6-06. SCOPE OF WORK 2025 Medical Pharmacy Final.docx

Scottsdale Unified School District #48 Scope of Work

7575 E. Main Street Scottsdale, AZ 85251 480-484-6151

RFP#: 26001

PROJECT: MEDICAL AND PHARMACY BENEFITS

1. Introduction Scottsdale Unified School District #48 is a political subdivision of the State of Arizona and Maricopa County. The District consists of approximately 20,000 students and approximately 2,900 employees. There are 29 school locations, (15) K -5 Elementary Schools, (3) K-8 Schools, (6) 6-8 Middle Schools, (5) High Schools including an online High School, a District office, a building services/transportation center, a materials distribution center, and other miscellaneous locations.

The purpose of this bid is to evaluate the current structure, competitiveness of costs and savings opportunities, capabilities and services available, opportunities for increased employee satisfaction, and compliance of the following components of the current health benefit programs, which include the following:

· Third-party Administrator (TPA) for health benefits claims administration;

· Case Management (CM) and Utilization Management (UM);

· Nurse Navigation hotline and services

· Preferred Provider Organization (PPO) Network Access;

· Wellness Program;

· Pharmacy Benefit Management (PBM);

· Telemedicine services The current plan design summaries, plan documents, and available reporting such as: enrollment, utilization, and claims experience are included. For additional considerations, review the Scope of Work and the overviews included in the Questionnaire Sections of this RFP.

Please note, the data and reporting being released with this RFP, is all that will be provided. No additional data is available.

The successful vendor(s) will provide the Scottsdale Unified School District (SUSD) with the services outlined in the Scope of Work.

It is preferred that you not bid a separate price for any start-up/one-time administrative fees, as your annual/ongoing fees should incorporate such expenses. Additionally, it is preferred that there are no additional costs other than your proposed fee for the noted services.

For purposes of determining final rates, all proposals must be submitted net of commissions. USI Insurance Services, LLC (USI) has been retained to facilitate this request for proposals in addition to the proposal analysis and evaluations. USI is compensated through a consulting fee; therefore, all proposals should be submitted net of commissions.

The District is looking for competitive quotes, a long-term relationship, and rate guarantees or rate caps for the full term of the contract(s) requested. Additionally, the District is open to innovative strategies to control costs. All proposals must be submitted via this formal procurement process. Any proposals received outside of this process will not be considered.

If you are unable to administer any portion of the current plan designs, please be very specific in your completion of the Deviations Exhibit contained in the Vendor Forms section of this RFP. If this form is not summarized with all deviations, it will be expected that you will administer the exact services as they are described today in the plan document and SBCs.

General Overview The Scottsdale Unified School District (SUSD) is currently staffed by approximately 2,382 active benefits-eligible employees.

SUSD offers a variety of benefits for eligible employees and their dependents. Hire dates in the first half of the month result in a benefits effective date of the first of the month immediately following the hire date. Hire dates in the second half of the month result in a benefits effective date of the first of the month following 30 days.

The District is a member of the Kairos Trust and has been since July 1, 2017. The following is a list of benefits received through the Trust, the carrier providing the administration, and how long the carrier has been in place:

Medical Administration – UMR (July 1, 2021) – previously with BlueCross BlueShield of Arizona (BCBSAZ) Medical Network – UnitedHealthcare (UHC) Choice Plus Network (July 1, 2021) – previously with BCBSAZ Utilization Management/Case Management UMR (July 1, 2021) Nurse Navigators Program offered through Kairos Wellness and Disease Management – Offered through Kairos and UMR Telemedicine – Teladoc (July 1, 2021) Pharmacy Benefit Manager – MaxorPlus (July 1, 2019) – previously with BCBSAZ Active employees have a choice between four medical plan options:

PPO plan with a $2,000/$4,000, plan year, medical deductible and $100/$200Rx deductible, $1,700/$3,400 High-Deductible Health Plan (HDHP) $3,300/$5,000 HDHP (see note below), and

$5,000/$10,000 HDHP

Note: SUSD recently updated the $3,000 deductible option to $3,300 retroactively to 7/1/2025 in order to maintain compliance with IRS minimum deductible levels. SBC’s and the Benefit Guide will be corrected to reflect this plan. Bidders will be requested to quote plan designs that are compliance with 2026 IRS minimums.

Participants may use any provider under these plans but the differential between the in-network and out-of-network cost shares encourage in-network utilization. For the most recent plan year (7/24-6/25), 95% of services are with UHC-participating providers.

The wellness program includes discounts to fitness centers, an online health center, Real Appeal online weight loss, onsite events and workshops, a maternity care program and ongoing and complex condition care programs.

For additional information regarding the District and its plan offerings, you may visit the District’s website at https://www.susd.org/departments/human-resources/benefits Contributions The District covers the majority of cost for the HDHP plans ($1700, $3000, $5000) employee only premiums and 75% of the PPO plan premiums. Dependent coverage is the responsibility of the employees.

The District contributes $500 to the $3,000 HDHP and $1,000 to the $5,000 HDHP enrollee’s health savings accounts. Employer paid HSA contributions are split into 2 payments, the first in July or August depending on when the employees’ benefit deductions start and the second in January of the same school year. First contributions are pro-rated for new hires depending on their hire date.

Proposed Options The District is interested in receiving proposals for the status quo structure and services outlined above, as well as variations described in this RFP. The District will evaluate a fully bundled/integrated approach, for the medical and pharmacy programs.

The District is looking for competitive quotes, a long-term relationship, and rate guarantees or rate caps for the full term of the contract(s) requested.

The District prefers to minimize employee disruption. Proposals should reflect the current benefit plan designs, except for changes that may be required due to mandated changes.

If you are unable to administer any portion of the current plan designs, please be very specific in your completion of the Deviations Exhibit contained in the Vendor Forms section of this RFP.

The District may consider participation in a public entity pool or benefit trust option, formed pursuant to A.R.S. 11-952.01 or A.R.S. 15-382 in lieu of awarding all or part of the health benefits programs to bidders responding to this solicitation; should the District determine that participation in a pool or trust is in the best interest of the District.

1. Scope of Work The Scottsdale Unified School District is soliciting proposals from qualified vendors to provide the following services:

MEDICAL PLAN ADMINISTRATION

Account Management

· Provide a designated Account Manager and Account Management Team Carrier/Vendor Billing & Reconciliation Administration

· Calculate all provider administration fees for payment of all vendors on behalf of the District.

Secure Vendor Portal Access

· Access to Vendor Portal for Employees to view claim status, EOB’s, etc.

· Employer and/or Designated Consultant access to Claims Data Reporting Portal to view and download online reports.

Customer(Member) Services

· Provide customer service to answer inquiries on claims, eligibility, provider network, services, coverage, or other inquiries Monday through Friday from 8:00 AM to 6:00 PM (AZ time).

Open Enrollment Support

· Prepare and provide Benefit Presentations in collaboration with the District

· Attend Open Enrollment Meetings Telemedicine

· Provide 24/7 telemedicine services

· General Medical, Mental Health and Dermatology and on-line physical therapy consultations Communication/Education Materials

· Provide bilingual communication/educational materials Booklets/Certificates/Identification Cards

· Provide Booklets/Certificates and Identification Card generation and electronic access. Note the District desires ID card mailing to members.

Claims Administration

· Provide access to claim forms for out-of-network claim reimbursement

· Receive and adjudicate claims and process payments of benefits in accordance with the plan documents on a timely and accurate basis.

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

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

· Provide access to an Explanation of Benefits (EOB) to the Participants for benefits paid, pending or denied. Provide a reason(s) for denial of benefits and provide notice for the review and appeal of such denied claims

· Provide 1099 forms (as applicable)

· Provide Summary of Benefits and Coverages (SBCs)

· Perform Recovery of Payments as needed for payments of $25 or more

· Administer a Fraud and Abuse Detection Program

· Review/Audit large claims for provider billing accuracy

· Provide Full Claims Fiduciary Services (all levels of appeals – no litigation) Eligibility/Enrollment Administration

· Administer eligibility based on the District’s eligibility criteria as defined in plan documents

· Accept electronic eligibility files from the District’s Benefits Administration system, iVisions (Tyler Technologies).

Reporting

· Provide reporting deliverables as requested in the Reporting section of the Questionnaire.

MEDICAL CASE MANAGEMENT, UTILIZATION REVIEW, DISEASE MANAGEMENT

Utilization Management (UM) including Prior Authorization Services Inpatient stays in Hospitals, Extended Care Facilities, or residential treatment facilities Partial hospitalizations Organ and tissue transplants Home Health Care Durable Medical Equipment, excluding braces and orthotics, over $1,500 or Durable Medical Equipment rentals over $500 per month Prosthetics over $1,000 Qualifying Clinical Trials Chemotherapy (cancer diagnosis) Dialysis Inpatient stays in Hospitals or Birthing Centers that are longer than 48 hours following normal vaginal deliveries or 96 hours following Cesarean sections

· MRI, MRA, PET, CT scans, CTA, and nuclear cardiology

· Medical Specialty Medication

· Covered person receives prior authorization for one facility, but then is transferred to another facility, prior authorization is needed before going to new facility, except in the case of an emergency Concurrent Review services if needed Clinical Advocacy

· Post-hospital discharge outreach

· High emergency room utilization outreach

· Clinical claims review

· Worker’s compensation claim redirection

· Clinical claim liaison between provider, participant, vendor (UMR and Maxor)

· High-cost claim review for directing further review by UMR and/or auditor

· High-cost prescription oversight

· EOB education and claim resolution

· Clinical healthcare/Nurse navigation

· Providers: Clinical Care Advocacy (CCA) will find providers, call to ensure they are accepting new patients, and supply participants with an active list of accepting providers. CCA will offer to schedule appointments too.

· Guide participants and providers through the prior authorization process (UMR and Maxor)

· Pharmacy issue resolution point of contact

· Offer lower out-of-pocket solutions: copay assistance programs, alternative sites of service, and generic medications over brand medications

· Poor drug adherence outreach

· Preventive wellness gaps in care outreach

· Post-biometric screening outreach

· Bridging the gap between medical management programs and wellness strategies

· Mental health oversight

· Determine the appropriateness and level of care for ongoing stays.

Comprehensive Case Management (CM) Program Assist participants to learn more about their illness and risk factors and understand treatment options and expected outcomes.

Understand and wisely use their health benefits and case management services Access other resources outside their insurance plan Avoid more expensive care or duplication of services Coordinate services among many different providers Disease Management Programs

· Neuromuscular / Autoimmune Disorders: ALS, Multiple Sclerosis, Myasthenia Gravis, Rheumatoid Arthritis

· Cardiovascular Disorders: Hypertension, Heart Failure, CAD

· Respiratory Disorders: Asthma, COPD

· Behavioral Health Disorders: Depression, General, Anxiety Disorder

· Blood Disorders: HIV, Hep C, Sickle Cell Anemia

· Gastrointestinal Disorders: Ulcerative Colitis, Crohn’s Disease

· Oncology: Breast, Prostate, Colorectal, Lung

· Endocrine Disorders: Diabetes (Type 1 and Type 2)

· Genitourinary Disorders: Chronic Kidney Disease (CKD) Claim and UM Appeals

· Handle all levels of the Appeal Process for services provided. (no litigation)

PREFERRED PROVIDER ORGANIZATION (PPO) NETWORK ACCESS

The current medical program includes access to a National network of PPO providers with best-in-classdiscounts. It is the District’s intent to continue to incorporate these services into the medical plan administration. Your proposal should assume that the following services will be provided:

· Provide a comprehensive PPO provider network with competitive discounts for Arizona participants as well as any out-of-state participants.

· Provide a network that includes a sufficient number of providers for acute hospitals, health care professionals, ancillary providers such as durable medical equipment, skilled nursing facility, home health, rehabilitation, hospice, transplant centers of excellence, and behavioral health providers. SUSD desires to keep all facilities in the greater Phoenix/Scottsdale area in network, including access to Mayo.

PHARMACY BENEFIT MANAGER

Background

Pharmacy Program Description

Quantity Limits

• Agents for weight loss.

• Allergy serum/extracts.

• Anabolic steroids.

• Anti-wrinkle agents (ex. Renova).

• Blood, blood factors, blood plasma or biological sera.

• Cosmetic hair removal products (ex. Vaniqa).

• Depigmenting agents (ex. Hydroxyquinone).

• Devices, appliances, or supplies, including support garments & non-medicinal substances.

• Drugs for sexual dysfunction.

• Drugs indicated for cosmetic uses.

• Fertility agents.

• Fluoride supplements, other than specified under covered.

• Hair growth stimulants.

• Insulin pump supplies.

• Low Value Drug List.

• Homeopathic/natural legend product.

• Non-legend drugs (OTC’s), except as listed above.

• Nutritional supplements, including infant formula.

• Repackaged medications.

• Unapproved FDA medications.

The Plan currently has a Traditional pricing arrangement with 100% pass through of rebates. Bidders may propose either a Traditional pricing arrangement or a Pass-Through pricing arrangement; however, all bids must pass through 100% of Rebates.

WELLNESS BENEFITS ADMINISTRATION

Wellness Programs/Services

· Clinical care advocacy program

· Weight loss and lifestyle change program

· 24/7 online health center with customized risk assessments and wellness tools and articles

· Onsite services for flu shots, mammograms, biometric and skin cancer screenings

· Direct fitness program

· Maternity benefit program

· Ongoing condition care management program

· Complex condition care management program

INTERFACE AND COORDINATION WITH DISTRICT’S VENDORS

Stop Loss data is currently not available.

RATES AND FEES

Implementation allowances, staffing resources and guarantees to lessen the District’s financial and administrative responsibility associated with modifications to the current programs, are encouraged.

The District is interested in a multi-year guarantee for all fees and rates. ASO fees should include all claims incurred while under contract with the vendor, including a full year of claims run-out should your contract terminate.

EXHIBITS

Plan Design It is the District’s intention to continue to offer the current benefit plans, except for changes that may be required due to regulatory mandates. If you are unable to administer any portion of the current plan designs, please be very specific in your completion of the Deviations Exhibit contained in the RFP.

Census* Claims Experience* Enrollment/Eligibility*

*Proposers must request to receive the Exhibits to this RFP. Contact Mary Rhodes, mary.rhodes@usi.com and Jeff Thomason, jeffthomason@susd.org for the attachments and exhibits not contained in this document.

Questionnaire Instructions for Vendors:

A separate questionnaire for Medical Administration and Pharmacy Benefit Management will be provided to bidders with the release of data. Vendors are required to submit responses to these questionnaires with their proposal submission, otherwise responses will be considered nonresponsive.

Fee History ADMINISTRATIVE SERVICES ONLY—Medical and Pharmacy

1Medical claims administration includes UM, DM and Teladoc.

RFP #: 26001 Page 1 of 1 Due: October 15, 2025 image1.png