Request for Proposal for Pharmacy Benefit Management ... · PDF fileRequest for Proposal for...

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




Customer Service Manager

Name

Title

Address

City, State, ZIP

Telephone #

E-mail Address




Claims Manager

Name

Title

Address

City, State, ZIP

Telephone #

E-mail Address




Implementation Coordinator

Name

Title

Address

City, State, ZIP

Telephone #

E-mail Address




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.


Clinical Pharmacist

Name

Title

Address

City, State, ZIP

Telephone #

E-mail Address




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.


Company Name

Contact Person

Title

City, State

Telephone #

Fax Phone #

E-mail Address


3.


Company Name

Contact Person

Title

City, State

Telephone #

Fax Phone #

E-mail Address


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.


4.


Company Name

Contact Person

Title

City, State

Telephone #

Fax Phone #

E-mail Address


Please provide references for two clients (public or private sector) who began utilizing Your prescription drug benefit

administration services within the last twelve months.


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:

Select one

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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


Response


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


Response


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


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

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Response


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

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Response


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

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Response


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 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

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Response


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

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Response


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

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Response


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.

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Response


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

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Response


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 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


Response


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


Response


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


Response


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


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 Date of Rating


w Date of rating

Dunn and Bradstreet


w Date of Rating


w Date of rating

Fitch


w Date of Rating


w Date of rating

Weiss


w Date of Rating


w Date of rating

Moody's


w Date of 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".


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


ResponseQuestion

1,000 - 4,999 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



2010



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


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".


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


Recovery (in dollars) as a percent of total

book of business drug spend.

2009









2010 YTD









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.


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


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







scripts)


from 5/1/2010 - 7/31/2010

h.) Ratio of Pharmacists to pharmacy

technicians


dispensed per Pharmacist per hour.


during 5/1/2010 - 7/31/2010 for



during 5/1/2010 - 7/31/2010 for


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


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


2009 Actual


Prescription accuracy


2009 Actual



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)


Volume (in units)


Volume (in units)


Volume (in units)


Volume (in units)


Volume (in units)


Volume (in units)


Volume (in units)


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)


ResponseQuestion

b.) Address







scripts)


from 5/1/2010 - 7/31/2010

h.) Ratio of pharmacists to pharmacy

technicians


dispensed per Pharmacist per hour.


during 5/1/2010 - 7/31/2010 for



during 5/1/2010 - 7/31/2010 for


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


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


ResponseQuestion


2009 Actual

2010 (as of July 31, 2010)

Percent of calls resolved on the first contact


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


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


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)


Program #2












XI. CLINICAL MANAGEMENT


ResponseQuestion

Program #3












Program #4












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".


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


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


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


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


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?


Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-5b: Additional Questionnaire Answers

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Instructions: Use this space to continue responses for "Attachment A-5a: Questionnaire" when answers exceed 1,024

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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ITN No.: DMS 10/11-010 Page 43 A-5b Additional Question Answer

Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-6: Subcontractors Questionnaire


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








results.













Florida?Select one








results.








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






Florida?Select one








results.













Florida?Select one








results.













Florida?Select one








results.














Florida?Select one


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.


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


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.


E.


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


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


SAMPLE FORMAT


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!


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


































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


Days of Therapy

Total Number of

Distinct Utilizers

Average Days

Supply per

Script


Paid

Average Amount

Paid per Script

Participating

Pharmacy of Broad

Network

(Yes or No)

Participating

Pharmacy of

Limited Network



















































Pharmacy

NABP

Number


Days of Therapy

Total Number of

Distinct Utilizers

Average Days

Supply per

Script


Paid

Average Amount

Paid per Script

Participating

Pharmacy of Broad

Network

(Yes or No)

Participating

Pharmacy of

Limited Network


















Request for Proposal for Pharmacy Benefit Management ServicesAttachment A-10: Pharmacy Disruption based on Total Paid Amount

Pharmacy

NABP

Number


Days of Therapy

Total Number of

Distinct Utilizers

Average Days

Supply per

Script


Paid

Average Amount

Paid per Script

Participating

Pharmacy of Broad

Network

(Yes or No)

Participating

Pharmacy of

Limited Network





































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


Days of Therapy

Total Number of

Distinct Utilizers

Average Days

Supply per

Script


Paid

Average Amount

Paid per Script

Participating

Pharmacy of Broad

Network

(Yes or No)

Participating

Pharmacy of

Limited Network



















































Pharmacy

NABP

Number


Days of Therapy

Total Number of

Distinct Utilizers

Average Days

Supply per

Script


Paid

Average Amount

Paid per Script

Participating

Pharmacy of Broad

Network

(Yes or No)

Participating

Pharmacy of

Limited Network

















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

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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


TherapyRx Count

Formulary

Tier

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TherapyRx Count

Formulary

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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


c.) 100% of written inquiries

shall be responded to within

three (3) business days.

Quarterly$1,000 per percentage point, or



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



contract auditors)


Measurement



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



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


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


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



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



PG-10 Participant Inquiry

Response Time

a.) Percent of telephone inquiries

returned by a customer service

representative.

99.0% within two (2)

business daysQuarterly



99.0%

Select one

b.) Percent of written inquiries

responded to by a customer service

representative.

99.0% within ten (10)

business daysQuarterly



99.0%

Select one


Performance

Indicator



contract auditors)


Measurement



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



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



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


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



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



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



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



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




c.) The Service Provider shall accurately

dispense all mail order prescriptions as

prescribed.99.9% or greater Quarterly


or fraction thereof, less than

99.9%

Select one


Performance

Indicator



contract auditors)


Measurement



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




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


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



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



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



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


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




received.

Select one

Due annually: within 45

calendar days of the end of the

reporting year.

Annually




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



accurate.

Quarterly$1,000 per report or


100% of annual reports or



accurate.

Annually$1,000 per report or


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


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


Requirements.**


Performance

Indicator



contract auditors)


Measurement



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.


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



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


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



98.0%

Select one

For suburban areas, 98% of



pharmacy within five (5) miles


pharmacy exists within five (5)

miles.



98.0%

Select one

For rural areas, 98% of



pharmacy within ten (10) miles


pharmacy exists within ten (10)

miles.



98.0%

Select one


Performance

Indicator



contract auditors)


Measurement



Willingness

to Comply with the

Standard/Goal

PG-26 Decline in Participating

Pharmacies Nationwide:

1.0%



1.0%

Select one

Florida only:

1.0%



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


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

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