Att H - Reference Check Form.docx

Request for Proposal/Partnership 27-88864 Reference Check Form Attachment H Solicitation for Pharmacy Benefit Administrator (PBA) Services

Reference Check Form Due Date: January 8, 2027 @ 3:00 PM Eastern Time

Instructions

You have been asked by the vendor listed below to provide a reference as they are responding to the current solicitation with the state of Indiana. This is a standard form created by the State of Indiana and your input is very much appreciated. During this competitive process, a representative from the State of Indiana may contact you directly for more detail. If you have any questions, please direct your inquiries to the State of Indiana representative listed on the bottom right of this form.

Please provide the information requested below and submit this reference check form to:

idoareferences@idoa.in.gov.

The subject line of the email submissions must clearly state the following:

RFP 27-88864 Reference – [INSERT COMPANY NAME]

Vendor Name

Reference Contact Information Reference Company Name

Contact Name

Contact Title

Contact Telephone Number

Contact Email

Company Mailing Address

Company City, State, Zip

Company Website Address

Industry of Company

State of Indiana Contact:

Robert Cohen, Category Director – Major Procurements Rcohen@idoa.in.gov Indiana Department of Administration Questions

Please provide a response to each of the questions listed below regarding the vendor listed above.

1. If you decline to provide a reference, please indicate that below and provide any comments you would be willing to share regarding the reason.

2. How long did you/have you and/or members of your team worked with the vendor? Please provide specific dates of service.

3. With what type of internal and external stakeholders did the vendor have to communicate with?

4. Has the vendor been cited for any financial audit issues? If you are able, please briefly describe the issue and any corrective actions that were required. Did the vendor ultimately address the issue(s) in a satisfactory manner?

5. Has the vendor been subject to any requests for corrective action to cure performance issues? If you are able, please briefly describe the issue and any corrective actions that were required. Did the vendor ultimately address the issue(s) in a satisfactory manner?

6. Would you rate your experience with the quality of services/work provided by the vendor as poor, satisfactory, above average, or superior? Please provide an explanation supporting the rating you have selected.

7. Would you rate the vendor’s knowledge of your business as poor, satisfactory, above average, or superior? Please provide an explanation supporting the rating you have selected.

8. Would you rate the overall quality of the vendor’s staff as poor, satisfactory, above average, or superior? Please provide an explanation supporting the rating you have selected.

9. Would you describe the quality of the vendor’s engagement and communication with stakeholders (internal and external) throughout the project as poor, satisfactory, above average, or superior? Please provide an explanation supporting the rating you have selected.

10. Would you rate the vendor’s ability to provide the appropriate staff and resources as needed for the project as poor, satisfactory, above average, or superior? Please provide an explanation supporting the rating you have selected.

11. Would you rate the vendor’s performance regarding cost and/or schedule overruns on the project as poor, satisfactory, above average, or superior? Please provide an explanation supporting the rating you have selected.

12. Are there any additional topics you believe Indiana should consider during its reference evaluation, or any further comments you would like to share?

13. Would your overall rating of the vendor be poor, satisfactory, above average, or superior?