Addendum_No._3_Notification.pdf

1STATE OF CALIFORNIA — DEPARTMENT OF CORRECTIONS AND REHABILITATION EDMUND G. BROWN JR., GOVERNOR

DIVISION OF ADMINISTRATIVE SERVICES

OFFICE OF BUSINESS SERVICES

9838 Old Placerville Road Suite B-2 Sacramento, CA 95827

May 16, 2016

TO: PROSPECTIVE BIDDER

RE: INVITATION FOR BID (IFB) NUMBER 6000001895, ADDENDUM NUMBER 3

IFB package has been revised and a revised portion is enclosed. You may view or download a copy of the revised IFB document(s) by accessing the California State Contracts Register (CSCR) at www.caleprocure.ca.gov. The following corrections have been made to the IFB:

A. Rate Sheet (Exhibit B-1) has been revised to identify (Quantitive) in Item 2; identify hourly rate in

Items 69, 70, and 73; change from flat rate to annual rate in Item 75; add Items 76, 77 and 78; and include the California conservation and fire camps.

B. List of Participating Worksites (Exhibit F) has been revised to include the California conservation and fire camps.

The deadline for submission of your bid will remain unchanged.

**Your bid package must include the revised Exhibit B-1, Rate Sheet, Addendum Number 3.**

If you submit a new bid, your first bid will be returned unopened. However, if you have already submitted a bid and you do not submit a new bid, your current bid shall remain in our files, unopened, until the new bid opening date.

We regret any inconvenience this may have caused. If you have any questions or need assistance from this office, please do not hesitate to contact me at (916) 255-6144.

Questions regarding the Cal eProcure internet site or downloading documents should be directed to the Fiscal Service Center, Vendor Management at 1-855-421-6355.

Sincerely, Maria Costa

MARIA COSTA

Contract Analyst Institution Contracts Section Contracts Management Branch

Enclosures

California Department of Corrections and Rehabilitation (CDCR) Rate Sheet

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

Upon approval of any services not specifically identified in Exhibit B-1, Rate Sheet, the Contractor will be reimbursed for actual cost plus 20% and applicable taxes. The Contractor must include cost substantiation as specified in Exhibit A, Scope of Work.

The Basis for Award shall be based on the Average Rate of services. The "Basis for Award" is strictly used for bidding purposes only to determine the lowest responsible bidder.

STAFF MEDICAL MONITORING SERVICES

Electronic bid packages include an Excel version of this Rate Sheet (Exhibit B-1) in addition to the PDF file in order to assist bidders in computing accurate totals. Bidders should download the Excel version and complete all highlighted cells. Bidders are also required to include a Compact Disk (CD) of the completed Excel version of the Rate Sheet along with the printed version when submitting their bid.

The quantities listed on Exhibit B-1, Rate Sheet, are the State's estimates only and are offered as a basis for comparison of bids. The State does not expressly or by implication agree that the actual amount of work will correspond therewith and reserves the right to increase/omit portions of the work as may be deemed necessary or advisable by the State. Any and all services performed outside the Scope of Work, Exhibit A, shall be at the sole risk and expense of the Contractor.

If it is determined to be in the best interest of the State, the State may extend this Agreement, with no increase in service cost, for two (2), optional one (1) year terms. The rates applied for this additional term are specified in this Exhibit B-1, Rate Sheet. The Contractor is obligated to this extended term of service at the time of bid.

NOTE: Bidders may bid on one or more Worksite groups. Your bid shall be for all locations within that group. Bidders are not required to bid on all groups. However, bidders are required to bid each item within the Group. Failure to indicate a dollar amount (BLANK CELL) in any item may be grounds to reject the entire group bid. A zero dollar amount ($0.00) listed for any and/or all items shall be interpreted and understood by the State to mean that the bidder shall perform any such services at no cost to the State.

For each Group the Contractor is not providing a bid, the Contractor shall type "NO BID" in the yellow highlighted cell. ONLY TYPED BID SHEETS WILL BE CONSIDERED. HANDWRITTEN SHEETS WILL BE DEEMED NON-RESPONSIVE AND WILL BE

REJECTED.

Contractor may offer a discount to the amount paid on invoices received and accepted by the CDCR in order for the invoices to be paid within thirty

(30) days of receipt. Discount offered on invoices must be at least one percent of the invoice amount and a minimum of $50.00.

*Discount offered on invoices paid within 30 days of receipt =

*The percent of discount (highest prevails) may be used in the event of tie bids. Refer to the Notice to Prospective Bidders, Bid Submission Requirements.

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail.

Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone.

99202

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) (Quantitive)

99204

LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.)

99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001

ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator.

(Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010, 71030

HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010

CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000

CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

92552

CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 81000

AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

***SERVICES DESCRIPTION RATE

A. PHYSICAL EXAMINATION (ITEMS 1-12)

Group 1: Avenal State Prison (ASP)

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

13 Spirometry Testing 94010 14 Blood Chemistry Panel 80050 15 Blood Lead Levels 83655 16 Blood Chemistry CBC 85025 17 Zinc Protoporphrin Test 84202 18 Blood Urea Nitrogen Test 84520 19 Serum Creatinine Test 92565 20 Urinalysis Exam-automated, microscopy 81001 21 Resting EKG 93000 22 Exercise/Stress EKG 93015 23 Chest X-ray read by a B Reader 71030 24 Cadmium in urine 82300 25 Beta-2 microglobulin in urine 82232 26 Cadmium in blood 82300 27 Chest X-ray-single view 71010 28 Urinalysis Exam 81000 29 Audiogram 92552 30 Chickenpox Immunity Screening-IgG 82784 31 Varicella (Chickenpox) Vaccine 90716 32 Measles Immunity Screen 82784 33 Measles/Mumps/Rubella Vaccine 90707 34 Liver Panel - SGPT and SGOT 80076 35 PPD Skin Test for TB 86580 36 Cell Mediated Immunity Blood Test for TB 86480 37 Chest X-ray for TB Infection 71020 38 T-dap (Tetanus/Diphtheria/Pertussis) Vaccine 90715 39 Influenza Vaccination (TIV) 90656 40 Influenza Vaccination (TIV - egg free) 90656 41 Influenza Vaccination Nasal (TIV) 90656 42 Pregnancy Test 84703 43 Male Fertility Test 89310 44 Stool Guaiac 82270 45 Limited Follow-up Exam. Established Patient 99213 46 Detailed Follow-up Exam. Established Patient 99214 47 Quantitative Fit Testing N/A 48 Hepatitis B Vaccine 90746 49 HIV Test 86701 50 HIV Blood Draw 36415 51 Bloodborne Pathogen Assessment 99214 52 TB Symptom Interview without TST N/A 53 CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) N/A 54 TB skin testing (new employee) 86480 x2 55 Laboratory Services (As Requested) N/A 56 Hepatitis B Surface Antigen 87340 57 Hepatitis B Surface Antibody Titer 86317 58 Hepatitis C Antibody 86803 59 Hepatitis B Antigen Test 87340 60 Mumps Immunity Screening 86735 61 Rubella immunity Screening 86762 62 Hepatitis B Core Antibody Test 86705 63 Truvada (Single Pill-Blister Pack)-Medication N/A 64 Raltegravir (25 mg)-Medication N/A 65 Oseltamivir (75 mg)-Medication N/A 66 Isoniazid (300 mg)-Medication N/A 67 Rifapentine (150 mg)- Medication N/A 68 Pyridoxine (50 mg)-Medication N/A 69 Post Exposure Follow Up Consultation (hourly rate) N/A 70 Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation)(hourly rate) N/A

CPT

71 Physician Consultation (hourly rate) N/A 72 Medical Examination Team - Site Mobilization (per individual) N/A 73 TB Risk Assessment (hourly rate) N/A 74 Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) N/A 75 Maintenance of Lockbox/Medications (annual rate) N/A 76 Qualitative Fit Testing N/A 77 Worksite Approved Lockbox (estimated max $1,000) N/A 78 Travel-Per Camp Site per Visit (estimated max $500) N/A

$1,000.00

B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) RATE

RATE

**Basis for Award

$1,500.00

$19.23

$500.00

Average Rate for Group 1 (ASP):

Divided by :

78Total Number of Rates:

C. ADDITIONAL SERVICES (ITEMS 71-75)

Sum Total of Rates (A+B+C):

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail.

Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone.

99202

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) (Quantitive)

99204

LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.)

99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001

ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator.

(Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010, 71030

HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010

CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000

CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

92552

CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 81000

AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

RATE

A. PHYSICAL EXAMINATION (ITEMS 1-12)

***SERVICES DESCRIPTION

Group 2: Calipatria State Prison (CAL) and Centinela State Prison (CEN)

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

13 Spirometry Testing 94010 14 Blood Chemistry Panel 80050 15 Blood Lead Levels 83655 16 Blood Chemistry CBC 85025 17 Zinc Protoporphrin Test 84202 18 Blood Urea Nitrogen Test 84520 19 Serum Creatinine Test 92565 20 Urinalysis Exam-automated, microscopy 81001 21 Resting EKG 93000 22 Exercise/Stress EKG 93015 23 Chest X-ray read by a B Reader 71030 24 Cadmium in urine 82300 25 Beta-2 microglobulin in urine 82232 26 Cadmium in blood 82300 27 Chest X-ray-single view 71010 28 Urinalysis Exam 81000 29 Audiogram 92552 30 Chickenpox Immunity Screening-IgG 82784 31 Varicella (Chickenpox) Vaccine 90716 32 Measles Immunity Screen 82784 33 Measles/Mumps/Rubella Vaccine 90707 34 Liver Panel - SGPT and SGOT 80076 35 PPD Skin Test for TB 86580 36 Cell Mediated Immunity Blood Test for TB 86480 37 Chest X-ray for TB Infection 71020 38 T-dap (Tetanus/Diphtheria/Pertussis) Vaccine 90715 39 Influenza Vaccination (TIV) 90656 40 Influenza Vaccination (TIV - egg free) 90656 41 Influenza Vaccination Nasal (TIV) 90656 42 Pregnancy Test 84703 43 Male Fertility Test 89310 44 Stool Guaiac 82270 45 Limited Follow-up Exam. Established Patient 99213 46 Detailed Follow-up Exam. Established Patient 99214 47 Quantitative Fit Testing N/A 48 Hepatitis B Vaccine 90746 49 HIV Test 86701 50 HIV Blood Draw 36415 51 Bloodborne Pathogen Assessment 99214 52 TB Symptom Interview without TST N/A 53 CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) N/A 54 TB skin testing (new employee) 86480 x2 55 Laboratory Services (As Requested) N/A 56 Hepatitis B Surface Antigen 87340 57 Hepatitis B Surface Antibody Titer 86317 58 Hepatitis C Antibody 86803 59 Hepatitis B Antigen Test 87340 60 Mumps Immunity Screening 86735 61 Rubella immunity Screening 86762 62 Hepatitis B Core Antibody Test 86705 63 Truvada (Single Pill-Blister Pack)-Medication N/A 64 Raltegravir (25 mg)-Medication N/A 65 Oseltamivir (75 mg)-Medication N/A 66 Isoniazid (300 mg)-Medication N/A 67 Rifapentine (150 mg)- Medication N/A 68 Pyridoxine (50 mg)-Medication N/A 69 Post Exposure Follow Up Consultation (hourly rate) N/A 70 Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation)(hourly rate) N/A

CPT

71 Physician Consultation (hourly rate) N/A 72 Medical Examination Team - Site Mobilization (per individual) N/A 73 TB Risk Assessment (hourly rate) N/A 74 Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) N/A 75 Maintenance of Lockbox/Medications (annual rate) N/A 76 Qualitative Fit Testing N/A 77 Worksite Approved Lockbox (estimated max $1,000) N/A 78 Travel-Per Camp Site per Visit (estimated max $500) N/A

RATEB. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70)

RATEC. ADDITIONAL SERVICES (ITEMS 71-75)

**Basis for Award

$19.23

$1,000.00

Average Rate for Group 2 (CAL and CEN):

Total Number of Rates:

Divided by :

$1,500.00Sum Total of Rates (A+B+C):

$500.00

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail.

Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone.

99202

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) (Quantitive)

99204

LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.)

99204, 80050, 83655, 85025, 84202, 84520

ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator.

(Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010, 71030

HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010

CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000

CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

92552

CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 81000

AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

Group 3: California Institution for Men (CIM), California Institution for Women (CIW) and Inmate Ward Labor (IWL)-Region III, Mailbu Fire Camp (FC), Puerta La Cruz Conservation Camp (CC), Rainbow Conservation Camp (CC)

***SERVICES DESCRIPTION

A. PHYSICAL EXAMINATION (ITEMS 1-12)

RATE

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

13 Spirometry Testing 94010 14 Blood Chemistry Panel 80050 15 Blood Lead Levels 83655 16 Blood Chemistry CBC 85025 17 Zinc Protoporphrin Test 84202 18 Blood Urea Nitrogen Test 84520 19 Serum Creatinine Test 92565 20 Urinalysis Exam-automated, microscopy 81001 21 Resting EKG 93000 22 Exercise/Stress EKG 93015 23 Chest X-ray read by a B Reader 71030 24 Cadmium in urine 82300 25 Beta-2 microglobulin in urine 82232 26 Cadmium in blood 82300 27 Chest X-ray-single view 71010 28 Urinalysis Exam 81000 29 Audiogram 92552 30 Chickenpox Immunity Screening-IgG 82784 31 Varicella (Chickenpox) Vaccine 90716 32 Measles Immunity Screen 82784 33 Measles/Mumps/Rubella Vaccine 90707 34 Liver Panel - SGPT and SGOT 80076 35 PPD Skin Test for TB 86580 36 Cell Mediated Immunity Blood Test for TB 86480 37 Chest X-ray for TB Infection 71020 38 T-dap (Tetanus/Diphtheria/Pertussis) Vaccine 90715 39 Influenza Vaccination (TIV) 90656 40 Influenza Vaccination (TIV - egg free) 90656 41 Influenza Vaccination Nasal (TIV) 90656 42 Pregnancy Test 84703 43 Male Fertility Test 89310 44 Stool Guaiac 82270 45 Limited Follow-up Exam. Established Patient 99213 46 Detailed Follow-up Exam. Established Patient 99214 47 Quantitative Fit Testing N/A 48 Hepatitis B Vaccine 90746 49 HIV Test 86701 50 HIV Blood Draw 36415 51 Bloodborne Pathogen Assessment 99214 52 TB Symptom Interview without TST N/A 53 CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) N/A 54 TB skin testing (new employee) 86480 x2 55 Laboratory Services (As Requested) N/A 56 Hepatitis B Surface Antigen 87340 57 Hepatitis B Surface Antibody Titer 86317 58 Hepatitis C Antibody 86803 59 Hepatitis B Antigen Test 87340 60 Mumps Immunity Screening 86735 61 Rubella immunity Screening 86762 62 Hepatitis B Core Antibody Test 86705 63 Truvada (Single Pill-Blister Pack)-Medication N/A 64 Raltegravir (25 mg)-Medication N/A 65 Oseltamivir (75 mg)-Medication N/A 66 Isoniazid (300 mg)-Medication N/A 67 Rifapentine (150 mg)- Medication N/A 68 Pyridoxine (50 mg)-Medication N/A 69 Post Exposure Follow Up Consultation (hourly rate) N/A 70 Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation)(hourly rate) N/A

CPT

71 Physician Consultation (hourly rate) N/A 72 Medical Examination Team - Site Mobilization (per individual) N/A 73 TB Risk Assessment (hourly rate) N/A 74 Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) N/A 75 Maintenance of Lockbox/Medications (annual rate) N/A 76 Qualitative Fit Testing N/A 77 Worksite Approved Lockbox (estimated max $1,000) N/A 78 Travel-Per Camp Site per Visit (estimated max $500) N/A

Average Rate for Group 3 (CIM, CIW and IWL-Reg. III, Malibu FC, Puerta La Cruz CC, Rainbow CC):

$1,000.00

$19.23

**Basis for Award

$500.00

$1,500.00

RATE

Sum Total of Rates (A+B+C):

Divided by :

C. ADDITIONAL SERVICES (ITEMS 71-75)

Total Number of Rates:

B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) RATE

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail.

Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone.

99202

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) (Quantitive)

99204

LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.)

99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001

ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator.

(Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010, 71030

HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010

CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000

CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

92552

CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 81000

AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

Group 4: California Correctional Center (CCC) and High Desert State Prison (HDSP), Alder Conservation Camp (CC), Antelope Conservation Camp (CC), Ben Lomond Conservation Camp (CC), Chamberlain Creek Conservation Camp (CC), Deadwood Conservation Camp (CC), Delta Conservation Camp (CC), Devil's Garden Conservation Camp (CC), Eel River Conservation Camp (CC), High Rock Conservation Camp (CC), Intermountain Conservation Camp (CC), Ishi Conservation Camp (CC), Konocti Conservation Camp (CC), Parlin Fork Conservation Center (CC), Salt Creek Conservation Camp (CC), Sugar Pine Conservation Camp (CC), Trinity River Conservation Camp (CC), Valley View Conservation Camp (CC), Washington Ridge Conservation Camp (CC)

***SERVICES DESCRIPTION RATE

A. PHYSICAL EXAMINATION (ITEMS 1-12)

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

13 Spirometry Testing 94010 14 Blood Chemistry Panel 80050 15 Blood Lead Levels 83655 16 Blood Chemistry CBC 85025 17 Zinc Protoporphrin Test 84202 18 Blood Urea Nitrogen Test 84520 19 Serum Creatinine Test 92565 20 Urinalysis Exam-automated, microscopy 81001 21 Resting EKG 93000 22 Exercise/Stress EKG 93015 23 Chest X-ray read by a B Reader 71030 24 Cadmium in urine 82300 25 Beta-2 microglobulin in urine 82232 26 Cadmium in blood 82300 27 Chest X-ray-single view 71010 28 Urinalysis Exam 81000 29 Audiogram 92552 30 Chickenpox Immunity Screening-IgG 82784 31 Varicella (Chickenpox) Vaccine 90716 32 Measles Immunity Screen 82784 33 Measles/Mumps/Rubella Vaccine 90707 34 Liver Panel - SGPT and SGOT 80076 35 PPD Skin Test for TB 86580 36 Cell Mediated Immunity Blood Test for TB 86480 37 Chest X-ray for TB Infection 71020 38 T-dap (Tetanus/Diphtheria/Pertussis) Vaccine 90715 39 Influenza Vaccination (TIV) 90656 40 Influenza Vaccination (TIV - egg free) 90656 41 Influenza Vaccination Nasal (TIV) 90656 42 Pregnancy Test 84703 43 Male Fertility Test 89310 44 Stool Guaiac 82270 45 Limited Follow-up Exam. Established Patient 99213 46 Detailed Follow-up Exam. Established Patient 99214 47 Quantitative Fit Testing N/A 48 Hepatitis B Vaccine 90746 49 HIV Test 86701 50 HIV Blood Draw 36415 51 Bloodborne Pathogen Assessment 99214 52 TB Symptom Interview without TST N/A 53 CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) N/A 54 TB skin testing (new employee) 86480 x2 55 Laboratory Services (As Requested) N/A 56 Hepatitis B Surface Antigen 87340 57 Hepatitis B Surface Antibody Titer 86317 58 Hepatitis C Antibody 86803 59 Hepatitis B Antigen Test 87340 60 Mumps Immunity Screening 86735 61 Rubella immunity Screening 86762 62 Hepatitis B Core Antibody Test 86705 63 Truvada (Single Pill-Blister Pack)-Medication N/A 64 Raltegravir (25 mg)-Medication N/A 65 Oseltamivir (75 mg)-Medication N/A 66 Isoniazid (300 mg)-Medication N/A 67 Rifapentine (150 mg)- Medication N/A 68 Pyridoxine (50 mg)-Medication N/A 69 Post Exposure Follow Up Consultation (hourly rate) N/A 70 Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation)(hourly rate) N/A

CPT

71 Physician Consultation (hourly rate) N/A 72 Medical Examination Team - Site Mobilization (per individual) N/A 73 TB Risk Assessment (hourly rate) N/A 74 Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) N/A 75 Maintenance of Lockbox/Medications (annual rate) N/A 76 Qualitative Fit Testing N/A 77 Worksite Approved Lockbox (estimated max $1,000) N/A 78 Travel-Per Camp Site per Visit (estimated max $500) N/A

B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) RATE

$1,000.00 $500.00

Sum Total of Rates (A+B+C): $1,500.00 Divided by : /

Total Number of Rates: 78

C. ADDITIONAL SERVICES (ITEMS 71-75) RATE

Average Rate for Group 4 (CCC,HDSP, Alder CC, Antelope CC, Ben Lomond CC, Chamberlain Creek CC, Deadwood CC, Delta CC, Devil's Garden CC, Eel River CC, High Rock CC, Intermountain CC, Ishi CC, Konoci CC, Parlin Fork CC, Salt Creek CC, Sugar Pine CC, Trinity River CC, Valley View CC, Washington Ridge CC):

$19.23

**Basis for Award

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail.

Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone.

99202

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) (Quantitive)

99204

LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.)

99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001

ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator.

(Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010, 71030

HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010

CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000

CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

AUDIOGRAM - CCR 1597: Physical Exam to establish a baseline audiogram for employees exposed at or about the action level, Report of audiometric test results. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

92552

CALIFORNIA COMMERCIAL DRIVERS EXAMINATION - 49CFR391.41 - 391.49 & CVC 12517.2 - Physical examination including visual acuity, hearing, blood pressure, pulse rate, urinalysis, etc., and complete CA DMV DL 51. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 81000

AEROSOL TRANSMISSIBLE DISEASE - CCR 5199: Physical Exam and Letter of Clearance to return to work (w/wo restricted activity). (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

***SERVICES DESCRIPTION RATE

A. PHYSICAL EXAMINATION (ITEMS 1-12)

Group 5: Folsom State Prison (FSP), California State Prison-Sacramento (SAC) and Inmate Ward Labor (IWL)-Region I

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

13 Spirometry Testing 94010 14 Blood Chemistry Panel 80050 15 Blood Lead Levels 83655 16 Blood Chemistry CBC 85025 17 Zinc Protoporphrin Test 84202 18 Blood Urea Nitrogen Test 84520 19 Serum Creatinine Test 92565 20 Urinalysis Exam-automated, microscopy 81001 21 Resting EKG 93000 22 Exercise/Stress EKG 93015 23 Chest X-ray read by a B Reader 71030 24 Cadmium in urine 82300 25 Beta-2 microglobulin in urine 82232 26 Cadmium in blood 82300 27 Chest X-ray-single view 71010 28 Urinalysis Exam 81000 29 Audiogram 92552 30 Chickenpox Immunity Screening-IgG 82784 31 Varicella (Chickenpox) Vaccine 90716 32 Measles Immunity Screen 82784 33 Measles/Mumps/Rubella Vaccine 90707 34 Liver Panel - SGPT and SGOT 80076 35 PPD Skin Test for TB 86580 36 Cell Mediated Immunity Blood Test for TB 86480 37 Chest X-ray for TB Infection 71020 38 T-dap (Tetanus/Diphtheria/Pertussis) Vaccine 90715 39 Influenza Vaccination (TIV) 90656 40 Influenza Vaccination (TIV - egg free) 90656 41 Influenza Vaccination Nasal (TIV) 90656 42 Pregnancy Test 84703 43 Male Fertility Test 89310 44 Stool Guaiac 82270 45 Limited Follow-up Exam. Established Patient 99213 46 Detailed Follow-up Exam. Established Patient 99214 47 Quantitative Fit Testing N/A 48 Hepatitis B Vaccine 90746 49 HIV Test 86701 50 HIV Blood Draw 36415 51 Bloodborne Pathogen Assessment 99214 52 TB Symptom Interview without TST N/A 53 CDPH compliant/PHB accepted risk assessment questionnaire (Ordered by PHB) N/A 54 TB skin testing (new employee) 86480 x2 55 Laboratory Services (As Requested) N/A 56 Hepatitis B Surface Antigen 87340 57 Hepatitis B Surface Antibody Titer 86317 58 Hepatitis C Antibody 86803 59 Hepatitis B Antigen Test 87340 60 Mumps Immunity Screening 86735 61 Rubella immunity Screening 86762 62 Hepatitis B Core Antibody Test 86705 63 Truvada (Single Pill-Blister Pack)-Medication N/A 64 Raltegravir (25 mg)-Medication N/A 65 Oseltamivir (75 mg)-Medication N/A 66 Isoniazid (300 mg)-Medication N/A 67 Rifapentine (150 mg)- Medication N/A 68 Pyridoxine (50 mg)-Medication N/A 69 Post Exposure Follow Up Consultation (hourly rate) N/A 70 Reporting Contact Investigation (Exhibit A-3(a) Summary Report of Case Contact Investigation)(hourly rate) N/A

CPT

71 Physician Consultation (hourly rate) N/A 72 Medical Examination Team - Site Mobilization (per individual) N/A 73 TB Risk Assessment (hourly rate) N/A 74 Blood Borne Pathogen (BBP) Screening and Training (per individual, per test rate) N/A 75 Maintenance of Lockbox/Medications (annual rate) N/A 76 Qualitative Fit Testing N/A 77 Worksite Approved Lockbox (estimated max $1,000) N/A 78 Travel-Per Camp Site per Visit (estimated max $500) N/A

B. INDIVIDUAL MEDICAL/TEST SERVICES (ITEMS 13-70) RATE

C. ADDITIONAL SERVICES (ITEMS 71-75) RATE

Average Rate for Group 5 (FSP, SAC, IWL-Reg. I): $19.23 **Basis for Award

$1,000.00 $500.00

Sum Total of Rates (A+B+C): $1,500.00 Divided by : /

Total Number of Rates: 78

Bid Number 6000001895 Exhibit B-1

Addendum Number 3

CPT

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (A) Medical Questionnaire submitted by mail.

Letter of Clearance to wear a respirator, OR referral for completion of Section B below if unable to clear via review of questionnaire alone.

99202

RESPIRATORY PROTECTION EXAMINATION - CCR 5144: (B) In addition to Medical Questionnaire above, Physical Exam and Letter of Clearance to wear a respirator. If additional tests are necessary to clear individual tests below. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.) (Quantitive)

99204

LEAD MEDICAL EXAMINATION - CCR 1532.1/5198: Physical Exam, Blood Chemistry Panel, Blood Lead, CBC, Zinc Protoporphrin, Blood Urea Nitrogen, Serum Creatinine, Urinalysis, Letter of Clearance regarding the employee's ability to perform Lead Work including ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to perform additional test(s) which may be deemed necessary.)

99204, 80050, 83655, 85025, 84202, 84520, 82565, 81001

ABESTOS MEDICAL EXAMINATION - CCR 1529/5208: Physical Exam, Spirometry, Chest X-ray, Letter of Clearance regarding employee's ability to perform Asbestos work including ability to wear a respirator.

(Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010, 71030

HAZARDOUS SUBSTANCE EXAMINATION - CCR 5192: Physical Exam, Spirometry, Letter of Clearance regarding the employee's ability to perform Hazardous Materials work and ability to wear an air purifying respirator or self contained breathing apparatus. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 94010

CHROMIUM MEDICAL EXAMINATION - CCR 1532.2/5206: Physical Exam and Letter of Clearance relative to Chromium work and ability to wear a respirator. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204

CADMIUM INITIAL EXAMINATION - CCR 1532/5207: Physical Exam, Cadmium in Urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr), with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 82300, 82232

CADMIUM PERIODIC MEDICAL SURVEILLANCE - CCR 1532/5207: Physical Exam, Chest X-ray, Pulmonary function tests, Cadmium in urine (CdU), standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M), standardized to grams of creatinine (g/Cr) with pH specified, standardized to grams of creatinine (g/Cr), Cadmium in blood (CdB), standardized to liters of whole blood (lwb). Blood Urea Nitrogen, Complete Blood Count, and Serum Creatinine. Urinalysis including the determination of albumin, glucose and total and low molecular weight proteins. Prostate Palpation. Letter of Clearance. (Must contact the Contract Liaison to obtain written prior authorization to preform additional test(s) which may be deemed necessary.)

99204, 71010, 94010, 82300, 82232, 84520, 85025, 82565, 81000

CADMIUM MEDICAL EXAMINATION FOR RESPIRATOR USE - CCR 1532/5207: Physical Exam including blood pressure test, Cadmium in Urine (CdU) standardized to grams of creatinine (g/Cr), Beta-2 microglobulin in urine (ß2 -M),…