Attachment_A.2_-_Network_and_Formulary_Disruption_(4_TABS_TO_COMPLETE)_FINAL.xlsx

XLSX spreadsheet 57 KB Posted

Attached to
25-P-115TF Self-Funded Group Health Plan Administrative Services
Solicitation number
25-P-115TF
Issued by
Volusia County, Florida

About this file

The document is an Attachment A.2 Network and Formulary Disruption spreadsheet for Volusia County Government's self-funded group health plan administrative services Request for Proposals (RFP). The RFP seeks a contract for comprehensive group health plan benefits for county employees, retirees, and COBRA participants, including chiropractic network, claims administration, Employee Assistance Program, national supplemental network, managed prescription benefits, provider networks, and utilization management. The contract is structured for an initial five-year term from January 1, 2027, with a potential subsequent five-year renewal contingent on mutual written agreement and county council approval.

The spreadsheet provides detailed information on the proposed network, including top facility providers across hospitals, urgent care centers, laboratories, and durable medical equipment suppliers in the Volusia County, Florida area. It includes comprehensive listings of participating physicians across various specialties, a pharmacy network comparison, and a drug formulary worksheet detailing medication tiers and coverage. The document appears to be part of a competitive bidding process where potential contractors must demonstrate their network breadth, provider coverage, and pharmaceutical benefit structures to be considered for the county's self-insured health plan administrative services contract.

View the file

Other files

File Type Posted
25-P-115TF_Self-Funded_Group_Health_Plan_Administrative_Services_(Addendum_#6_Revision).pdf PDF
25-P-115TF_Self-Funded_Group_Health_Plan_Administrative_Services.pdf PDF
Exhibit_D_-_Insurance_Requirements_(For_DRAFT_Contract)_FINAL_.pdf PDF
25-P-115TF_Self-Funded_Group_Health_Plan_Admin_Srvs_Agreement_FINAL_DRAFT.pdf PDF
Exhibit_M_-_Pharmacy_Claims_Pricing_File_(1_TAB_TO_COMPLETE,_DO_NOT_SUBMIT)_FINAL.xlsx XLSX spreadsheet
Exhibit_L_-_Medical_Discount_Pricing_File_(3_TABS_TO_COMPLETE,_DO_NOT_SUBMIT)_FINAL.xlsx XLSX spreadsheet
Exhibit_K_–_Medical_Claims_Pricing_File_(3_TABS_TO_COMPLETE,_DO_NOT_SUBMIT)_FINAL.xlsx XLSX spreadsheet
Exhibit_J_-_Large_Claims_2022-2024_(3_TABS_to_VIEW)_FINAL.xlsx XLSX spreadsheet
Exhibit_I_-_Census_(3_TABS_to_VIEW)_FINAL.xlsx XLSX spreadsheet
Exhibit_H_-_Claims_Experience_(2_TABS_to_VIEW)_FINAL.xlsx XLSX spreadsheet
Exhibit_G_-_County_Computing_Security_Procedures_FINAL.pdf PDF
Exhibit_F_-_HIPPA_Business_Associate_Agreement_FINAL.pdf PDF
Exhibit_E_-_Human_Trafficking_Affidavit_FINAL.pdf PDF
Exhibit_C_-_Summary_Plan_Document_(2025)_FINAL.pdf PDF
Attachment_B.1_Pharmacy_Pricing_Guarantees_(1_TAB_TO_COMPLETE)_FINAL.xlsx XLSX spreadsheet
Exhibit_B_-_Fees_and_Performance_Guarantees_FINAL.docx DOCX document
Exhibit_A.4_-_Onsite_Job_Descriptions_FINAL.pdf PDF
Exhibit_A.3_-_Claims_Reporting_Fields_FINAL.pdf PDF
Attachment_A.1_-_Worksheet_Health_Plan_Administrative_Services_FINAL.docx DOCX document
Exhibit_A_-_Scope_of_Services_FINAL.pdf PDF
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Text version

Top Facilities

TOP FACILITY PROVIDERS

Contractor Legal Name:
Instructions: Please list the participating hospitals and facilities and place an "X" in the columns under the plan(s). Leave the field blank if the provider is not in your network.
Hospital NameNPINetwork
ADVENTHEALTH DAYTONA BCH590973502
ADVENTHEALTH ORLANDO590724459
ORLANDO HLTH INC591726273
HCA FL LK MONROE HSP591978725
ADVENTHEALTH FISH MEML593149293
ADVENTHEALTH DELAND593256803
HALIFAX MED CTR596001217
ADVENTHEALTH PALM COAST592951990
Urgent Care NameNPINetwork
ADVENTHEALTH CENTRA CARE593209688
MD NOW812644596
PRIMECARE AT TWIN LAKES450527284
ORLANDO CARENOW URGENT C812644596
MEDFAST URGENT CARE CTR141973790
HALIFAX HLTH EXPRESS CAR854283262
LabsNPINetwork
QUEST DIAG382084239
LAB CORP OF AMER840611484
MYRIAD GENETIC LAB870514323
Durable Medical Equipment NameNPINetwork
APRIA HLTHCARE LLC330057155
ROTECH591450889
NATIONWIDE MED INC611423158
NUMOTION431922598

&"Arial,Bold"25-P-115TF &"Arial,Bold"Attachment A.2 Network and Formulary Disruption

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Top Physicians

TOP PHYSICIANS

Contractor Legal Name:
Instructions: Please list the participating hospitals and facilities and place an "X" in the columns under the plan(s). Leave the field blank if the provider is not in your network.
PHYSICIAN/PRACTICE NAMENPISPECIALTYPROVIDER ZIPCODENetworkHigh Performance Network
DODD III MD PAUL M650825133Oncology (Cancer)32174
IVX HLTH84445749460197
HARRIS DO ERIC MICHAEL650825133Internal Medicine32117
KHAN MD MUDUSSARA A650825133Oncology (Cancer)32117
GUPTA MD SHEMIN650825133Internal Medicine32763
HILL MD JOHN M271970908PCP32720
MELGEN MD VICTOR W201908250Internal Medicine32720
MASCARO MD PEDRO G591680273Anesthesiology32174
MEDSOLUTIONS INC26018118530368
KUMAR MD JAYA B650017482Ophthalmology32114
SAI MD PADMAJA650825133Oncology (Cancer)32164
PIRKOWSKI MD MICHAEL462439971Radiology32117
JONES MD JEREMY C593337028Internal Medicine55480
LANDIS MD MILES M593214635PCP32763
KHARFAN DABAJA MD MOHAMED590714831Internal Medicine55480
PATEL MD DANIEL V264050587Internal Medicine32114
BUSTINZA-LINAR MD ERNESTO650825133Internal Medicine32720
BENEZETTE DO ALYN L593609982Neurology32174
AMERICAN SPECIALTY PHYSI45551325592121
ALEXANDER DO CHRISTOPHER650825133Oncology (Cancer)32174
SHER MD TAIMUR593337028PCP55480
KOHEN MD MICHAEL D591641576Allergy/Immunology32114
ATTIA DO STEVEN N590714831Oncology (Cancer)55480
CHEN MD RUQIN593337028Oncology (Cancer)55480
GARCIA MD CRISTINA50608888PCP32168
ALBER MD THOMAS J593214635PCP32763
ADVENTHEALTH IMAG55078938730394
LIU MD WING YI462354804Cardiology32169
BROOKS REHAB CTR59224937230374
PANCHAL PA SHAINA S593549147PCP32720
MIDDLETON MD MICHAEL A320602652PCP32814
COLPOYS MD MARGARET E591198552PCP32174
AMER SPEC HLTH CLEARINGH562403146Chiropractor92121
THOMPSON MD CHRISTOPHER P842330677Otolaryngology32771
WANG MD HUIJIAN J473793197Cardiology32129
BROWN PA ALICIA593549147PCP32720
HOCKEY APRN DANIELLE T591198552PCP32720
WILLIAMS MD MICHELLE F592988646PCP32763
KASE MD ADAM M590714831PCP55480
MARKS DO ETAN A593549147Dermatology33445
ACCREDO HLTH GRP INC11335853563195
CURRY MD JESSICA R593209688PCP31193
FORAN MD JAMES M590714831Internal Medicine55480
ALHAJ MOUSTAFA MD MUHAMAD590714831Internal Medicine55480
ROY MD VIVEK590714831Internal Medicine55480
STEWART MD MICHAEL W590714831Ophthalmology55480
AYALA MD ERNESTO590714831Internal Medicine55480
CASTRO MD DANIEL592021436Internal Medicine32720
APORTELA MD ROBERT M650736246Pathology33484
PAVLOVIC MD BOJAN593609982Anesthesiology32174
TIPTON MD PHILIP W590714831Neurology55480
WHITE MD JOHN A542129332Obstetrics/Gynecology32114
BLASINI MD WILFREDO824681345Pathology33916
AHUJA MD RATAN K593149293Cardiology32885
SHOEMAKER DO WHITNEY E943438276Obstetrics/Gynecology32174
AL-MALT MD AHMED M590973502Obstetrics/Gynecology32746
KINDRED MD CHLOE L932208118PCP32117
BEG MD MIRZA S593609982PCP32174
ORTEGA MD GREGORY L592021436Internal Medicine32771
ARAB MD DINESH M590973502Cardiology32117
COASTAL DIAG GRP LLC46160623375038
FISCHER-CARNE MD TINA L932208118PCP32168
SCHUTT-AINE MD LUC-MARIE593256803PCP32720
LOPEZ MD RUBEN J900307107PCP04915
METCHICK MD LEE N200997592Endocrinology/Diabetes/Metabolism32724
DESAI MD MEETESH S590973502Obstetrics/Gynecology32117
PAIK MD CHRISTOPHER L593256803PCP32720
GRAHAM MD GARY R592297461Radiology32763
SHAH MD DEVANG593599451Otolaryngology32763
SANDHU MD NEIL371711187Dermatology32720
FELLER MD LANCE S830713334Internal Medicine32885
WILDER DO JOEY D590973502PCP32128
AILANI MD RAJESH K200604706Internal Medicine32720
SHARMA MD AKASH590714831Other55480
OREZZOLI MD LUIS O591296526PCP32114
GRIFFITH MD SUE-ELLEN E932208118PCP32720
SUAH MD MICHAEL J593449961Dermatology32174
ROBERTSON II MD TED E462354804Obstetrics/Gynecology32129
TANNER-ST JAMES MD CAROL590973502PCP32117
MATHURA MD SHIVA A863907911PCP32713
DOUGHNEY MD KATHLEEN B650825133Internal Medicine32127
SANCHEZ ACNP STEPHANIE R873073312PCP32174
ASIF MD MOHAMMED A593256803PCP32724
GUIDO MD JAY C592297461Urology32174
FERNANDEZ-MAYMI MD CARLOS590973502PCP32117
QUADRAT MD OTAKAR592898487Cardiology32114
JAMIDAR MD HUMAYUN A592898487Cardiology32114
1ST STEP THRP LLC27179079434741
ROTHBAUM MD DANIEL L593599451Otolaryngology32763
GANDAM VENKATA MD HIMABIN593657077Anesthesiology32117
BARISH MD JACOB L650825133Oncology (Cancer)30368
MEYERS MD JOHN W542129332Obstetrics/Gynecology32114
ROUGHT PA ARIELLE B593549147Dermatology32713
LA STARZA MD MARK W932208118PCP32174
ADVENTHEALTH LAB59072445930394
AULL DO CODY B842330677Otolaryngology32789
WAITE MD KARL E593454606Ophthalmology32136
HALINSKI MD JOSEPH A812733588PCP32724
FISHMAN MD GARY S590973502Otolaryngology32117
POWELL ARNP BROOKE A591198552PCP32720

&"Arial,Bold"25-P-115TF&"-,Regular" &"Arial,Bold"Attachment A.2

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Pharmacy

PHARMACY NETWORK

Contractor Legal Name:
Instructions: Place an "X" next to each pharmacy that is included in your Company's network as proposed to the County. Leave the field blank if the pharmacy is not part of your network.
NPIPharmacy NameNetwork Pharmacy
1255348330WALGREENS
1316191505PUBLIX
1770916736ACCREDO HEALTH GROUP
1720182637CVS
1316964521WAL-MART
1063645026EXPRESS SCRIPTS
1477740298RX TO GO LLC
1437577988ONCO360
1962013094CARENOW PHARMACY

&"Arial,Bold"25-P-115TF &"Arial,Bold"Attachment A.2

Formulary

DRUG FORMULARY COMPARISON WORKSHEET

Contractor Legal Name:
INSTRUCTIONS: Complete the worksheet below by providing the specific formulary tier for each drug listed. Use "1" for Tier 1, "2" for Tier 2, and "3" for Tier 3. Use "4" for Drugs not covered. Do not re-sort.
NDCDrug NameFormulary Tier
00093317431ALBUTEROL HFA 90 MCG INHALER
00378827052ALBUTEROL SUL 2.5 MG/3 ML SOLN
29300034905ALLOPURINOL 100 MG TABLET
00781106110ALPRAZOLAM 0.25 MG TABLET
00781107710ALPRAZOLAM 0.5 MG TABLET
00781107905ALPRAZOLAM 1 MG TABLET
29300039810AMLODIPINE BESYLATE 10 MG TAB
67877019810AMLODIPINE BESYLATE 5 MG TAB
65862050320AMOX-CLAV 875-125 MG TABLET
00143988701AMOXICILLIN 400 MG/5 ML SUSP
65862001705AMOXICILLIN 500 MG CAPSULE
65862001401AMOXICILLIN 500 MG TABLET
57237002901AMOXICILLIN 875 MG TABLET
51991062090ANASTROZOLE 1 MG TABLET
00378395005ATORVASTATIN 10 MG TABLET
00378395105ATORVASTATIN 20 MG TABLET
00378395205ATORVASTATIN 40 MG TABLET
00378395305ATORVASTATIN 80 MG TABLET
60505083305AZELASTINE 0.1% (137 MCG) SPRY
00781808926AZITHROMYCIN 250 MG TABLET
42806071405BENZONATATE 100 MG CAPSULE
68382009101BENZONATATE 200 MG CAPSULE
11877001140BINAXNOW COVID-19 AG SELF TEST
42192060716BROMPHEN-PSE-DM 2-30-10 MG/5ML
68180031909BUPROPION HCL XL 150 MG TABLET
68180032002BUPROPION HCL XL 300 MG TABLET
00093005401BUSPIRONE HCL 10 MG TABLET
10702025350BUTALB-ACETAMIN-CAFF 50-325-40
67877054360CEFDINIR 300 MG CAPSULE
65862090901CELECOXIB 200 MG CAPSULE
00093314705CEPHALEXIN 500 MG CAPSULE
00116200116CHLORHEXIDINE 0.12% RINSE
00143992801CIPROFLOXACIN HCL 500 MG TAB
00093083205CLONAZEPAM 0.5 MG TABLET
00093321205CLONAZEPAM 1 MG TABLET
29300046810CLONIDINE HCL 0.1 MG TABLET
65862035705CLOPIDOGREL 75 MG TABLET
69680011225CYANOCOBALAMIN 1,000 MCG/ML VL
52817033200CYCLOBENZAPRINE 10 MG TABLET
29300041301CYCLOBENZAPRINE 5 MG TABLET
08627005303DEXCOM G6 SENSOR
00527551337DEXTROAMP-AMPHET ER 20 MG CAP
64850051501DEXTROAMP-AMPHET ER 30 MG CAP
42806034101DEXTROAMP-AMPHETAMIN 10 MG TAB
42806034401DEXTROAMP-AMPHETAMIN 20 MG TAB
00555097402DEXTROAMP-AMPHETAMIN 30 MG TAB
00172392770DIAZEPAM 10 MG TABLET
16571020150DICLOFENAC SOD EC 75 MG TAB
27808023302DOXYCYCLINE HYCLATE 100 MG CAP
42806031250DOXYCYCLINE HYCLATE 100 MG TAB
51991074710DULOXETINE HCL DR 30 MG CAP
51991074810DULOXETINE HCL DR 60 MG CAP
00003089421ELIQUIS 5 MG TABLET
69097084805ESCITALOPRAM 10 MG TABLET
43547028211ESCITALOPRAM 20 MG TABLET
00555088602ESTRADIOL 1 MG TABLET
59651005290EZETIMIBE 10 MG TABLET
00172572860FAMOTIDINE 20 MG TABLET
00172572960FAMOTIDINE 40 MG TABLET
00310621030FARXIGA 10 MG TABLET
57237000511FLUCONAZOLE 150 MG TABLET
50111064801FLUOXETINE HCL 20 MG CAPSULE
60505082901FLUTICASONE PROP 50 MCG SPRAY
11534016503FOLIC ACID 1 MG TABLET
00054429731FUROSEMIDE 20 MG TABLET
49483060550GABAPENTIN 100 MG CAPSULE
45963055650GABAPENTIN 300 MG CAPSULE
00172208380HYDROCHLOROTHIAZIDE 25 MG TAB
00406012505HYDROCODONE-ACETAMIN 10-325 MG
27808003503HYDROCODONE-ACETAMIN 5-325 MG
00406012410HYDROCODONE-ACETAMIN 7.5-325
00093506101HYDROXYZINE HCL 25 MG TABLET
64380080807IBUPROFEN 600 MG TABLET
64380080707IBUPROFEN 800 MG TABLET
00597015330JARDIANCE 25 MG TABLET
00168009960KETOCONAZOLE 2% CREAM
45802046564KETOCONAZOLE 2% SHAMPOO
47781065110LEVOTHYROXINE 100 MCG TABLET
69238183007LEVOTHYROXINE 25 MCG TABLET
47781064310LEVOTHYROXINE 50 MCG TABLET
47781064610LEVOTHYROXINE 75 MCG TABLET
00378180710LEVOTHYROXINE 88 MCG TABLET
43547041611LISINOPRIL 10 MG TABLET
43547041711LISINOPRIL 20 MG TABLET
43547041911LISINOPRIL 40 MG TABLET
43547041511LISINOPRIL 5 MG TABLET
00430042014LO LOESTRIN FE 1-10 TABLET
69315090405LORAZEPAM 0.5 MG TABLET
69315090510LORAZEPAM 1 MG TABLET
43547036211LOSARTAN POTASSIUM 100 MG TAB
43547036011LOSARTAN POTASSIUM 25 MG TAB
43547036111LOSARTAN POTASSIUM 50 MG TAB
68382005105MELOXICAM 15 MG TABLET
68382005005MELOXICAM 7.5 MG TABLET
49483062081METFORMIN HCL 1,000 MG TABLET
49483062210METFORMIN HCL 500 MG TABLET
70010049105METFORMIN HCL ER 500 MG TABLET
31722053301METHOCARBAMOL 500 MG TABLET
70010077001METHOCARBAMOL 750 MG TABLET
59746000103METHYLPREDNISOLONE 4 MG DOSEPK
55111046605METOPROLOL SUCC ER 25 MG TAB
55111046705METOPROLOL SUCC ER 50 MG TAB
00378001805METOPROLOL TARTRATE 25 MG TAB
68645019059METOPROLOL TARTRATE 50 MG TAB
50111033402METRONIDAZOLE 500 MG TABLET
65862057490MONTELUKAST SOD 10 MG TABLET
00002149580MOUNJARO 5 MG/0.5 ML PEN
00002148480MOUNJARO 7.5 MG/0.5 ML PEN
45802011222MUPIROCIN 2% OINTMENT
47781030301NITROFURANTOIN MONO-MCR 100 MG
70700015010OMEPRAZOLE DR 20 MG CAPSULE
65862018730ONDANSETRON HCL 4 MG TABLET
57237007710ONDANSETRON ODT 4 MG TABLET
31722063231OSELTAMIVIR PHOS 75 MG CAPSULE
00406052301OXYCODONE-ACETAMINOPHEN 10-325
00406051205OXYCODONE-ACETAMINOPHEN 5-325
00169418113OZEMPIC 0.25-0.5 MG/DOSE PEN
00169413013OZEMPIC 1 MG/DOSE (4 MG/3 ML)
00169477212OZEMPIC 2 MG/DOSE (8 MG/3 ML)
65862056090PANTOPRAZOLE SOD DR 40 MG TAB
10702002501PHENTERMINE 37.5 MG TABLET
00121075908PREDNISOLONE 15 MG/5 ML SOLN
60219170705PREDNISONE 10 MG TABLET
60219170801PREDNISONE 20 MG TABLET
70436015542PROMETHAZINE-DM 6.25-15 MG/5ML
68462026290ROSUVASTATIN CALCIUM 10 MG TAB
68462026390ROSUVASTATIN CALCIUM 20 MG TAB
82009002030ROSUVASTATIN CALCIUM 40 MG TAB
72205002799ROSUVASTATIN CALCIUM 5 MG TAB
65862001305SERTRALINE HCL 100 MG TABLET
65862001105SERTRALINE HCL 25 MG TABLET
65862001205SERTRALINE HCL 50 MG TABLET
58160082311SHINGRIX VIAL KIT
60219175303SILDENAFIL 100 MG TABLET
68180047903SIMVASTATIN 20 MG TABLET
65862042005SULFAMETHOXAZOLE-TMP DS TABLET
55111029398SUMATRIPTAN SUCC 100 MG TABLET
27241011203TADALAFIL 5 MG TABLET
65862059805TAMSULOSIN HCL 0.4 MG CAPSULE
00574082701TESTOSTERONE CYP 200 MG/ML
55111018015TIZANIDINE HCL 4 MG TABLET
65162062711TRAMADOL HCL 50 MG TABLET
50111056101TRAZODONE 100 MG TABLET
13668033005TRAZODONE 50 MG TABLET
51672128202TRIAMCINOLONE 0.1% CREAM
65862044990VALACYCLOVIR HCL 1 GRAM TABLET
65862044890VALACYCLOVIR HCL 500 MG TABLET
42806054701VITAMIN D2 1.25MG(50,000 UNIT)
00169452414WEGOVY 2.4 MG/0.75 ML PEN
65862016001ZOLPIDEM TARTRATE 10 MG TABLET

&"Arial,Bold"25-P-115TF &"Arial,Bold"Attachment A.2

&"Arial,Regular"Page &P of &N

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