27-FORM C - Manor ISD - Medical RFP Workbook.xlsx
XLSX spreadsheet 2 MB Posted
- Attached to
- Manor ISD - 2026 Medical RFP
- Solicitation number
- 26-010RFP – RE-ISSUED
- Issued by
- Travis County, Texas
About this file
Summary
This is a Request for Proposal (RFP) workbook issued by Manor Independent School District for fully insured medical and prescription drug plans, level-funded medical and prescription drug plans, and stop loss products. The district is seeking proposals from vendors to provide comprehensive medical administration, pharmacy benefit management (PBM), and related services. The RFP includes three current BlueCross BlueShield of Texas (BCBSTX) plan models—HMO $3,000, HDHP PPO $3,400, and PPO $1,400—which will be weighted for scoring purposes. The release date was April 16, 2026, with questions due by April 22, 2026 at 2:00 PM CST. An addendum was released on April 24, 2026, and proposals are due April 30, 2026 at 12:00 PM CST. The effective date of coverage is September 1, 2026, with a contract duration of one year. No Best and Final Offer round will be conducted. The district explicitly reserves the right to award portions to different vendors, award to a single vendor, or make no award. This solicitation is a re-issue following rejection of all prior proposals to ensure adequate competition and best value.
Pricing must include a $12.50 PCPM commission and $100,000 in annual targeted allowances, with credits and allowances paid annually. Vendors must confirm whether payments are made once or ongoing and provide documentation outlining allowable usage for each allowance type. The district requests that reimbursements be issued either by paying the vendor directly or reimbursing the client, with vendors outlining required documentation such as invoices, W-9 forms, descriptions of services, and proof of payment. Scoring will be weighted across plan design and rates (40%), quality of goods and services (30%), administration (15%), reputation (7.5%), and proposal specifications adherence (7.5%). Current vendors must not submit competing proposals from the same organization. Vendors must complete all workbook sections, provide an executive summary and standard proposal using the provided template, submit performance guarantees, network disruption reports, and comprehensive responses to 31 proposal specification requirements and detailed questionnaires covering general company information, ASO administration, general administration, network contractuals, case disease management, utilization management, and PBM operations.
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Cover
Manor ISD
| Request for Proposal # 26-008 |
| for |
| Fully Insured Medical and Rx, Level Funded Medical and Rx |
| Release Date: April 16th, 2026 |
| Questions Due: April 22nd, 2026 @ 2:00 PM CST |
| Addendum Release: April 24th, 2026 |
| Proposal Due Date: April 30th, 2026 @ 12:00PM CST |
| There will not be a Best and Final Offer round. Please provide your best and final offer upfront. |
Disclaimer: Much effort has been made to provide all necessary and accurate information in this Request for Proposal. It is the sole responsibility of the proposers to ensure that they have all information necessary to complete submission of their proposals. If more information is needed, please submit through Bonfire.
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&"Arial,Regular"&7 © 2018 ARTHUR J. GALLAGHER & CO. &"Arial,Regular"&7AJG.COM
General Information
| General Information | ||
| There will not be a Best and Final Offer round. Please provide your best and final offer upfront. | ||
| Please consider the following information for your proposal. | ||
| 1. | EFFECTIVE DATE: | September 1, 2026 |
2. CONTRACT DURATION: 1 Year
3. VENDOR HISTORY: BCBSTX
| 4. | ELIGIBILITY: |
| Full Time Employees (EEs) as defined by the Client and variable EEs working ACA 30 Hours/week; Retirees are not covered. Full-time professional and para-professional - coverage is effective the first of the month following the employment date - i.e. employees hired on February 15th, will receive coverage as of March 1st. |
5. District Plan is a PPACA is a "non-grandfathered" plan.
6. The client has three current BCBSTX Plans. Please refer to the 2025 SBCs for further information. The client will consider these three models for weighted average scoring. Proposals will be scored on these three models.
7. Assume that current 2025 benefit coverage will remain intact for purposes of developing your cost, network, utilization management, modeling strategies.
8. Please include the below commissions and targeted allowances.
| Product | Inforce Carrier | Requested Commissions | Targeted Allowances | |
| 1 | Fully Insured Medical and Rx, Level Funded Medical and Rx | BCBSTX (Fully Insured) | $12.50 PCPM | $100,000 annually**** |
****Please pay credits/allowances annually and confirm if credits/allowances are paid 1x and/or ongoing.
If you have any documents that outline what is an allowable or permitted usage based on each type of allowance, please provide with your RFP response.
Gallagher is requesting that you allow reimbursements to be issued either by paying the vendor, including Gallagher, directly OR reimbursing the client. Please outline the documents needed to submit for reimbursement in your RFP response – Invoice, W-9, description of the services provided, proof of payment, etc.
| 9. | All reporting files and other supporting documentation can be found attached to the bid posting. |
| 10. | All workbook pages must be completed and returned with your proposal. |
| 11. | The client does not want competing multiple proposals from the same vendor, so manage your internal proposal process to assure that one (1) proposal is presented. |
| 12. | PLEASE provide an Executive Summary, as well as your standard Proposal with this submission. PLEASE note, you MUST provide your responses in our standard template in order to be considered for this RFP. |
| Disclaimer: | |
| Much effort has been made to provide all necessary and accurate information in this Request for Proposal. It is the sole responsibility of the proposers to ensure that they have all information necessary to complete submission of their proposals. If more information is needed, please reach out to please submit through Bonfire. |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Scope of Work Scope of Work
| There will not be a Best and Final Offer round. Please provide your best and final offer upfront. | |
| Please consider the following information / requirements for your proposal. | |
| A. | Network Disruption Report |
| Vendors will be required to complete a Network Disruption Report as part of their RFP submission. Please refer to the separate exhibit that was included in the documentation attached to the bid. |
| B. | Claims Target Guarantees |
| Vendors will be required to provide a Claims Target Guarantee. Please provide us with your standard format when responding to this RFP. |
| C. | Pharmacy Benefit Management |
| The client is requesting vendors to include PBM administration as a part of their Medical proposal response. The client will not consider any standalone PBM vendors quotes. |
| D. | Medical Plan Options |
| BCBSTX HMO 3000 | |
| BCBSTX HDHP PPO 3400 | |
| BCBSTX PPO 1400 |
| E. | Scoring Matrix | |
| Plan Design to Rates | 40.0% | |
| a) Indicated plan design requests matched or exceeded. | ||
| b) Rates | ||
| c) Availbility of Carrier Credits | ||
| Quality of Goods and Services | 30.0% | |
| a) Response to contract terms/banking arrangements/timelines | ||
| b) Experience and Qualifications of Client/Customer Service team | ||
| c) Size and coverage of Networks | ||
| d) Performance Standards and Guarantees | ||
| e) Quantity and Quality of services promised. | ||
| Administration | 15.0% | |
| a) All lines offered by one carrier | ||
| b) Single Point of Contact | ||
| c) Reference Feedback | ||
| d) Carrier Credit amounts | ||
| Reputation | 7.5% | |
| a) Financial Stability - AM Best | ||
| b) Years Writing Proposed Benefits | ||
| Proposal Specifications | 7.5% | |
| a) Adherence to Proposal Specifications |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Proposal Specifications
| Proposal Specifications |
| Company Legal Business Name: __________________________________________________________________ |
| All vendors must complete this section. | ||
| Proposal Specifications | ||
| # | Specification | Agree / Disagree |
| 1 | There will not be a Best and Final Offer round. Please provide your best and final offer upfront. | |
| 2 | The effective date of coverage, September 1, 2026, is acknowledged and accepted. | |
| 3 | If you have provided a level-funded quote, your proposal includes a full breakdown of your rates detailing administrative/fixed fees and funding. | |
| 4 | All fees / premiums are requested on the General Information tab. | |
| 5 | Preliminary renewal rates must be submitted six months prior to the effective date. | |
| 6 | You completed all sections of the workbook in their entirety, in the format requested. | |
| 7 | The vendor will be responsible for producing an Rx addendum to be added to the Summary Plan Description. The client reserves the right to review / revise the addendum. | |
| 8 | Vendor agrees to provide an Rx addendum within 90 days of the effective date. | |
| 9 | The vendor will be responsible for producing the Summary Plan Description. The client reserves the right to review / revise the SPD prior to final printing. | |
| 10 | Vendor agrees to provide an SPD draft within 60 days of the effective date. | |
| 11 | Vendor agrees to provide all communication materials in electronic (pdf) format. | |
| 12 | Vendor agrees to provide Summary of Benefits and Coverage (SBC) within 14 business days after notification of final plan designs. | |
| 13 | Vendor agrees to provide all standard reports to the client and its professional advisor. | |
| 14 | Do you agree to provide the consultant with monthly reports for the data warehouse at no additional charge? | |
| 15 | Claims experience must be provided at least monthly, including each renewal. | |
| 16 | You are in compliance with all HIPAA Privacy, Electronic Data Interface (EDI) and Security Regulations and will use HIPAA 834 (ASC X12N 834) for the file transmission layout. | |
| 17 | You have reviewed and accept the Plan’s eligibility provisions. | |
| 18 | Your contract must require no more than a 90-day notice of termination. Your contract cannot prohibit the group from terminating coverage at any time. There must be no penalties for late notification or for termination off anniversary. | |
| 19 | Vendor agrees to comply with the Performance Guarantees, and penalties for non-compliance, as provided in this RFP. | |
| 20 | Vendor has specifically listed all deviations from the RFP and coverage requirements. NOTE: Deviations MUST be listed; vendors cannot simply make “general” references to the proposal. | |
| 21 | If the client wishes to carve-out the pharmacy benefit, TPA agrees to take weekly feeds from the pharmacy vendor and will mine/integrate the data into the medical management program. | |
| 22 | Vendor agrees to provide Rx integration files for OOP / ACA compliance. | |
| 23 | Vendor agrees to administer a spousal surcharge if the client decides to implement such a program. | |
| 24 | Vendor agrees to provide a dedicated reporting contact for the client and its consultant. This person would be responsible for running ad hoc reports for the client and/or its consultant’s discretion, at no additional cost to the client. | |
| 25 | Vendor agrees to allow the client to interview and select the account management team of its choice within your organization. | |
| 26 | Your organization has online capabilities in the following areas: |
1) Provider selection – tools that will help members select reputable and effective providers
2) Quality comparison – tools that will help members compare quality outcomes of providers and facilities
3) Price comparison – tools that will allow members to compare the price for services of various hospitals, providers, lab and x-ray facilities, etc.
4) Wellness information and tools (i.e. BMI calculator, target heart rate calculator)
| 27 | You must permit the employer to have access to all files on request (e.g., a claims audit). |
| 28 | Please include any programs or tools that can enhance a member’s experience. |
| 29 | As part of your proposal response, please compare the employer’s current plan document, which has been included, to your proposed stop loss policy and identify any areas where there are gaps in coverage or include in your proposal a statement that you will mirror the employer’s plan document. |
| 30 | The client intends to include your RFP responses as part of the overall Contract. Please acknowledge you understand and agree to this expectation. |
| 31 | Vendor agrees to provide bi-lingual benefit summaries and SPDs at no additional cost. |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Deviations Tab
| Proposal Specifications |
| Company Legal Business Name: __________________________________________________________________ |
| If you have any Deviations to the Proposal Specifications, OR need to add additional commentary on any item of the Questionnaire, please include this here | ||
| Proposal Specifications | ||
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Performance Guarantees
| Medical Performance Guarantees |
| Company Legal Business Name: _______________________________________________________________________ |
| Answers are limited to 50 characters | ||
| Implementation | Metric | $ PEPY at Risk |
| ID Card Production & Distribution |
| Account Management | Metric | $ PEPY at Risk |
| Overall Account Management |
| Claim Administration | Metric | $ PEPY at Risk |
| Turnaround Time | ||
| Financial Accuracy | ||
| Total Claim Accuracy |
| Member Satisfaction | Metric | $ PEPY at Risk |
| Member Satisfaction |
| Member Services | Metric | $ PEPY at Risk |
| Telephone Service Factor | ||
| Average Speed of Answer | ||
| Abandonment Rate | ||
| First Call Resolution |
Total $ PEPY at Risk $0.00
<Please enter your Guarantees Disclaimer here>
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Additional Guarantees
| *ADDITIONAL GUARANTEES |
| Please record all answers on this excel spreadsheet |
| Discount Guarantees | ||
| Please provide for each network you are quoting. If you do not provide guarantees on all networks quoted, please indicate. | ||
| Carrier | Carrier | |
| Network | Network | |
| Guaranteed Discount % | ||
| % of Admin Fee at Risk | ||
| Annual Fees at Risk $ |
| In-Network Utilization Guarantees | |||
| Please provide for each network you are quoting. If you do not provide guarantees on all networks quoted, please indicate. | |||
| Carrier | Carrier | ||
| Network | Network | ] | |
| Guaranteed In-Network Utilization % | |||
| % of Admin Fee at Risk | |||
| Annual Fees at Risk $ |
| Claim Target/Net Cost Guarantees | |||
| Please provide for each network you are quoting. If you do not provide guarantees on all networks quoted, please indicate. | |||
| Carrier | Carrier | Carrier | |
| Network | Network | Network | |
| Is this network the only network you are proposing? | |||
| If not, do you provide guarantees on the other network? | |||
| Applicable up to Claim $ Amount | |||
| Billed or Paid Claims? | |||
| Estimated Annual Admin. Fee Subject to Discount | |||
| % of Admin Fee at Risk | |||
| Annual Fees at Risk $ | |||
| PEPM Fees at Risk | |||
| Target Claim Factor | |||
| Risk-Free Corridor Range (PEPM) | |||
| *Risk Corridor Range - Customer Pays (PEPM) | |||
| *Amount at Risk | |||
| *Risk Corridor Range - Administrator Pays (PEPM) | |||
| *Amount at Risk | |||
| <Please enter your Guarantees Disclaimer here> |
| Billed | Yes |
| Paid | No |
&A Page &P of &N
Medical Plan Designs
| Medical Plan Designs |
| Company Legal Business Name: ______________________________________________________________________________________________________________________________________________________________________ |
| Please record all answers on this excel spreadsheet. | ||||||||||||
| CURRENT | PROPOSED | |||||||||||
| Carrier Name | BlueCross BlueShield of Texas | CARRIER NAME | ||||||||||
| Plan Name | HMO $3,000 Plan | HDHP PPO $3,400 Plan | PPO $1,400 Plan | PLAN NAME | PLAN NAME | PLAN NAME | ||||||
| Network | BLUE ESS (HMO) | BLUE CH (PPO) | BLUE CH (PPO) | NETWORK | NETWORK | NETWORK | ||||||
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |
| Deductible Type | Embedded | N/A | Embedded | Embedded | Embedded | Embedded | ||||||
| Calendar Year (CY) Deductible (Individual / Family) | $3,000 / $6,000 | N/A | $3,400 / $6,800 | $5,500 / $11,000 | $1,400 / $4,000 | $2,000 / $6,000 | ||||||
| Out-of-Pocket Max Type | Embedded | N/A | Embedded | Embedded | Embedded | Embedded | ||||||
| CY Out-of-Pocket Max (Individual / Family): To include copays, coinsurance any charges that apply to your deductible | $9,000 / $16,300 | N/A | $8,000 / $16,000 | $20,250 / $40,500 | $7,000 / $14,000 | $23,700 / $47,400 | ||||||
| Coinsurance (member pays after deductible) | 30% | N/A | 30% | 50% | 20% | 40% |
| Preventive Care | Covered 100% | Not Covered | Covered 100% | 50% after deductible | Covered 100% | 40% after deductible |
| Primary Care Visit | $50 Copay | Not Covered | 30% after deductible | 50% after deductible | $50 Copay | 40% after deductible |
| Specialist Visit | $70 Copay | Not Covered | 30% after deductible | 50% after deductible | $70 Copay | 40% after deductible |
| Virtual Visits | $50 Copay | Not Covered | 30% after deductible | Not Covered | $15 Copay | Not Covered |
| Urgent Care | $50 Copay | Not Covered | 30% after deductible | 50% after deductible | $50 Copay | 40% after deductible |
| Emergency Room | 30% after deductible | 30% after deductible | Facility: $500 Copay then 20%; |
Physician: 20% after deductible
| Inpatient Hospital | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 20% after deductible | 40% after deductible |
| Outpatient Surgery | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 20% after deductible | 40% after deductible |
| Chiropractic (visit limits may apply) | PCP: $50 Copay; |
SPC: $70 Copay;
| Inpatient and Outpatient Services: 30% after deductible | Not Covered | 30% after deductible |
| (Combined 35 visits) | 50% after deductible | $70 Copay; |
Outpatient Services: 20% after deductible
| (Combined 120 visits) | 40% after deductible | |
| Phys/Occ/Speech Therapy (visit limits may apply) | PCP: $50 Copay; |
SPC: $70 Copay;
| Inpatient and Outpatient Services: 30% after deductible | Not Covered | 30% after deductible |
| (Combined 35 visits) | 30% after deductible | |
| (Combined 35 visits) | $70 Copay; |
Outpatient Services: 20% after deductible (Combined 120 visits) 40% after deductible (Combine 120 visits)
| Diagnostic Test (X-ray, blood work) | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | PCP: $50 Copay | ||||||||
| SPC: $70 Copay | 40% after deductible | ||||||||||||
| Imaging (CT/PET scan, MRI) | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 20% after deductible | 40% after deductible | |||||||
| PRESCRIPTION DRUG BENEFIT | |||||||||||||
| Deductible (Individual / Family) | N/A | Not Covered | Combined with Medical | $200 Per Person | |||||||||
| Retail | 30 Days | Not Covered | 30 Days | 30 Days | |||||||||
| Tier I / Tier II / Tier III | $15 / 30% Copay / 50% Copay | Not Covered | 20% / 25% / 50% after deductible | 20% / 25% / 50% after deductible + 50% coinsurance | $20 / $45 / $95 after deductible | $20 / $45 / $95 after deductible + 50% coinsurance | |||||||
| Specialty | 30% Copay | Not Covered | 20% after deductible | 20% after deductible + 50% coinsurance | $20 / $45 / $95 after deductible | $20 / $45 / $95 after deductible + 50% coinsurance | |||||||
| Mail Order | 90 Days | Not Covered | 90 Days | 90 Days | |||||||||
| Tier I / Tier II / Tier III | $30 / 30% Copay / 50% Copay | Not Covered | 20% / 25% / 50% after deductible | Not Covered | $50 / $112.50 / $237.50 after deductible | Not Covered | |||||||
| COST ANALYSIS | |||||||||||||
| PEPM Rates - Enrollment per AMP | HMO | HDHP | PPO | HMO $3,000 Plan | HDHP PPO $3,400 Plan | PPO $1,400 Plan | PLAN NAME | PLAN NAME | PLAN NAME | ||||
| Employee (EE) Only | 454 | 295 | 129 | $525.53 | $508.30 | $680.16 | $0.00 | $0.00 | $0.00 | ||||
| EE + Spouse | 6 | 2 | 2 | $1,467.39 | $1,510.23 | $1,665.09 | $0.00 | $0.00 | $0.00 | ||||
| EE + Child(ren) | 63 | 35 | 35 | $991.74 | $980.93 | $1,144.99 | $0.00 | $0.00 | $0.00 | ||||
| EE + Family | 6 | 4 | 7 | $1,751.05 | $1,804.27 | $2,016.15 | $0.00 | $0.00 | $0.00 | ||||
| Total Enrollment | 529 | 336 | 173 | ||||||||||
| Estimated Monthly Premium | $320,381 | $194,519 | $145,259 | $0 | $0 | $0 | |||||||
| Estimated Annual Premium | $3,844,571 | $2,334,223 | $1,743,102 | $0 | $0 | $0 | |||||||
| Dollar Difference from Current | -$3,844,571 | -$2,334,223 | -$1,743,102 | ||||||||||
| Percent Change from Current | -100.0% | -60.7% | -45.3% | ||||||||||
| Total Combined Annual Cost | |||||||||||||
| CURRENT | PROPOSED | ||||||||||||
| Estimated Annual Premium | $7,921,896 | $0 | |||||||||||
| Dollar Difference from Current | -$7,921,896 | ||||||||||||
| Percent Change from Current | -100.0% | ||||||||||||
| PLAN PROVISIONS | |||||||||||||
| Rate Guarantee | 1 Year rate guarantee ending 08/31/2026 |
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© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Alt 1 Medical Plan Designs
| Medical Plan Designs |
| Company Legal Business Name: ______________________________________________________________________________________________________________________________________________________________________ |
| Please record all answers on this excel spreadsheet. | ||||||||||||
| Alternate 1 | PROPOSED | |||||||||||
| Carrier Name | CARRIER NAME | |||||||||||
| Plan Name | $5,000 Plan | HDHP $3,500 Plan | $2,500 Plan | PLAN NAME | PLAN NAME | PLAN NAME | ||||||
| Network | HMO | PPO | HMO | NETWORK | NETWORK | NETWORK | ||||||
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |
| Deductible Type | Embedded | N/A | Embedded | Embedded | Embedded | N/A | ||||||
| Calendar Year (CY) Deductible (Individual / Family) | $5,000 / $10,000 | N/A | $3,500 / $7,000 | $6,000 / $12,000 | $2,500 / $7,500 | N/A | ||||||
| Out-of-Pocket Max Type | Embedded | N/A | Embedded | Embedded | Embedded | N/A | ||||||
| CY Out-of-Pocket Max (Individual / Family): To include copays, coinsurance any charges that apply to your deductible | $10,000 / $20,000 | N/A | $8,000 / $16,000 | $20,250 / $40,500 | $10,000 / $20,000 | N/A | ||||||
| Coinsurance (member pays after deductible) | 30% | N/A | 30% | 50% | 30% | N/A |
| Preventive Care | Covered 100% | Not Covered | Covered 100% | 50% after deductible | Covered 100% | Not Covered |
| Primary Care Visit | $50 Copay | Not Covered | 30% after deductible | 50% after deductible | $50 Copay | Not Covered |
| Specialist Visit | $70 Copay | Not Covered | 30% after deductible | 50% after deductible | $70 Copay | Not Covered |
| Virtual Visits | $50 Copay | Not Covered | 30% after deductible | Not Covered | $15 Copay | Not Covered |
| Urgent Care | $50 Copay | Not Covered | 30% after deductible | 50% after deductible | $50 Copay | Not Covered |
| Emergency Room | 30% after deductible | 30% after deductible | Facility: $500 Copay then 30%; |
Physician: 30% after deductible
| Inpatient Hospital | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 30% after deductible | Not Covered |
| Outpatient Surgery | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 30% after deductible | Not Covered |
| Chiropractic (visit limits may apply) | PCP: $50 Copay; |
SPC: $70 Copay;
| Inpatient and Outpatient Services: 30% after deductible | Not Covered | 30% after deductible |
| (Combined 35 visits) | 50% after deductible | $70 Copay; |
Outpatient Services: 30% after deductible
| (Combined 120 visits) | Not Covered | |
| Phys/Occ/Speech Therapy (visit limits may apply) | PCP: $50 Copay; |
SPC: $70 Copay;
| Inpatient and Outpatient Services: 30% after deductible | Not Covered | 30% after deductible |
| (Combined 35 visits) | 30% after deductible | |
| (Combined 35 visits) | $70 Copay; |
Outpatient Services: 30% after deductible
| (Combined 120 visits) | Not Covered | ||||||||||||
| Diagnostic Test (X-ray, blood work) | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | PCP: $50 Copay | ||||||||
| SPC: $70 Copay | Not Covered | ||||||||||||
| Imaging (CT/PET scan, MRI) | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | 30% after deductible | Not Covered | |||||||
| PRESCRIPTION DRUG BENEFIT | Alternate 1 | ||||||||||||
| Deductible (Individual / Family) | N/A | Not Covered | Combined with Medical | $200 Per Person | Not Covered | ||||||||
| Retail | 30 Days | Not Covered | 30 Days | 30 Days | Not Covered | ||||||||
| Tier I / Tier II / Tier III | $15 / 30% Copay / 50% Copay | Not Covered | 20% / 25% / 50% after deductible | 20% / 25% / 50% after deductible + 50% coinsurance | $20 / $45 / $95 after deductible | Not Covered | |||||||
| Specialty | 30% Copay | Not Covered | 20% after deductible | 20% after deductible + 50% coinsurance | $20 / $45 / $95 after deductible | Not Covered | |||||||
| Mail Order | 90 Days | Not Covered | 90 Days | 90 Days | Not Covered | ||||||||
| Tier I / Tier II / Tier III | $30 / 30% Copay / 50% Copay | Not Covered | 20% / 25% / 50% after deductible | Not Covered | $50 / $112.50 / $237.50 after deductible | Not Covered | |||||||
| COST ANALYSIS | |||||||||||||
| PEPM Rates - Enrollment per AMP | Plan 1 | Plan 2 | Plan 3 | PLAN NAME | PLAN NAME | PLAN NAME | |||||||
| Employee (EE) Only | $0.00 | $0.00 | $0.00 | ||||||||||
| EE + Spouse | $0.00 | $0.00 | $0.00 | ||||||||||
| EE + Child(ren) | $0.00 | $0.00 | $0.00 | ||||||||||
| EE + Family | $0.00 | $0.00 | $0.00 | ||||||||||
| Total Enrollment | 0 | 0 | 0 | ||||||||||
| Estimated Monthly Premium | $0 | $0 | $0 | ||||||||||
| Estimated Annual Premium | $0 | $0 | $0 | ||||||||||
| Dollar Difference from Current | $0 | $0 | $0 | ||||||||||
| Percent Change from Current | 0.0% | 0.0% | 0.0% | ||||||||||
| Total Combined Annual Cost | |||||||||||||
| Alternate 1 | PROPOSED | ||||||||||||
| Estimated Annual Premium | $0 | ||||||||||||
| Dollar Difference from Current | $0 | ||||||||||||
| Percent Change from Current | 0.0% | ||||||||||||
| PLAN PROVISIONS | |||||||||||||
| Rate Guarantee |
&G
© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Alt 2 Medical Plan Designs
| Medical Plan Designs |
| Company Legal Business Name: ______________________________________________________________________________________________________________________________________________________________________ |
| Please record all answers on this excel spreadsheet. | ||||||||
| Alternate 2 | PROPOSED | |||||||
| Carrier Name | CARRIER NAME | |||||||
| Plan Name | $5,000 Plan | HDHP $3,500 Plan | PLAN NAME | PLAN NAME | ||||
| Network | HMO | PPO | NETWORK | NETWORK | ||||
| In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | In-Network | Out-of-Network | |
| Deductible Type | Embedded | N/A | Embedded | Embedded | ||||
| Calendar Year (CY) Deductible (Individual / Family) | $5,000 / $10,000 | N/A | $3,500 / $7,000 | $6,000 / $12,000 | ||||
| Out-of-Pocket Max Type | Embedded | N/A | Embedded | Embedded | ||||
| CY Out-of-Pocket Max (Individual / Family): To include copays, coinsurance any charges that apply to your deductible | $10,000 / $20,000 | N/A | $8,000 / $16,000 | $20,250 / $40,500 | ||||
| Coinsurance (member pays after deductible) | 30% | N/A | 30% | 50% |
| Preventive Care | Covered 100% | Not Covered | Covered 100% | 50% after deductible |
| Primary Care Visit | $50 Copay | Not Covered | 30% after deductible | 50% after deductible |
| Specialist Visit | $70 Copay | Not Covered | 30% after deductible | 50% after deductible |
| Virtual Visits | $50 Copay | Not Covered | 30% after deductible | Not Covered |
| Urgent Care | $50 Copay | Not Covered | 30% after deductible | 50% after deductible |
| Emergency Room | 30% after deductible | 30% after deductible | ||
| Inpatient Hospital | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible |
| Outpatient Surgery | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible |
| Chiropractic (visit limits may apply) | PCP: $50 Copay; |
SPC: $70 Copay;
| Inpatient and Outpatient Services: 30% after deductible | Not Covered | 30% after deductible | |
| (Combined 35 visits) | 50% after deductible | ||
| Phys/Occ/Speech Therapy (visit limits may apply) | PCP: $50 Copay; |
SPC: $70 Copay;
| Inpatient and Outpatient Services: 30% after deductible | Not Covered | 30% after deductible |
| (Combined 35 visits) | 30% after deductible |
(Combined 35 visits)
| Diagnostic Test (X-ray, blood work) | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | ||||
| Imaging (CT/PET scan, MRI) | 30% after deductible | Not Covered | 30% after deductible | 50% after deductible | ||||
| PRESCRIPTION DRUG BENEFIT | Alternate 2 | |||||||
| Deductible (Individual / Family) | N/A | Not Covered | Combined with Medical | |||||
| Retail | 30 Days | Not Covered | 30 Days | |||||
| Tier I / Tier II / Tier III | $15 / 30% Copay / 50% Copay | Not Covered | 20% / 25% / 50% after deductible | 20% / 25% / 50% after deductible + 50% coinsurance | ||||
| Specialty | 30% Copay | Not Covered | 20% after deductible | 20% after deductible + 50% coinsurance | ||||
| Mail Order | 90 Days | Not Covered | 90 Days | |||||
| Tier I / Tier II / Tier III | $30 / 30% Copay / 50% Copay | Not Covered | 20% / 25% / 50% after deductible | Not Covered | ||||
| COST ANALYSIS | ||||||||
| PEPM Rates - Enrollment per AMP | Plan 1 | Plan 2 | PLAN NAME | PLAN NAME | ||||
| Employee (EE) Only | $0.00 | $0.00 | ||||||
| EE + Spouse | $0.00 | $0.00 | ||||||
| EE + Child(ren) | $0.00 | $0.00 | ||||||
| EE + Family | $0.00 | $0.00 | ||||||
| Total Enrollment | 0 | 0 | ||||||
| Estimated Monthly Premium | $0 | $0 | ||||||
| Estimated Annual Premium | $0 | $0 | ||||||
| Dollar Difference from Current | $0 | $0 | ||||||
| Percent Change from Current | 0.0% | 0.0% | ||||||
| Total Combined Annual Cost | ||||||||
| Alternate 2 | PROPOSED | |||||||
| Estimated Annual Premium | $0 | |||||||
| Dollar Difference from Current | $0 | |||||||
| Percent Change from Current | 0.0% | |||||||
| PLAN PROVISIONS | ||||||||
| Rate Guarantee |
&G
© 2018 ARTHUR J. GALLAGHER &"Arial,Regular"&7AJG.COM
Questionnaire
| Medical Administration Questionnaire |
| Company Legal Business Name: __________________________________________________________________ |
| Affirmation / discussion must be given on each of the following topics. | ||
| Section I - General Company Information | ||
| # | Question | Vendor Response |
| 1. | Please confirm your organization will be ready to begin services on September 1, 2026 | |
| 2. | Indicate what year the company was founded. | |
| 3. | Describe the ownership structure. | |
| 4. | What is the total number of employer clients that you have for the services you are proposing? What is the average size of your client as well as the largest? | |
| 5. | What is the legal name of your organization as it should appear on the Agreement? | |
| 6. | What is the name of your parent organization if you have one? | |
| 7. | Please provide the main address, phone number, fax number, email address, web address for your company as well as your internal identification code for this RFP. | |
| 8. | Provide the contact information of the individual authorized to answer questions related to this RFP, including their name, title, physical address, direct office phone number, fax number, cell phone number and email address. | |
| 9. | To the extent applicable, are you now and will you remain duly licensed and in full compliance with all federal and state statutory administrative requirements? | |
| 10. | Do you agree to do what is necessary to execute an agreement within 30 days of award of service(s)? | |
| 11. | How many school districts or other public institutions do you provide similar services for? What is the largest school district you currently service? | |
| 12. | Provide three references for three current accounts comparable in size to the client (prefer public sector account, school district and/or Texas based references). Provide two former accounts lost in the past year also in comparable size to the client. Include reference contact name, office phone number and email address. Include the length of relationship, number of employees of the reference and services provided to the reference. | |
| 13. | Where will the account team be located? | |
| 14. | If you plan on using any third-party organizations please provide a detailed list of who will participate in the execution of the services you will provide as a part of your proposal response (name, nature of relationship, length of affiliation). | |
| 15. | Please provide the number of employees in your organization. | |
| 16. | Please provide the ratings of your company (A.M. Best, Moody's, Standard & Poor's). | |
| 17. | Have you recently been acquired or been involved with any mergers/acquisitions? If yes, please describe. | |
| 18. | Will you need to hire additional customer service personnel if awarded this business? | |
| 19. | Provide a detailed implementation plan, including action items and due dates. Include support for implementation and open enrollment | |
| 20. | Will you agree to comply with the proposed medical plan Performance Guarantees (as outlined in this RFP)? If you are unable to comply with the proposed guarantees, provide your alternate proposal. |
| Section II - ASO Discuss Topics | ||
| # | Question | Vendor Response |
| 1. | Any and all administrative fees must be noted on ASO Pricing Sheet. Services performed via claims fund transfers must be noted on the grid; as a fixed cost PEPM (Transparency). | |
| 2. | Please confirm you will provide the District with 24 month's Run-Out upon termination | |
| 4. | Discuss your Claim subrogation process and recovery fees charged to the plan. | |
| 5. | Discuss internal quality assessment programs; internal audit procedures including additional protocols in place for ICD-10 accuracy. | |
| 6. | Discuss fraud and abuse programs. | |
| 7. | Discuss disaster recovery and emergency operations pertaining to data back ups. | |
| 8. | Audit Requirements; Client retains acces to 100% of all claims data including all data fields necessary to perform a 100% analysis of claims paid by plan for the applicable period, including but not limited to all claims payment fields, provider name, provider billing address, and all provider contact information including phone number. The carrier will remove any restrictions that may restrict client access to service including selection of a third party audit vendor. Willingness to provide a copy of the adminstrators written audit policy. |
| Section III - General Administration Information | ||
| # | Question | Vendor Response |
| 1 | What is the normal lead-time required to implement a group? | |
| 2 | Do you require a deposit or imprest claims? If so, how much do you require? | |
| 3 | What mediums do you accept for plan enrollment? | |
| 4 | Describe your eligibility file feed process. | |
| 5 | How often is membership updated? | |
| 6 | Can you maintain membership by employee and dependent? | |
| 7 | Describe your client billing process. | |
| 8 | Can you house employee’s location/department in your system for billing and claims reporting? If this requires additional lines of code to accommodate, confirm there will be no additional cost. | |
| 9 | If you are awarded this business, how soon after the notification of the award would you be able to have a draft of the Administrative Agreement(s) / ID Cards? | |
| 10 | With respect to ID cards: | |
| 11 | Do you charge a fee for card preparation? | |
| 12 | Do you cahrge for replacement cards? | |
| 13 | Can you put the plan sponsor name and logo on the ID cards? Is there an additional cost for this? | |
| 14 | Can you do a combination medical / Rx card? Is there an additional cost for this? | |
| 15 | Will your communication and ID cards for the client's employees be sent to employee’s residence? | |
| 16 | Will you agree to submit to independent audits at no expense to the client? | |
| 17 | Will you allow the client a 60 day grace period to pay your monthly invoice? | |
| 18 | Describe internal performance standards for the customer service unit. | |
| 19 | Describe the capabilities your website has for the following items: |
• Price comparison – tools that will allow members to compare the price of prescription drugs by pharmacy
• Lower cost alternatives available
• Provider selection – tools that will help members select reputable and effective providers
• Quality comparison – tools that will help members compare quality outcomes of providers and facilities
• Price comparison – tools that will allow members to compare the price for services of various hospitals, providers, lab and x-ray facilities, etc.
• Wellness information and tools (i.e. BMI calculator, target heart rate calculator)
| 20 | Describe your internal and/or external data-warehousing capabilities. |
| 21 | Please confirm if members and plan sponsors can perform the following tasks ONLINE? |
| Enrollment (New Hires and Open Enrollment) | |
| Changes in Status | |
| Billing (Plan Administrators Only) | |
| Claim Inquiry | |
| Provider Search | |
| ID Card Request | |
| Electronic EOB | |
| Terminations | |
| Access Provider Directories | |
| Reinstatements | |
| Health Risk Assessments | |
| Other | |
| 22 | Is there an additional cost for online member self-service tools? If yes, describe. |
| 23 | Are provider directories available online? |
| 24 | Are special or ad hoc reports available to the client? Are there any additional costs associated with any of these reports? |
| 25 | Confirm you will handle Escheat for the client and provide an overview of your options. |
| 26 | Please let the client know if funding will be handled on a checks issued, or checks cleared basis. |
| 27 | Describe your banking procedures. |
| 28 | It is the client's preference to have their TPA handle Disabled Dependent Eligibility Verification process for disabled dependents. Please confirm you can handle this on behalf and provide detail on how your processes work and how you share the final decision. |
| 29 | The client has a plan year of 9/1-8/31 but accumulations for deductible and out of pocket run on a calendar year basis. Please confirm your systems can acommodate this structure. |
| 30 | The client expects it's chosen Medical TPA to provide monthly, ongoing claims feeds to it's Consultant's Data Warehouse. Please confirm you will do this at no additional charge |
| 31 | Are claims on an auto pay or auto notify cadence? |
| Section IV - Network Contractuals | ||
| # | Question | Vendor Response |
| 1 | Disruption report by network product. Disruption report must be on “PAID” claims basis and total “number” of provider matches. Each line item must note the match (yes/no) and a summary report on the two criteria noted must be included. Use proposed networks to match against all plans. | |
| 2 | Note Hospital contractual stability over the next three (3) years at highly utilized facilities. Highest utilizing hospital profile report found in bid attachments. | |
| 3 | Please provide some commentary regarding your organizations approach to Centers of Excellence networks, as well as your efforts to ensure Providers and Facilities in your networks meet or exceed all HEDIS measures? | |
| 4 | The client is committed to self-funding with full accountability/reporting of it's Health Plan. Please CONFIRM you have listed any and all capitations and/or any other fees that would be going through the claims funding ACH account in the ASO Pricing Sheet tab. | |
| 5 | Describe how your organization prices out-of-network claims and the measures you take to ensure the District's overall costs are being minimized when Out-of-Network utilization occurs. | |
| 6 | The District currently opts into the Mental Health Parity. Discuss how your organization approaches Mental Health Benefits and the measures you take to ensure costs are managed accurately and effectively when their members need these services. | |
| 7 | The current availability of formal ACO contractual models with risk sharing contractual; which hospitals, how your Carrier develops shared predictive/evidence medicine protocols/models, in the clinical relational culture? These models MUST be contractually in place not a simulation concept. What are these plan models branded under in the marketplace? Name? | |
| 8 | How various professional clinical ACO partnership agreements, such as Memorial Hermann, are embedded into each ACO plan model? Discuss the current availability of formal ACO contractual models with risk sharing, how your Carrier develops shared predictive/evidence medicine protocols/models, in the clinical relational culture. These models MUST be contractually in place not a simulation concept. Are these plan models branded under in the marketplace? Name? | |
| 9 | The availability of EPO plans, “skinny network” plan options, which systems are included, how the vendor measures cost and utilization efficacy benchmarks for participating hospitals. | |
| 10 | Describe how out-of-network providers are reimbursed by your organization. Provide an overview of your process, including discussion on initiatives to negotiate single case provider contracts. | |
| 11 | Initiatives to negotiate single case Provider contracts. | |
| 12 | Discuss “high performance “surgical network initiatives. | |
| 13 | Discuss the availability of “referenced based pricing” strategies. The client is NOT considering these plan models at this time but does not want to eliminate any possible options for it's Health Plans. | |
| 14 | Discuss your ability to offer “navigating tools” and strategies to direct patient care to lower cost procedural codes like OP X-Ray and Lab services. | |
| 15 | Discuss any Air Ambulance contracts to minimize balance billing issues for plan members. | |
| 16 | Provide details on how your plan handles out-of-area dependents, specifically as it relates to limited-network plans. | |
| 17 | How are out of network allowable amounts determined? Please explain methodology and any partnerships or vendors used in the determination of reasonable and customary. | |
| 18 | Do you own your Texas provider network or do you do subcontract the network quoted? If you should subcontract, please identify network. | |
| Describe the following: | ||
| Provider Selection Process | ||
| Credentialing Process | ||
| Recredentialing Process | ||
| 19 | Does your network include clinician-staffed clinics in a retail setting? (e.g. RediClinic, etc.) Please elaborate. | |
| 20 | Do you have tiered network capabilities? Please elaborate and provide suggestions for the client in this area. | |
| 21 | Are out of network charges applicable to discounts, percentage of savings arrangements, Medicare plus allowance? Please describe. | |
| 22 | The client is NOT interested in any Shared Savings Arrangements. Please confirm your proposals do not include this. If so, please clearly outline below when Shared Savings Arrangements would be applied and clearly outline any fees/costs associated with such programs. | |
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| Section V - Case Disease Management | ||
| # | Question | Vendor Response |
| 1 | Discuss Telemedicine initiatives; not exclusive to telephonic applications, but including audio/visual web based abilities. | |
| 2 | Describe the navigation tools available for increasing member advocacy as a consumer such as OP lab, imaging, ER, Urgent care, etc. | |
| 3 | Describe your processes for standard pre-certification and utilization review procedures for inpatient and outpatient surgical procedures. | |
| 4 | Discuss the integration capabilities of your managed behavioral healthcare programs with other programs/plans subject to the Mental Health Parity Act, such as EAP and utilization management treatment plans. | |
| 5 | Discuss in detail the integration of all the various data components that feed your predictive model and note any vendors that are outsourced and their function. | |
| 6 | Does your organization provide any "Nurse Lines"? If so, please provide some commentary regarding this service. | |
| 7 | Does your organization provide any Wellness programs, web based publications, health risk assessments, wellness reminders, etc. to promote overall population health? | |
| 8 | Discuss your communication efforts and campaigns to engage members identified as high-risk? | |
| 9 | Describe your Advocacy process of transitional care form in-hospital to out-patient settings. | |
| 10 | Describe your Health Risk Assessments and/or Personal Health Record capabilities? | |
| 11 | Does your organization provide focused disease management treatment groups? Please provide details if applicable. | |
| 12 | Describe any Web based wellness incentive programs. | |
| 13 | Describe your Case Manager advocacy on-site at strategic Hospital systems, if available. | |
| 14 | How will you assist the client and their employees in emphasizing employee health and promote and encourage healthy behaviors? | |
| 15 | How will you promote and encourage high quality care (including use of evidence-based treatment) from the providers? | |
| 16 | What results are you able to provide, as it pertains to wellness programs and initiatives? | |
| 17 | Describe in detail your large case/catastrophic case management program. | |
| 18 | During case management, does your staff negotiate fee reductions with providers and vendors? | |
| 19 | Describe your catastrophic case management program. What reports will be provided and at what frequency? | |
| 20 | Is your DM program developed internally, or provided through an outside vendor? If an outside vendor, please indicate the name(s) of the firm(s). | |
| 21 | Describe any in- or out-of-state Centers of Excellence required by your plans. | |
| 22 | What diagnoses / chronic conditions are covered? | |
| 23 | How do you identify potential DM candidates? What sources of data do you use? | |
| 24 | Does your organization propose to provide the following DM intervention? | |
| Written Communications | ||
| Group Education | ||
| On-on-One Interventions | ||
| Telephone Monitoring | ||
| Clinical Interventions | ||
| Other Proposed Interventions (describe) | ||
| 25 | Describe your diabetic management approach. | |
| 26 | How will outcomes be reported for each proposed intervention? | |
| 27 | Give detailed information about the technology platforms you currently support, including: |
• Hardware platforms (e.g., desktop, servers, etc.)
• Operating system(s)
• Database management software
• Communications protocols supported
• Distribution options and capabilities
| 28 | Describe how your program would interface with the Plan's: |
| Prescription drug benefits. | |
| Mental Health Benefits | |
| 29 | Describe your reporting capabilities and methodology. |
| 30 | Are the following reports available to the client? If so, indicate frequency next to your response. |
| Cost Savings Reports | |
| Utilization Reports | |
| 31 | How do you measure the cost-effectiveness of your program? |
| 32 | Are the costs included in your quotation? If not, what are the additional costs? |
| 33 | Are you willing to guarantee return on investment (ROI)? If yes, please describe terms and conditions in detail. |
| 34 | Are you willing to provide multiple year rate guarantee? How many years? |
| Section VI - Utilization Management | ||
| # | Question | Vendor Response |
| 1. | Do you have a standard pre-certification requirement for any of the following: |
(Respond Y / N)
| Hospitalizations | |
| Outpatient Surgery | |
| Specified Diagnosis Procedures | |
| Durable Medical Equipment | |
| Corrective Appliances / Prosthetics | |
| Skilled Nursing Facility | |
| Home Health Care | |
| Musculoskeletal Services (e.g. chiropractic) | |
| Medical Services (e.g. physical therapy) | |
| Inpatient Mental Health / Substance Abuse | |
| Outpatient Mental Health / Substance Abuse | |
| Other | |
| 2. | Does precertification include the analysis and determination of any of the following: |
| Appropriate level of care (e.g., IP vs. OP) | |
| Reasonable length of stay of IP confinement | |
| Actual medical necessity & appropriateness of surgery or service being requested (e.g., does service require performance?) | |
| Necessity for the services of an assistant surgeon with each operative procedure analysis | |
| Necessity for a proposed preoperative hospital day | |
| Necessity for a proposed 23-hour observation stay following OP surgery | |
| Other (Explain) | |
| 3. | Within the past twelve months, in what percentage of all precertification cases was a letter of noncertification (denial) for Medical Necessity / Appropriateness for the procedure/service issued? |
| 4. | What percentage of ALL preservice reviews requires your physician advisor review for decision making? |
| 5. | Does your firm perform concurrent review services? |
| 6. | Please advise the following for the concurrent review staff (should total 100%): |
| % of Full-time EE's of the UM firm | |
| % of Part-time EE's of the UM firm | |
| % Subcontracted/Consulting reviewers (e.g., on-call only, registry, home health agency personnel) | |
| 7. | Indicate your standard method of reporting savings from the review of IP hospitalization. |
| 8. | Indicate your standard method of reporting savings from the review of OP hospitalization. |
| 9. | Does your organization perform hospital bill audits? If yes, describe the program and the basis of your compensation. |
| Section XI- Pharmacy Benefit Manager (PBM) | ||
| # | Question | Vendor Response |
| 1. | Confirm that your organization will propose three year contract terms, with annual rate guarantees. | |
| 2. | For Traditional Offers, confirm that your organization will propose a $0.00 base administration fee. |
For Transparent Offers, confirm that your organization will charge all base and ancillary administration fees on a per net paid claim basis.
| 3. | Confirm that your organization's proposed pricing is not contingent upon a minimum number of lives at the time of implementation or throughout the contract term. |
| 4. | Confirm that you define pass-through rates as charging the client the same amount that is paid to the retail pharmacies and to mail order pharmacies (if not wholly-owned). |
| 5. | Confirm that all financial guarantees in your organization's financial proposal will be guaranteed on a contract year basis. |
| 6. | Confirm that all guarantees will be reconciled/reported/paid no later than 90 days after the end of each contract year. |
| 7. | Confirm that guarantee reconciliations, and any amounts due, will be reported and paid proactively by PBM, and will not need to be requested by CLIENT. |
| 8. | Confirm that all guarantees will be trued up individually; no guarantees can be cross-subsidized (surplus offsetting shortfalls, etc.) between delivery channels or within a delivery channel (Retail 30 and Retail 90 are considered separate delivery channels). |
| 9. | Confirm that the risk on guarantees is dollar for dollar on any shortfall with no limit to the amount at risk. |
| 10. | Confirm that any surplus on any financial guarantee is retained 100% by CLIENT. |
| 11. | Confirm that your organization's financial proposal is based on the plan design, clinical rules and data contained within this RFP. (No changes need to be made by CLIENT in order to attain the financial pricing terms offered.) |
| 12. | Confirm that your organization's financial proposal is not contingent upon the adoption of any ancillary services. (Current programs such as clinical, UM, plan design, etc. are incorporated into the offer assuming no change.) |
| 13. | Confirm that your organization will use Medi-Span as the source of AWP. |
| 14. | Confirm that the AWP price will be based on the actual 11 digit NDC of the package size dispensed on the date dispensed. |
| 15. | Confirm that your organization will use the NDC of the original packaging manufacturer rather than repackaged NDC. |
| 16. | Confirm that your organization's definitions of "Brand" and "Generic" will be based on the following: |
A drug with a Medi-Span code of "Y" on the date dispensed will be considered a generic; all other Medi-Span codes ("M","N","O") will be considered brands.
| 17. | Confirm that your organization will not exclude single-source generics, dual-source generics or triple-source generics and will not reclassify generics to brands. |
| 18. | Are short-supply generics, limited distribution generics, house generics, or ANY other type of generic product included in your BRAND discount guarantees and/or reconcilitation? If ‘Yes’, indicate in the Explanation field. |
| 19. | Is there ever a situation when a member will be charged their full copay/coinsurance amount when the drug cost is lower? If 'Yes', indicate in the Explanation field. |
| 20. | Does your plan design mandate the use of brands rather than generics, or prefer brands over generics in any therapeutic category for which there are FDA approved generics commercially available? If 'Yes', please provide therapeutic category, brand name of drug, generic name of drug, and tier values. Will the member pay the brand copay rather than the generic copay based on this plan design? Please explain. |
| A. | Retail Network Pricing |
| 1. | For Traditional Offers, confirm that your organization's contract and adjudication system will reflect the below claim billing formula: |
Lower of AWP-X%+dispensing fee, MAC+dispensing fee, or U&C.
AWP-X% represents a minimum fixed discount for all claims should the U&C or MAC price be less aggressive.
Aggregate annual guaranteed brand discounts are not requested.
2. For Transparent Offers, confirm that your organization's contract and adjudication system will reflect the below claim billing formula:
Lower of AWP-X%+dispensing fee, MAC+dispensing fee, or U&C.
AWP-X% represents your organization's most aggressive retail pharmacy contract rate with each pharmacy.
Aggregate annual guaranteed brand discounts are requested on the "Financial Offer" tab.
| 3. | Confirm that both the plan sponsor and member will receive the financial benefit of U&C pricing. |
| 4. | Confirm that the member will always pay the “lowest of 3” (discounted price, copay, U&C). |
Any excess copay from the member will not be retained by your organization.
| 5. | Confirm that there is no minimum charge at retail for any transaction at any retail network store. |
| 6. | Confirm that member contributions (copays, coinsurance, selection penalties, ancillary charges, etc.) will not be included in any calculations: |
Calculations include adjudication, billing, guarantee reconciliation, etc.
7. Confirm that no other monies (audit/clinical/therapeutic interchange, DUR savings) will be included in any calculations:
Calculations include adjudication, billing, guarantee reconciliation, etc.
8. For Traditional and Transparent Offers, confirm that your organization's financial proposal will include an "all in" aggregate annual guaranteed generic discount using "Brand"/"Generic" definitions above.
Compounds, specialty products filled at the Specialty Pharmacy, OTC products, 340B claims, onsite/in-house pharmacy claims (if applicable), and direct member reimbursement (paper) claims may be excluded.
All other generics will be included in the guarantee.
9. For Transparent Offers, confirm that your organization's financial proposal will include an "all in" aggregate annual guaranteed brand discount using "Brand"/"Generic" definitions above.
Compounds, specialty products filled at the Specialty Pharmacy, OTC products, 340B claims, onsite/in-house pharmacy claims (if applicable), and direct member reimbursement (paper)…
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