Attachment 11 - Required State Forms Acknowledgement Form.docx
DOCX document 29 KB Posted
- Solicitation number
- BD-26-1049-GIC00-07GIC-130036
- Issued by
- Massachusetts
About this file
This is a Required State Forms Acknowledgement Form from the Massachusetts Group Insurance Commission (GIC) for Pharmacy Benefit Manager services covering approximately 305,133 Commercial members and 120,011 EGWP (Employer Group Waiver Plan) members. The form serves as verification that bidders have reviewed and understand the mandatory state forms required for contract execution. Responses are due August 5, 2026, with a bidders' conference tentatively scheduled for July 29, 2026. The RFR will be released on or about July 8, 2026 via COMMBUYS (file number BD-26-1049-GIC00-07GIC-130036). The contract commences July 1, 2027, and vendors may bid on Commercial, EGWP, or both contracts separately, with each evaluated independently.
The acknowledgement form requires bidders to certify completion and understanding of seven mandatory documents: Business Associate Agreement/Confidentiality Agreement, Commonwealth Standard Contract Form, Commonwealth Terms and Conditions, Contractor Authorized Signatory Listing, Electronic Funds Transfer Sign up Form, W-9 Request for Taxpayer Identification Number, and Prompt Payment Discount Form. Any alterations, addendums, or deviations to these forms may disqualify the bid submission. The form must be signed in blue ink by an authorized signatory and submitted with the bid. CVS Health (Caremark) is the incumbent, currently administering both Commercial and separate EGWP contracts. The Commercial population generates approximately $830.6 million in annual pharmacy gross costs, while the EGWP population generates approximately $736.7 million annually. Prospective bidders must demonstrate substantial experience managing large-scale pharmacy benefit programs and comply with Massachusetts' 2025 PBM law and Division of Insurance licensing requirements.
View the file
Other files
Show all 22
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Procurement ID: ______________________
Required State Forms Acknowledgement
The following forms provided on the COMMBUYS website and made part of this RFR will be required to be completed and signed unaltered by the successful bidder.
I, as an authorized representative of the bidder, verify that our firm has reviewed the forms below, understand that the GIC will require us to sign these forms if awarded the contract, and that any alterations, addendums, or deviations to these forms may disqualify the bid submission from consideration by the GIC and that the signed forms will be incorporated into the final contract.
I further verify that we understand that there may be other documents requiring signature included in this RFR and that no contract will be finalized without these signed documents.
Business Associate Agreement/Confidentiality Agreement Commonwealth Standard Contract Form Commonwealth Terms and Conditions Contractor Authorized Signatory Listing Electronic Funds Transfer Sign up Form W-9 Request for Taxpayer Identification Number Prompt Payment Discount Form
Company Name
Printed Name
Title
Authorized Signatory (Sign in Blue Ink) GIC-RSFA Rev. 11/2016
File details come from the government source that posted it. Updated .