Request for Proposal for Pharmacy Benefit Management ... · PDF fileRequest for Proposal for...
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Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-1: Minimum Requirements
Minimum RequirementsResponse
Yes/No
1. Qualified Respondents must provide proof of having at least five years experience providing pharmacy benefit
management services in the State of Florida including administration of a retail pharmacy network. (Please
submit as Response Attachment A-1: Years of Experience.)Select one
2. Qualified Respondents must provide proof of having at least five hundred thousand (500,000) covered lives
(excluding discount card programs) across the Respondent's pharmacy benefit management book of business as
of the proposal submission date. (Please submit as Response Attachment A-1: Covered Lives Experience.)Select one
3. Qualified Respondents must provide proof of having at least one (1) employer group of sufficient size (100,000
covered lives or more) and composition (both Medicare and non-Medicare) as the State of Florida. (Please
submit as Response Attachment A-1: Large Client Experience and include the contact name, address,
telephone number and e-mail address. This client may also be provided as a reference in Attachment A-2:
Respondent Information.)
Select one
4. Qualified Respondents must provide proof of having three (3) government clients with at least 25,000 covered
lives. (Please submit as Response Attachment A-1: Government Client Experience and include the contact
name, address, telephone number and e-mail address. This client may also be provided as a reference in
Attachment A-2: Respondent Information.)
Select one
5. Qualified Respondents must provide proof of an administration of at least one hundred million dollars
($100,000,000) in annual pharmacy benefit claims, services or product income in calendar year 2009 in the State
of Florida. (Please submit as Response Attachment A-1: 2009 Florida Revenue.)
Select one
6. Qualified Respondents must provide proof of current URAC accreditation. (Please submit as Response
Attachment A-1: URAC Accreditation.) (URAC, formerly known as the Utilization Review Accreditation
Commission, is the independent, non-profit organization that provides accreditation and certification for
pharmacy benefit managers.)
Select one
7. Qualified Respondents must meet the network access criteria shown below. (Verification shall be determined
upon receipt of Attachment A-7: Access to Network Pharmacies, which will be submitted with the final
proposal.)
w For urban areas, 95% of Subscribers will have at least one participating retail pharmacy within 3 miles of their
home ZIP Code if a pharmacy exists within 3 miles of their home ZIP Code.
w For suburban areas, 95% of Subscribers will have at least one participating retail pharmacy within 5 miles of
their home ZIP Code if a pharmacy exists within 5 miles of their home ZIP Code.
w For rural areas, 95% of Subscribers will have at least one participating retail pharmacy within 10 miles of their
home ZIP Code if a pharmacy exists within 10 miles of their home ZIP Code..
Instructions: Please complete each cell with the requested information. Items in the response column with the words, "Select one",
contain a drop down list of options. Please select a response from those options, as applicable, to indicate whether the Respondent
meets the corresponding requirement. If the Respondent selects "Yes", there cannot be a qualifier in "Attachment A-14: Deviations
Page".
This tab must be completed and submitted both as part of the pre-qualification process (as described in Section 2.3 of the ITN) and with
the Respondents final proposal documents.
Representations made by the Respondent in this proposal become contractual obligations that must be met during the contract
term.
Select one
ITN No.: DMS 10/11-010 Page 1 A-1 Minimum Requirements
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-2: Respondent Information
I. GENERAL INFORMATION
Respondent's Legal Name
Address
City
State
Zip
Web Address
Operational Date
Corporate Tax Status
Federal Employer
Identification Number
II. CONTACT INFORMATION
Primary Contact
Name
Title
Address
City, State, ZIP
Telephone #
Fax Phone #
Cell Phone #
E-mail Address
III. ACCOUNT MANAGEMENT TEAM
Executive Sponsor:
Name
Title
Address
City, State, ZIP
Telephone #
E-mail Address
Years of industry experience
Years with the organization
Years in current position
Please provide the following information regarding the account service team that would be assigned to the State's
account. In addition, please submit a biography for each team member shown below as Attachment A-2: Account
Team Biographies.
This individual will be the highest ranking officer with direct involvement in the State's account.
Representations made by the Respondent in this proposal become contractual obligations that must be met
during the contract term.
Instructions: Please complete each cell with the requested information. Items in the response column with the words,
"Select one", contain a drop down list of options. Please select a response from those options as applicable.
Please note that the Respondent’s Legal Name entered in Attachment A-2 will automatically be used to populate other
areas of the MS Excel attachments. The Respondent (i.e. legal entity) identified here must match the Respondent as
identified in the Transmittal Letter.
Please identify the primary contact responsible for the overall development of the Respondent's proposal.
Select one
Response
ITN No.: DMS 10/11-010 Page 2 A-2 Respondent Information
Account Manager
Name
Title
Address
City, State, ZIP
Telephone #
E-mail Address
Years of industry experience
Years with the organization
Years in current position
Customer Service Manager
Name
Title
Address
City, State, ZIP
Telephone #
E-mail Address
Years of industry experience
Years with the organization
Years in current position
Claims Manager
Name
Title
Address
City, State, ZIP
Telephone #
E-mail Address
Years of industry experience
Years with the organization
Years in current position
Implementation Coordinator
Name
Title
Address
City, State, ZIP
Telephone #
E-mail Address
Years of industry experience
Years with the organization
Years in current position
This individual will be responsible for the supervision of the claims processing unit designated for the
State's account.
This individual will have overall day-to-day responsibility for planning, supervising and performing
account services for the State.
This individual will be responsible for the supervision of the Customer Service unit designated for
the State's account.
This individual will be responsible for managing the activities associated with initial program
implementation and ensuring a successful execution of the Final Implementation Plan submitted by
the Respondent.
ITN No.: DMS 10/11-010 Page 3 A-2 Respondent Information
Clinical Pharmacist
Name
Title
Address
City, State, ZIP
Telephone #
E-mail Address
Years of industry experience
Years with the organization
Years in current position
IV. REFERENCES
1.
Information Reference #1 Reference #2
Company Name
Contact Person
Title
City, State
Telephone #
Fax Phone #
E-mail Address
Number of Covered Lives
2.
Information Reference #1 Reference #2
Company Name
Contact Person
Title
City, State
Telephone #
Fax Phone #
E-mail Address
Number of Covered Lives
3.
Information Reference #1 Reference #2
Company Name
Contact Person
Title
City, State
Telephone #
Fax Phone #
E-mail Address
Number of Covered Lives
Please provide references for two former clients (public or private sector) with more than 100,000 covered lives for
whom You provided similar prescription drug benefits administration.
Please provide references for two clients (public or private sector) with more than 100,000 covered lives for whom
You currently provide similar prescription drug benefits administration.
Please complete the following tables with the requested reference information. No reference should be duplicated.
References provided shall include at least one reference for which the proposed account manager currently provides
service.
This individual will be responsible for monitoring the State's utilization patterns and developing cost
containment programs designed to reduce overall costs.
Please provide references for two public sector clients for whom You currently provide similar prescription drug
benefits administration network and mail services.
ITN No.: DMS 10/11-010 Page 4 A-2 Respondent Information
4.
Information Reference #1 Reference #2
Company Name
Contact Person
Title
City, State
Telephone #
Fax Phone #
E-mail Address
Number of Covered Lives
Please provide references for two clients (public or private sector) who began utilizing Your prescription drug benefit
administration services within the last twelve months.
ITN No.: DMS 10/11-010 Page 5 A-2 Respondent Information
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-3: Plan Design
I. PLAN DESIGN CAPABILITIES
PD-1 Please indicate whether or not the Respondent is able and willing to support and administer the following:
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PD-2Select one
PD-3Select one
PD-4Select one
II. 2011 PLAN DESIGN
Retail Pharmacy
(Up to 30 Days Supply)
Mail Order Pharmacy
(Up to 90 Days Supply)
$7 $14
$30 $60
$50 $100 Member Pays 50% (after integrated deductible)
Member Pays 30% (after integrated deductible)
Member Pays 30% (after integrated deductible)
o.) Copays specific to drug classes
u.) Generic Copay Waiver Program
Please indicate whether or not the Respondent is able and willing to support and administer the proposed benefit plan
design, which is presented below in Section II: 2011 Plan Design.
Type of Drug
Generics
Preferred Brands
Other Brands
Please indicate whether or not the Respondent is able and willing to customize refill-too-soon edits and comply with
state emergency orders for early fills.
Representations made by the Respondent in this proposal become contractual obligations that must be met during the
contract term.
Standard PPO and
Standard HMO Plans
Health Investor
HMO and PPO Plans
b.) Coinsurance at Mail
c.) Mixed copays at Retail (fixed dollar and percent)
p.) Copays based on previous drug trials (e.g., higher copay if claims history does not include trial of first-
line/preferred drug/drug class)
j.) HSA plan design integration with medical plan vendor
h.) Annual Out-of-pocket ("OOP") maximums per family/coverage unit
k.) HRA plan design integration with medical plan vendor
a.) Coinsurance at Retail
d.) Mixed copays at Mail (fixed dollar and percent)
f.) Minimum/Maximum amounts with coinsurance
Please indicate whether or not the Respondent is able and willing to offer more than one formulary. (Please note
that the State is not requesting a proposal for more than one formulary at this time.)
e.) 90 days supply at Retail
q.) Copays based on place of service (e.g., incentives to use preferred retail pharmacies, specialty pharmacies, etc.)
m.) Coverage of over the counter ("OTC") products
Instructions: In Section I, please indicate Your ability to administer the following plan provisions. Section II requires no response, but is a
reference document outlining the State’s plan design.
g.) Annual Out-of-pocket ("OOP") maximums per person
i.) Out-of-pocket maximum per script
l.) Greater than four coverage tiers
t.) Mandatory Mail Order
r.) Copays dependent on participant's behavior (e.g., enrollment or stratification level in a disease management
program).
s.) Custom preferred drug list ("PDL")
n.) First x-number of fills free
ITN No.: DMS 10/11-010 Page 6 A-3 Plan Design
Request for Proposal for Pharmacy Benefit Management Services
Attachment A-4: Administrative Requirements
Response
Agree or Disagree
The Service Provider shall provide all services specified in this ITN, including but not limited to the following:
ImplementationAR-1 The Service Provider shall submit the final Implementation Plan to the Department for approval not later than 14
calendar days following execution of the Contract. If the Implementation Plan is not determined by the Department to be
sufficient, Service Provider will diligently work to deliver a final Implementation Plan satisfactory to the Department.
The Implementation Plan shall be based on the proposed Implementation Plan submitted in response to Q-127(f) of
Attachment A-5a: Questionnaire.
The Implementation Plan shall fully detail all steps necessary to begin full performance of the Contract on January 1,
2012, 12:00:00 a.m., specify expected dates of completion of all such steps, and identify the persons responsible for each
step. The Implementation Plan shall include but is not limited to:
w Establishing an interactive Participant web site, dedicated toll-free phone line and Department approved
communications in advance of the fall 2011 Open Enrollment period.
w Participating in fall 2011 Open Enrollment benefit fairs and meetings sponsored by the Department.
w Regular project implementation status meetings with Contract Manager.
w Applying the provisions of the Benefit Document as the description of covered services, exclusions, limitations, etc.;
establishing and successfully implementing any necessary edits, controls or other functions to ensure accurate Plan
coverage for Participants.
w Testing eligibility files, reviewing key procedures and program process controls (i.e. approval, design, testing,
acceptance, user involvement, segregation of duties, and documentation.) Functional acceptance approval by the
Department is required.
w A schedule to finalize and validate billing procedures, invoice design, and other financial processes.
w Design and present to the Department for approval all communication materials to be used for Plan Participants.
Communication materials include but are not limited to ID cards, brochures, explanation of benefit statement forms,
paper claim (reimbursement) forms, mail order pharmacy forms, standard letters, system generated letters, templates,
envelopes, clinical program notices and letters, and posters.
w Ensuring the mailing of ID cards and Plan education materials to Participants no later than December 20, 2011 for
coverage effective January 1, 2012.
w Detailing a plan to educate and enforce Plan benefits, utilization management, and other Plan specifics to all
participating pharmacy providers.
w Develop and present to the Department for approval complete details, calculations, and methodology for measuring
performance of each Performance Guarantee standard included in Attachment A-12.
The development and execution of the Implementation Plan is subject to PG-1 of Attachment A-12: Performance
Guarantees and the liquidated damages of Section 6.1 of the Contract for failure to meet the milestones identified
therein.AR-2 The Service Provider shall be 100% operational prior to the effective date of January 1, 2012, 12:00:00 a.m.
Service Provider is subject to the liquidated damages of Section 6.1 of the Contract for failure to meet this milestone. Select one
Representations made by the Respondent in this proposal become contractual obligations that must be met during the contract
term.
Requirements
Instructions: Please complete each item with the requested information. Items in the response column with the words "Select one"
contain a drop down list of options. Please select a response from those options as applicable. If the Respondent agrees to commit to
the full scope of an item, as written and without condition or qualification, the appropriate response is “Agree.” If the Respondent agrees
to commit to the full scope of an item, but would like to propose an alternative to the requirement, the appropriate response is “Agree with
suggested alternative.” If the Respondent does not intend to commit to the full scope of an item and wants to propose a deviation to the
item, then the appropriate response is "Disagree." All "Disagree" responses must be addressed in Attachment A-14: Deviations Page.
Select one
Evaluators will score each response. A response of “Disagree” without an acceptable alternative will receive 0 points. A response of
“Agree” will be awarded 1 point. An enhanced value alternative may receive 2 points. Please identify how your proposed alternative
enhances the overall value to the State.
ITN No.: DMS 10/11-010 Page 7 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-3 The Service Provider shall provide initial ID cards (without Social Security Numbers) to all Participants no later than
December 20, 2011 subject to PG-18 of Attachment A-12: Performance Guarantees.Select one
Account ManagementAR-4 Account Manager
a.) The Service Provider shall assign a dedicated (but not necessarily exclusive) account manager as the primary contact
for the Department.
Select one
b.) The account manager shall participate on the implementation team. Select one
c.) If requested by the Department, the account manager shall be replaced with one that the Department is allowed to
interview and approve. Select one
AR-5 Account Management Team
a.) The Service Provider will assign a dedicated (but not necessarily exclusive) Account Management Team, which shall
include an executive sponsor, an account manager, a customer service manager, a claims manager and a registered
pharmacist or PharmD.
Select one
b.) The Service Provider agrees that replacement of personnel to the Account Management Team assigned to this
Contract shall be subject to the Department’s approval which will not be unreasonably withheld. Select one
c.) The Account Management Team must be able to devote the time and resources needed to successfully manage the
account including being available for frequent telephonic, email, and on-site consultations.Select one
d.) All written, telephonic, and e-mail communication from the Department shall be returned as described in PG-4 of
Attachment A-12: Performance Guarantees.Select one
e.) The Account Management Team must be thoroughly familiar with the Service Provider’s functions and operations
that relate directly or indirectly to the Department and the Plan.Select one
f.) The Account Management Team must act on behalf of the State in effective advancing the interests of the State
through the Service Provider's corporate structure.Select one
g.) The Service Provider shall maintain a current Account Management Team organizational chart (provided initially in
Q-130(f)). In the event of any changes to the organizational chart and/or the Account Management Team, the Service
Provider shall promptly notify the Department of such change and provide detailed information regarding new personnel
including name, professional background, mailing and physical address, email address and phone numbers. All Account
Management Team changes are subject to the approval of the Department, which shall not be unreasonably withheld.
Select one
h.) The Account Management Team shall be subject to two Report Card/ Performance Reviews by the Department each
year; performance as measured by the Report Card shall be subject to the standards and liquidated damages as described
in PG-5 of Attachment A-12: Performance Guarantees. The Department shall develop and provide the Service
Provider a copy of the Report Card.
Select one
AR-6 The Service Provider shall assign a dedicated (but not necessarily exclusive) Customer Service Team for the Department.Select one
AR-7 The Service Provider shall assign a dedicated (but not necessarily exclusive) Eligibility Manager for the Department.Select one
AR-8 The Service Provider shall assign a dedicated (but not necessarily exclusive) Billing Manager for the Department.Select one
AR-9 a.) Quarterly Meeting
The Service Provider shall attend all quarterly meetings at the State offices in Tallahassee, Florida. The Service Provider
shall not be entitled to additional compensation for meeting preparation or attendance. The meetings shall be held no
later than 45 calendar days following quarter end. The meeting to review the fourth quarter of a calendar year is
considered a quarterly meeting. See PG-2 in Attachment A-12: Performance Guarantees.
Select one
b.) Agenda
The Service Provider shall provide for Department approval a draft agenda five (5) business days in advance of a
meeting allowing changes to the agenda and a reasonable opportunity to prepare for the meeting. At a minimum, during
the meeting the Service Provider and Department will discuss goals, expectations and priorities; review the Service
Provider’s quarterly reports and other issues such as performance guarantees, quality assurance, operations, network
pharmacy status and access, benefit and program changes or enhancements, legislative issues, audits, cost trends,
utilization, program outcomes, customer service issues, future goals and planning, and other issues reasonably related to
the Contract. The Service Provider shall address past performance and anticipated future performance, and compare the
Plan’s experience to national trends and the Service Provider’s total book of business.
Select one
c.) Minutes
Within three (3) business days after any meeting, the Service Provider shall provide the Department detailed and well-
documented draft meeting minutes. The Department shall review and revise the draft minutes as appropriate and return
to the Service Provider. Service Provider shall provide the Department with final minutes within three (3) business days
after receipt of the revised minutes. Minutes shall include a list and description of all deliverables, identify the
responsible party and provide a projected delivery date.
Select one
ITN No.: DMS 10/11-010 Page 8 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-10 Progress meetings, issue meetings and emergency meetings will be held as needed. Either party may call such a meeting,
subject to reasonable notice. Any meeting held in person shall be at the State offices in Tallahassee, Florida. The
Service Provider shall not be entitled to additional compensation for meeting preparation or attendance. Select one
Support ServicesAR-11 Benefit Fairs
a.) The Service Provider shall participate in all locations of the annual Open Enrollment Benefit Fairs that are sponsored
by the Department or its designee. (Twenty-one fairs are scheduled for the fall of 2010; however, number and locations
may vary each year.) Service Provider representatives attending the Benefit Fairs shall be trained on the Plan. Open
Enrollment is held annually in the fall for enrollment coverage effective the following January 1; participation is subject
to PG-3 in Attachment A-12: Performance Guarantees.
Select one
b.) The Service Provider shall be responsible for all costs associated with participating in Benefit Fairs including a
proportionate share of facility fees.Select one
c.) The Service Provider shall not solicit State employees for enrollment or otherwise during the employee's working
hours or in the employee's work place, except during meetings which may be scheduled by the Department. Select one
AR-12 The Service Provider shall not discuss with Participants or perspective Participants or in any manner allude to coverages,
products, or materials other than those explicitly related to the Plan without the permission of the Department. Such
prohibition shall also apply to the Plan specific web site.
Select one
AR-13 The Service Provider shall share in the expenses for printing and mailing the State of Florida Open Enrollment materials,
including but not limited to the Benefit Guide and universal enrollment forms, the cost for which will be shared among
all benefit plan providers including medical, dental, prescription drug, life insurance, and supplemental plans offered by
the Department.
Select one
AR-14 The Service Provider shall assist the Department (i.e., review, clarify, edit as necessary and confirm accuracy) as
requested in the development of Department communications regarding the Plan.Select one
AR-15 The Service Provider shall upon request of the Department review, clarify, edit as necessary, and confirm the accuracy
of all prescription drug program information in the annual Benefit Guide and the Department’s benefit web site
(MyBenefits).
Select one
AR-16 Plan Materials
a.) No promotional or Participant education materials related to the Plan may be distributed or otherwise communicated
without the prior review and written approval of the Department.
b.) Subject to the Department's customization and written approval, the Service Provider shall be responsible for the
development of pharmacy benefit information including but not limited to 1) the Open Enrollment brochures and
promotions, and 2) other Plan-related printed materials (e.g., promotional, Participant education, ID cards, benefit
brochures, claim forms, clinical program notices and letters, notices, preformatted letters, templates, system generated
letters and notifications, two Benefit Statements (one in conjunction with Open Enrollment year-to-date and one first
quarter of each year reflecting the full prior calendar year), correspondence forms, Explanations of Benefit (EOBs) and
other written materials and forms). The Service Provider shall be responsible for writing, printing, distributing and
mailing all such information.
c.) Upon request of the Department , the Service Provider shall review, clarify, edit as necessary, and confirm the
accuracy of any Prescription Drug Program information described in the Benefit Document.
d.) The Service Provider shall provide upon request of the Participant printed materials in a medium widely accepted for
the hearing and/or visually impaired.
e.) Upon request of the Participant, the Service Provider shall provide Plan materials in Spanish.
f.) All printed material shall be provided in electronic format with final versions submitted to the Department in PDF file
format.AR-17 ID Cards
a.) The Service Provider shall provide Participants with ID cards either as a new Participant resulting from Open
Enrollment or as an otherwise newly enrolled Participant.
b.) The Service Provider shall mail one (1) ID card for each individual contract and at least one (1) additional ID card for
each family contract.
c.) The Service Provider will provide additional ID cards as requested by the Participant.
d.) A unique Participant-identifying number that is not a SSN shall be displayed on the ID Cards. Although never
displayed, the SSN shall be the number of record and maintained in the Service Provider’s information system. ID cards
shall be compliant with State of Florida and NCPDP standards.
e.) ID cards including those mailed in the fall of 2011 for the 2012 coverage year, annual Open Enrollment periods and
otherwise as required due to Plan or law changes shall be mailed in accordance to the provisions of PG-18 of
Attachment A-12: Performance Guarantees. AR-18 Returned Mail
Mail returned to the Service Provider shall be held for 30 days during which time the Service Provider shall search for an
updated address with each subsequent file coming from People First. After 30 days, the Service Provider shall store
copies on its document imaging system and destroy the returned mail.
Select one
Select one
Select one
ITN No.: DMS 10/11-010 Page 9 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-19 Special Post-Office Boxes
Service Provider shall maintain dedicated post office boxes which shall be used exclusively for the Plan and Plan
Participants.
Select one
AR-20 Department Inquiries, Account Service and Dispute Support
Service Provider shall, upon request of the Department or its attorneys and at no additional cost, assist the Department in
responding to inquiries received by the Department from Participants, pharmacy providers, or other persons. Such
requests shall 1) be given a priority status, 2) be subject to a method of tracking, 3) result in the delivery of all requested
information, documentation, etc., and 4) be handled or overseen by a lead customer service person. When the
Department is required to provide instant responses, the Service Provider shall immediately assist the Department in
preparing its reply including providing data and documentation within the timeframes prescribed by the Department at
that time.
Select one
AR-21 Public Records Requests and Subpoenas
Service Provider shall upon request and at no additional cost provide the Department with any necessary data,
documents, etc. to enable the Department to timely respond to Public Record Requests and subpoenas.
Select one
AR-22 Responding to Requests for Legislative Initiatives
Service Provider shall make available all necessary resources to assist the Department in responding to Legislative
inquiries and requests including, but not limited to, the account team, analytics and outcomes, research and development,
actuarial support, and government relations department. Service Provider shall respond within the timeframe set by the
Department, which will be determined at the time of the inquiry depending upon the scope and complexity of the
request. Support for such legislative initiatives shall be at no additional cost to the Department.
Select one
AR-23 Underwriting and Actuarial Services
Service Provider shall provide the Department with underwriting and/or actuarial services as needed at no additional cost
to the Department.
Select one
AR-24 Consulting Services
Service Provider shall upon request provide consulting services at no additional cost to the Department related to the
Services, e.g. to verify improved pricing, review consolidated claims platforms and other situations.Select one
Customer ServiceAR-25 a.) The Service Provider shall maintain a customer service unit dedicated (but not necessarily exclusive) to perform all
aspects of Participant-related customer service and shall include a state-of-the-art call center. Calls to this unit shall be
accepted and answered promptly by a live customer service representative during the hours of 7:00 a.m. to 7:00 p.m.
(ET), Monday through Friday, excluding State holidays set forth in section 110.117, Florida Statutes.
Select one
b.) The Service Provider shall maintain an exclusive toll-free customer service number, for use by Participants, which
will permit access from anywhere in the United States. The toll-free line shall be supported by live customer service
representatives (consistent with AR-25(a)) and by an automated voice-response system 24 hours a day and 7 days a
week. Such automated voice-response system shall provide an option for the caller to opt-out to a live representative
during normal operating hours at any time during the call. Telephonic responsiveness is subject to PG-6 in Attachment
A-12: Performance Guarantees.
Select one
AR-26 The customer service operation must include the following:
a.) Integrated member support for retail, mail order and specialty pharmacy services; Select one
b.) Plan specific training and knowledge to assist Participants, prospective Participants, physicians, pharmacists, etc.
regarding the Plan;Select one
c.) The ability to assist Participants who contact the Service Provider's Customer Service Team with only their name
and/or SSN;Select one
d.) The ability to maintain an eligibility file that identifies eligible Participants and other pertinent information regarding
Participants;Select one
e.) A procedure for handling emergency requests (i.e. vacation requests, early fills); Select one
f.) Adequate and appropriate access to the customer service system for Participants with disabilities (e.g. TTY and online
access for deaf, full-service phone access for blind); andSelect one
g.) Sufficient personnel available to provide multi-lingual (Spanish at a minimum) service and the ability to provide
service to the hearing and vision impaired.Select one
AR-27 The Service Provider shall maintain a service disruption plan or procedure to continue customer service activities when
existing service is temporarily unavailable due to either scheduled or unforeseen events (e.g., relocating offices,
repairing/restoring utility or power supply, upgrading phone systems, and other events.) The Department shall be
notified in advance for scheduled disruptions and as soon as possible for other events.
Select one
AR-28 The Service Provider shall provide and maintain a Plan specific Participant web site, with 24/7 access, for prescription
drug and health information. This web site shall include links to the Department web site and other State, federal, and
condition specific web sites as appropriate to make available a multitude of information to Participants. Such web-based
access shall include the ability to, at a minimum:
w track Health Investor Plan accumulator information including separate tracking for both individual and family
coverage (coinsurance and deductibles);
Select oneITN No.: DMS 10/11-010 Page 10 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
w place online refills, check order status and track mail order shipment;
w track prescription history (3 years minimum);
w check drug cost;
w locate participating pharmacies and hours of operation;
w order ID cards;
w communicate with a pharmacist or a customer service representative;
w access the preferred drug list;
w access Plan benefit information;
w access forms and brochures;
w access preventive educational information; and
w access to general health, prescription compliance and chronic disease information.
AR-29 The Service Provider shall adhere to all standards as described in the Customer Service Performance Guarantees, PG-6
through PG-12 in Attachment A-12: Performance Guarantees.Select one
Retail Pharmacy Network Requirements - In-State and NationwideAR-30 The Service Provider shall provide a retail pharmacy in-state and nationwide network in accordance with the provisions
of the Contract and subject to the standards described in PG-25 through PG-27 of Attachment A-12: Performance
Guarantees.
Select one
AR-31 The Service Provider shall provide written notice to the Department of anticipated material changes to the retail
pharmacy network which may impact Plan Participants. Such written notice shall be provided at least 45 days in
advance or as soon as feasible if the terminating pharmacy or pharmacy chain gives the Service Provider less than 45
days notice.
Select one
AR-32 The Service Provider shall provide impacted Participants 45 days written notice or as soon as feasible if the terminating
pharmacy (or pharmacy chain) gives the Service Provider less than 45 days notice. For the purposes of this
requirement, Participant shall mean a Participant who has had a prescription filled within the last 30 calendar days or a
Participant that has an active refill on file with the terminating pharmacy or pharmacy chain.
Select one
AR-33 The Service Provider shall be receptive to requests by the Department to add additional pharmacies to the network on a
general, regional, or other specific basis; however, the Service Provider shall not be required to add any pharmacy or
pharmacy chain unless the retail network fails to meet contracted standards for access as described in PG-25 of
Attachment A-12: Performance Guarantees.
Select one
AR-34 The Service Provider shall annually conduct on-site audits for a minimum of 3% of Florida based retail network
pharmacies and a minimum of 1% of all retail network pharmacies nationwide. Audit specifications shall be approved
by the Department. The Service Provider shall provide a quarterly report to the Department of such audits including at a
minimum complete details of the audit, findings, resolution, and financial impact to the Plan and/or Participants. See AR-
64(n).
Select one
AR-35 The Service Provider shall, at no additional cost to the Department, defend the Department, the State and/or Participants
against any litigation brought by participating network providers seeking payment for Covered Services provided by
such participating network providers in excess of the applicable payment negotiated by the Service Provider. The
Service Provider agrees to pay all resulting damages awarded or settlement amounts in any such litigation, provided that
the Department, the State and/or the affected Participants did provide timely written notification to the Service Provider
that such litigation had been brought; and provided that the Service Provider had sole control of the defense of such
litigation and any related settlement negotiations.
Select one
Mail Order Pharmacy RequirementsAR-36 The Service Provider shall provide a mail order and a specialty pharmacy or pharmacies in accordance with the
provisions of the Contract and subject to the standards described in PG-16 of Attachment A-12: Performance
Guarantees.
Select one
AR-37 The Service Provider’s mail order and specialty pharmacy or pharmacies shall be licensed, permitted, or registered as
required by law.Select one
AR-38 The Service Provider shall immediately communicate any delays in fulfillment of specialty prescriptions to the
Participant.Select one
AR-39 The Service Provider shall send prescription orders to Participants that do not provide appropriate payments with their
prescription order, up to a $100 ceiling for each Participant. After the $100 ceiling is reached, the Service Provider may
implement standard accounts receivable policies and procedures.
Select one
AR-40 If requested, the Service Provider shall provide Subscriber/Participant with notification of any credits/overpayments on
their accounts.Select one
AR-41 The Service Provider shall not require the State to pay outstanding balances owed by the Subscriber/Participant.Select one
AR-42 The Service Provider shall not require the Department to implement programs that encourage use of the mail or specialty
pharmacy. Unless at the direction of the Department and within the Plan design, there shall be no limitations or
requirements placed on retail, mail order or specialty pharmacy use.
Select one
AR-43 The Service Provider shall assist Participants with the transfer of a prescription from one mail order or specialty facility
to the Service Provider's mail order or specialty facility. Select one
AR-44 The Service Provider shall ship all prescriptions via US Postal Service or other appropriate carrier(s) to the address
provided by the Department, its designee, or the Participant.Select one
Select one
ITN No.: DMS 10/11-010 Page 11 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-45 The Service Provider shall coordinate delivery with the Participant to ensure that the efficacy of the prescription shall be
maintained. Such coordinated delivery may, when appropriate, include an expedited delivery method and appropriate
packaging (e.g. cold packs.)
Select one
AR-46 The Service Provider shall promptly make arrangements with another drug provider if the Service Provider is unable to
fill and deliver the prescription to avoid any disruption of therapy.Select one
Data Processing and Interface RequirementsAR-47 The Service Provider shall ensure that the Plan’s data will not be sold or shared with another organization without the
prior written authorization of the Department.Select one
AR-48 The Service Provider shall provide at least six (6) months notice of any significant planned system upgrades or changes,
including but not limited to claims, customer service, eligibility, operating systems and any other changes that may
materially affect the Plan. Changes shall be subject to prior written approval by the Department.Select one
AR-49 The Service Provider shall accept electronic transfer of eligibility data in a format prescribed by the Department.Select one
AR-50 The Service Provider shall accurately convert Department’s data files, including the Department’s master enrollment file
and any other relevant files to the Service Provider's data system.Select one
AR-51 a.) File transfers between the Service Provider and the Department shall be exchanged using a method prescribed by the
Department.Select one
b.) File transfers with other entities shall be exchanged in a secure method approved by the Department. Select one
AR-52 The Service Provider shall maintain an information system capable of electronically transmitting, receiving, and
updating Participant information (e.g. eligibility, change of address, coverage, etc.)Select one
AR-53 a.) The Service Provider shall maintain eligibility records for all Participants based on the Department's eligibility file.Select one
b.) The Service Provider agrees that the Department's eligibility file shall be the official system of record. Select one
c.) The Service Provider shall maintain eligibility reconciliation between Service Provider files and the Department's
eligibility files.Select one
AR-54 The Service Provider shall process and/or update eligibility immediately for a Participantin accordance with PG-17 of
Attachment A-12: Performance Guarantees, if requested by the Department or its authorized agent or designee. Select one
AR-55 a.) The Service Provider shall provide, on a monthly basis (or at another frequency determined by the Department), a file
of all claim activity to the Department and/or its authorized third-party data aggregator. This file shall be formatted as
prescribed by the Department.
Select one
b.) The Service Provider confirms that it is willing and able to provide a claim activity file as shown in Attachment E:
Claims Data Record Layout.Select one
AR-56 The Service Provider shall retain records as required by the Contract or longer if required by State and/or federal laws or
regulations.Select one
AR-57 If the Department chooses to implement an Evidence Based Medicine or Disease Management program at any point
during the contract term, the Service Provider shall cooperate fully with the Department’s vendor, including coordination
of care management activities and transmission of data to and from the vendor in a mutually acceptable format, at no
additional cost.
For the purposes of this ITN, "Evidence Based Medicine" means the process designed to apply the best available
evidence gained from the scientific method to medical decision making.
For the purposes of this ITN, "Disease Management" means an approach to patient care that seeks to limit preventable
adverse events by maximizing patient adherence to prescribed treatments and to health-promoting behaviors.
AR-58 The Service Provider shall accept a file from the incumbent mail and specialty pharmacies to transfer member's current
mail and specialty pharmacy prescriptions.Select one
AR-59 Upon termination for any reason, the Service Provider shall provide the Department and/or the new vendor with a file to
transfer Participant’s current mail and/or specialty pharmacy prescriptions.Select one
AR-60 The Service Provider shall provide the Department, within 30 days of notice of termination, all data and records required
by the Department. The transfer shall be in a file format to be determined based on the mutual agreement between the
Department and the Service Provider.
Select one
Reporting and Deliverable RequirementsAR-61 The Service Provider shall respond to requests made by the Department or its designee regarding Plan-specific financial
and statistical files, prescription processing, Participant services, network adequacy, patient management, and drug
utilization reports. The Service Provider shall acknowledge report requests within one (1) business day and shall provide
an expected timeline for completion and delivery.
Select one
AR-62 The Service Provider shall deliver the required management information reporting in a format specified by the
Department that provides utilization, claims reporting, rebates, and administrative services data both by plan (Standard,
Health Investor and combined) and by subgroup. The subgroups at a minimum are: Active, COBRA, Retirees Under 65,
and Retirees 65 and Over. The Service Provider shall provide monthly claims and enrollment in these specified
subgroups.
Select one
Select one
ITN No.: DMS 10/11-010 Page 12 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-63 The Service Provider shall provide the required data and forecasts in support of the State Employee Group Program's
Estimating Conference Report. Such data shall be provided in the timeframes and layout specified by the Department. Select one
AR-64 The Department requires a number of regular monthly, quarterly, semi-annual and annual reports and/or deliverables.
The Service Provider shall provide these reports in a format approved by the Department and electronically to the
Department and/or its designee. Each monthly, quarterly, semi-annual and annual report described below shall be subject
to the accuracy and timeliness provisions of PG-19and PG-20 of Attachment A-12: Performance Guarantees. In
order to assert a trade secret protection of any information provided in such reports, the Service Provider shall also
provide a redacted copy at the time of delivery.
Monthly Reports and Deliverables include:
a.) Paid Claim Report
The Service Provider shall provide, on a monthly basis, a paid claim report showing paid claims by pharmacy type
(retail, mail order, or specialty), number of Subscribers and number of Participants, both by plan and by Subscriber
subgroup (Active, COBRA, Retirees Under 65, and Retirees 65 and Over).
Select one
b.) RDS Interim Cost Report
The Service Provider shall calculate and submit, on a monthly basis, Retiree Drug Subsidy (RDS) interim cost reports as
described in AR-69 or as otherwise prescribed by the Department.
Select one
c.) Aged Claim Report
The Service Provider shall provide the Department with a monthly report listing those Participants whose claims were
not finalized during the month within the thirty (30) day timeframe and the status of any such claim.Select one
Quarterly Reports and Deliverables include:
d.) Fraud and Abuse Report
The Service Provider shall provide a quarterly report with complete details of all instances of fraud and/or abuse as
prescribed in AR-84.
Select one
e.) Utilization Summary Report
The Service Provider shall provide the data elements shown in D-1 thru D-5 of Attachment D: Standard Reporting
Formats to the Department and/or its designee on a quarterly basis.
Select one
f.) Performance Guarantee Summary Report
The Service Provider shall provide a quarterly performance guarantee report for each guarantee prescribed in
Attachment A-12: Performance Guarantees in the format prescribed in "D-6_PG Report Card" of Attachment D:
Standard Reporting Formats or an alternate format if prescribed by the Department.
Select one
g.) Trend Analysis Report
The Service Provider shall provide a report explaining any unusual trend results (high/low) relative to the industry, the
Service Provider’s book of business and similar groups.
Select one
h.) PBM Revenues Report
The Service Provider shall provide in complete detail all revenue sources of the PBM related to the Plan including all
rebates, revenues, payments, compensation, offsets, remuneration and any and all other forms of consideration of any
kind (“Third-party Consideration” see ITN Section 2.5.3(d)).
Such report shall provide, at a minimum, details of the following revenues received directly or indirectly in connection
with the Plan: w Prescription Pricing Components (e.g. retail, mail and specialty pharmacy AWP, AWP discounts, dispensing fees,
etc.);
w Manufacturer payments (e.g. formulary rebates, administrative fees, educational grants, detailing payments,
bonuses, etc.), including amount and source;
w Administrative fees or payments from labelers or wholesalers (e.g. discounts, rebates, grants, detailing payments,
bonuses, etc.) including amount and source;
w Outreach and outcomes of any other arrangement(s) from which the PBM may profit; and
w The value and nature of any and all other Third-party Consideration from each source.
i.) Formulary Management Report
The Service Provider shall provide in complete detail quarterly updates of formulary management information, including
at a minimum:
w Mail Maximum Allowable Cost (MAC) and retail MAC lists that identify changes by drug name, dosage and NDC
number. (Note: If the MAC lists are the same for mail and retail, only one set of changes need be provided.)
w Preferred Drug List and Formulary changes that impact the second (i.e. “preferred”) tier and third (i.e. “non-
preferred”) tier shall identify changes by drug name, dosage, and NDC number;
w The rationale used to make the MAC/formulary/PDL changes;
w The process for notifying Participants impacted by the formulary or PDL changes;
w Projected Plan and Participant impact (e.g. number of Participants, costs, savings, etc.) by drug; and
Select one
Select one
ITN No.: DMS 10/11-010 Page 13 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
w Any arrangements with prescribing providers, medical groups, pharmacy providers, individual practice associations,
or other persons associated with activities of the Service Provider to encourage formulary compliance or otherwise
manage prescription benefits, including a description of outreach efforts and outcomes.
j.) Cost Containment Report
The Service Provider shall provide, to the extent applicable to the Plan design in place, full disclosure and quarterly
reports of utilization management programs (e.g. prior authorization, drug limitation, etc.) including but not limited to
affected drugs, costs, savings, outcomes, and number of affected Participants.
Select one
k.) Drug Substitution/Therapeutic Interchange Report
The Service Provider shall provide full disclosure quarterly reports of drug intervention, drug substitution and drug
repackaging that occurs in connection with the Plan, including but not limited to:
w drug name, dosage, strength and NDC number of the drug prior to substitution, intervention or repackaging;
w drug name, dosage, strength and NDC number of the drug after substitution, intervention or repackaging;
w the price of each drug;
w therapeutic basis or cost savings for the intervention or substitution;
w the manufacturer of each drug;
w the labeler or packager of each drug;
w the aggregate number of interventions, substitutions or repackaging during the reporting period; and
w any compensation from any source related to any drug intervention or substitution (also reported in the PBM
Revenues Report.)
l.) The Service Provider shall provide the Department and/or the Department's designee the necessary data for testing
whether or not improper drug substitution occurred during the prior quarter.Select one
m.) The Service Provider shall provide the Department and/or the Department's designee the necessary reporting that
demonstrates any changes in treatment patterns within a specific therapeutic class.Select one
n.) Pharmacy Audit Results Report
Based on the results of the Service Provider’s on-site audits as specified in AR-34, the Service Provider shall provide a
report detailing the audit, its findings, and financial impact to the Plan and Participants. The Pharmacy Audit Report
shall be subject to the provisions of PG-27 of Attachment A-12: Performance Guarantees.
Select one
o.) Benchmark Cost and Utilization Report
The Service Provider shall provide benchmark data on pharmacy costs and utilization for clients of similar size and
complexity.
Select one
p.) Specialty Drug List Report
The Service Provider shall provide in complete detail quarterly updates of its Specialty Drug List in the format shown in
Section I of Attachment B-7: Drug List Analysis or other format prescribed by the Department. The Service Provider
shall list separately those specialty drugs added to the list and those specialty drugs deleted from the list. Included with
each of these quarterly updates, the Service Provider shall provide the following:
w The rationale used to make such changes;
w The process for notifying those impacted by the specialty drug list changes;
w Projected Plan and Participant impact (e.g. number of Participants, costs, savings, etc.) by drug; and
w Any arrangements of the Service Provider to encourage appropriate use and/or otherwise manage the utilization of
the specialty drug in question, including a description of outreach efforts and outcomes.
q.) Pipeline Report
The Service Provider shall provide a report that lists brand drugs which are expected to lose patent protection during the
following 24 months. The report shall include the expected date of the change in status from brand to generic, and the
projected utilization and cost impact to the Plan.
Select one
r.) Retail Pharmacy Survey
The Service Provider shall survey a statistically valid sample of Participants using retail prescription services to verify
satisfaction levels relating to the Service Provider’s customer service unit and other related services and to gauge
satisfaction with the Plan. The Service Provider shall provide a copy of the survey instrument and results to the
Department. The survey instrument and results reporting format or style shall be approved in advance by the
Department. Survey results are subject to the provisions of PG-12 of Attachment A-12: Performance Guarantees.
Select one
s.) Mail Order Pharmacy Survey
The Service Provider shall survey a statistically valid number of Participants using the mail order prescription services to
verify satisfaction levels relating to the Service Provider's customer service unit and other related services and to gauge
satisfaction with the Plan. The Service Provider shall provide a copy of the survey instrument and results to the
Department. The survey instrument and results reporting format or style shall be approved in advance by the
Department. Survey results are subject to the provisions of PG-12 of Attachment A-12: Performance Guarantees.
Select one
Annual Reports and Deliverables include:
t.) The Service Provider shall provide a report listing Participants in any Drug Utilization Review (DUR) program
including at least the following:
w Unique Participant identifier;
Select one
Select one
Select one
Select one
ITN No.: DMS 10/11-010 Page 14 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
w Description of the intervention / DUR program;
w Source of the intervention referral (i.e. pharmacy, Department staff, claims data, etc.);
w Date of approval for DUR program;
w Length of DUR authorization;
w Financial impact to the State for the specific intervention;
u.) RDS Final Reconciliation Report
The Service Provider shall calculate and submit annually the Final Reconciliation cost report for the Retiree Drug
Subsidy (RDS) program as described in AR-69.
Select one
v.) Contribution Development Report
The Service Provider shall deliver to the Department written verification that it continues to provide the Department its
Best Pricing as prescribed in Section 11.8 of the Contract which, at the discretion of the Department, may be verified by
an independent third party with audit expertise in the PBM industry. Such written verification shall be provided to the
Department September 30, 2013 and every September 30 thereafter that this Contract is in effect. The written
verification shall include at a minimum:w Projected costs for renewal year;
w Estimate of IBNR at end of current year, including the most recent 36 months of incurred/paid triangular reports;
w Complete documentation of the methodology and assumptions used to develop the projected costs; and
w Disclosure of supporting data and assumptions used in the calculations, including monthly paid claims, enrollment,
large claims analysis, trend analysis, demographic analysis, etc.
w.) SAS 70 Report
See AR-107.Select one
x.) Performance Bond Report
The Service Provider shall provide the Department with verification that a sufficient bond is valid and will remain in
force for the calendar year as prescribed in Section 7.2 of the Contract.
Select one
AR-65 The Service Provider shall provide, upon request of the Department, a description of all Drug Utilization Review (DUR)
Programs available to the Department, the protocols for each program, a complete list of medications subject to these
programs and the cost to the Department, if any, for the implementation of any such programs.Select one
AR-66 The Service Provider shall prepare and provide, at no additional cost, ad hoc reports in formats required by the
Department.Select one
AR-67 Online Reporting and Management Tools: Computer Access to Plan Data
a.) The Service Provider shall provide the Department, at no additional cost, online user access for unlimited users to its
reporting and management services, systems and/or programs. The Service Provider shall provide corresponding
manuals and any other printed or digital material or CDs used in connection with the systems (related documents). At a
minimum, this online tool shall have data accumulation and ad hoc reporting capability. The license fee, if any, shall not
be part of any training allowance.
Select one
b.) Training: Service Provider shall upon request of the Department provide designated Department staff with training at
the Department's facilities or, if more appropriate, at the Service Provider’s facility, regarding relevant Plan
administration activities, i.e., online reporting and management tools, of the Service Provider. Service Provider shall pay
all expenses, including travel costs, for adequate training of Department staff. Additional training beyond the initial
training following Contract implementation date may be required from time to time as system updates occur, new
Department staff is hired and need training, or other factors with all expenses to be paid by the Service Provider.
Select one
Other ServicesAR-68 Medicare Modernization Act (MMA) Services
The Service Provider shall work closely with Department decision-makers in understanding and maximizing their
options in serving the retiree health benefit market, e.g., accessing federal subsidies for qualified employer-sponsored
coverage, or employing health savings account (HSA) strategies. The Service Provider shall support the Department’s
needs in the following areas:w Enrollment and eligibility
w Marketing and communication outreach
w Reporting
w Compliance
w CMS connectivity
w Web site capabilities
w Benefits and Plan design
w Retail network set-up and management
w Claims processing (including coordination of benefits, electronic prescribing, and rebates/discounts)
w Drug lists and clinical management
w Finance
w Customer Care Centers
w Grievance and appeals processes
w Mail service and specialty pharmacy
w Accreditation
Select one
Select one
Select one
ITN No.: DMS 10/11-010 Page 15 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
w Record retention
w Administrative matters
Additional Medicare Part D services include:
w Differentiating Medicare Part B vs. Part D claims
w Reporting
w Audit accountability (False Claims Act issues)
w RDS Subsidy Calculations
w Subsidy Report Submission to CMS
w Eligibility Tracking and Reconciliation, and
w Other Part D support as agreed to between the Department and the Service Provider.
AR-69 Retiree Drug Subsidy Program
While the State is participating in the Retiree Drug Subsidy program, the Service Provider shall calculate and submit to
CMS interim subsidy cost reports on a monthly basis, or as required by the Department or CMS, which includes at least
the following:a.) At least semi-monthly eligibility submission to CMS, in CMS-required formats, and response file
management/coordination with the Department;
b.) At least semi-monthly extraction of data elements from the CMS response files and the load of that data into the
maintained eligibility records;
c.) Monthly submission of claims data to CMS via the Retiree Drug Subsidy web site pertaining to the Plan’s
Participants, application for subsidy, and the submission of the final reconciliation file due within 15 months after the
end of the Plan Year. (Such claims shall be in the format specified by CMS, and shall be sent at a frequency required
by CMS in future guidance so that the State will receive payments on a timely basis.)
AR-70 The Service Provider shall maintain and upon request provide information as required for the Department including but
not limited to:
a.) drug lists and prior authorizations necessary to categorize Part B covered drugs for appropriate primary or
secondary Plan coverage;
b.) Storage of data for CMS audit, and participation in CMS audits, as needed;
c.) Exchange eligibility and enrollment data as necessary with the CMS COB Coordinator for accurate administration
and processing of COB;
d.) Record retention (claims, utilization management and eligibility data) for the period required by CMS; and
e.) Claims data necessary to support audit processes.
AR-71 In cooperation with the State, the Service Provider shall calculate (including adjustments for actual rebates, discounts
and price concessions) and submit the RDS Final Reconciliation cost report for each Plan year for which the Service
Provider administers the Plan no later than 45 days prior to the Department's deadline. Currently, the annual deadline for
the Final Reconciliation is June 30th.
Select one
AR-72 The Service Provider shall appropriately process electronic (in real time) and paper claim submissions for COB as
secondary payor for Medicare Part B and Part D enrollees subject to the COB benefit provisions in the Benefit
Document.
Select one
AR-73 Patient Protection and Affordable Care Act
The Service Provider shall work closely with the Department in understanding and maximizing its options and
compliance with the Patient Protection and Affordable Care Act. Services shall include but are not limited to supporting
the Department’s participation in the Early Retiree Reinsurance Program.
Select one
Claims ProcessingAR-73 Claims Processing and Adjudication
The Service Provider shall establish and perform all aspects of Claims processing, coordination of benefits, claims
reimbursement, point-of-sale transactions, adjudication, and payment in accordance with the Benefit Document. The
Service Provider shall verify benefits and eligibility before authorizing prescriptions and billing the Department.
Select one
AR-74 Audit Trail
The Service Provider shall establish and maintain an effective audit trail for each claim/prescription received/filled. Select one
AR-75 Standard Claims Administration Practices
Claims shall be received, processed and adjudicated in accordance with best industry practices using nationally
recognized standards.
Select one
AR-76 Pursuant to paragraph 110.123(5)(g), Florida Statutes, the Service Provider shall provide written notice to Participants if
any payment to any provider remains unpaid thirty (30) calendar days after receipt of the Claim. Service Provider shall
provide the Department with a monthly report listing those Participants having Claims not finalized within the thirty (30)
day timeframe and the status of any such Claims. Paper claims shall be processed according to PG-9 of Attachment A-
12: Performance Guarantees.
Select one
AR-77 Coordination of Benefits
The Service Provider shall provide Medicare Part D services. This includes, but is not limited to, differentiating
Medicare Part B vs. Part D claims at no additional cost to the Department. The Service Provider shall have in place all
necessary systems and processes to ensure accurate processing and coordination of benefits in accordance with all COB
provisions of the Plan.
Select one
Select one
Select one
Select one
ITN No.: DMS 10/11-010 Page 16 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-78 Coordination with Medicare’s Third-Party Administrators
The Service Provider shall be responsible for coordinating with Medicare’s third-party administrators to ensure that
claims are processed with primary and secondary payors without involving the Participant and at no cost to the
Department.
Select one
AR-79 Explanation of Benefits Statement (EOB)
The Service Provider shall furnish each Participant with an Explanation of Benefits Statement for each paper Claim that
is processed. The EOB shall include specific claim detail and accumulative balances relating to either plan (Standard or
Health Investor). Availability online is acceptable provided accumulation balances are displayed.
Select one
AR-80 Inaccurate Payments
a.) Upon discovery, notification, or recoveries as part of audits or other activities, the Service Provider shall fully rectify
the inaccurate payment or other situation, including but not limited to collecting overpayments or mis-payments,
whenever payment is made that is not in accordance with the terms of the Benefit Document and to the extent such
recoveries are attributable to the Plan. The Service Provider shall recover these overpayments and refund 100% to the
Department, if applicable. The Service Provider shall be responsible for correcting inappropriate payment issues. Such
overpayments shall not be reduced by contingency fees or other fees charged by an auditor or other recovery service.
Select one
b.) The Service Provider shall reimburse the Participant in the event that a recovery impacts the Participant's cost share.Select one
AR-81 Accounting System
The Service Provider shall maintain an accounting system and employ accounting procedures and practices conforming
to generally accepted accounting principles and standards. The Service Provider’s accounting records and procedures
shall be open to inspection by the Department, or its authorized representatives, at any time during the Contract period
and for so long thereafter as the Service Provider is required to maintain records provided, however, that any such
inspections shall be subject to confidentiality protocol requirements. All charges, costs, expenses, etc applicable to the
Contract shall be readily ascertainable from such records. Supporting documentation for all charges, fees, guaranteed
savings and rebate payments including reimbursement invoices for prescription drug payment shall be readily
ascertainable from such records. The Service Provider shall ensure that the claims data can and will be available for
review and/ or audited annually.
Select one
AR-82 Participant Appeal Services
The Service Provider shall provide Participant appeal services as described in Appendix B at no additional charge to the
Department.
Select one
AR-83 The Service Provider shall, at no additional charge to the Department, contract with an independent vendor or vendors to
assist the Department in the resolution of Level II Appeals specific to medical necessity opinions consistent with the
appeals program as described in Appendix B. The Service Provider shall at no additional charge to the Department assist
through its independent vendor with Participant requested reviews of prescription drug denials as allowed by and in
accordance with the Affordable Care Act.
Select one
AR-84 Fraud and Abuse Investigative Services
The Service Provider shall investigate any fraudulent, suspected fraud or suspicious activity, prescription-related or
otherwise relating to the Plan, which it believes to be fraudulent or abusive whenever detected by the Service Provider or
brought to the attention of the Service Provider by the Department or other persons. The Service Provider shall timely
notify the Department of any fraudulent or abusive Claims or other activities relating to the Plan which it uncovers and
shall fully cooperate with and assist the Department, law enforcement and State agencies in their investigations or
inquiries regarding any such matters and in any related recovery efforts. The Service Provider shall have established
procedures and system edits to aggressively monitor and proactively search for cases and potential cases of fraud and
abuse including providing the State with a quarterly report of fraud activities and discoveries relating to this Contract.
Select one
AR-85 Special Claims Reimbursement
The Service Provider shall process expenses incurred on behalf of Participants receiving services out-of-state on any
prescriptions including but not limited to surcharges and assessments required by other states.Select one
Clinical ServicesAR-86 The Service Provider shall provide ongoing utilization management including monitoring and enforcement of
compliance with best industry practices using nationally recognized standards.Select one
AR-87 The Service Provider shall, at no cost to the Department, implement Plan design system, program and process/procedural
changes at the direction of the Department. Select one
AR-88 Returned Drug Process
The Service Provider, subject to the Department’s approval and in compliance with State law, shall have in place a
process for handling prescription drugs returned to its facility. This policy shall document the entire process including
but not limited to how credit for returned drugs is applied to the Department.
Select one
AR-89 Utilization and Benefit Management Program Decisions
Any and all utilization and benefit management program decisions shall be made solely to determine coverage and
benefits, if any, for under the Plan. The Parties shall do nothing to restrict the options of health care pharmacy providers
to consult fully with patients about treatment options.
Select one
ITN No.: DMS 10/11-010 Page 17 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-90 Concurrent Drug Utilization Review (DUR)
The Service Provider shall perform at no additional fee concurrent utilization review by contracting with participating
pharmacies using an online system prior to dispensing drugs. The Service Provider’s mail order and specialty pharmacy
services shall also be required to process prescriptions through an online system prior to dispensing drugs.
Select one
AR-91 The Service Provider shall provide a computerized concurrent DUR program that monitors Participant’s drug therapies
in a real-time, online data processing environment. The system shall provide concurrent DUR capabilities to the
participating retail, mail order and specialty pharmacies to allow intercession and counseling of Participants regarding
their drug therapy.
Select one
AR-92 The concurrent DUR program shall analyze the filling and refilling of prescriptions against prescriptions previously
filled through the prescription retail and mail order services. Criteria to be analyzed during the concurrent review
include but are not limited to:
w Drug-drug interactions;
w Drug-age contraindications;
w Drug-disease contraindications;
w Drug-allergy contraindications;
w Over utilization or under utilization;
w Early refills (defined as cases where 70% of previous prescription would have been depleted if used as prescribed to
prevent early refills);
w Inappropriate or excessive dosages;
w Therapeutic duplication; and
w Other situations that may endanger the health and welfare of program Participants.
AR-93 Retrospective Drug Utilization Review (DUR)
The Service Provider shall perform retrospective DUR that analyzes drug prescribing, dispensing and utilization patterns
of practitioners and Participants. Critical components of the retrospective review include but are not limited to:
a.) The Service Provider shall appoint a multi-disciplinary committee of relevant health care professionals comprised
of physicians and pharmacists skilled in drug therapy, pharmacology and medical therapeutics to oversee retrospective
reviews.
b.) The multi-disciplinary committee shall analyze detailed system-generated patient and practitioner profiles based on
the top 100 prescribing practitioners (physician profiling).
c.) A comprehensive educational intervention program shall be used to notify practitioners of potential therapeutic
complications, duplications or other situations that may endanger the health and welfare of Participants.
d.) The objective of the retrospective DUR program includes but are not limited to:
w Duration of therapy;
w Therapy duplication;
w Drug and disease appropriateness;
w Contraindications;
w Preferred Drug List compliance;
w Generic utilization;
w Fraud and abuse; and
w Monitoring the interaction among various treatments, medicines, and therapies.
e.) Geriatric management services shall be included as part of the Service Provider’s retrospective DUR concurrent
case management program at no additional cost to the Department.AR-94 Prior Authorization Services
The Service Provider shall provide at no additional cost, a prior authorization program to enforce any specific provisions
of the Plan and the terms of the Contract. The Service Provider shall provide a detailed flow chart thoroughly explaining
and depicting the process.
Select one
AR-95 Other Utilization Management / Concurrent Case Management
The Service Provider shall administer a Concurrent Case Management or individual benefits management program.
Concurrent Case Management is defined as the management of cost effective pharmacy services and supplies prior to or
during the use of such services and supplies for Participants having catastrophic or chronic health conditions.
Select one
AR-96 Preferred Drug List (PDL) Management
The Service Provider shall actively manage and maintain the PDL, at no additional cost, including but not limited to:
w Maintaining independence with respect to decisions about the PDL if the Service Provider is owned by a
pharmaceutical manufacturer or drug store chain.
w The Service Provider shall immediately notify the Department of any drug removed from the PDL due to safety
concerns or regulatory action requiring that the Service Provider remove the drug.
Select one
Select one
Select one
ITN No.: DMS 10/11-010 Page 18 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
w The PDL is subject to the review and the approval of the Department. The PDL shall be updated no more frequently
than quarterly. The Service Provider shall provide the Department at least 30 days advance notice of any additions or
deletions to the PDL. The Service Provider shall provide affected Participants 60 days prior written notice and a 90
day grace period following receipt of such notice. Additionally, an updated PDL shall be mailed upon request to the
Department and/or Participant and posted on the Service Provider’s Plan specific web site.
AR-97 Specialty Drug List
The Service Provider shall provide quarterly updates of its specialty drug list in a format prescribed by the Department.
The Service Provider shall list separately those specialty drugs added or deleted from the list. Included with the list of
specialty drug additions and deletions, the Service Provider shall provide the following:
w The rationale used to make such changes;
w The process for notifying impacted Participants of the specialty drug list changes;
w Projected Plan and Participant impact (e.g. number of Participants, costs, savings, etc.) by drug; and
w Any process or procedures of the Service Provider to encourage appropriate use and/or otherwise manage the
utilization of the added specialty drug(s), including a description of outreach efforts.AR-98 Auto-generic Substitution Programs
The Service Provider shall have at no additional cost to the Department an auto-generic substitution program. The
savings from the auto-generic substitution program shall not be included in any other program savings calculations.Select one
AR-99 Therapeutic Interchange at Mail Order
The Service Provider shall at no additional cost to the Department provide therapeutic interchange at mail order. The
new drug shall not have a higher cost in any way (AWP or net cost) than the originally prescribed drug and shall be
subject to the Department’s or its designee’s right to annually audit the program.
Select one
AR-100 Pharmacy and Physician Profiling
The Service Provider shall at no additional cost to the Department have programs targeting pharmacies and physicians
for inclusion into its program.
Select one
AR-101 Disease Management Programs
The Service Provider shall be able to provide a full range of disease management programs including but not limited to:
w Asthma (pediatric and adult)
w Coronary Artery Disease
w Chronic Obstructive Pulmonary Disease
w Depression
w Diabetes
w Heart Failure
w Ulcer
w Musculoskeletal/Headache Chronic Pain
w Hypertension
w Complex Chronic Conditions
w Other management programs (obesity, arterial fibrillation, gastro-intestinal, stroke)
AR-102 The Service Provider’s Disease Management programs shall be accredited and certified by the appropriate industry
accrediting body.Select one
AR-103 The Service Provider shall provide clinical resources to the Department to assist in interpreting pharmacy data and
developing cost management strategies.Select one
AR-104 Generic Drugs
a.) The Service Provider shall create and provide MAC pricing at both mail order and retail pharmacies. The MAC
pricing applied at mail shall be at least equivalent to the MAC pricing applied at retail but in no case shall it produce a
higher cost to the Plan than the retail MAC on a drug by drug basis.b.) The Service Provider shall meet or exceed the Generic Substitution Rate prescribed in PG-23 of Attachment A-12:
Performance Guarantees.
AuditsAR-105 Compliance and Performance Audits
The Department may conduct or have conducted performance and/or compliance audits, audits of specific claims or
other areas of the Service Provider as determined by the Department. Reasonable notice shall be provided for audits
conducted at the Service Provider's premises. Audits may include but shall not be limited to audits of procedures,
computer systems, claims files, customer service records, accounting records, internal audits, and quality control
assessments. The Service Provider shall work with any representative selected by the Department to conduct such
audits.
Select one
AR-106 Quality Assurance Reviews for the Auditors
On a regularly scheduled basis, the Service Provider shall review its procedures and processes to assess quality
performance on claims, suspense, adjustments, as well as customer service inquiries by phone, mail, e-mail, etc. At the
time of the audit, the Service Provider shall advise the Department on how the following areas are handled to ensure
quality:w Technical Select one
Select one
Select one
Select one
Select one
ITN No.: DMS 10/11-010 Page 19 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
w Mail order prescription fill
w Prescription and inquiry turnaround times
w Financials
w Telephone and customer service
w Paper claims payments and reimbursement
AR-107 SAS 70 External Audit
The Service Provider shall, at its expense, undergo an annual audit in accordance with the AICPA Statement of Auditing
Standards, A.U. Section 324-Reports on the Processing of Transactions by Service Organizations, specifically reporting
on the Policies and Procedures Placed in Operation and Tests of Operating Effectiveness. The report shall cover the 12
month time period of July 1 through June 30 of each year; the report for the first year shall cover the six month time
period of January 1 through June 30. Reports are due to the Department within forty-five (45) days of the
audit/accounting firm’s release to the Service Provider. The audit shall be performed by an independent
accounting/auditing firm. Service Provider is required to provide prior timely notice to the Department of the
independent accounting/auditing firm conducting the audit with the Department being permitted to review and comment
on the audit period and the associated scope of the audit.
Select one
AR-108 Audits
a.) The Service Provider shall provide the State of Florida, the Department and the Department's third party auditor at
least the following audit access, in addition to any other audit rights specified in the ITN, the Technical Proposal, and the
Financial Proposal:w to audit any data necessary to ensure the Service Provider is complying with all contract terms, such audit rights to
include but not be limited to: 100% of pharmacy claims data, which includes at least all NCPDP fields from the most
current version and release; retail pharmacy contracts; data management and pharmaceutical manufacturer
agreements; approved and denied utilization management reviews; clinical program outcomes; appeals; and
information related to the reporting and measurement of performance guarantees;
w to audit post termination;
w to audit more than once a year if the audits are different in scope or for different services;
w to perform additional audits during the year of similar scope if requested as a follow-up to ensure significant or
material errors found in an audit have been corrected and are not recurring, or if additional information becomes
available to warrant further investigation; and
w to submit to an annual audit of contractual compliance.
b.) The Service Provider shall cooperate with requests for information, which includes but is not limited to the timing of
the audit, deliverables, data/information requests and your response time to questions during and after the process. The
Service Provider shall also provide a response to all findings that the Service Provider receives within 15 days, or at a
later date if mutually determined to be more reasonable based on the number and type of findings.
AR-109 The Service Provider confirms that release statements from its pharmaceutical manufacturers are not required for the
Department or its designee to conduct compliance and performance audits on any of the Service Provider’s
pharmaceutical manufacturer contracts relating to this Contract.
Select one
AR-110 Service Provider agrees to the additional audit provisions of Contract Section 4 Audit. Select one
Payment SpecificationsAR-111 The Service Provider shall accept monthly payments of PEPM administration fees based on the Department’s eligibility
report data (as calculated by the Department) after the close of the month.Select one
AR-112 The Service Provider shall accept payment processed through normal State transmittal process (i.e. EFT transfer to the
Service Provider) and timeliness guidelines.Select one
AR-113 The Service Provider agrees to confirm bank transfers as they occur. Select one
AR-114 Invoicing for Contracted Fees
a.) The Service Provider shall provide the Department a detailed (itemized) invoice for administrative fees and charges
no later than the 15th day of each month following the month services were rendered. Required detail and
documentation for such invoices shall be as specified by the Department and shall provide sufficient detail for pre and
post audit. Invoices and supporting documentation shall be provided in paper and electronically.
Select one
b.) Upon determination by the Department that the invoices are satisfactory and that payment is due, the Department
shall process each invoice in accordance with the provisions of section 215.422, Florida Statutes. The Department shall
forward payment through electronic funds transfer to the Service Provider for the invoiced amount. If the Department
contests the invoice charges as submitted, additional documentation may be requested. Select one
c.) If the Department fails to make timely payment in accordance with the provisions of section 215.422, Florida
Statutes, the Service Provider may be entitled to an interest penalty set by the Chief Financial Officer pursuant to section
55.03, Florida Statutes, which shall be due and payable in addition to the invoice amount. Pursuant to the provisions of
section 215.422, Florida Statutes, a Vendor Ombudsman resides within the Department of Financial Services with duties
to act as an advocate for the Service Provider or other vendors who may experience problems in obtaining timely
payments from a State agency.
Select one
Select one
Select one
ITN No.: DMS 10/11-010 Page 20 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-115 Invoicing for Prescription Costs
a.) The Service Provider shall furnish the Department with an itemized invoice for reimbursement of prescription claims
costs on a weekly basis for mail, retail and specialty prescriptions separately and in the aggregate. The invoice shall
include appropriate dispensing fees, the agreed upon discounted ingredient costs, and net member out-of-pocket costs.
All such required data shall be provided using the Invoice Template prescribed in A "D-7_Invoice Template" of
Attachment D: Standard Reporting Formats or an alternate format if so prescribed by the Department.
Select one
b.) Weekly invoices shall be specific to a given month with the last invoice perhaps being less than a full seven days to
capture the period from the ending date of the previous invoice to the end of the specific month. Select one
AR-116 All invoices (e.g., weekly prescription cost invoices, monthly contracted fees invoices) shall set forth details specified by
the Department for a proper pre-audit and post-audit that shall include, but not be limited to, standard requirements such
as an invoice statement provided on Service Provider letterhead, an invoice number, the employer or client number, the
billing period, an invoice date and addressed to the Department, and other particulars. The total invoice amount,
supported by a summary of charges itemized and subtotaled by delivery system (mail order, point-of-service, paper
claim), shall include the quantity of the prescription drugs dispensed, gross charge, subscriber out-of-pocket cost, and net
charge.
Select one
AR-117 The Department shall make every effort to forward reimbursements to the Service Provider within seven (7) calendar
days of receipt of an acceptable and approved invoice. The Department shall forward payment through electronic funds
transfer for the approved amount. The parties agree that required vouchering, banking and reimbursement procedures
and protocols to ensure reimbursement efficiency and effectiveness shall occur prior to the effective date of this Contract
and shall be subject to Implementation Performance Standards in PG-1 of Attachment A-12: Performance
Guarantees.
Select one
AR-118 Prescription claim costs reversals/credits shall be credited and shown as a separate line item on the subsequent invoice.
The Service Provider shall provide detail documentation that specifies such reversals/credits. Select one
AR-119 Remittance of Manufacturer Payments
a.) Monthly payments for the minimum Guaranteed Rebate Amounts shall be paid to the Department by the 15th of the
month after the reporting month. Payment shall be made through electronic funds transfer. The Service Provider shall
provide the Department a detailed report accompanying and supporting the rebate payment based upon a format
specified by the Department.
Select one
b.) In addition to the minimum Guaranteed Rebate Amount for the most recent month, the Service Provider shall pay to
the Department by the 15th of the month after the reporting month any Rebates received by the Service Provider and not
previously remitted to the Department that are in excess of the minimum Guaranteed Rebate Amount for each of the
previous months of the Contract.
Select one
c.) The Service Provider shall also remit to the Department any Manufacturer Payments other than Rebates received
during the prior month. Select one
d.) The Service Provider agrees that the rebate process, including the agreements with the Pharmaceutical Manufacturer,
can be audited by the State or the State's designated representative. Select one
e.) The Service Provider shall be subject to rebate payment and reconciliation standards as prescribed in PG-24 of
Attachment A-12: Performance Guarantees.Select one
AR-120 The Service Provider agrees that, upon contract termination or expiration, the cost of any work required by a new
provider to bring records in unsatisfactory condition up to date shall be the obligation of the new provider and such
expenses shall be reimbursed by the Service Provider within three (3) months of the end of the contract term.Select one
Special ProvisionsAR-121 In the event of a change in vendors or expiration of this Contract, at the termination or expiration of this Contract, the
Service Provider shall be responsible for the administration of claims incurred through the termination or expiration date. Select one
AR-122 All claim records and eligibility data used by the Service Provider shall remain the property of the State as Plan sponsor
and Plan administrator.Select one
AR-123 The Service Provider shall be knowledgeable of actual or pending State and federal laws, regulations, policies,
procedures, and rules specific to employee benefit plans, pharmacy benefit management, pharmacy and prescription
drugs, and other topics related to the provisions of this Plan and shall, at no additional cost, provide the Department with
interpretation as to the impact of such laws or regulations on the Plan.
Select one
AR-124 The Service Provider shall absorb the cost of programming any benefit design changes. Select one
AR-125 The Service Provider has reviewed ITN No: DMS 10/11-010 and understands and agrees to all provisions described
therein.Select one
AR-126 The Service Provider shall develop, implement, and maintain a Disaster Recovery Plan which shall be approved by the
Department on or before the effective date of this Contract. At a minimum, the plan shall maintain backup of State
files/data and shall be fully operational within 24 hours of a disaster. The plan shall guarantee the same or better level of
service as before the Disaster Recovery Plan was activated. Any changes to the plan throughout the term of the Contract
must be approved by the Department.
Select one
ITN No.: DMS 10/11-010 Page 21 A-4 Administrative Requirements
Response
Agree or DisagreeRequirements
AR-127 The Service Provider shall agree to provisions of the Business Associate Agreement included in the Contract attached to
this ITN. Select one
AR-128 The Service Provider shall agree to the provisions and terms of the Contract attached to this ITN. Select one
ITN No.: DMS 10/11-010 Page 22 A-4 Administrative Requirements
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-5a: Questionnaire
Representations made by the Respondent in this proposal become contractual obligations that must be met during the contract term.
Response
Q-1 a.) Describe the Respondent's experience
in providing PBM services, including a
brief history of the organization, its
growth on a national level, and its
ownership structure.b.) Describe the Respondent's experience
with Florida based clients.
c.) Describe the Respondent's experience
with public sector clients.
Q-2 a.) How many years has the Respondent
administered pharmacy benefits?
b.) How many years has the Respondent
administered pharmacy benefits to Florida
based clients?
c.) How many years has the Respondent
provided PBM services with particular
attention to individual employer-
sponsored plans?Q-3 Is the Respondent compliant with all
applicable HIPAA administrative
simplification rules?
Select one
Q-4 a.) To the best of Your knowledge, will
You be involved in any acquisitions or
mergers within the next 12 months?
Select one
If yes, please describe.
b.) Have You been involved in any recent
acquisitions or mergers?
w Within the last year? Select one
w 1-2 years ago? Select one
w 2-5 years ago? Select one
w None in the last five years Select one
If yes, please describe.
Q-5 Confirm that You have the following
insurance coverages.
a.) Worker's Compensation Please label as "Response Attachment A-5: Insurance Certificate - Worker's Compensation".
b.) Errors & Omissions Please label as "Response Attachment A-5: Insurance Certificate - E&O Insurance".
c.) Commercial General Liability Please label as "Response Attachment A-5: Insurance Certificate - Commercial General Liability".
Q-6 Please provide an overview of Your
organization's top three cost containment
initiatives that could align with the State
Plan’s population and Plan design. For
each initiative, provide detail on how the
program would work, the impact to the
Participant and why the State would
benefit from this initiative.
Please label as "Response Attachment A-5: Cost Containment Initiatives".
DO NOT include pricing or fee data.
Instructions: Please provide a response to each of the following questions. If a drop down list is available, please select a response from that
list. To the extent that You have provided an answer to the question in another area of Your proposal, please repeat Your answer in the space
provided AND provide a reference to the original answer.
If Your response for a question exceeds 1,024 characters in length, complete your response in "Attachment A-5b Additional Questionnaire
Answers" using the directions provided in Attachment A-5b. Continued responses should be labeled clearly with both the Section number and
the corresponding question number (for example, A-5a, Q-2).
If a response attachment is required, the attachment can be provided in either MS Word, MS Excel or Adobe pdf format unless specified
otherwise.
Question
I. ORGANIZATION INFORMATION
ITN No.: DMS 10/11-010 Page 23 A-5a Questionnaire
ResponseQuestion
Q-7 a.) Please provide a copy of the last two
(2) year-end financial statements or best
available equivalent report and an
analysis of those financial
statements/reports (independently audited
preferred).b.) Provide abbreviated profit and loss
statements and abbreviated balance sheets
for the last two (2) years.
Q-8 Provide a copy of Your most recent
financial ratings and complete the
following table.
Please label as "Response Attachment A-5: Financial Ratings".
A.M. Best
w Current Financial Rating
w Date of Rating
w Prior Financial Rating
w Date of rating
Standard & Poor's
w Current Financial Rating
w Date of Rating
w Prior Financial Rating
w Date of rating
Dunn and Bradstreet
w Current Financial Rating
w Date of Rating
w Prior Financial Rating
w Date of rating
Fitch
w Current Financial Rating
w Date of Rating
w Prior Financial Rating
w Date of rating
Weiss
w Current Financial Rating
w Date of Rating
w Prior Financial Rating
w Date of rating
Moody's
w Current Financial Rating
w Date of Rating
w Prior Financial Rating
w Date of rating
Q-9 Describe any litigation and/or
government action taken, proposed or
pending against Your company or any
entities of Your company during the most
recent five (5) years. This information
shall include notice whether the
Respondent has had it's registration
and/or certification suspended or revoked
in any jurisdiction within the last 5 years,
along with an explanation.
Q-10 Please provide a list of all anticipated
Third-party Consideration (as described
in ITN Section 2.5.3(d).
For each item on the list, provide the
following: a.) a definition of that item; and
b.) demonstrate how that revenue will be
accounted for and passed through to the
State.
Q-11 a.) Total number of covered lives, as of
August 1, 2010.
b.) Percent of covered lives, as of August
1, 2010, who are covered through an
employer group.
Please label as "Response Attachment A-5: Financial Statements".
Note that the requested financial information must be for the entity proposing to provide services under this contract and
not for any prospective owners or parent companies not directly involved in the provision of services.
Please label as "Response Attachment A-5: Revenue Sources Disclosure".
ITN No.: DMS 10/11-010 Page 24 A-5a Questionnaire
ResponseQuestion
Q-12 a.) Total number of clients (including
employers and commercial/insurers), as
of August 1, 2010.
b.) Total number of statewide public
entities, as of August 1, 2010.
Q-13 Total mail order prescription volume,
based on days of therapy, for the period
August 1, 2009 through July 31, 2010.
Q-14 Total number of mail order prescriptions
dispensed for the period August 1, 2009
through July 31, 2010.
Q-15 Total retail prescription volume, based on
days of therapy, for the period August 1,
2009 through July 31, 2010.
Q-16 Total number of retail prescriptions
dispensed for the period August 1, 2009
through July 31, 2010.
Q-17 a.) Total number of covered lives in the
State of Florida, as of August 1, 2010.
b.) Percent of covered lives in the State of
Florida, as of August 1, 2010, who are
covered through an employer group.
Q-18 a.) Total number of clients (including
employers and commercial/insurers) in
the State of Florida, as of August 1, 2010.
b.) Total number of statewide public
entities in the State of Florida, as of
August 1, 2010.
Q-19 Total mail order prescription volume in
the State of Florida, based on days of
therapy, for the period August 1, 2009
through July 31, 2010.Q-20 Total number of mail order prescriptions
dispensed in the State of Florida for the
period August 1, 2009 through July 31,
2010.Q-21 Total retail prescription volume in the
State of Florida, based on days of therapy,
for the period August 1, 2009 through
July 31, 2010.Q-22 Total number of retail prescriptions
dispensed in the State of Florida for the
period August 1, 2009 through July 31,
2010.Q-23 a.) Overall number of chain pharmacies in
the proposed retail network as of August
1, 2010.
b.) Percent of these pharmacies that are
not on-line (i.e. the pharmacy cannot auto-
adjudicate in real time).
Q-24 a.) Overall number of independent
pharmacies in the proposed retail network
as of August 1, 2010.
b.) Percent of these pharmacies that are
not on-line (i.e. the pharmacy cannot auto-
adjudicate in real time).
Q-25 Total number of mail order service
centers as of August 1, 2010.
Q-26 Percent of capacity at which the mail
order service centers are functioning.
Q-27 Please provide a distribution of employer
clients by number of Participants in the
following categories as of August 1,
2010. (Clients do not need to be
identified.)Less than 1,000 Participants
ITN No.: DMS 10/11-010 Page 25 A-5a Questionnaire
ResponseQuestion
1,000 - 4,999 Participants
5,000 - 9,999 Participants
10,000 - 49,999 Participants
50,000 - 99,999 Participants
100,000 - 499,999 Participants
500,000 or more Participants
Q-28 Provide the following enrollment history
metrics as of January 1st of each year.
2008
Number of covered lives
Number of employer clients
2009
Number of covered lives
Number of employer clients
2010
Number of covered lives
Number of employer clients
Q-29 For the time period beginning August 1,
2009 through July 31, 2010, provide the
following for Your book of business
under your managed retail and mail
pharmacy programs. All cost data should
be based on total cost before Participant
copays/coinsurance.
Average Ingredient Cost
Single-source Brand
Multi-source Brand
Generic
Percentage Dispensing Rates
Single-source Brand
Multi-source Brand
Generic
Prescription Counts
Single-source Brand
Multi-source Brand
Generic
Average Cost (PEPM)
Ingredient plus dispensing fee
Average Days Supply
Generic
Q-30 Provide the following data on Your MAC
program.
a.) Number of generic classes on MAC
list
b.) Number of multi-source brand drugs
for which the MAC list provides
substitution alternatives (all dosage forms
of multi-source drug counted as one)
c.) Package size basis for maximum MAC
price
d.) MAC drugs as a percent of total
generic drugs dispensed
e.) Average MAC cost as a percent of
total generic drug cost
f.) Average generic cost as a percent of
average multi-source brand drug cost
g.) Expected total generic dispensing rate
using MAC program
h.) Guarantee on total generic dispensing
rate using MAC program
i.) Expected MAC savings as a percent of
plan ingredient cost (total brand and
generic cost)
j.) Number of MAC drugs added in the
past 12 months
ITN No.: DMS 10/11-010 Page 26 A-5a Questionnaire
ResponseQuestion
Q-31 a.) Will you contractually commit to
maximize the use of State of Florida
residents, state products (produced and/or
purchased within the State of Florida) and
other Florida-based businesses in
delivering the Services?
Select one
b.) If yes, provide details regarding your
commitment.
c.) Please provide the estimated number
and types of jobs for Florida residents
resulting from this contract. Indicate job
classifications, number of employees in
each classification, the aggregate Florida
payroll, and percentages to which the
Contractor has committed at both prime
and, if applicable, subcontract levels.
d.) Provide, as a response attachment, a
description of the benefits that will accrue
to the State of Florida economy as a
direct or indirect result of the
Respondent's performance of this contract
resulting from this RFP. The Respondent
will take in to consideration the following
elements. (Do not include any detail of
the Financial Proposals with this
technical information.)
w The estimated percentage of contract
dollars to be recycled into Florida's
economy in support of the contract
through the use of Florida
subcontractors, suppliers, and joint
venture partners. Respondents should
be as specific as possible and provide a
breakdown of expenditures in this
category.w Tax revenues to be generated for
Florida and its political subdivisions as
a result of this contract. Indicate tax
category (sales tax, inventory taxes,
and estimated personal income taxes
for new employees). Provide a
forecast of the total tax revenues
resulting from the Contract.
e.) Provide the estimated annual total
dollars that will be committed to Minority
Business Enterprises, Woman-Owned
Business Enterprises and Service-
Disabled Veteran Business Enterprises
(as those terms are defined by Florida
Statutes).
Q-32 Please complete the following table
regarding the Respondent's proposed
broad network.
a.) Total # of available pharmacies
nationwide
b.) Total # of available pharmacies in
Florida
c.) Describe the network that You
propose for the State of Florida.
d.) List the geographic locations within
the United States that are NOT served by
the network proposed for the State.
III. RETAIL PHARMACY ACCESS and NETWORK MANAGEMENT
II. FLORIDA BASED BUSINESS PREFERENCE
Label as "Response Attachment A-5: Benefits to the Florida Economy".
ITN No.: DMS 10/11-010 Page 27 A-5a Questionnaire
ResponseQuestion
Q-33 Please identify the major chain
pharmacies that are not part of the
proposed network.
Q-34 What percentage of the proposed network
is made up of independent pharmacies
versus major chains?
Q-35 List the elements of your various
pharmacy audit programs. Include
frequency of the audit for each element
and the audit method.Type of Audit
Frequency
Method
Type of Audit
Frequency
Method
Type of Audit
Frequency
Method
Type of Audit
Frequency
Method
Q-36 Provide the results of Your field audit
programs for calendar years 2008, 2009
and 2010.
2008
Audits completed as a percent of all
contracted pharmacies.
Pharmacies put on probation as a percent
of all contracted pharmacies.
Pharmacies terminated as a percent of all
contracted pharmacies.
Recovery (in dollars) as a percent of total
book of business drug spend.
2009
Audits completed as a percent of all
contracted pharmacies.
Pharmacies put on probation as a percent
of all contracted pharmacies.
Pharmacies terminated as a percent of all
contracted pharmacies.
Recovery (in dollars) as a percent of total
book of business drug spend.
2010 YTD
Audits completed as a percent of all
contracted pharmacies.
Pharmacies put on probation as a percent
of all contracted pharmacies.
Pharmacies terminated as a percent of all
contracted pharmacies.
Recovery (in dollars) as a percent of total
book of business drug spend.
Q-37 How are audit recoveries paid or remitted
to clients?
Q-38 a.) The State is also interested in
evaluating the advantages of a more
limited pharmacy network. Are You
willing and able to offer the State a more
limited network?
Select one
b.) What are the benefits of utilizing a
limited or narrow network rather than a
broad network?
c.) What are the drawbacks of utilizing a
limited or narrow network rather than a
broad network?
d.) Total # of pharmacies in Florida in
Your proposed limited network.
e.) Describe the limited network that You
propose for the State of Florida.
ITN No.: DMS 10/11-010 Page 28 A-5a Questionnaire
ResponseQuestion
f.) List any geographic locations within
Florida that are NOT served by the
network proposed for the State.
Q-39 Provide sample Participant
communications materials, including
request letters for clinical programs,
switching programs and sample EOBs.
Label as "Response Attachment A-5: Sample Participant Communications Materials".
Q-40 Provide a detailed utilization management
program list, including specific drug
names in each program.
Label as "Response Attachment A-5: Detailed Utilization Management Program List".
Q-41 Provide a detailed description of how
Your organization determines which
drugs are preferred versus non-preferred.Label as "Response Attachment A-5: Formulary Development Criteria".
Q-42 Provide a discussion on post-AWP
pricing methodology, including
Respondent's preparedness and
implementation of the new standard.
Label as "Response Attachment A-5: Post-AWP Pricing Methodology".
Q-43 Identify which of the following edits are
performed at the point of service:
a.) Ineligible participant Select one
b.) Ineligible drug Select one
c.) Incorrect AWP Select one
d.) UCR input Select one
e.) Duplicate Rx Select one
f.) Refill too soon Select one
g.) Incorrect dosage Select one
h.) Rx splitting Select one
i.) Drug interactions Select one
j.) Over utilization Select one
k.) Under utilization Select one
l.) Coordination of Benefits ("COB") Select one
m.) Benefit maximums for certain drug
typesSelect one
n.) Drug is inappropriate for the patient
due either to age or sexSelect one
o.) Other (specify)
Q-44 a.) Describe the methods You currently
have in place to influence prescribing
behavior, if any.
b.) Can the Department opt-in or opt-out
of these programs?Select one
Q-45 Identify how You propose to monitor and
increase Participant's prescription
compliance.
Q-46 Describe Your process for handling a
Participant who submits a non-preferred
drug claim.
Q-47 How would You propose to optimize the
mix between retail and mail order
prescriptions?
Q-48 Please describe programs You have
implemented to expedite conversion to
newly released generic medications.
Please provide examples.Q-49 a.) Please describe your managed
injectable program, if available. (Do not
include fees in your response.)
b.) Are You partnered with anyone?
c.) Does Your proposed pricing include
the cost of this program? (Do not include
actual fees in your response.)
Q-50 How are out-of-network claims
processed?
Q-51 a.) Do You currently have e-prescribing
capabilities?Select one
b.) If yes, please describe the process.
IV. ADMINISTRATION
ITN No.: DMS 10/11-010 Page 29 A-5a Questionnaire
ResponseQuestion
c.) If not, please describe any future plans
that You may have for implementing e-
prescribing capabilities.
Q-52 Please provide the following information
for both the primary and secondary Mail
Order facility locations that will be
provided to the State.
Primary Mail Order Facility Location
a.) Name
b.) Address
c.) City, State, ZIP
d.) Days and hours of Operation
e.) Is this facility wholly owned by the
Respondent? If not, please provide the
name of the owner of the facility.
f.) Quarterly dispensing capacity (#
scripts)
g.) Number of prescriptions dispensed
from 5/1/2010 - 7/31/2010
h.) Ratio of pharmacists to pharmacy
technicians
i.) Average number of prescriptions
dispensed per Pharmacist per hour
j.) Average turnaround time in days
during 5/1/2010 - 7/31/2010 for
prescriptions that required no
intervention.k.) Average turnaround time in days
during 5/1/2010 - 7/31/2010 for
prescriptions that required an
intervention.
Secondary Mail Order Facility Location
a.) Name
b.) Address
c.) City, State, ZIP
d.) Days and hours of Operation
e.) Is this facility wholly owned by the
Respondent? If not, please provide the
name of the owner of the facility.
f.) Quarterly dispensing capacity (#
scripts)
g.) Number of prescriptions dispensed
from 5/1/2010 - 7/31/2010
h.) Ratio of Pharmacists to pharmacy
technicians
i.) Average number of prescriptions
dispensed per Pharmacist per hour.
j.) Average turnaround time in days
during 5/1/2010 - 7/31/2010 for
prescriptions that required no
intervention.k.) Average turnaround time in days
during 5/1/2010 - 7/31/2010 for
prescriptions that required an
intervention.Q-53 If You own Your own mail order
pharmacy, are purchase discounts passed
along to the plan or kept as margin by the
PBM?Q-54 Provide the average number of
clinicians/pharmacists at the primary Mail
Order facility for the following:
Pharm D.
Full-time
Part-time
Registered Pharmacist
V. MAIL ORDER MANAGEMENT
ITN No.: DMS 10/11-010 Page 30 A-5a Questionnaire
ResponseQuestion
Full-time
Part-time
Pharmacy Technicians
Full-time
Part-time
Other clinical staff
Full-time
Part-time
Q-55 Please describe Your process for
maintaining credits or issuing payments
to Participants for account credits on file.
Q-56 a.) How will You help Participants
transfer prescriptions from a retail or mail
order facility to Your mail order facility?
b.) What documentation is required of the
Participant to transfer a prescription to
Your mail order facility?
c.) How long does the process take to
transfer a prescription to Your mail order
facility?
Q-57 Describe Your process for ordering refills
by mail and include a sample refill order
form. Label as "Response Attachment
A-5: Sample Refill Order Form".
Q-58 a.) Describe Your process for ordering
refills by phone.
b.) What percentage of fills are ordered
by phone?
c.) How far in advance can Participants
order a refill?
Q-59 a.) Describe what quality controls are in
place to ensure accurate dispensing of
prescriptions.
b.) How many levels of review take place
and who conducts the reviews?
Q-60 Describe on-line integration, if any, with
retail pharmacies to ensure non-
duplication and to identify potential
adverse interactions.Q-61 Describe Your drug safety policies as
they relate to safe delivery of
prescriptions that may be subject to
environmental requirements (e.g.
temperature, etc).Q-62 Please describe Your drug restocking
policies.
Q-63 a.) How often do you switch generic
manufacturers for particular products?
b.) How are Participants notified of the
switch?
Q-64 Provide Your claim processing standards
versus actual results for 2009 and 2010
YTD for the following:
Turnaround time for routine prescriptions
Claim processing standard
2009 Actual
2010 YTD (as of August 1, 2010)
Turnaround time for prescriptions requiring intervention
Claim processing standard
2009 Actual
2010 YTD (as of August 1, 2010)
Prescription accuracy
Claim processing standard
2009 Actual
2010 YTD (as of August 1, 2010)
ITN No.: DMS 10/11-010 Page 31 A-5a Questionnaire
ResponseQuestion
Q-65 List the top ten manufacturers of generic
medications for Your book of business by
volume for the time period from 8/1/2009
- 7/31/2010.1. Manufacturer Name
Volume (in units)
2. Manufacturer Name
Volume (in units)
3. Manufacturer Name
Volume (in units)
4. Manufacturer Name
Volume (in units)
5. Manufacturer Name
Volume (in units)
6. Manufacturer Name
Volume (in units)
7. Manufacturer Name
Volume (in units)
8. Manufacturer Name
Volume (in units)
9. Manufacturer Name
Volume (in units)
10. Manufacturer Name
Volume (in units)
Q-66 a.) Are on-site audits performed at Your
mail service pharmacies? Select one
b.) Describe the frequency and types of
audits performed.
c.) Is the Mail Service Pharmacy that will
support the State's mail order program
subjected to the same audit programs as
your Retail Network?
Select one
Q-67 Please describe the process for notifying
Participants of:
a.) Expiration date of their prescription
b.) Their next refill date and the number
of refills
c.) Prescriptions not on formulary
d.) Generic substitution availability
Q-68 a.) Describe Your system of providing
patient advisory information with
prescriptions filled, including next refill
date and the number of refills.b.) What percentage of prescriptions
receives a patient information
supplement?
c.) Provide sample materials of Your
patient advisory information.Label as "Response Attachment A-5: Patient Advisory Information".
Q-69 a.) How is the Participant billed (i.e.
before or after the prescription is filled)?
b.) How does the Participant know which
copay applies?
Q-70 Does the Respondent e-mail:
a.) Refill reminders Select one
b.) Savings intervention opportunity
messagesSelect one
c.) COB messages Select one
Q-71 Provide an alternative to AR-39 whereby
prescriptions are typically not mailed until
payment is made by the Participant.
Q-72 If different from the Mail Order pharmacy
location, provide the following
information for Your specialty pharmacy
that will be provided to the State.
Specialty Pharmacy Location
a.) Name
VI. SPECIALTY PHARMACY (Biotech and Injectables)
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ResponseQuestion
b.) Address
c.) City, State, ZIP
d.) Days and hours of Operation
e.) Is this facility wholly owned by the
Respondent? If not, please provide the
name of the owner of the facility.
f.) Quarterly dispensing capacity (#
scripts)
g.) Number of prescriptions dispensed
from 5/1/2010 - 7/31/2010
h.) Ratio of pharmacists to pharmacy
technicians
i.) Average number of prescriptions
dispensed per Pharmacist per hour.
j.) Average turnaround time in days
during 5/1/2010 - 7/31/2010 for
prescriptions that required no
intervention.k.) Average turnaround time in days
during 5/1/2010 - 7/31/2010 for
prescriptions that required an
intervention.Q-73 a.) Is your specialty pharmacy part of a
specialty pharmacy network?Select one
b.) If yes, please provide the locations of
the other specialty pharmacies in the
network.
Q-74 a.) Does Your organization offer an
integrated specialty program? Select one
b.) If yes, describe the operations of the
program and include elements describing
your Participant outreach, case and care
management abilities.Q-75 a.) Does Your organization own a
specialty pharmacy?Select one
b.) If so, are purchase discounts passed
along to the plan or kept as margin by the
PBM?
Q-76 Please describe the status, scope and
management strategies of your specialty
pharmacy services in the following areas:
a.) injectable and infusion therapies
b.) high-cost ($5,000 per year and up)
therapies
c.) therapies that require complex care
d.) major disease conditions treated
Q-77 a.) Is there separate pricing for injectable
and biotech products? Select one
b.) If yes, please describe.
Q-78 a.) How long has Your organization had
this program in place?
b.) How many patients do you currently
provide services to?
Q-79 Please provide a client reference for this
program.
Organization
Contact Name
Title
Telephone
Q-80 Describe the process to address
exclusivity or limited distribution
scenario.
Q-81 Do You provide any of the following
programs?
a.) a package recovery program Select one
b.) a vial/assay management program Select one
c.) a ready to inject program Select one
ITN No.: DMS 10/11-010 Page 33 A-5a Questionnaire
ResponseQuestion
Q-82 Do You report on compliance and
adherence to therapy as part of Your
standard reporting package?
Q-83 How do You report on Participant
outcomes for specialty drug management
programs (ROI, clinical results, etc)?
Q-84 a.) What is the location (city/state) of the
customer service call center the
Respondent will be utilizing for the State
Plan? (Please note that this location
cannot be offshore.)b.) What is the turnover rate of CSRs for
this location?
c.) Does this location also handle claims
and utilization review functions? Select one
d.) If not, please provide the location(s)
(city/state) for claims administration and
utilization review.
Q-85 a.) Please identify any secondary
customer service call center location(s).
b.) Describe how these additional
location(s) will support the primary
location.
Q-86 Describe the customer service unit
(organization, staffing and services,
training and turnover) that would handle
the State's account.Q-87 a.) Does Your organization provide
clients with a dedicated customer service
unit?
Select one
b.) If yes, define what is meant by
dedicated.
Q-88 Briefly describe the training program in
general as well as the specific training
that each associate receives to prepare to
manage the State's benefit. Include length
of time it takes to go from training to
CSR.Q-89 Briefly outline recent system changes.
Include any plans or timelines to
scheduled budgeted changes.
Q-90 a.) Are there any scheduled changes to
any of the CSR support platforms? Select one
b.) If so, include description of old and
new platform along with a timeline of
when the changes will be implemented.
Q-91 How would the customer service unit be
staffed?
Q-92 a.) What are the customer service hours
of operation?
b.) Describe what services are available
during these hours of operation?
Q-93 How do you track and monitor phone
service on an account-specific basis?
Q-94 Provide Your phone service standard
versus actual results for 2009 and 2010
YTD for the primary customer service
center proposed for this contract.Average speed to answer
Phone service standard
2009 Actual
2010 (as of July 31, 2010)
Call abandonment rate
VII. CUSTOMER SERVICE
ITN No.: DMS 10/11-010 Page 34 A-5a Questionnaire
ResponseQuestion
Phone service standard
2009 Actual
2010 (as of July 31, 2010)
Percent of calls resolved on the first contact
Phone service standard
2009 Actual
2010 (as of July 31, 2010)
Q-95 a.) Does Your automated call answer
system provide the estimated wait time to
speak to a live customer service
representative and an option to opt-out to
a live customer service representative at
anytime during the call?
Select one
b.) If no, please explain.
Q-96 How does Your customer service system
support and provide access to individuals
with disabilities and individuals with
limited English speaking abilities?
Address in particular deaf and blind
Participants as well as individuals who
primarily speak Spanish.
Q-97 a.) Do you expect to make major changes
to the service organization (e.g. moving
to a different location, merging units,
etc)?
Select one
b.) If yes, please describe the changes and
the expected timing.
Q-98 What are Your standards regarding
turnaround time for issuing identification
cards and accuracy?
Q-99 Please describe Your appeals process
including your brand/generic appeals
process.
Q-100 a.) Provide a copy of the latest customer
satisfaction survey Your organization has
conducted.
Label as "Response Attachment A-5: Customer Satisfaction Survey".
b.) How was the survey instrument
developed?
c.) Do You use an independent outside
vendor to conduct the survey? If so, who?
d.) Are survey results released to the
public?
e.) How is the sample of survey
respondents selected?
f.) What was the date of the most recent
survey conducted?
g.) Based on the most recent survey
conducted, what percentage of
respondents were either very satisfied or
satisfied with the services of Your
organization?
Q-101 Please describe the claims data system
that will be used to keep track of the
State's prescription drug claims,
including:a.) System "trade name"
b.) System organization
c.) Date claims system was put in place
d.) Number of system upgrades since
inception
e.) Annual budget and planned system
improvements for the hardware and
software used in providing the services.
VIII. DATA REPORTING & INFORMATION EXCHANGE
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ResponseQuestion
Q-102 List the reports and provide examples of
the standard reporting package you will
be delivering to the State in addition to
the required reports identified in this ITN.
Label as "Response Attachment A-5:
Sample Standard Reporting Package".
Q-103 a.) Describe typically requested ad hoc
reports.
b.) What is your typical turnaround time
for ad hoc reports?
Q-104 a.) Will You provide normative data
against which the State can benchmark its
plan?
b.) What is the source of the data and
what specific benchmark information will
You provide?
Q-105 Describe Your organization's policies and
procedures surrounding the sale and
sharing of any Participant information
(i.e. when it happens, context and
purpose, etc.). Please note that the State
will not permit sharing of Participant
information for the purposes of
marketing/targeting and communications
to Participants by a third party. Also,
please address new limits from the HI-
TECH Act.
Label as "Response Attachment A-5: Sale/Sharing of Participant Information".
Q-106 Provide a description of the Medicare
Part D services You will provide to the
Department as part of your proposal.
Q-107 Since the inception of Medicare Part D,
the State has elected the Retiree Drug
Subsidy ("RDS"). The State is interested
in examining the effect, both
administratively and financially, of
adopting an alternate approach,
outsourcing as much of the administration
as possible.a.) Discuss Your experience and ability to
assist in the administration of the RDS
Subsidy approach, excluding the
associated cost(s).
Label as "Response Attachment A-5: Medicare Part D - RDS Subsidy Approach".
b.) Discuss Your experience and ability to
assist in the administration of a direct
contract approach, excluding the
associated cost(s).
Label as "Response Attachment A-5: Medicare Part D - Direct Contract Approach".
c.) Discuss Your experience and ability to
assist in the administration of an indirect
contract approach, excluding the
associated cost(s).
Label as "Response Attachment A-5: Medicare Part D - Indirect Contract Approach".
d.) Discuss Your experience and ability to
assist in the administration of a Medicare
Advantage plan, excluding the associated
cost(s).
Label as "Response Attachment A-5: Medicare Part D - Medicare Advantage Plan".
e.) Provide a description of any additional
Medicare Part D services You that are
available.
Q-108 a.) What practices and policies have You
implemented to ensure the confidentiality
of all confidential information, including
protected health information as defined
by the HIPAA privacy rule, Participant
information, or other sensitive
information of the State and its Plan
Participants?
IX. MEDICARE PART D OPTIONS
X. HIPAA COMPLIANCE
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ResponseQuestion
b.) How often do You update Your
HIPAA policies and procedures?
Q-109 Please identify and describe all breaches
of HIPAA privacy and security provisions
within the last 18 months.Label as "Response Attachment A-5: HIPAA Privacy and Security Breaches".
Q-110 a.) Please describe how the HI-TECH Act
provisions concerning the receipt of
payment in exchange for PHI or data and
marketing communications will impact
communications and initiatives by Your
organization concerning formulary
compliance or use of medications.
b.) Explain how Your organization pays
for such communications and education
initiatives and how that might be
impacted by the HI-TECH Act
provisions.
Q-111 Does your organization have the
capability to integrate medical and
pharmacy claims data to enhance DUR
and DM initiatives?
Select one
Q-112 Describe how Your clinical programs
utilize the following:
a.) Evidenced-based approach
b.) Outcomes data (savings and
Participant impact).
c.) Funding from pharmaceutical
manufacturers.
Q-113 Please describe the process and
philosophy used by your P&T Committee
in making their formulary decisions.
Q-114 Please provide the following information
for each prospective/retrospective DUR
program You offer and include two
references. Please do not include any fee
information. See Attachment B-10.
Program #1
Description of the program
Number of programs implemented to date
Describe expected outcomes
improvement or cost savings from
utilizing the program.
Describe the qualifications of the staff
administering the program, any
specialized training they receive, and the
turnover rate for these staff persons.
Reference #1 (name/contact/phone)
Reference #2 (name/contact/phone)
Program #2
Description of the program
Number of programs implemented to date
Describe expected outcomes
improvement or cost savings from
utilizing the program.
Describe the qualifications of the staff
administering the program, any
specialized training they receive, and the
turnover rate for these staff persons.
Reference #1 (name/contact/phone)
Reference #2 (name/contact/phone)
XI. CLINICAL MANAGEMENT
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ResponseQuestion
Program #3
Description of the program
Number of programs implemented to date
Describe expected outcomes
improvement or cost savings from
utilizing the program.
Describe the qualifications of the staff
administering the program, any
specialized training they receive, and the
turnover rate for these staff persons.
Reference #1 (name/contact/phone)
Reference #2 (name/contact/phone)
Program #4
Description of the program
Number of programs implemented to date
Describe expected outcomes
improvement or cost savings from
utilizing the program.
Describe the qualifications of the staff
administering the program, any
specialized training they receive, and the
turnover rate for these staff persons.
Reference #1 (name/contact/phone)
Reference #2 (name/contact/phone)
Q-115 How often do You provide clients with a
report that details the utilization and
outcome of the clients’ clinical programs?Select one
Q-116 Describe Your abuse/fraud detection
program and Your ability to manage
controlled substance utilization. At a
minimum, discuss the following:a.) When the program originally
developed.
b.) How capable are You of tailoring the
program for specific clients?
c.) How willing are You to implement
unique program parameters for the State?
d.) What benchmarks do You use to
identify aberrant utilization patterns?
How were these developed? How often
are they updated?
e.) What are the minimum and maximum
time frames over which utilization is
tracked to identify aberrant usage?
f.) What medications or therapeutic
categories are tracked?
g.) Can You track prescriber activity
separate from Participant utilization in
identifying potential fraud or abuse?
h.) How much outreach to prescribers
and/or pharmacies is done? What is the
timeframe for that?
i.) What are Your lockdown/limit
capabilities?
j.) We require quarterly reporting on this
program. How quickly can the
information for each quarter be analyzed
to provide a report? What support
functions are available to the State in
interpreting the report (i.e. clinical
manager with a Pharm.D, staff with
medical expertise)?
Label as "Response Attachment A-5: Fraud/Abuse Detection and Controlled Substance Management Program".
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ResponseQuestion
k.) Provide a schedule that describes how
the process works, identifying the close
of quarter, when prescriber/pharmacy
outreach is done, analysis of utilization
data and prescriber/pharmacy responses,
production of reports to the State, etc.
Q-117 a.) Are there tools available to
Participants who don’t register on Your
site?
Select one
b.) If yes, please describe.
Q-118 a.) Can You do prospective modeling for
patients and demonstrate their personal
savings associated with changing
medications from their current
prescriptions?
Select one
b.) Does this modeling process provide
the information required by state law and
this ITN regarding drug substitution?Select one
c.) Does this function use existing claim
history, State specific plan design and
pricing as a starting point?
Select one
d.) If you have this capability, what have
You seen for utilization patterns and
changes from brand to generic
medications?
Q-119 What percentage of Your employer
sponsored organization’s employees
register on your site (e.g., they sign up
and get a password)?
Q-120 a.) Describe Your personalization and
push messaging capabilities.
b.) How do these capabilities impact cost
or quality for Your clients?
Q-121 The State would like direct access to the
Respondent's eligibility systems for
review and input purposes. Describe your
ability to provide the State with direct
access to the eligibility system only.
Q-122 Are you able to receive eligibility data via
the Internet?Select one
Q-123 Please describe the eligibility system that
will be used to keep track of the State's
eligibility files, including:
a.) System "trade name"
b.) System organization
c.) Date eligibility system was put in
place
d.) Number of system upgrades since
inception
e.) Annual budget and planned system
improvements for the hardware and
software used in providing the services.
Q-124 a.) Is eligibility processing real-time with
the claim system?Select one
b.) If no, what is the delay time? Select one
Q-125 Briefly describe Your process for
correcting data in the event of a data tape
which contains "bad data".
Label as "Response Attachment A-5: Fraud/Abuse Detection and Controlled Substance Management Program".
XIII. ELIGIBILITY
XIV. IMPLEMENTATION PROGRAM / TRANSITION
XII. INTERNET TOOLS
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ResponseQuestion
Q-126 Please discuss Your procedures and
processes for handling the following
during the transition period:
a.) Transition of care for mail and
specialty drugs
b.) Employee communications regarding
change in administrators
Q-127 Implementation Plan
a.) Name of the person with overall
responsibility for planning, supervising
and implementing the program for the
State of Florida.b.) Title
c.) What other duties, if any, will this
person have during implementation?
Please include the number and size of
other accounts for which this person will
be responsible during the same time
period.d.) What percentage of this person's time
will be devoted to the State of Florida
account during the implementation
process?e.) Provide an organizational chart
identifying the names, area of expertise,
functions, and reporting relationships of
key people directly responsible for
implementing the State's account. In
addition, resumes of these individuals
should be included.
Label as "Response Attachment A-5: Implementation Team Organizational Chart".
f.) Provide a detailed implementation plan
that clearly demonstrates the
Respondent's ability to meet the State of
Florida's requirements to have a fully
functioning program in place and
operable on January 1, 2012. This
implementation plan should include a list
of specific implementation
tasks/transition protocols and a time-table
for initiation and completion of such
tasks, beginning with the contract award
and continuing through the effective date
of operation (January 1, 2012). The
implementation plan should be specific
about requirements for information
transfer as well as any services or
assistance required from the State during
implementation. See also requirements of
AR-1.
Label as "Response Attachment A-5: Implementation Plan".
Q-128 a.) Do you anticipate any major transition
issues during implementation? Select one
b.) If yes, please describe.
Q-129 Describe the organization and structure of
the account service team that will support
the State of Florida. Include the rationale
for this structure and the ways in which it
is particularly responsive to the State's
needs and goals.
Q-130 a.) Name of the person with overall
responsibility for planning, supervising
and performing account services for the
State of Florida.b.) Title
XV. ACCOUNT MANAGEMENT
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ResponseQuestion
c.) Where will the account manger be
located?
d.) What other duties, if any, does this
person have? Please include the number
and size of other accounts for which this
person is responsible.e.) What percentage of this person's time
will be devoted to the State of Florida
account?
f.) Please provide an organizational chart
identifying the names, functions and
reporting relationships of key people
directly responsible for account support
services to the State. It should also
document how many account executives
and group services representatives will
work full-time on the State's account and
how many will work part-time on the
State's account.
Label as "Response Attachment A-5: Account Management Team Organizational Chart".
g.) Describe account management
support, including the mechanisms and
processes in place to allow State of
Florida personnel to communicate with
account service representatives, hours of
operation; types of inquiries that can be
handled by account service
representatives; and a brief explanation of
information available on-line. The State
of Florida requires identification of an
account services manager to respond to
inquiries and problems, and a description
of how the Respondent's customer service
and other support staff will respond to
subscriber or client inquiries and
problems.
Label as "Response Attachment A-5: Account Management Support".
Q-131 Please provide a biography of each team
member, including length of time with
your organization, positions held and
associated responsibilities.
Label as "Response Attachment A-2: Account Team Biographies".
Q-132 Will this team be responsible for
implementing the State's account?
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Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-5b: Additional Questionnaire Answers
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characters in length. Responses must be numbered to correspond to the question number and section number (A-5a) to which
it pertains.
Representations made by the Respondent in this proposal become contractual obligations that must be met during the
contract term.
ITN No.: DMS 10/11-010 Page 42 A-5b Additional Question Answer
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Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-6: Subcontractors Questionnaire
Representations made by the Respondent in this proposal become contractual obligations that must be met during the contract term.
Subcontractor #1SQ-1 Provide a brief summary of the history of the
Subcontractor's company and information about the
growth of the organization on a national level and within
the State of Florida.SQ-2 Specifically what roles will the Subcontractor have in
the performance of the Contract?
SQ-3 a.) Explain the process for monitoring the performance
of the Subcontractor and measuring the quality of their
results.
b.) List any services for which the Subcontractor will be
solely responsible and describe how the Subcontractor
will be monitored and managed.
SQ-4 Describe any significant government action or litigation
taken or pending against the Subcontractor's company
or any entities of the Subcontractor's company during
the most recent five (5) years.
SQ-5 a.) Is the Subcontractor compliant with all applicable
HIPAA administrative simplification rules?
b.) What procedures do You have in place to ensure
Subcontractor compliance?
SQ-6 Is this Subcontractor a MWBE certified by the State of
Florida?Select one
Subcontractor #2SQ-1 Provide a brief summary of the history of the
Subcontractor's company and information about the
growth of the organization on a national level and within
the State of Florida.SQ-2 Specifically what roles will the Subcontractor have in
the performance of the Contract?
SQ-3 a.) Explain the process for monitoring the performance
of the Subcontractor and measuring the quality of their
results.
b.) List any services for which the Subcontractor will be
solely responsible and describe how the Subcontractor
will be monitored and managed.
SQ-4 Describe any significant government action or litigation
taken or pending against the Subcontractor's company
or any entities of the Subcontractor's company during
the most recent five (5) years.
SQ-5 a.) Is the Subcontractor compliant with all applicable
HIPAA administrative simplification rules?
b.) What procedures do You have in place to ensure
Subcontractor compliance?
SQ-6 Is this Subcontractor a MWBE certified by the State of
Florida?Select one
Subcontractor #3SQ-1 Provide a brief summary of the history of the
Subcontractor's company and information about the
growth of the organization on a national level and within
the State of Florida.SQ-2 Specifically what roles will the Subcontractor have in
the performance of the Contract?
SQ-3 a.) Explain the process for monitoring the performance
of the Subcontractor and measuring the quality of their
results.
b.) List any services for which the Subcontractor will be
solely responsible and describe how the Subcontractor
will be monitored and managed.
SQ-4 Describe any significant government action or litigation
taken or pending against the Subcontractor's company
or any entities of the Subcontractor's company during
the most recent five (5) years.
Instructions: Please complete one section of the table below for each Subcontractor that the Respondent proposes to have perform any of the
required functions under this contract. Clearly indicate if a proposed Subcontractor is a MWBE certified by the State of Florida, if responding for an
MWBE Subcontractor.
Question Response
ITN No.: DMS 10/11-010 Page 44 A-6 Subcontractor Questions
SQ-5 a.) Is the Subcontractor compliant with all applicable
HIPAA administrative simplification rules?
b.) What procedures do You have in place to ensure
Subcontractor compliance?
SQ-6 Is this Subcontractor a MWBE certified by the State of
Florida?Select one
Subcontractor #4SQ-1 Provide a brief summary of the history of the
Subcontractor's company and information about the
growth of the organization on a national level and within
the State of Florida.SQ-2 Specifically what roles will the Subcontractor have in
the performance of the Contract?
SQ-3 a.) Explain the process for monitoring the performance
of the Subcontractor and measuring the quality of their
results.
b.) List any services for which the Subcontractor will be
solely responsible and describe how the Subcontractor
will be monitored and managed.
SQ-4 Describe any significant government action or litigation
taken or pending against the Subcontractor's company
or any entities of the Subcontractor's company during
the most recent five (5) years.
SQ-5 a.) Is the Subcontractor compliant with all applicable
HIPAA administrative simplification rules?
b.) What procedures do You have in place to ensure
Subcontractor compliance?
SQ-6 Is this Subcontractor a MWBE certified by the State of
Florida?Select one
Subcontractor #5SQ-1 Provide a brief summary of the history of the
Subcontractor's company and information about the
growth of the organization on a national level and within
the State of Florida.SQ-2 Specifically what roles will the Subcontractor have in
the performance of the Contract?
SQ-3 a.) Explain the process for monitoring the performance
of the Subcontractor and measuring the quality of their
results.
b.) List any services for which the Subcontractor will be
solely responsible and describe how the Subcontractor
will be monitored and managed.
SQ-4 Describe any significant government action or litigation
taken or pending against the Subcontractor's company
or any entities of the Subcontractor's company during
the most recent five (5) years.
SQ-5 a.) Is the Subcontractor compliant with all applicable
HIPAA administrative simplification rules?
b.) What procedures do You have in place to ensure
Subcontractor compliance?
SQ-6 Is this Subcontractor a MWBE certified by the State of
Florida?Select one
Subcontractor #6SQ-1 Provide a brief summary of the history of the
Subcontractor's company and information about the
growth of the organization on a national level and within
the State of Florida.SQ-2 Specifically what roles will the Subcontractor have in
the performance of the Contract?
SQ-3 a.) Explain the process for monitoring the performance
of the Subcontractor and measuring the quality of their
results.
b.) List any services for which the Subcontractor will be
solely responsible and describe how the Subcontractor
will be monitored and managed.
SQ-4 Describe any significant government action or litigation
taken or pending against the Subcontractor's company
or any entities of the Subcontractor's company during
the most recent five (5) years.
SQ-5 a.) Is the Subcontractor compliant with all applicable
HIPAA administrative simplification rules?
b.) What procedures do You have in place to ensure
Subcontractor compliance?
ITN No.: DMS 10/11-010 Page 45 A-6 Subcontractor Questions
SQ-6 Is this Subcontractor a MWBE certified by the State of
Florida?Select one
ITN No.: DMS 10/11-010 Page 46 A-6 Subcontractor Questions
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-7: Access to Network Pharmacies
Urban Areas
Suburban Areas
Rural Areas
A. Please note the geo-mapping method used below.
B.
Number Percent Number Percent
C.
Number Percent Number Percent
Bay County #DIV/0! 0 #DIV/0!
Alachua County #DIV/0! 0 #DIV/0!
Baker County #DIV/0! 0 #DIV/0!Bradford County #DIV/0! 0 #DIV/0!
Brevard County #DIV/0! 0 #DIV/0!
Broward County #DIV/0! 0 #DIV/0!
Calhoun County #DIV/0! 0 #DIV/0!
Charlotte County #DIV/0! 0 #DIV/0!
Citrus County #DIV/0! 0 #DIV/0!
Clay County #DIV/0! 0 #DIV/0!
Collier County #DIV/0! 0 #DIV/0!
Columbia County #DIV/0! 0 #DIV/0!
De Soto County #DIV/0! 0 #DIV/0!
Dixie County #DIV/0! 0 #DIV/0!
Duval County #DIV/0! 0 #DIV/0!
Escambia County #DIV/0! 0 #DIV/0!
Flagler County #DIV/0! 0 #DIV/0!
Franklin County #DIV/0! 0 #DIV/0!
Gadsden County #DIV/0! 0 #DIV/0!
Gilchrist County #DIV/0! 0 #DIV/0!
Glades County #DIV/0! 0 #DIV/0!
Gulf County #DIV/0! 0 #DIV/0!
Hamilton County #DIV/0! 0 #DIV/0!
Total Number of
In-Network
Pharmacies
Total Number of
In-Network
Pharmacies
Select one
For Response Attachment A-7: GeoAccess Report - Broad Network, please provide the following report format for all Subscribers.
Instructions: The State is interested in the availability of key pharmacies to its Participant population in both a broad, national retail network and a
narrower retail network that is a subset of the national network. To assist the Respondent in completing the standard GeoAccess report for
pharmacies, the State will provide the Respondent with a census file as part of Attachment C: Confidential Documents. The file will include the
following fields: Subscriber identifier, Participant identifier, age, gender, ZIP Code, sub-type and contract type. This file will be sent to only those
Respondents who submit a NDA to the Procurement Officer as described in Section 2.3 of this ITN.
Geographic Area
(Subtotal by County)
Average Distance to
Pharmacy
Zip CodeAverage Distance to
Pharmacy
Total Number of
Subscribers
Subscribers Matched Subscribers Not Matched
Provide subtotals of Response Attachment A-7 GeoAccess Report - Broad Network report by county.
Total Number of
Subscribers
Subscribers Matched Subscribers Not Matched
Attachment A-7 is to be completed for all Subscribers included in the census file. The reports should include the average distance to each pharmacy,
the number of pharmacies in the ZIP Code, the number of Subscribers that meet the access requirements above and the number of Subscribers that
do not meet the access requirements above.
In addition to the standard GeoAccess hard copy reports, the data must be supplied in electronic format that has read/write capabilities. Do not send
the data in a read-only file. Label the complete GeoAccess reports as Response Attachment A-7: GeoAccess Report - Broad Network or
Response Attachment A-7: GeoAccess Report - Limited Network, as applicable. Parts B and D of Attachment A-7 show the required reporting
format for the Respondent’s response attachment for the GeoAccess Reports for the broad and more limited networks, respectively.
In addition, the Respondent shall complete the exhibits in Parts C and E of Attachment A-7, which summarizes the GeoAccess data for pharmacies by
Florida county. Please note that the Respondent need only to populate the highlighted cells in the exhibit; all other cells will be calculated based on the
values entered in the highlighted cells.
Using the ZIP Code data provided in the tab labeled "Attachment A-7 GeoAccess Data" of Attachment C: Confidential Documents, prepare and
provide a GeoAccess report based on the standards outlined below for both the broad retail network proposed and an alternative more limited retail
network. The Respondent shall prepare a GeoAccess report for each network proposed (the broad network and the more limited network).
Respondents shall use the definitions of Urban, Suburban and Rural as they are defined by standard Geo Access guidelines.
Access to Pharmacies
1 within 3 miles
1 within 5 miles
1 within 10 miles
SAMPLE FORMAT
ITN No.: DMS 10/11-010 Page 47 A-7 Access to Pharmacies
Hardee County #DIV/0! 0 #DIV/0!
Hendry County #DIV/0! 0 #DIV/0!
Hernando County #DIV/0! 0 #DIV/0!
Highlands County #DIV/0! 0 #DIV/0!
Hillsborough County #DIV/0! 0 #DIV/0!
Holmes County #DIV/0! 0 #DIV/0!
Indian River County #DIV/0! 0 #DIV/0!
Jackson County #DIV/0! 0 #DIV/0!
Jefferson County #DIV/0! 0 #DIV/0!
Lafayette County #DIV/0! 0 #DIV/0!
Lake County #DIV/0! 0 #DIV/0!
Lee County #DIV/0! 0 #DIV/0!
Leon County #DIV/0! 0 #DIV/0!
Levy County #DIV/0! 0 #DIV/0!
Liberty County #DIV/0! 0 #DIV/0!
Madison County #DIV/0! 0 #DIV/0!
Manatee County #DIV/0! 0 #DIV/0!
Marion County #DIV/0! 0 #DIV/0!
Martin County #DIV/0! 0 #DIV/0!
Miami-Dade County #DIV/0! 0 #DIV/0!
Monroe County #DIV/0! 0 #DIV/0!
Nassau County #DIV/0! 0 #DIV/0!
Okaloosa County #DIV/0! 0 #DIV/0!
Okeechobee County #DIV/0! 0 #DIV/0!
Orange County #DIV/0! 0 #DIV/0!
Osceola County #DIV/0! 0 #DIV/0!
Palm Beach County #DIV/0! 0 #DIV/0!
Pasco County #DIV/0! 0 #DIV/0!
Pinellas County #DIV/0! 0 #DIV/0!
Polk County #DIV/0! 0 #DIV/0!
Putnam County #DIV/0! 0 #DIV/0!
Santa Rosa County #DIV/0! 0 #DIV/0!
Sarasota County #DIV/0! 0 #DIV/0!
Seminole County #DIV/0! 0 #DIV/0!
St. Johns County #DIV/0! 0 #DIV/0!
St. Lucie County #DIV/0! 0 #DIV/0!
Sumter County #DIV/0! 0 #DIV/0!
Suwannee County #DIV/0! 0 #DIV/0!
Taylor County #DIV/0! 0 #DIV/0!
Union County #DIV/0! 0 #DIV/0!
Volusia County #DIV/0! 0 #DIV/0!
Wakulla County #DIV/0! 0 #DIV/0!
Walton County #DIV/0! 0 #DIV/0!
Washington County #DIV/0! 0 #DIV/0!
D.
Number Percent Number Percent
E.
Number Percent Number Percent
Bay County #DIV/0! 0 #DIV/0!
Alachua County #DIV/0! 0 #DIV/0!
Baker County #DIV/0! 0 #DIV/0!Bradford County #DIV/0! 0 #DIV/0!
Brevard County #DIV/0! 0 #DIV/0!
Broward County #DIV/0! 0 #DIV/0!
Calhoun County #DIV/0! 0 #DIV/0!
Charlotte County #DIV/0! 0 #DIV/0!
Citrus County #DIV/0! 0 #DIV/0!
Clay County #DIV/0! 0 #DIV/0!
Collier County #DIV/0! 0 #DIV/0!
Columbia County #DIV/0! 0 #DIV/0!
De Soto County #DIV/0! 0 #DIV/0!
Dixie County #DIV/0! 0 #DIV/0!
Duval County #DIV/0! 0 #DIV/0!
For Response Attachment A-7: GeoAccess Report - Limited Network, please provide the following report format for all eligible Subscribers.
Zip CodeAverage Distance to
Pharmacy
Total Number of
In-Network
Pharmacies
Total Number of
Subscribers
Subscribers Matched Subscribers Not Matched
Provide subtotals of Response Attachment A-7 GeoAccess Report - Limited Network report by county.
Geographic Area
(Subtotal by County)
Average Distance to
Pharmacy
Total Number of
In-Network
Pharmacies
Total Number of
Subscribers
Subscribers Matched Subscribers Not Matched
SAMPLE FORMAT
ITN No.: DMS 10/11-010 Page 48 A-7 Access to Pharmacies
Escambia County #DIV/0! 0 #DIV/0!
Flagler County #DIV/0! 0 #DIV/0!
Franklin County #DIV/0! 0 #DIV/0!
Gadsden County #DIV/0! 0 #DIV/0!
Gilchrist County #DIV/0! 0 #DIV/0!
Glades County #DIV/0! 0 #DIV/0!
Gulf County #DIV/0! 0 #DIV/0!
Hamilton County #DIV/0! 0 #DIV/0!
Hardee County #DIV/0! 0 #DIV/0!
Hendry County #DIV/0! 0 #DIV/0!
Hernando County #DIV/0! 0 #DIV/0!
Highlands County #DIV/0! 0 #DIV/0!
Hillsborough County #DIV/0! 0 #DIV/0!
Holmes County #DIV/0! 0 #DIV/0!
Indian River County #DIV/0! 0 #DIV/0!
Jackson County #DIV/0! 0 #DIV/0!
Jefferson County #DIV/0! 0 #DIV/0!
Lafayette County #DIV/0! 0 #DIV/0!
Lake County #DIV/0! 0 #DIV/0!
Lee County #DIV/0! 0 #DIV/0!
Leon County #DIV/0! 0 #DIV/0!
Levy County #DIV/0! 0 #DIV/0!
Liberty County #DIV/0! 0 #DIV/0!
Madison County #DIV/0! 0 #DIV/0!
Manatee County #DIV/0! 0 #DIV/0!
Marion County #DIV/0! 0 #DIV/0!
Martin County #DIV/0! 0 #DIV/0!
Miami-Dade County #DIV/0! 0 #DIV/0!
Monroe County #DIV/0! 0 #DIV/0!
Nassau County #DIV/0! 0 #DIV/0!
Okaloosa County #DIV/0! 0 #DIV/0!
Okeechobee County #DIV/0! 0 #DIV/0!
Orange County #DIV/0! 0 #DIV/0!
Osceola County #DIV/0! 0 #DIV/0!
Palm Beach County #DIV/0! 0 #DIV/0!
Pasco County #DIV/0! 0 #DIV/0!
Pinellas County #DIV/0! 0 #DIV/0!
Polk County #DIV/0! 0 #DIV/0!
Putnam County #DIV/0! 0 #DIV/0!
Santa Rosa County #DIV/0! 0 #DIV/0!
Sarasota County #DIV/0! 0 #DIV/0!
Seminole County #DIV/0! 0 #DIV/0!
St. Johns County #DIV/0! 0 #DIV/0!
St. Lucie County #DIV/0! 0 #DIV/0!
Sumter County #DIV/0! 0 #DIV/0!
Suwannee County #DIV/0! 0 #DIV/0!
Taylor County #DIV/0! 0 #DIV/0!
Union County #DIV/0! 0 #DIV/0!
Volusia County #DIV/0! 0 #DIV/0!
Wakulla County #DIV/0! 0 #DIV/0!
Walton County #DIV/0! 0 #DIV/0!
Washington County #DIV/0! 0 #DIV/0!
ITN No.: DMS 10/11-010 Page 49 A-7 Access to Pharmacies
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-8: Pharmacies by County
Florida County Broad Network Limited NetworkAlachua County
Baker County
Bay County
Bradford County
Brevard County
Broward County
Calhoun County
Charlotte County
Citrus County
Clay County
Collier County
Columbia County
De Soto County
Dixie County
Duval County
Escambia County
Flagler County
Franklin County
Gadsden County
Gilchrist County
Glades County
Gulf County
Hamilton County
Hardee County
Hendry County
Hernando County
Highlands County
Hillsborough County
Holmes County
Indian River County
Jackson County
Jefferson County
Lafayette County
Lake County
Lee County
Leon County
Levy County
Liberty County
Madison County
Manatee County
Marion County
Martin County
Miami-Dade County
Monroe County
Nassau County
Okaloosa County
Okeechobee County
Orange County
Osceola County
Palm Beach County
Pasco County
Pinellas County
Polk County
Putnam County
Santa Rosa County
Instructions: For each of the counties listed below, please indicate the number of contracted pharmacies in both the broad retail
network proposed and an alternative more limited retail network.
Number of Contracted Pharmacies
ITN No.: DMS 10/11-010 Page 50 A-8 Pharmacies by County
Florida County Broad Network Limited NetworkSarasota County
Seminole County
St. Johns County
St. Lucie County
Sumter County
Suwannee County
Taylor County
Union County
Volusia County
Wakulla County
Walton County
Washington County
ITN No.: DMS 10/11-010 Page 51 A-8 Pharmacies by County
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-9: Pharmacy Disruption based on Days of Therapy
Pharmacy
NABP
Number
Pharmacy NameTotal Number of
Days of Therapy
Total Number of
Distinct Utilizers
Average Days
Supply per
Script
Rx CountTotal Amount
Paid
Average Amount
Paid per Script
Participating
Pharmacy of Broad
Network
(Yes or No)
Participating
Pharmacy of
Limited Network
(Yes or No)Select one Select one
Select one Select one
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Instructions: From tab labeled "Attachment A-9 Data" of Attachment C: Confidential Documents, copy and paste the Pharmacy NABP Number, Pharmacy Name, Total Number of Prescriptions,
Total Number of Distinct Utilizers, Average Days Supply per Script, Total Quantity, Total Amount Paid and Average Amount Paid per Script into the table below. Then, complete each row by selecting
either a "Yes" or "No" from the drop down list in both column I and J to indicate whether or not the named provider is an in-network provider of the network described. All other responses will be treated
as a "No" response.
Pharmacy NABP numbers are confidential information and should be treated accordingly. Please destroy all confidential information within 5 business days of award of contract as described in the
Confidentiality and Non-Disclosure Agreement.
ITN No.: DMS 10/11-010 Page 52 A-9 Pharm Disruption_DOT
Pharmacy
NABP
Number
Pharmacy NameTotal Number of
Days of Therapy
Total Number of
Distinct Utilizers
Average Days
Supply per
Script
Rx CountTotal Amount
Paid
Average Amount
Paid per Script
Participating
Pharmacy of Broad
Network
(Yes or No)
Participating
Pharmacy of
Limited Network
(Yes or No)Select one Select one
Select one Select one
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ITN No.: DMS 10/11-010 Page 53 A-9 Pharm Disruption_DOT
Pharmacy
NABP
Number
Pharmacy NameTotal Number of
Days of Therapy
Total Number of
Distinct Utilizers
Average Days
Supply per
Script
Rx CountTotal Amount
Paid
Average Amount
Paid per Script
Participating
Pharmacy of Broad
Network
(Yes or No)
Participating
Pharmacy of
Limited Network
(Yes or No)Select one Select one
Select one Select one
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ITN No.: DMS 10/11-010 Page 54 A-9 Pharm Disruption_DOT
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-10: Pharmacy Disruption based on Total Paid Amount
Pharmacy
NABP
Number
Pharmacy NameTotal Number of
Days of Therapy
Total Number of
Distinct Utilizers
Average Days
Supply per
Script
Rx CountTotal Amount
Paid
Average Amount
Paid per Script
Participating
Pharmacy of Broad
Network
(Yes or No)
Participating
Pharmacy of
Limited Network
(Yes or No)Select one Select one
Select one Select one
Select one Select one
Select one Select one
Select one Select one
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Instructions: From tab labeled "Attachment A-10 Data" of Attachment C: Confidential Documents, copy and paste the Pharmacy NABP Number, Pharmacy Name, Total Number of Prescriptions,
Total Number of Distinct Utilizers, Average Days Supply per Script, Total Quantity, Total Amount Paid and Average Amount Paid per Script into the table below. Then, complete each row by selecting
either a "Yes" or "No" from the drop down list in column I and J to indicate whether or not the named provider is an in-network provider of the network described. All other responses will be treated as a
"No" response.
Pharmacy NABP numbers are confidential information and should be treated accordingly. Please destroy all confidential information within 5 business days of award of contract as described in the
Confidentiality and Non-Disclosure Agreement.
ITN No.: DMS 10/11-010 Page 55 A-10 Pharm Disruption_Paid
Pharmacy
NABP
Number
Pharmacy NameTotal Number of
Days of Therapy
Total Number of
Distinct Utilizers
Average Days
Supply per
Script
Rx CountTotal Amount
Paid
Average Amount
Paid per Script
Participating
Pharmacy of Broad
Network
(Yes or No)
Participating
Pharmacy of
Limited Network
(Yes or No)Select one Select one
Select one Select one
Select one Select one
Select one Select one
Select one Select one
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ITN No.: DMS 10/11-010 Page 56 A-10 Pharm Disruption_Paid
Pharmacy
NABP
Number
Pharmacy NameTotal Number of
Days of Therapy
Total Number of
Distinct Utilizers
Average Days
Supply per
Script
Rx CountTotal Amount
Paid
Average Amount
Paid per Script
Participating
Pharmacy of Broad
Network
(Yes or No)
Participating
Pharmacy of
Limited Network
(Yes or No)Select one Select one
Select one Select one
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ITN No.: DMS 10/11-010 Page 57 A-10 Pharm Disruption_Paid
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-11: Formulary Analysis
I.
II.
TierNumber of
Medications
Generic
Preferred Brand
Non-Preferred Brand
III.
NDC-9 Drug NameTotal Number of Days of
TherapyRx Count
Formulary
Tier
Select one
Select one
Select one
Select one
Select one
Select one
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MAC Indicator
(if applicable)GPI Code
Please provide your PDL in the format shown below in electronic format using MS Excel with read/write capabilities. Submit the MS
Excel file labeled as "Response Attachment A-11: Preferred Drug List".
Preferred Drug List
Formulary Tiers
From tab A-11 of Attachment C: Confidential Documents, copy and paste the NDC-9 Code, Drug Name, Total
Days of Therapy and Rx Count into the table below. In column F, select the formulary tier applicable for each drug.
Using the following chart, please indicate the number of all medications currently available on the market (no
exclusions) and how these drugs fall into the formulary tiers shown below based on the formulary proposed for the
State.
Formulary Analysis
NDC-9 Code
Drug Classification
(Generic or Preferred
Brand)
Brand Name
(if applicable)Drug Name
SAMPLE FORMAT
ITN No.: DMS 10/11-010 Page 58 A-11 Formulary Analysis
NDC-9 Drug NameTotal Number of Days of
TherapyRx Count
Formulary
Tier
Select one
Select one
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ITN No.: DMS 10/11-010 Page 59 A-11 Formulary Analysis
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ITN No.: DMS 10/11-010 Page 60 A-11 Formulary Analysis
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-12: Performance Guarantees
Performance
Indicator
Reporting Measurement
(subject to audit by the State and/or
contract auditors)
Performance StandardFrequency of
Measurement
Proposed Measurement Methodology
(Formula used to measure results)Amount at Risk
Willingness
to Comply with the
Standard/Goal
Account Management
PG-1 Final Implementation
Plan
The Service Provider shall provide the
final Implementation Plan, inclusive of
all the details as described in AR-1 of
Attachment A-4: Administrative
Requirements, to the Department for
approval no later than the date
specified.
Delivery no later than 14
calendar days following
execution of the Contract.
One time measurement
$500 per day for each calendar
day past the due date that the
final Implementation Plan,
inclusive of all details, if not
received and approved by the
Department.
Select one
PG-2 Quarterly Meetings The Account Management team shall
attend and participate in all required
quarterly performance meetings.100% attendance Quarterly
$1,000 per meeting in which
each member of the Account
Management Team is not in
attendance unless an absence is
pre-approved by the
Department.
Select one
PG-3 Open Enrollment
Benefit Fairs
The Service Provider shall guarantee
trained staffing at each annual open
enrollment meeting and/or benefit fair
sponsored by the Department or its
designee.
100% of open enrollment
meetings shall be staffed by
trained personnel.
Annually$10,000 per benefit fair not
staffed.Select one
PG-4 Account Management
Team Responsiveness
a.) 100% of telephonic
inquiries shall be responded to
within one (1) business day.
Quarterly$500 per percentage point, or
fraction thereof, less than 100%Select one
b.) 100% of e-mail inquiries
shall be responded to within
one (1) business day.
Quarterly$500 per percentage point, or
fraction thereof, less than 100%Select one
c.) 100% of written inquiries
shall be responded to within
three (3) business days.
Quarterly$1,000 per percentage point, or
fraction thereof, less than 100%Select one
Representations made by the Respondent in this proposal become contractual obligations that must be met during the contract term.
It is critical to the success of the State's benefits plans that services be maintained in a timely manner and that the Service Provider operates in an extremely reliable manner. It would be impracticable and extremely difficult to fix the actual damage
sustained by the State in the event of certain delays or failures in claims administration, service, reporting, and attendance of Service Provider personnel on scheduled work and provision of services to the State Employees, Retirees and Dependents
served by this Contract. The State and the Service Provider, therefore, presume that in the event of certain such delays and failures, the amount of damage which will be sustained from a failure to perform to certain standards will be the amounts set
forth in Attachment A-12: Performance Guarantees.
Instructions: Please provide in column F the specific formula You propose to be used to calculate performance results for each performance standard described below. In column H, please indicate your willingness to comply with the Performance
Standards and the Amount at Risk shown below by selecting the applicable response from the drop down menu. If the Respondent agrees to commit to the full scope of an item, as written and without condition or qualification, the appropriate response
is “Agree to this PG as written.” If the Respondent agrees to commit to the full scope of an item, but would like to propose an alternative to the requirement, the appropriate response is “Agree with suggested alternative.” All "Disagree" responses
must be addressed in Attachment A-14: Deviations Page.
The Account Management Team
assigned to the Department shall
respond to telephone, e-mail and other
written inquiries from the Department
within the time period specified.
Respondents will report results (as shown in Attachment D-6: PG Report Card) on all performance measurements quarterly per the requirements set forth below. Performance results and reporting will also be audited annually by the Department or its
contracted auditor.
Evaluators will score each response. A response of “Disagree” without an acceptable alternative will receive 0 points. A response of “Agree” will be awarded 1 point. An enhanced value alternative may receive 2 points. Please identify how your
proposed alternative enhances the overall value to the State.
See section 6.3 of the Draft Contract for terms and conditions. The State, at its option for amount due the State as liquidated damages, may deduct such from any money payable to the Service Provider or may bill the Service Provider as a separate
item.
ITN No.: DMS 10/11-010 Page 61 A-12 Performance Guarantees
Performance
Indicator
Reporting Measurement
(subject to audit by the State and/or
contract auditors)
Performance StandardFrequency of
Measurement
Proposed Measurement Methodology
(Formula used to measure results)Amount at Risk
Willingness
to Comply with the
Standard/Goal
PG-5 Account Management
Team Performance
Review
Performance of the Account
Management Team shall be based on
semi-annual Report Cards developed by
the Department.
Score of at least a 4.0 on
average on a scale of 1 to 5.Semi-annually
$50,000 for each Report Card
with an average score of less
than 4.0.
Select one
Customer Service Center
PG-6 Average Speed to
Answer
a.) The dedicated toll-free customer
service phone line shall answer calls
within 30 seconds. Measurement shall
be from the initial ring.
99.9% of calls shall be
answered within an average of
30 seconds or less
Quarterly
$2,500 per percentage point, or
fraction thereof, less than
99.9%
Select one
b.) The dedicated toll-free customer
service phone line shall provide an opt
out option to a live person at any time
during the call during the required hours
of live customer service operation
specified in AR-25 of Attachment A-4:
Administrative Requirements. For
those Participants who require
assistance, a live customer service
representative will answer calls within
the time specified. Measurement shall
be from the point at which the caller
requests live assistance via the IVR.
99.9% of calls shall be
answered within an average of
30 seconds or less
Quarterly
$1,000 per percentage point, or
fraction thereof, less than
99.9%
Select one
PG-7 Call Abandonment
Rate
The call abandonment rate of the
dedicated toll-free customer service
phone line shall not exceed the specified
rate.
Less than or equal to 3.0% Quarterly
$5,000 per percentage point, or
fraction thereof, greater than
3.0%
Select one
PG-8 Customer Service
Availability
The dedicated customer service toll-free
number shall be staffed and available
during the hours of 7:00 a.m. and 7:00
p.m. (ET), Monday through Friday
excluding State holidays.
100% or greater Quarterly$5,000 per percentage point, or
fraction thereof, less than 100%Select one
PG-9 Paper Claims a.) Paper claims not needing additional
information or documentation (i.e. clean
claims) shall be finalized within the
time specified. Measurement shall be
from date of initial receipt.
98.0% within seven (7)
business days of the requestAnnually
$1,000 per percentage point, or
fraction thereof, less than
98.0%
Select one
b.) All paper claims shall be finalized
within the time specified. Measurement
shall be from date of initial receipt.
100% within
14 business daysAnnually
$1,000 per percentage point, or
fraction thereof, less than 100%Select one
PG-10 Participant Inquiry
Response Time
a.) Percent of telephone inquiries
returned by a customer service
representative.
99.0% within two (2)
business daysQuarterly
$2,500 per percentage point, or
fraction thereof, less than
99.0%
Select one
b.) Percent of written inquiries
responded to by a customer service
representative.
99.0% within ten (10)
business daysQuarterly
$2,500 per percentage point, or
fraction thereof, less than
99.0%
Select one
ITN No.: DMS 10/11-010 Page 62 A-12 Performance Guarantees
Performance
Indicator
Reporting Measurement
(subject to audit by the State and/or
contract auditors)
Performance StandardFrequency of
Measurement
Proposed Measurement Methodology
(Formula used to measure results)Amount at Risk
Willingness
to Comply with the
Standard/Goal
PG-11 Appeals a.) Level 1 Appeals shall be finalized
within the specified time frames from
receipt date of complete information or
documentation.
99.0% within:
15 days/pre-service,
30 days/post service, and
72 hours/urgent
Quarterly
$5,000 per percentage point, or
fraction thereof, less than
99.0%
Select one
b.) Reviews by an independent external
review organization shall be finalized
within the specified time frames from
the date of complete information or
documentation.
99.0% within:
15 days/pre-service,
30 days/post service, and
72 hours/urgent
Quarterly
$5,000 per percentage point, or
fraction thereof, less than
99.0%
Select one
PG-12 Subscriber Satisfaction
Survey
a.) Percent of Subscribers satisfied to
very satisfied with the services provided
at retail pharmacies.95.0% or greater Quarterly
$10,000 per percentage point,
or fraction thereof, greater than
95.0%
Select one
b.) Percent of Subscribers satisfied to
very satisfied with the services provided
at the mail order pharmacy.95.0% or greater Quarterly
$10,000 per percentage point,
or fraction thereof, greater than
95.0%
Select one
Administration
PG-13 Retail Network On-line
Availability Rate
The on-line system shall be available 24
hours a day, 7 days per week. 99.9% or greater Quarterly
$5,000 per percentage point, or
fraction thereof, less than
99.9%
Select one
PG-14 Retail Electronic
Claims: Timeliness
The automated claims system shall
process electronically submitted claims
within the time period specified. 100% within 25 seconds Quarterly
$5,000 per percentage point, or
fraction thereof, less than
100%.
Select one
PG-15 Retail Electronic
Claims: Financial
Accuracy
Electronic payment accuracy rate shall
be equal to the total dollars paid
correctly as a percent of the total dollars
paid.
99.9% or greater Quarterly
$5,000 per percentage point, or
fraction thereof, less than
99.9%
Select one
PG-16 Mail Order Dispensing
Turnaround Time
a.) The Service Provider shall dispense
all prescriptions under the mail service
program not requiring intervention
within the time specified.
100% within two (2) business
days of receiptQuarterly
$5,000 per percentage point, or
fraction thereof, less than 100%Select one
b.) The Service Provider shall dispense
or return to the Participant all
prescriptions requiring intervention
within the time specified.
If a prescription is returned to the
Participant, a written explanation as to
why it could not be dispensed shall be
provided to the Participant.
100% within five (5) business
days of receiptQuarterly
$5,000 per percentage point, or
fraction thereof, less than 100%Select one
c.) The Service Provider shall accurately
dispense all mail order prescriptions as
prescribed.99.9% or greater Quarterly
$10,000 per percentage point,
or fraction thereof, less than
99.9%
Select one
ITN No.: DMS 10/11-010 Page 63 A-12 Performance Guarantees
Performance
Indicator
Reporting Measurement
(subject to audit by the State and/or
contract auditors)
Performance StandardFrequency of
Measurement
Proposed Measurement Methodology
(Formula used to measure results)Amount at Risk
Willingness
to Comply with the
Standard/Goal
PG-17 Eligibility Transactions a.) Eligibility files shall be accurately
and timely loaded within the time
specified.
100% within two (2) business
days of receiptQuarterly
$1,000 per percentage point, or
fraction thereof, less than 100%Select one
b.) Urgent or emergency manual
enrollment updates at the request of the
Department or its designee shall be
completed in the time frame specified.
100% within the same business
day if requested during normal
business hours; otherwise
during the next business day.
Quarterly$2,500 per percentage point, or
fraction thereof, less than 100%Select one
PG-18 ID Cards a.) Implementation: ID cards shall be
mailed to Subscribers no later than
December 20, 2011.
99.0% no later than December
20, 2011Quarterly
$1,000 per percentage point, or
fraction thereof, less than
99.0%
Select one
b.) Maintenance: ID cards throughout
the calendar year shall be mailed within
the time specified.
99.0% or more within four (4)
business days of receipt.Quarterly
$1,000 per percentage point, or
fraction thereof, less than
99.0%
Select one
c.) Open Enrollment (excluding fall
2011): ID cards shall be mailed within
the time specified.
99.0% or more shall be mailed
within ten (10) business days of
receipt.
Quarterly
$1,000 per percentage point, or
fraction thereof, less than
99.0%
Select one
PG-19 Timeliness of the
Delivery of Reports and
Deliverables
Due monthly: within 10
calendar days of end of the
reporting month.
Monthly
$250 per day for each calendar
day past the due date that a
report or deliverable is not
received.
Select one
Due quarterly: within 45
calendar days of end of the
reporting quarter.
Quarterly
$250 per day for each calendar
day past the due date that a
report or deliverable is not
received.
Select one
Due annually: within 45
calendar days of the end of the
reporting year.
Annually
$250 per day for each calendar
day past the due date that a
report or deliverable is not
received.
Select one
PG-20 Accuracy of Reports
and Deliverables
100% of monthly reports or
deliverables shall be
mathematically and otherwise
accurate.
Monthly$1,000 per report or
deliverable.Select one
100% of quarterly reports or
deliverables shall be
mathematically and otherwise
accurate.
Quarterly$1,000 per report or
deliverable.Select one
100% of annual reports or
deliverables shall be
mathematically and otherwise
accurate.
Annually$1,000 per report or
deliverable.Select one
PG-21 Ad hoc Reporting a.) Non-complex reports shall be
delivered to the Department and/or the
Department's designee within the
timeframe specified.
Within two (2) business days Quarterly
$1,000 per report per day for
each calendar day past the due
date that a report is not
received.
Select one
b.) Complex reports shall be delivered
to the Department and/or the
Department's designee within the
timeframe specified.
Within ten (10) business days Quarterly
$1,000 per report per day for
each calendar day past the due
date that a report is not
received.
Select one
Reports and deliverables shall be
delivered to the Department and/or the
Department's designee within the time
period specified.
**Please note that the Proposed Amount
at Risk will apply to each report or
deliverable outlined in AR-64 of
Attachment A-4: Administrative
Requirements.**
Reports and deliverables that are
delivered to the Department shall be
accurate. (This Performance guarantee
does not apply to de minimis errors and
omissions, as determined by the
Department.)
**Please note that the Proposed Amount
at Risk will apply to each report or
deliverable outlined in AR-64 of
Attachment A-4: Administrative
Requirements.**
ITN No.: DMS 10/11-010 Page 64 A-12 Performance Guarantees
Performance
Indicator
Reporting Measurement
(subject to audit by the State and/or
contract auditors)
Performance StandardFrequency of
Measurement
Proposed Measurement Methodology
(Formula used to measure results)Amount at Risk
Willingness
to Comply with the
Standard/Goal
PG-22 Medicare Part D / RDS a.) Monthly cost reports shall be
submitted to CMS no later than the
specified date.
100% of monthly reports shall
be submitted no later than the
17th calendar day of every
month for costs through
previous month.
Quarterly
$25,000 per day for each
calendar day that a monthly
report is submitted to CMS
after the 17th day of the month
Select one
b.) Back-up files shall be delivered to
the Department within the time period
specified following the submission of
monthly and annual cost reports sent to
CMS.
100% of backup file shall be
delivered within one (1)
business day
Quarterly for the
monthly file
submissions; Annually
for the annual
reconciliation.
$5,000 per day for each
calendar day past the due date
that a Back-Up File is not
received.
Select one
c.) Annual reconciliation shall be
submitted to CMS within required
guidelines and must contain accurate
data.
100% Annually
$25,000 for non-compliance
with each required guideline,
including data accuracy.
Select one
PG-23 Generic Substitution
Rate
The generic substitution rate will be
greater than or equal to the rate
specified at the mail order pharmacy.97.5% or greater Monthly
$5,000 per percentage point, or
fraction thereof, less than
97.5%
Select one
PG-24 Manufacturer Payments Rebates and other Manufacturer
Payments shall be paid to the State as
described in AR-119 of Attachment A-
4: Administrative Requirements
within the time period specified.
100% shall be paid no later
than the 15th calendar day
following the reporting month.
Monthly
$10,000 per day for each
calendar day past the due date
that a rebates are not received.
Select one
Pharmacy Network
PG-25 Access Rate The Service Provider shall establish and
maintain a network of participating
retail pharmacies to provide service
under the plan.
For urban areas, 98% of
Subscribers shall have at least
one participating retail
pharmacy within three (3) miles
of their home ZIP Code if a
pharmacy exists within three
(3) miles.
Annually
$5,000 per percentage point, or
fraction thereof, less than
98.0%
Select one
For suburban areas, 98% of
Subscribers shall have at least
one participating retail
pharmacy within five (5) miles
of their home ZIP Code if a
pharmacy exists within five (5)
miles.
$5,000 per percentage point, or
fraction thereof, less than
98.0%
Select one
For rural areas, 98% of
Subscribers shall have at least
one participating retail
pharmacy within ten (10) miles
of their home ZIP Code if a
pharmacy exists within ten (10)
miles.
$5,000 per percentage point, or
fraction thereof, less than
98.0%
Select one
ITN No.: DMS 10/11-010 Page 65 A-12 Performance Guarantees
Performance
Indicator
Reporting Measurement
(subject to audit by the State and/or
contract auditors)
Performance StandardFrequency of
Measurement
Proposed Measurement Methodology
(Formula used to measure results)Amount at Risk
Willingness
to Comply with the
Standard/Goal
PG-26 Decline in Participating
Pharmacies Nationwide:
1.0%
$5,000 per percentage point, or
fraction thereof, greater than
1.0%
Select one
Florida only:
1.0%
$5,000 per percentage point, or
fraction thereof, greater than
1.0%
Select one
PG-27 Network Pharmacy
Audits
a.) Percent of network pharmacies
within the State of Florida audited on-
site each calendar year. 3.0% or greater
$5,000 for each percentage
point, or fraction thereof, less
than 3.0% of network
pharmacies not audited on-site
each year.
Select one
b.) Percent of network pharmacies
outside the State of Florida audited on-
site each calendar year . 1.0% or greater
$5,000 for each percentage
point, or fraction thereof, less
than 1.0% of network
pharmacies not audited on-site
each year.
Select one
Annually
The percent of retail pharmacies in the
Service Provider's network shall not
decline by more than the percentage
specified. Measurement will be the
ratio of the number of pharmacies in the
network on the last day of the plan year
to the number of pharmacies in network
on the first day of the plan year.
Annually
ITN No.: DMS 10/11-010 Page 66 A-12 Performance Guarantees
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-13: Alternative Cost Management Programs
Program DescriptionEstimated ROI and
Calculation Methodology
IMPORTANT - DO NOT INCLUDE FEES OR PRICING DATA. SEE ATTACHMENT B-9
The description of alternative cost management programs described here shall be incorporated into the Contract. These programs must be
available for the State to elect during the entire Contract period.
Instructions: The Respondent shall provide information on specific programs that the Respondent suggests that the State consider in order to help
the State better manage total costs, including costs to the State and to its Subscribers, while minimizing the disruption/inconvenience to Participants.
These alternative cost management programs may include changes to the current program. Examples might include disease management programs,
a custom formulary or a retail network designed to accommodate the State's specific employee and retiree population.
w A brief description of the program;
w The potential impact on participants (specify the percentage of participants that would be impacted and to what
extent);w Administrative requirements on the State to implement the program; and
In the column labeled "Description" below and for each alternative cost management program, the Respondent shall specify the following:
w Additional information you believe the State will need to evaluate the potential impact to implement the program.
w Do not include fees or financial information.
ITN No.: DMS 10/11-010 Page 67 A-13 Alternative Cost Mngmt
Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-14: Deviations Page
R Deviations have been provided in the exhibit below.
Signature of Authorized Representative
Title
Date
Section
Number
Question
NumberResponse
Representations made by the Respondent in this proposal become contractual obligations that must be met during
the contract term.
Instructions: The Respondent shall complete this attachment regardless of whether deviations or suggested alternatives
from the administrative requirements or performance guarantees are proposed. The top right of the worksheet includes
macros for the Respondent to indicate whether deviations are included in the table below the signature line.
Prior to printing the final proposal, the Respondent shall ensure that the print area of this document is set
appropriately. If no deviations or suggested alternatives are claimed, then the print area shall end following the title of the
individual signing the document. Otherwise, the print area shall end following the last deviation or suggested alternative
described in the table.
I hereby certify that I have reviewed the pharmacy benefit and administrative services contained in this ITN. On behalf of ,
I agree to honor those terms as described in the specifications, except as noted in this section.
All deviations from the specifications of the ITN and suggested alternatives must be clearly defined using this worksheet.
Explanations must be numbered to correspond to the question number and section number to which it pertains. If
explanations exceed 1,024 characters, please continue the response on the next row. This section must be signed by an
officer of Your company. If You are not claiming any deviations, press the "No Deviations" button at the top right and have
an officer sign the certification.
ITN No.: DMS 10/11-010 Page 68 A-14 Deviations Page
Section
Number
Question
NumberResponse
ITN No.: DMS 10/11-010 Page 69 A-14 Deviations Page