider channels (e.g., mail utilization rates decline or 90-day retail utilization increases).

10. The PBM agrees to provide online, real time, claim system access to the College or its designee, including access to historical claims data for up to three years following termination of the agreement.

11. The PBM agrees that all future edits required because of plan design changes implemented by the College shall be completed, after testing, by the PBM within 45 days of request/advisory by the College.

12. All applicable administrative fees will be on a per paid claim basis.

13. All applicable fees include the cost of claims incurred/filled during the effective dates of this contract regardless of when they are actually processed and paid (run-out).

14. All customer service call recordings and notes between the PBM and the College’s members will be property of the College.

15. The PBM agrees to document 100% of the College’s customer service calls through call recordings and call notes. PBM will forward written transcripts of calls at the College request within two business days of the request being made.

16. The College reserves the right to access all call recordings or call notes from customer service calls with its members. PBM agrees to allow the College the right to request call recordings and/or notes at any time.


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CONTRACTUAL EXPECTATIONS YES NO 17. The PBM agrees to allow the College access to its member

website with a dummy login prior to the go-live date.

18. The PBM will provide the College with a virtual tour of its CSR system and any custom messaging system.

19. The PBM agrees to, at minimum, quarterly calls to review customer service issues. The PBM agrees to allow the College to review customer service quality issues to the resolution endpoint.

20. The PBM agrees to a minimum of one annual meeting with call center executives to discuss services regarding enrollment and member issues.

21. The PBM agrees to grandfather the College’s current formulary for up to 90 days following the contract effective date.

22. The PBM agrees to provide daily data transmissions (may include feeds to data warehouses) to the medical administrator vendors at no charge and two full, annual electronic claims files, in NCPDP format, at no charge as needed. PBM will also interact/exchange data with all vendors as needed at no additional charge.

23. The PBM will provide electronic access to monthly claims information by medical plan offering to the College and/or its designee(s).

24. There are NO additional fees (beyond those outlined in the Financial Section) required to administer the services outlined in this RFP. Any mandatory fees, including clinical and formulary programs fees, must be clearly outlined in the Financial Section.

25. The PBM agrees to a review and negotiate the pricing applied to newly introduced generic drugs annually.

26. With the exception of FDA recalls or other safety issues, the PBM agrees it will not remove brand or generic drug products from its formulary or preferred drug list unless there is a substantive reason that will be discussed with the College prior to its removal and subject to the College’s approval.

27. The PBM will respond to and incorporate future Health Care Reform changes in full compliance with the law and at no additional cost to the College.

28. The PBM agrees to no additional charges for any retroactive claims reprocessing and member reimbursements due to retroactive plan design adjustments.

29. The PBM agrees to adjudicate prescription claims for compound medications with the same dispensing fees and logic associated with traditional claims.


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FINANCIAL SECTION Bidders are required to complete all financial forms as instructed. Bidders should provide proposed fees and guarantees separately for each year of the three-year contract, so that the College’s pricing terms keep pace with expected market trends. We ask all bidders to provide a pass through (transparent) pricing proposal as described in this RFP. Please note this is a pass through (transparent) arrangement. The services provided should include, but should not be limited to, the services referred to in the “PBM Services to be Provided” section. The financial proposal submitted must exclude Wal-Mart and Sam’s Club from the pharmacy network. Administrative Fees Complete the following Administrative Fee Tables:

PASS THROUGH (TRANSPARENT) PROPOSAL

ADMINISTRATIVE FEES RESPONSE

7/1/2014-6/30/2015

7/1/2015-6/30/2016

7/1/2016-6/30/2017

1. Complete the following Administrative Fee Table

Retail/Mail Administrative Fee $ per paid

claim

$ per paid

claim

$ per paid

claim Services to be included in fees

above:

Toll Free Phone Lines Y or N Y or N Y or N Monthly Data Feeds to the College or Designee(s)

Y or N Y or N Y or N

Prospective /Concurrent/Retro DUR


Standard Reports Y or N Y or N Y or N Ad Hoc Reports Y or N Y or N Y or N I D Cards Y or N Y or N Y or N COB Program Y or N Y or N Y or N Mandatory Mail Program Y or N Y or N Y or N Dose Optimization Program Y or N Y or N Y or N Prior Authorization Program Y or N Y or N Y or N Step Therapy Program Y or N Y or N Y or N Quantity Limitations Y or N Y or N Y or N


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7/1/2014-6/30/2015

7/1/2015-6/30/2016

7/1/2016-6/30/2017

Custom System Overrides Y or N Y or N Y or N Annual EOB Statements Y or N Y or N Y or N Retro Termination Letters Y or N Y or N Y or N Group Coding Y or N Y or N Y or N Drug Notification Letters Y or N Y or N Y or N Formulary Administration/Management


ID Cards Y or N Y or N Y or N Pharmacy Directories and other member materials


Standard 1st level appeals processing


Standard 2nd level appeals processing


Urgent appeals processing Y or N Y or N Y or N Overrides Y or N Y or N Y or N Audit Recovery Fees Y or N Y or N Y or N

Services not included in fees above (i.e., services marked “N” above) (show fees separately):

• • • •

2. Detail all services and supplies to be provided under your basic fees that are not included in your response to question one.

3. Will there be any additional charges if plans/benefits are restructured or new classes of eligible members are added? If so, how are these charges determined and state amount of charges?

4. Confirm that postage is included in all mail order prescriptions and any mailings.

5. Confirm that quoted fees include postage paid mail order envelopes for member prescription submission.

6. Confirm that mail order and specialty drug dispensing fees will remain


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7/1/2014-6/30/2015

7/1/2015-6/30/2016

7/1/2016-6/30/2017

constant throughout the contract term and will not be increased due to changes in postage charges.

7. Detail all data related services included under the base administrative fees including ad hoc reporting, electronic claims files, plan design options, custom mailings, etc.

In addition, detail any data-related service fees not included in the base administrative fees.

8. Confirm that multi-language communication phone line support is included in the base administrative fee. List the languages available to the College members speaking to your customer service representatives.


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Prescription Drug Pricing AWP Reimbursement Basis - Complete the following tables using the drug reimbursement that your organization is willing to guarantee on a dollar-for-dollar basis for each year of the contract. Columns marked "AWP Discount” are to be completed using a discount from 100% AWP and dispensing fee logic. All guarantees must be based on the AWP unit cost dispensed at the point of sale, and post September 26, 2009 AWP rollback.


Year 1 (7/1/2014-6/30/2015)

Broadest Retail Network (List any Major Retail Chains Excluded)

AWP Discount Retail Supply Up to 30 days

AWP Discount Retail Supply 31-90 days

AWP Discount Mail Supply 1-90 days

Brand Drugs1

Discount from AWP2 for all brands % % % Dispensing Fee Per Rx $ per

Rx $ per

Rx $ per

Rx Generic Drugs3

Discount from AWP2 for all generics (composite discount of MAC and Non-MAC prices, discounted AWP, or usual and customary retail price)

% % %

Dispensing Fee Per Rx $ per Rx

$ per Rx

$ per Rx

Rebates

Three Tier Plan – Per Rx (brand & generic)

$ per Rx

$ per Rx

$ per Rx

1 Including both single source and multi-source brands. 2 Post September 26, 2009 AWP rollback 3 Including single-source generics.


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Year 2 (7/1/2015-6/30/2016)





Brand Drugs1


Rx $ per

Rx $ per

Rx Generic Drugs3


% % %


$ per Rx

$ per Rx

Rebates


$ per Rx

$ per Rx

$ per Rx

Year 3 (7/1/2016-6/30/2017)





Brand Drugs4


Rx $ per

Rx $ per

Rx Generic Drugs6


% % %


$ per Rx

$ per Rx

Rebates


$ per Rx

$ per Rx

$ per Rx

4 Including both single source and multi-source brands. 5 Post September 26, 2009 AWP rollback 6 Including single-source generics.


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3. Are any prescriptions excluded from the guaranteed prescription drug and specialty pharmacy program pricing as described in your responses in the Financial Sections above? If so, describe in detail, and provide a minimum guaranteed AWP discount for these prescriptions at both retail and mail, and indicate, based on the College’s attached prescription drug claims information for calendar year 2012, the percent retail and mail AWP excluded for these prescriptions from your guarantees. Otherwise, your above responses will be assumed applicable to all prescriptions.

Prescription Type:_________________ Retail Mail

Minimum Guaranteed AWP Discount

Rx Type’s AWP as a Percent of all AWP Prescription Type:_________________ Retail Mail


Rx Type’s AWP as a Percent of all AWP Prescription Type:_________________ Retail Mail


Rx Type’s AWP as a Percent of all AWP

4. Please confirm your proposed drug type designation or classification (e.g. brand, generic) source (i.e. First DataBank, Medi-Span, Redbook, Other). If other, please specify.

Allowances

Allowance Description Response Implementation Place the $ (dollar) Per Member

amount or the flat dollar ($) amount you are offering the College.

Audit Place the dollar ($) Per Member amount or the flat dollar ($) amount you are offering the College to be used annually to verify the College is receiving discounted costs and major services as contracted as well as 100% of rebates.


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Generic Drugs - Dispensing Rates

1. Complete the table below for contract Years 1, 2, and 3. Note that generic dispensing rate includes only true instances of generic dispensing (i.e., exclude multi-source brand drugs dispensed under member-pay-difference plan designs).

Guaranteed GDR Retail ≤ 30

days Retail >30

days Mail Order

7/1/2014-6/30/2015 % % %

7/1/2015-6/30/2016 % % %

7/1/2016-6/30/2017 % % %

2. What dollar amount are you prepared to put at risk for failure to meet your GDR guarantee?

Specialty Pharmacy Program Pricing

1. Please provide your organization’s definition and qualification criteria of a “specialty drug product.”

2. Provide an AWP-based pricing list of all specialty pharmaceuticals that your company dispenses and distributes to providers and patients. Your pricing must include adequate supplies of ancillaries such as needles, swabs, syringes, and containers. The following items must be included in your list:

a. Product Name

b. Therapeutic Group/Therapeutic Category

c. Guaranteed Minimum AWP Discount for all specialty pharmacy program prescriptions for both Open and Exclusive specialty arrangements

Complete the following tables:


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3. Please provide the open and exclusive guaranteed default specialty discount guarantees.

4. Please provide the open and exclusive mode specialty discount guarantees.

5. Please provide the open and exclusive average specialty discount guarantees.

6. Are your proposed guarantees for your retail/mail program contingent upon the College's purchase of your specialty drug program?

7. Based on the College’s attached prescription drug claims information for calendar year 2012, indicate the percent retail and mail specialty prescriptions and specialty AWP on the following table:

8. Based on the College’s attached prescription drug claims information through September,

2013 for prescriptions that were dispensed at retail, and your specialty pharmacy program pricing list provided in response to question 1 in the Specialty Pharmacy Program Pricing, what is the weighted average AWP discount for specialty prescriptions on the list?

9. Based on the College’s attached prescription drug claims information through September, 2013 for prescriptions that were dispensed at mail, and your specialty pharmacy program pricing list provided in response to question 1 in the Specialty Pharmacy Program Pricing, what is the weighted average AWP discount for specialty prescriptions on the list?

Open Specialty Pharmacy Program 7/1/2014-6/30/2015

7/1/2015-6/30/2016

7/1/2016-6/30/2017

Dispensing Fee $ per Rx $ per Rx $ per Rx

Administrative Fee $ per Rx $ per Rx

$ per Rx

Minimum Rebate Guaranteed $ per Rx $ per Rx $ per Rx

Exclusive Specialty Pharmacy Program 7/1/2014-6/30/2015

7/1/2015-6/30/2016

7/1/2016-6/30/2017

Dispensing Fee $ per Rx $ per Rx $ per Rx

Administrative Fee $ per Rx $ per Rx

$ per Rx

Minimum Rebate Guaranteed $ per Rx $ per Rx $ per Rx

Specialty Rxs at Retail as a Percent of all Retail Rx’s %

Specialty AWP at Retail as a Percent of all Retail AWP %

Specialty Rxs at Mail as a Percent of all Mail Rx’s %

Specialty AWP at Mail as a Percent of all Mail AWP %


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Performance Guarantees The College will require specific performance guarantees. All guarantees shall be set and measured annually, and must have the ability to measure performance separately based on its experiences with the chosen PBM. Measurement of performance guarantees may be based on internal self-reporting, subject to independent audit.

1. The College is looking for flat dollar ($) performance guarantee amounts. Indicate the amount you are willing to place at risk for each item listed in the table below. In addition, you may provide other guarantees designed to differentiate your program.

Standard

Measurement Criteria

(BOB or College specific)

Penalty Dollars at Risk

Timing of Payments

Implementation Clean Implementation

No systems errors, ID card delays, and the College online access to all tools prior to effective date

Implementation Timeline

Implementation team will be assigned and introduced to the College at least 3 months in advance of effective date

Implementation Team

Implementation team members will not change and will be responsible for the accurate installation of all administrative, clinical and financial parameters for the College’s program

Implementation Satisfaction Scorecard

Assigned Account Executive will work with the College prior to the start of implementation to agree on terms of a satisfaction scorecard to be issued to the College after effective date for completion

Payment Accuracy & System Performance Protected Health Information

PBM guarantees no incidents in violation of HIPAA Security Rules which results in a transmission of electronic PHI for the College’s covered members

Plan Administration Accuracy

Implementation of all plan design changes will be 100% accurate


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Standard




Timing of Payments

Pricing Change Accuracy

Implementation of all pricing changes will be 100% accurate

Financial accuracy (electronic and paper claims)

Percentage of claim payments made without error relative to the total dollars paid will be at least 99%

Mail Service Non-Financial Accuracy

The mail service pharmacy shall guarantee dispensing accuracy of at least 99.995% (correct participant name, correct participant address, correct drug, correct dosage form, and correct strength)

System Downtime At least 99.5% access to its systems by all the retail pharmacies in PBM’s network 24 hours a day, 7 days a week, 365 days a year

Invoicing Errors All invoicing errors will be credits back to the College by next billing cycle or PBM will pay interest

Claims Eligibility Data

Eligibility loads not to exceed 24-hours after receipt

Eligibility Data Error Reporting

Eligibility file error reporting on all eligibility file updates will be provided to the College within 2 business days

Eligibility Error Rate Audits

Error rate identified through quarterly audits shall not exceed, on an average basis, 2%

Retail Pharmacy Audit

PBM will perform an on-site audit of 3% or more of their retail pharmacies which dispense greater than 500 claims a year

Retail Pharmacy Turnover

Less than 5% of retail pharmacies will leave the retail network


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Standard




Timing of Payments

Claims Detail File All claims detail files sent to external vendors will be provided within 8 days of request or scheduled delivery date

Account Management

College Approval of Member Communications

100% of all member communications will be approved by the College – exceptions for drug recalls and urgent patient safety communications

Delivery of Standard Reports

Within 30 days of end of reporting quarter

Accuracy of Standard Reports

All standard reports provided will be 100% accurate

Pharmacy Audit Resolution

48 hours after receipt of clean Rx claim

PBM Account Team’s Performance

The College may assess a penalty after the first Contract Year and each successive Contract Year, if the College’s benefits staff do not rate PBM account team’s performance for such Contract Year an average of 3 or better on a scale of 1 to 5 (5 being the best based on a range of performance criteria agreed to between the College and PBM at the beginning of such Contract Year)

Account Management Turnover

Account team members will remain constant for at least the first 18 months of the contract period, unless a change in account management staff is requested by the College

Member Services Mail Turnaround – Prescriptions not requiring intervention

95% of prescriptions dispensed within average of 2 business days and 100% within average of 3 business days


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Standard




Timing of Payments

Mail Turnaround – Prescriptions requiring intervention

95% of prescriptions dispensed within average of 4 business days and 100% within average of 5 business days

Paper Claims Turnaround

95% of prescriptions reimbursed within average of 10 business days and 100% within average of 14 business days

ID Cards Mailing

98% of all ID cards are sent within 5 business days of receipt of eligibility. 100% mailed within 10 business days.

Mailing Member Materials

All applicable member materials (for example, mail order forms) will be mailed at least 10 days prior to the effective date and will be 100% accurate (provided that eligibility file was received at least 30 days prior to the effective date).

Phone Average Speed of Answer

100% of calls to the College-specific toll free line shall be answered within 20 seconds (excluding IVR)

Phone Abandonment Rate

100% of calls to the College-specific toll free line shall be answered with an abandonment rate of 3% of less

Written Inquiry Answer Time

95% of inquiries responded to in 5 business days – 100% in 20 business days

Member Satisfaction Survey

The PBM agrees to conduct a Member Satisfaction Survey for each contract year and that the Satisfaction Rate will be 90% or greater. A penalty may be assessed against the PBM for failure to meet this standard. “Member Satisfaction Rate” means (i) the number of Eligible Persons responding to PBM annual standard Patient


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Standard




Timing of Payments

Satisfaction Survey as being satisfied with the overall performance under the Integrated Program divided by (ii) the number of Eligible Persons responding to such annual Patient Satisfaction Survey; the College must provide timely approvals and responses, and a minimum of 20% of surveys must be returned for the Performance standard to be applicable.

Issue Resolution: Verbal Inquiries

PBM will resolve 99% of all telephone issues at the first point of contact (the number of telephone inquiries completely resolved at the time of initial contact divided by the total number of calls)

Issue Resolution: Written Inquiries

PBM will resolve 98% of all written inquiries within 10 business days of receipt of inquiry

Issue Resolution: the College Staff Involvement / Escalation

When the College contacts you with an elevated claim issue via phone, email or through their Consultant, you will respond within 24 hours and provide progress reports every 48 hours until the issue is resolved.


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QUESTIONNAIRE

Complete the following tables as per the Proposal Instructions:

Contact Information Organization Name:

Date Founded

Contact Person’s Name

Title

Address

City/State

Phone Number

E-mail Address

Fax Number References




Contract Start Date



Reason Termination

Date



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Organizational Stability & Experience

ORGANIZATIONAL STABILITY & EXPERIENCE RESPONSE

1. Provide the latest annual report, financial statement, SAS 70 type II, and other financial reports that indicate the financial position of your organization. Including:

a. Current ratio b. Days cash on hand c. Debt to equity ratio

2. Complete the following table: a. Parent Company b. Year PBM Established c. Membership count (total covered

lives)

Current (2013) 1 year prior (2012) 2 years prior (2011) % of total potential lives from the College (current)

% from MCO/HMO plans (current)

d. Number of Group Plans In Force (current)

Total Under 10,000 lives Over 100,000 lives Number of Health Plans

e. AWP dollars processed (calendar year 2012)

Retail Mail Order

3. Have you relocated staff, changed computer or telephone systems in the last 12 months?

Do you anticipate any major changes to your organization or structure in the next 12-24 months? If so, elaborate.

4. Indicate the number of any outstanding legal actions pending against your organization and/or owners.

Explain the nature and status of the action(s).

Can you assure the College these actions will not disrupt business operations?


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ORGANIZATIONAL STABILITY & EXPERIENCE RESPONSE

5. What general and professional liability coverage do you currently have in place for the entity that is proposing to protect the College from losses or negligence?

6. Provide a disclosure of all potential conflicts of interest (e.g. brand manufacturer payments, programs that shift prescriptions to drugs that are more expensive, etc.)

Outside Service Organizations Providing PBM Functions

OUTSIDE SERVICE ORGANIZATIONS PROVIDING PBM FUNCTIONS YES NO

NAME AND ADDRESS OF THE SERVICE PROVIDER

Complete the following indicating the provider of each PBM service.

a. Formulary Management (appeals, utilization management)

b. Any outsourced clinical programs (prior-authorizations, etc.)

c. Any outsourced administrative functions (including but not limited to all administrative functions listed in the fees section above)

d. Formulary Pharmacy and Therapeutics Committee

e. Drug Manufacturer rebate contracting

f. Retail Pharmacy Network contracting

g. Customer Service functions

h. Member Service functions (800 lines, internet, etc.)

i. Mail Order drug purchasing and dispensing

j. Electronic Claim Payment System

k. The College management reporting tools and standard report production

l. Specialty Pharmacy

m. The College invoicing / accounting

n. Other (Describe)


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OUTSIDE SERVICE ORGANIZATIONS PROVIDING PBM FUNCTIONS YES NO

NAME AND ADDRESS OF THE SERVICE PROVIDER

Describe what portion of the College’s business with your organization be serviced by a subcontractor or through leased services / networks

Administrative, Member & Claim Paying Services

ADMINISTRATIVE, MEMBER & CLAIM PAYING SERVICES RESPONSE

1. Which office would handle the general member servicing of the College?

What are the standard office hours for the sales and service office?

2. Will you agree to monthly conference calls and one annual face-to-face meeting with the College to discuss plan performance, present financial results, etc.?

What information would be shared at these meetings?

3. Will dedicated customer service representatives be assigned to this account?

4. Do customer service reps have online access to real time claim processing information?

5. For the customer service center proposed for the College provide the following for 2012:

a. Percent of calls abandoned b. Percent of calls handled by live

representative

c. Number of seconds to reach a live customer service representative

d. Inquiries made 6. Will you record 100% of customer service

calls? If not, what percentage of customer service calls will be recorded?

7. Do you offer the College online access to information and services via the Internet or through CRT interface? Are there quantity access limits? If yes, what information is accessible and at what additional cost, if any.


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8. Will the College be able to produce ID cards and/or temporary proof of benefit letters in “real time”?

9. Can your organization send recovery letters to members who continue to use their drug card after their termination? If yes, at what cost?

10. Will you survey the College members: annually regarding program administration satisfaction?

a. Annually regarding program administration satisfaction?

b. If yes, provide an example. 11. Will one toll-free number handle coverage

for the retail, mail order, and specialty program?

12. What hours will the telephone lines be staffed?

13. Are automated services available 24/7? 14. How do you service members travelling

internationally? What if international stay is for an extended period (visiting semester, etc.)?

15. Can you provide early refills for traveling members?

16. List the top five member complaints related to retail, mail order, and the specialty pharmacy program.

17. Do you provide member support services for selecting and/or locating network pharmacies and formulary look-ups?

18. How are members notified of the following events? (Indicate for each below: Phone, Written Document, or Other (specify)).

a. Plan Change b. New Drug Additions/Formulary

Changes

c. Change in Pharmacy Network Panel d. Ineligible, Banned, or Recalled Drug e. Generic Substitution f. Change in medical/clinical

management rules

19. How many sub-group levels can be captured in your claims and billing systems?


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20. Do you administer medical necessity appeals? Please describe the process in detail for your self-insured ERISA plans and the College.

21. How are out-of-network claims processed?

22. Describe any reports either clinical or financial in nature that would be provided to the College in order to help manage benefit costs.

23. How many days does the College have to pay once an invoice is received? What methods of payment are available (e.g., ACH, Direct Deposit, SurePay, Checks)? What exceptions are there to the standard payment terms?

24. Please confirm your organization can provide comprehensive plan sponsor benefit description set-up documents upon request or on an ongoing basis to the College. Please provide the guaranteed turn-around time for providing such requested documents.

Prescription Reimbursement Issues

PRESCRIPTION REIMBURSEMENT ISSUES RESPONSE 1. What is your proposed source for AWP

data?

First DataBank Medi-Span Redbook Other

2. How often are AWP prices updated in your adjudication system?

Monthly Quarterly Semi-annually Annually Other

3. What percent of your network pharmacy contracts include the “lesser of retail price, MAC price, or discounted price” provision?

0 – 20%, 21 - 40%, 41 - 60%,


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61 – 80%, 81 – 100%

4. How do you guarantee that members always receive this lowest price? What procedures are established to ensure that the pharmacy is in compliance with this provision?

5. Will you guarantee on a dollar-for-dollar basis that the average, realized AWP discounts for brand and generic drugs and quoted dispensing fees will be no less than those quoted at Retail and Mail Order for the life of the contract?

6. Explain in detail how network pharmacies’ U&C prices are captured and reported.

7. Describe the retail network pharmacy reimbursement process in detail.

8. a. Are there financial incentives to network pharmacies, physicians and other providers that are tied to utilization rates, compliance goals, quality of care outcomes, or other performance results?

b. If so, explain and include any incentive-based dispensing fees, bonuses, withholds, retroactive capitations, etc.

9. Describe any financial or other incentives you are willing to offer the College based on increased Internet utilization for mail order claim submission in recognition of the inherent cost savings.

10. Do your MAC price lists vary contractually between network pharmacies? If yes, why?

11. Will the retailers provide the lower of the discounted plan cost plus dispensing fee, member cost, U&C, or retail price for plan adjudication?

12. Explain in detail the process you propose regarding the College verification of drug manufacturer revenue transparency

13. Define your electronic process for determining a product's brand or generic status for both retail and mail order claims using First DataBank and/or Medi-Span definitions.

14. How often are your retail network provider contracts renegotiated?

Annually


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Formulary Management & Rebates FORMULARY MANAGEMENT & REBATES RESPONSE

1. a. Do you receive formulary rebates from manufacturers of generic drugs?

b. If yes, how will these be shared with the College?

2. a. If you require a formulary management fee, indicate amount or percentage proposed.

b. Other than these fees, do you guarantee that 100% of all rebates collected will be passed through to the College?

3. Describe how your preferred drug list is established. Include how specific drugs are selected and how often your P&T committee meets

Every two years Every 3 to 5 years Other

15. Is it possible for a retail pharmacy to submit NDC numbers for adjudication that contain AWP prices designed to maximize their discounted ingredient costs?

16. How do you ensure that submitted NDCs at retail are indicative of pharmacy drug purchasing patterns?

17. Does your organization share in any financial remuneration that retail pharmacies receive from drug manufacturers or other sources?

18. Specify if you are able to readily provide a detailed listing of all of the various ingredients that are included in multi-ingredient compound claims and confirm multi-ingredient compounds can take a specified cost-share.

19. Do you have the capabilities to capture and support cost share tiers based on diagnosis codes (ICDs) as well as associated claims reporting.


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FORMULARY MANAGEMENT & REBATES RESPONSE 4. a. Are any P&T Committee members

employed by or under contract with any drug manufacturers?

b. Are any P&T members directly employed by your organization?

5. Can you support custom changes to the preferred drug list at the request of the College?

6. Describe your process for defining “preventive drugs” for PPACA and High Deductible Plan purposes? How would you handle disputes between the College’s preventive drugs lists and your standards? How will you support the associated cost share tiers?

7. Will you guarantee that any preferred drug lists switches which are not economically advantageous to the College on an ingredient cost basis will be reported and reimbursed to the College on a dollar-for-dollar basis using the least expensive, therapeutically equivalent alternative drug as the basis for reimbursement?

8. Can the College be given the ability to authorize non-formulary overrides directly?

9. What percent of all available brand drugs are excluded from your formulary or preferred drug listing (based on total number of Rx dispensed for plans with an open formulary)?

10. Please provide the percentage of non-formulary brand drugs that have a generic equivalent.

11. What percent of all available brand drugs are non-preferred (not on your preferred drug list)?

12. Do you have a Formulary Grievance Process in place to address member concerns regarding preferred drug list alternatives? If yes, explain this process in detail.

13. Do you have the capabilities to have a specified cost-share for Multi-Source Brand drugs regardless of formulary status? (e.g., 75% co-insurance for all multi-source brands). Specify if there are system limitations where formulary coding supersedes any specific cost share coding


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FORMULARY MANAGEMENT & REBATES RESPONSE specified for multi-source brands.

Mail Order Program

MAIL ORDER PROGRAM RESPONSE 1. Complete the following for your proposed

mail order facility.

a. Where will the mail-order facility location for the College be?

b. What are the days and hours of operation for this facility?

c. What was the total number of prescriptions filled in calendar year 2012 for this facility?

d. Which organizations are used for delivery services?

2. a. Does your organization own the mail service facility?

b. If this is a subcontractor, whom do you contract with?

3. How far in advance may participants order a refill on a 90-day supply prescription?

a. 90 days in advance b. 60-89 days in advance c. 30-59 days in advance d. less than 30 days in advance e. Other

4. a. Will you agree that all mail order discount guarantees will be based on lowest listed NDC-level AWP cost?

b. If not, state your suggested pricing basis.

5. Will mail order pricing apply to all Rxs dispensed through mail order facilities?

6. Explain the proration of copayments at mail service. (e.g., if a member gets a 60 day supply instead of 90, then would they only pay 2/3rds of the mail service copay?)

7. How many calendar days advanced notice must a member provide in order to guarantee that their supply is received before the existing supply is depleted?

a. Less than 7 days


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MAIL ORDER PROGRAM RESPONSE b. 7-9 days c. 10-14 days d. Greater than 14 days

8. What is the average time in calendar days between receipt of claim and delivery to patient (include delivery time)?

9. What will you set the threshold for the uncollected member cost share at mail at?

10. Does your organization, or your associated facilities, repackage drug products for use in filling mail order prescriptions? If yes, does the AWP for repackaged drugs match the AWP of the same package size of the source labeler? If not, describe how you establish the AWP for your repackaged NDCs

11. Describe your policy on too-early refills and emergency supplies. Outline your process for prescriptions which are ordered prior to the first available refill date.

12. Explain the process for providing members with a short-term retail prescription supply in the case of delayed delivery of their mail order prescription.

13. How are members notified when a mail order prescription is delayed due to the following circumstances?

a. A prescription requiring clarification from the physician or physician’s agent (e.g., missing quantity, illegible drug name).

b. A clean prescription where the delay is due to operational, capacity, or drug supply issues.

c. A clean prescription where the delay is a result of a therapeutic switch intervention.

d. Other 14. a. Describe your quality controls to

ensure accurate dispensing of prescriptions.

b. How many levels of review take place and who conducts the reviews?


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MAIL ORDER PROGRAM RESPONSE 15. Describe online integration, if any, with

retail pharmacies to ensure non-duplication and to identify potential adverse interaction.

16. What are your contingency plans and procedures for providing backup service in the event of strike, natural disaster, or backlog?

17. How often do you switch generic manufacturers for particular products?

How are participants notified of the switch?

18. a. Are on-site audits performed at your mail service pharmacies?

b. Describe the frequency and types of audits performed and by whom.

19. Describe the process for notifying members of prescriptions not on the formulary.

20. When do you bill the patient? a. before the prescription is filled b. after the prescription is filled

21. How do you provide notification of a product recall (such as Vioxx) to the College and members?

22. How do you handle the following situations?

a. No co-pay included in envelope b. Bounced check from patient c. Terminated/not authorized credit card

23. Does your organization have the ability to administer a 90 day prescription at retail should The College wish to include such a provision?

Specialty Pharmacy Program

SPECIALTY PHARMACY PROGRAM RESPONSE 1. Explain any programs offered by your organization

designed to encourage appropriate utilization of specialty drug products.

2. What are your cost saving guarantees on your specialty drug programs?


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SPECIALTY PHARMACY PROGRAM RESPONSE 3. a. Will a member incur any additional costs for the

delivery of specialty drugs?

b. If so, outline all billing/payment methods and all associated costs.

4. Confirm that members will continue to be able to receive specialty prescriptions dispensed at retail pharmacies, and that these prescriptions are included under the retail guarantees.

5. Please describe your organization’s ability to limit specialty medication utilization to 30 days’ supply per month.

6. What differentiates your company and capabilities from other specialty drug vendors in a very competitive industry?

7. Do you agree to renegotiate specialty product pricing terms on an annual basis with the College?

8. Do you agree to include a contract provision enabling the College to “carve-out” specialty drug services annually without impact to non-specialty contractual provisions, terms, and pricing?

9. Explain in detail each point at which you make patient contact in the specialty drug dispensing and management process.

10. Provide the customer and member service operation hours of your specialty pharmacy program.

11. Please describe any additional service or value benefits provided by your specialty drug pharmacies (e.g. sharps disposal units at no cost upon request for injectable drug users, research of financial assistance options that may be available for members who request it, etc.)


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Attachment D: Benefit Handbook Plan Description

Attachment E: Open Enrollment Guide

Attachment F: Census and Claims (Medical and Pharmacy) *

Attachment G: Financial Workbook (includes provider disruption with tax IDs)

Attachment H: Cigna Plan Documents and Riders

A census file, two claims experience files and the financial workbook have not been included. These documents will be provided to vendors after completion and submission of the Confidentiality Agreement contained as Exhibit 3 in this RFP. The completed and signed agreement should be emailed to Linda Ellis, CPPB, Senior Buyer, at [email protected]. Vendors will then receive the census file via secure email from the College’s consultant, Segal Company.

