THE UNIFIED GOVERNMENT OF

ATHENS-CLARKE COUNTY(ACCGov)

DATE: April 2, 2026

TO: Pharmaceutical Providers

SUBJECT: RFP # 26030 – Pharmacy Benefit Administration

You are invited to submit a proposal for Pharmacy Benefit Administration, for the Benefits and Wellness Division of Athens-Clarke County Government (ACCGov), Human Resources.

Inquiries regarding proposals should be made to Angie Perteet, Senior Buyer 762-400-6053, email:

angie.perteet@accgov.com or accbids@accgov.com.

The estimated range of this project is $300,000.00.

Attached hereto is the Request for Proposal (RFP) instruction document. The written requirements contained in this (RFP) shall not be changed or superseded except by written addendum from the ACCGov Purchasing Division of the Finance Department. Failure to comply with the written requirements for this proposal may result in rejection of the proposal by ACCGov.

The Unified Government of Athens Clarke County is accepting electronic bid submissions. Bidders shall create a FREE account with OpenGov Procurement by signing up at https://procurement.opengov.com/signup. Once you have completed account registration, browse back to this page, click on "Draft Response", and follow the instructions to submit the electronic bid.

No later than 4:00 P.M. ET, Wednesday, May 6, 2026

A qualified interpreter for the hearing impaired is available upon request at least 10 (ten) days in advance of the proposal opening date. Please call (706) 613-3088 for more information. This service is in compliance with the Americans with Disabilities Act (ADA).

The ACCGov reserves the right to reject any and all proposals, to waive any technicalities or irregularities, and to award the contract based on the highest and best interest of ACCGov.

mailto:angie.perteet@accgov.com mailto:accbids@accgov.com

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TABLE OF CONTENTS

SECTION TITLE

I REQUEST FOR PROPOSAL SUBMISSION INSTRUCTIONS

II REQUEST FOR PROPOSAL OVERVIEW AND PROCEDURES

III SCOPE OF SERVICES

A. INTRODUCTION AND PURPOSE

B. GENERAL REQUIREMENTS

C. ADDITIONAL REQUIREMENTS

D. SPECIFIC TASKS

IV SELECTION PROCESS AND EVALUATION CRITERIA

V MANDATORY PROPOSAL FORMS

A: PROPOSAL FORM

B: ACKNOWLEDGEMENT OF ADDENDA

C: GEORGIA SECURITY & IMMIGRATION COMPLIANCE (GSIC) AFFIDAVIT

D: PROPOSAL – PBM NON-PRICING WORKSHEET

E: SCHEDULE OF PRICE PROPOSAL – PBM PRICING WORKSHEET

VI DOCUMENTS CHECKLIST

ADDITIONAL SUPPORTING DOCUMENTS:

A. ATHENS-CLARKE -202602

B. ATHENS-CLARKE RFP – RECORD LAYOUT

C. ATHENS-CLARKE RFP – ROLLUP SUMMARY AND SAMPLE

D. EMPLOYEE CENSUS

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SECTION I - REQUEST FOR PROPOSAL SUBMISSION INSTRUCTIONS

ALL PROPOSALS RECEIVED WILL BECOME A PART OF THE OFFICIAL CONTRACT FILE AND

MAY BE SUBJECT TO DISCLOSURE.

A complete signed proposal must include the documents listed below:

PROPOSAL FORMAT: Offerors are expected to examine the specifications, price schedule, and all instructions. Failure to do so will be at the offeror’s risk. Each offeror shall furnish the information required by the solicitation. The proposal and price schedule must be signed by an officer of the company, who is legally authorized to enter into a contractual relationship in the name of the offeror.

All proposals received will become a part of the official contract file and may be subject to disclosure.

PROPOSAL FORMAT: All proposals should include the information outlined below and in the following order:

1. Cover Letter: A brief cover letter of introduction and interest.

2. Table of Contents: Including all sections and subsections.

3. Business Information: State the full name and address of your organization and the branch office or subordinate element that will perform the services described in this proposal. Include a telephone number, the point of contact and official signature of an authorized company representative. Indicate whether you operate as a single proprietorship, partnership, or corporation. Include the state(s) in which you are incorporated and/or licensed to operate.

4. Qualifications and Experience: Include an organization chart and summary resumes of key personnel proposed for the project, including designations of the team leader, the person responsible for all proposed communications with the owner and all proposed sub-consultants and a description of their roles.

a. Current Project Assignments: Identify the current project assignment(s) and the currently identified completion date(s) for projects currently being managed by the key individuals proposed for our project.

b. Understanding of the Project: Statement of the firm's understanding of the project and proposed approach for providing requested services.

c. Additional Services Required: Based on the firm's understanding of the project, identify any additional services that might be required for a successful program.

5. References/Reference Projects: Include a minimum of three references for contracts of a similar nature, preferably public sector references. Include the name, address, telephone number, point of contact and description of the contract for each reference.

6. Financial Information and Documentation: Provide relevant information regarding organizational stability and strength. Documentation may include: A statement of organizational structure (e.g., sole proprietorship, partnership, corporation, joint venture, etc.), information regarding the make-up of that structure (e.g., owner, partners, board of directors, joint venture partners, etc.), a listing of financial references.

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7. Other Relevant Information: Include any other relevant information concerning the project in this section.

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THE UNIFIED GOVERNMENT OF ATHENS-CLARKE COUNTY

REQUEST FOR PROPOSAL (RFP)

RFP # 26030 – PHARMACY BENEFIT ADMINISTRATOR

ATHENS-CLARKE COUNTY HUMAN RESOURCES DEPARTMENT

ATHENS, GEORGIA

SECTION II - REQUEST FOR PROPOSAL OVERVIEW AND PROCEDURES

A. INTRODUCTION

PURPOSE

ACCGov desires to solicit competitive proposals from responsible vendors to provide a Pharmacy Benefit Management services for the Benefits and Wellness Division of the Human Resources Department, Athens, Georgia. ACCGov plans to enter into an agreement with the selected vendor effective January 1, 2027, for an initial period of 12 months. The vendor must guarantee first contract period rates/fees through December 31, 2027, and the the contract will automatically renew for additional one-year terms as noted under contract terms.

The contractor will provide services per the scope of services as indicated in Section III of this request for proposal (RFP).

B. RFP TIMETABLE

The anticipated schedule for the RFP and contract approval is as follows:

Proposal Documents Available…………………Thursday, April 2, 2026 Deadline for submission of questions ................ .. 2:00 P.M. ET Friday, April 17, 2026 Deadline for receipt of proposal ........................ ..4:00 P.M. ET, Wednesday, May 6, 2026 Proposals Valid Until ......................................... Minimum of 120 days from date of opening.

C. CONTACT PERSON

The contact person for this RFP is Angie Perteet, Senior Buyer. Question regarding this RFP must be requested from the contact person, in writing on the OpenGov website https://procurement.opengov.com/.

Offerors are encouraged to contact only the contact person stated above to clarify any part of this RFP.

Any such unauthorized contact shall not be used as a basis for responding to this RFP and also may result in the rejection of the offeror's submittal.

D. MINIMUM PROPOSAL ACCEPTANCE PERIOD

Proposals shall be valid and may not be withdrawn for a period of 120 days from the date specified for receipt of proposals.

E. ADDITIONAL INFORMATION/ADDENDA

ACCGov will issue responses to inquiries and any other corrections or amendments it deems necessary in written addenda issued prior to the proposal due date. Offerors should not rely on any representations, statements or explanations other than those made in this RFP or in any addendum to this RFP. Where there appears to be a conflict between the RFP and any addenda issued, the last addendum issued will prevail.

https://procurement.opengov.com/

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Request for additional information or clarifications must be made in writing no later than the date specified in the RFP Timetable. The request must contain the offeror's name, address, phone number, and email address.

Offerors must acknowledge any issued addenda. Proposals which fail to acknowledge the offeror’s receipt of any addendum will result in the rejection of the proposal if the addendum contained information which substantively changed the Owner’s requirements

Offerors who obtain this Request for Proposal from Georgia Procurement Registry, OpenGov Procurement or from other than the Purchasing Division are advised to re-visit the above websites to obtain any addenda which may be issued prior to the proposal closing date. ACCGov assumes no responsibility for Offerors’ failure to acknowledge any addenda issued.

F. LATE PROPOSALS, WITHDRAWALS, MODIFICATIONS AND REJECTIONS

Proposals shall not be modified, withdrawn, or canceled by the offeror for a period of one hundred twenty

(120) days following the time and date designated for the receipt of proposals, and each offeror so agrees in submitting his proposal. Negligence on the part of the Offeror in the preparation of his proposal shall not be grounds for the modification or withdrawal of a proposal after the time set for proposal closing.

Proposals received after the proposal due date and time are late and will not be considered. Modifications received after the proposal due date are also late and will not be considered.

G. PROPOSAL CLOSING

Proposal schedule prices will not be opened or read aloud publicly. A list of names of firms providing proposals may be obtained from Georgia Procurement Registry or via email request to E-Mail:

accbids@accgov.com after the proposal due date and time stated herein. A tabulation of prices may be obtained upon award.

H. NON-COLLUSION AFFIDAVIT

By submitting a proposal, the offeror represents and warrants that such proposal is genuine and not sham or collusive or made in the interest or on behalf of any person not therein named and that the offeror has not directly or indirectly induced or solicited any other offeror to put in a sham proposal, or any other person, firm or corporation to refrain from proposing and that the offeror has not in any manner sought by collusion to secure to that offeror any advantage over any other offeror.

By submitting a proposal, the offeror represents and warrants that no official or employee of ACCGov has, in any manner, an interest, directly or indirectly in the proposal or in the contract which may be made under it, or in any expected profits to arise therefrom.

I. GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT AFFIDAVIT

By submitting a proposal and executing the attached Affidavits, the offeror verifies its compliance with O.C.G.A. §13-10-91. The offeror further agrees to maintain records of such compliance and shall provide a copy of each such verification to ACCGov, at the time the subcontractor(s) is retained to perform such services.

http://ssl.doas.state.ga.us/PRSapp/PR_index.jsp http://ssl.doas.state.ga.us/PRSapp/PR_public_routing.jsp?route_code=nigp_list mailto:accbids@athensclarkecounty.com

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J. COST INCURRED BY OFFERORS

All expenses involved with the preparation and submission of proposals to the ACCGov, or any work performed in connection therewith shall be borne by the offeror(s). No payment will be made for any responses received or for any other effort required of or made by the offeror(s) prior to the commencement of work as defined by a contract approved by the governing body of ACCGov.

K. EQUAL OPPORTUNITY POLICY STATEMENT

It is the policy of ACCGov that no person or business shall be excluded from participation, denied the benefits of, or otherwise discriminated against in relation to the award and performance of any contract or subcontract on the grounds of race, color, creed, national origin, age, or sex.

L. HOLD HARMLESS AND INDEMNIFICATION

The Offeror agrees, insofar as it legally may, to indemnify and hold harmless ACCGov, its officers, employees and agents from and against all loss, costs, expenses, including attorneys' fees, claims, suits and judgments, whatsoever in connection with injury to or death of any person or persons or loss of or damage to property resulting from any and all operations performed by Offeror, its officers, employees, and agents under any of the terms of this contract.

M. AWARD OF CONTRACT

This is a past performance/technical/price trade-off source selection in which competing offeror’s past and present performance history and technical ability will be evaluated on a basis approximately equal to price. Award will be made to the responsible offeror whose proposal represents the best value after evaluation in accordance with the factors listed in Section IV herein. ACCGov may reject any or all proposals if such action is in the Unified Government’s interest.

N. QUALIFICATION OF OFFERORS

ACCGov may make such reasonable investigations as deemed proper and necessary to determine the ability of the offeror to perform the work and the offeror shall furnish to the Unified Government all such information and data for this purpose as may be requested. ACCGov reserves the right to reject any proposal if the evidence submitted by, or investigations of, such offeror fails to satisfy the Unified Government that such offeror is properly qualified to carry out the obligations of the contract and to complete the work contemplated therein.

ACCGov contractors/vendors must have a current Athens-Clarke County business license if they are physically located in Athens-Clarke County or if they perform a service in Athens-Clarke County.

Proposals from any offeror that is in default on the payment of any taxes, license fees, or other monies due to the Unified Government will not be accepted.

O. ALTERNATE PROPOSALS

Alternate proposals or proposals that deviate from the requirements of this solicitation will not be considered. Offerors shall not insert in their proposal any written statement which will have the effect of making any material change or changes in the Scope of Services or in any contract between the parties covering subject matter thereof.

P. OPEN RECORDS

In accordance with OCGA Section 50-18-72(a)(34) Any trade secrets obtained from a person or business entity that are required by law, regulation, bid, or request for proposal to be submitted to an agency. An entity submitting records containing trade secrets that wishes to keep such records confidential under this paragraph shall submit and attach to the records an affidavit affirmatively declaring that specific information in the records constitute trade secrets pursuant to Article 27 of Chapter 1 of Title 10. If such entity attaches such an affidavit, before producing such records in response to a request under this

Page | 8 article, the agency shall notify the entity of its intention to produce such records as set forth in this paragraph.

If the agency makes a determination that the specifically identified information does not in fact constitute a trade secret, it shall notify the entity submitting the affidavit of its intent to disclose the information within ten days unless prohibited from doing so by an appropriate court order. In the event the entity wishes to prevent disclosure of the requested records, the entity may file an action in superior court to obtain an order that the requested records are trade secrets exempt from disclosure. The entity filing such action shall serve the requestor with a copy of its court filing. If the agency makes a determination that the specifically identified information does constitute a trade secret, the agency shall withhold the records, and the requester may file an action in superior court to obtain an order that the requested records are not trade secrets and are subject to disclosure;

Q. NON-DISCRIMINATION ORDINANCE

Contractor agrees to abide by and be bound by Chapter 6-21 of the Code of Athens-Clarke County, Georgia, regarding Unlawful Discrimination and agrees to ensure that any and all subcontractors operating pursuant to this solicitation also agree to abide by and be bound by Chapter 6-21 of the Code of Athens-Clarke County, Georgia.”

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SECTION III - SCOPE OF SERVICES

The contractor shall provide all personnel, equipment, tools, materials, supervision, and other items and services necessary for Pharmacy Benefit Administration as per the scope of services outlined below for the period of the awarded contract.

A. INTRODUCTION AND PURPOSE

ACCGov is a unified city/county government located in the northeast section of the state of Georgia and is approximately sixty (60) miles northeast of Atlanta, Georgia. ACCGov (the government’s official name) was formed in 1991 by a referendum which required the combining of The City of Athens and Clarke County. ACCGov serves an area population of approximately 100,000 with annual growth projected at 1% per year. ACCGov provides a multitude of local and state-funded services, which includes, but is not limited to, Public Safety, Utility, Courts, Corrections, Tax and Fire Services.

ACCGOV employs approximately 1,500 full-time benefit eligible people and has approximately 800 benefit eligible retirees.

ACCGov provides self-funded health insurance coverage to approximately 1,500 benefit eligible employees and 800 retirees.

ACCGov is requesting proposals from vendors for self-insured pharmaceutical insurance coverage and benefit management for full-time employees, long term disability recipients, COBRA participants, and retirees of all ages, as well as, eligible dependents.

B. GENERAL REQUIREMENTS

1. Contract Performance Period: Contract performance period shall be from January 1, 2027, for twelve (12) months unless terminated by either party giving to the other written notice of termination in writing sixty (60) days prior to the proposed date of termination.

C. ADDITIONAL REQUIREMENTS

1. CONTRACT TERMS

All contracts will be awarded for an initial term of one (1) year, with the contracts automatically renewing for four (4) additional one-year renewal terms, subject to either party having the right of non-renewal upon written notice to the other as set forth in the contract.

The laws of the State of Georgia will govern the interpretation and the subject matter of any contract awarded under this solicitation.

The proper venue for any dispute arising out of the contract awarded under this solicitation or its subject matter will be the Superior Court of Athens-Clarke County, Georgia, or if federal jurisdiction is applicable, the United States District Court for the Middle District of Georgia, Athens Division.

No contract shall contain mandatory arbitration provisions nor require waiver of the right to a trial by jury.

No contract shall contain any provisions that violate the laws of the State of Georgia, including the Constitution of the State of Georgia. Such provisions include, but are not necessarily limited to, the following:

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• Provisions that require ACCGov to indemnify the vendor or hold the vendor harmless.

• Provisions that purport to require ACCGov to pay late payment penalties or interest.

• Provisions that purport to bind future commissions.

• Any confidentiality provisions that conflict with the Georgia Open Records Act or the

Georgia Open Meetings Act.

No contract will require ACCGov to add a vendor as an additional insured to its policies of insurance or risk pool coverage.

No contract will require ACCGov to pay any taxes that it is not otherwise legally obligated to pay under the laws of the United States or the State of Georgia.

When entering into a contract with ACCGov, a vendor must acknowledge the provisions of Chapter 6-21 of the Code of Athens-Clarke County, Georgia, entitled "Unlawful Discrimination," and to the extent applicable to the goods and/or services provided under the contract, agree to abide by said chapter.

By submitting a proposal in response to this RFP, the offeror understands and acknowledges that ACCGov is a local governmental entity in the State of Georgia and is therefore subject to certain responsibilities, restrictions, and immunities under the law. Any contractual provision that conflicts with any such responsibility, restriction, or immunity will be deemed null and void and have no effect whatsoever.

ACCGov reserves the right to require any entity contracting with ACCGov to present documentary proof that the person signing a contract on behalf of the entity has the authority to bind the entity to the contract.

Any proposed contracts submitted by a selected vendor will be subject to legal review. To expedite legal review, ACCGov requests that vendors ensure that any proposed contracts comply with the guidelines listed above.

2. TERMINATION FOR CAUSE: ACCGov reserves the right to terminate the resulting contract, in whole or in part, for failure to comply with any provisions of the contract as outlined by providing a written notice to the successful vendor at least ten (10) days before the effective date of termination. The successful vendor will not be relieved of any outstanding responsibilities or unfinished obligations under this contract.

The successful vendor has the right to terminate this contract for cause by providing a written notice of intent to the Purchasing Administrator to terminate at least sixty (60) days prior to the effective date of the contract termination.

3. TERMINATION WITHOUT CAUSE: ACCGov reserves the right to terminate the contract at any time without cause, in whole or in part, by providing a written notice to the other party at least thirty (30) days before the effective date of termination. The other party will not be relieved of any outstanding responsibilities or unfinished obligations under this contract that were incurred prior to termination.

4. CHANGES: Changes in the terms and conditions of this contract may be made only by written agreement of the parties.

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5. INSURANCE

Before commencing work under the contract, Contractor shall procure and maintain insurance which shall protect the Contractor and ACCGov from any claims for bodily injury, property damage, or personal injury which may arise out of operations under the agreement. Contractor shall procure the insurance policies at the Contractor’s own expense and shall furnish ACCGov an insurance certificate listing ACCGov as certificate holder. The insurance certificate must document that the liability insurance coverage purchased by the Contractor includes contractual liability coverage to protect ACCGov. The insurance certificate must provide the following information:

1) Name and address of authorized agent

2) Name and address of insured

3) Name of insurance company (licensed to operate in Georgia)

4) Description of coverage in standard terminology

5) Policy period

6) Limits of liability

7) Name and address of certificate holder (ACCGov)

8) Acknowledgement of notice of cancellation to ACCGov

9) Signature of authorized agent

10) Telephone number of authorized agent

11) Details of policy exclusions in comments section of insurance certificate

12) Additional Insured Endorsement

13) Reference to the proposal and project name

Note: It is the intent of ACCGov that certificates of insurance should comply with the pertinent Rules of the Commissioner of Insurance, which are found in Chapter 120-2-103 of the Official Compilation of the Rules and Regulations of the State of Georgia.

Each policy shall contain a provision that coverage afforded under the policies will not be canceled (or not renewed or allowed to lapse for any reason) until at least thirty (30) days after Owner has received notice thereof as evidenced by return receipt of registered letter. All policies must be issued by an insurance company licensed to do business in the State of Georgia, with a minimum AM Best rating of A-, and signed by an authorized agent.

The Contractor must submit, along with insurance certificate(s), an additional insured endorsement for all coverages as allowed by statute naming the Unified Government of Athens Clarke County, and a notice of cancellation endorsement. A Waiver of Subrogation must be provided for Worker’s Compensation coverage.

Coverages and Limits Required:

Workers Compensation (WC):

Workers Compensation Insurance (per Occurrence) in the amounts of the statutory limits established by the General Assembly of the State of Georgia (a self-insurer must submit a certificate from the Georgia Board of Works Compensation stating that the supplier qualifies to pay its own workers compensation claims). In addition, the supplier shall require all subcontractors occupying the premises or performing work under the contract to obtain an insurance certificate showing proof of Workers Compensation Coverage with the following minimum coverage:

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• Bodily injury by accident – per employee $1,000,000

• Bodily injury by disease – per employee $1,000,000

• Bodily injury by disease – policy limit $1,000,000

Commercial General Liability (CGL):

• Each Occurrence Limit $1,000,000

• Personal & Advertising Injury Limit $1,000,000

• General Aggregate Limit $2,000,000

• Products/Completed Ops. Aggregate Limit $2,000,000

Automobile Liability:

• Combined Single Limit $1,000,000

Professional Liability: $2,000,000

Cyber Liability: $5,000,000

• Per occurrence basis; if policy is claims made a retroactive date must be provided.

Umbrella Liability: $2,000,000

• Per occurrence basis.

Additional Insured: The vendor or contractor shall add “the Unified Government of Athens-Clarke County, its officers, employees, and agents” as an additional insured under the commercial general liability, automobile, and umbrella liability policies. The additional insured endorsement must be provided.

The Contractor shall insert the substance of this requirement, including this paragraph, in subcontracts under the contract that require work on ACCGov property and shall require subcontractors to provide and maintain a copy of all subcontractors’ proofs of required insurance, and shall make copies available to the Purchasing Administrator upon request.

D. SPECIFIC TASKS:

Pharmacy Benefit Management work shall include, but not be limited to the following:

Pharmacy “carve out” benefit. Provide pharmacy benefit management services with complete and detailed data review and analytic options. Approved vendor will process prescription drug claims, negotiate discounts and rebates with appropriate drug manufacturers and retailers, and maintain an approved drug formulary.

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SECTION IV - SELECTION PROCESS AND EVALUATION CRITERIA

ACCGov intends to evaluate proposals and award a contract without discussions with offerors. Therefore, the offeror’s initial proposal should contain the offeror’s best terms from a price and technical standpoint. The Unified Government reserves the right to conduct discussions if the Unified Government later determines them to be necessary.

EVALUATION CRITERIA

Evaluation criteria to be used in determining the selected firm in order of importance are:

PHASE 1: Technical Approach

1. ACCOUNT MANAGEMENT see applicable questions/answers. 20 points

2. GENERAL MARKET EXPERIENCE see applicable questions/answers. 15 points

3. ADDITIONAL BENEFITS, SERVICES, PROGRAMS 15 points

4. UNDERSTANDING OF THE REQUIREMENT and ability to meet RFP defined needs.

10 points

5. REFERENCES including applicable past work with the ACCGov. 10 points

PHASE 2: Pricing

1. PRICING including adequacy and relevancy for the performance of the requirements of the contract. 30 points

PROPOSAL EVALUATION AND CONTRACT AWARD

ACCGov intends to evaluate proposals and award a contract, without discussions with offerors. Any awards made under this solicitation will be made to a responsible offeror whose proposal represents the best value after evaluation in accordance with the factors listed in Section IV herein. ACCGov intends to evaluate proposals and award a single contract for the services represented in this solicitation. ACCGov presently intends to issue solicitations for other employee benefits at the same time or concurrently with this solicitation. Each solicitation will be awarded separately and have its own stand-alone contract; services will not be combined into a single contract even if the same entity (or related entities) is awarded multiple benefits solicitations. ACCGov may reject any or all proposals if such action is in the Unified Government's interest.

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SECTION V – PROPOSAL FORMS

A: PROPOSAL FORM

Proposal of___________________________________________________________

(Hereinafter called "Offeror"), organized and existing under the laws of the State of

__________________________, doing business as ________________________________*.

In compliance with your RFP, the Offeror hereby proposes and agrees to perform and furnish all work for the requirement known as RFP # 26030 Pharmacy Benefit Administration in strict accordance with the Proposal Documents, within the time set forth therein, and at the price proposed.

By submission of this Proposal, the Offeror certifies, and in the case of a joint Offer, each party thereto certifies as to its own organization that:

1. The Offeror has examined and carefully studied the Proposal Documents and the Addenda, receipt of all of which is hereby acknowledged at Section V-B.

2. The Offeror agrees that this proposal may not be revoked or withdrawn after the time set for the opening of proposals but shall remain open for acceptance for a period of one hundred twenty (120) days following such time.

Company:

Contact:

Address:

Phone: Fax

Email:

By checking this box, I acknowledge that I have read all insurance requirements and will meet requirements listed in RFP # 26030 Pharmacy Benefit Administration if awarded.

Authorized Representative/Title (print or type)

Authorized Representative (Signature)

Date

MANDATORY SUBMITTAL

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B: ADDENDA ACKNOWLEDGEMENT

The Offeror has examined and carefully studied the Specifications and the following Addenda, Receipt of all of which is hereby acknowledged:

Addendum No.

dated

Acknowledgement

Initial

Offerors must acknowledge any issued addenda. Proposals which fail to acknowledge the offeror’s receipt of any addendum will result in the rejection of the proposal if the addendum contained information which substantively changes the Owner’s requirements.

Company Name (printed):

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C: GEORGIA SECURITY & IMMIGRATION COMPLIANCE (GSIC) AFFIDAVIT

The Unified Government of Athens-Clarke County and Contractor agree that compliance with the requirements of O.C.G.A.

§ 13-10-91, as amended, and Rule 300-10-1-.02 of the Rules of the Georgia Department of Labor are conditions of this Agreement for the physical performance of services.

The Contractor further agrees that its compliance with the requirements of O.C.G.A. § 13-10-91, as amended, and DOL Rule 300-10-1-.02 is attested to on the executed Contractor Affidavit and Agreement attached hereto.

If employing or contracting with any subcontractor(s) in connection with this Agreement, Contractor further agrees:

(1) To secure from the subcontractor(s) an affidavit attesting to the subcontractor’s compliance with O.C.G.A. § 13-10-91, as amended, and DOL Rule 300-10-1-.02; such affidavit being in the form attached hereto; and

The failure of Contractor to supply the affidavit of compliance at the time of execution of this Agreement and/or the failure of Contractor to continue to satisfy the obligations of O.C.G.A. § 13-10-91, as amended, and DOL Rule 300-10-1-.02 as set forth in this Agreement throughout the contract period shall constitute a material breach of the contract. Upon notice of such breach, Contractor shall be entitled to cure the breach within ten days, upon providing satisfactory evidence of compliance with the terms of this Agreement and State law. Should the breach not be cured, Athens-Clarke County shall be entitled to all available remedies, including termination of the contract and damages.

SEE AFFIDAVIT ON FOLLOWING PAGE

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C: CONTRACTOR AFFIDAVIT & AGREEMENT UNDER O.C.G.A. § 13-10-91(b)(1)

By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, as amended, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf of The Unified Government of Athens-Clarke County, Georgia, has registered with, is authorized to use, and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the provisions and deadlines established in O.C.G.A. § 13- 10-91, as amended.

Furthermore, the undersigned will continue to use the federal work authorization program throughout the contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of such contract only with subcontractors who present an affidavit to the contractor with the information required by O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

Federal Work Authorization Company Identification Number Date of Authorization

Name of Contractor: _______________________________________________________________

Name of Project: _______________________________________________________________

Name of Public Employer: The Unified Government of Athens-Clarke County

I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on ____, ___________, 202__ in _______________________, _____________________.

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE

____ DAY OF ____________, 202_

Notary Public My Commission Expires:

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D: SCHEDULE OF SERVICES OR PRICE/PROPOSAL SCHEDULE

See pricing section located in the OpenGov Procurement Website (see link below)

(Pricing Worksheet must be submitted separately from Proposal)

* Pricing Form/Worksheet - (PBM RFP Pricing-Financial Document) is a separate attachment posted with this RFP **

Company Name (printed):

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SECTION VI DOCUMENTS CHECKLIST:

PROPOSAL DOCUMENTS CHECKLIST:

1. Cover Letter

2. Table of Contents

3. Business Information

4. Qualifications and Experience

5. References/Reference Projects

6. Financial Information and Documentation

7. Other Relevant Information

MANDATORY PROPOSAL FORMS (SECTION V) Offeror must complete, execute and include with the proposal the following mandatory documents:

A. Proposal form

B. Acknowledgement of Addenda

C. Georgia Security & Immigration Compliance (GSIC) Act Affidavit

D. Proposal – PBM Non-Pricing Worksheet

E. Schedule of Price Proposal – PBM Pricing Worksheet

ADDITIONAL SUPPORTING DOCUMENTS:

A. Athens-Clarke-202602

B. Athens-Clarke RFP – Record Layout

C. Athens-Clarke RFP - Rollup Summary and Sample

D. ACCGov Employee Census

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Q. NON-DISCRIMINATION ORDINANCE