HMO_Attachment D - Cost.xlsx
XLSX spreadsheet 577 KB Posted
- Attached to
- TPA Services for HMO
- Solicitation number
- ITN-02183
- Issued by
- Leon County, Florida
About this file
This document is an attachment to an Invitation to Negotiate (ITN) issued by the State of Florida, Department of Management Services (Department) for Third Party Administrative (TPA) Services for Health Maintenance Organization (HMO) coverage. The ITN is seeking pricing proposals for the administration of the state's current Standard and High-Deductible HMO plan options, including claims adjudication, customer service, network access/management, and care management. Respondents must provide fixed core administrative fees for an initial three-year contract term from 2024-2026, with up to three one-year renewal options through 2029. The ITN covers the State of Florida, as well as the jurisdictions of Leon County and the city of Tallahassee.
The pricing attachment requires respondents to indicate whether pharmacy benefits will be carved-in or carved-out to a separate Pharmacy Benefit Manager (PBM), and to exclude any broker or consultant commissions. Respondents must provide detailed fixed administrative fees on a per-member-per-month (PEPM) basis for each plan year of the contract term. The ITN does not mention any set-asides, incumbent providers, or specific funding sources, but indicates the state is self-insured for these HMO medical plan offerings.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Addendum No. 4.pdf | ||
| DMS-2223-072 HMO ITN.pdf | ||
| Revised Forms 5b and 6b.pdf | ||
| HMO_Attachment B - Technical.xlsx | XLSX spreadsheet | |
| HMO_Attachment E -Draft Contract.pdf | ||
| HMO_Attachment G - Benefits Doc_HMOSPD_2022.pdf | ||
| HMO_Attachment H - Data Use Agreement.pdf | ||
| Revised Attachment E -Draft Contract.pdf | ||
| Addendum No. 3.pdf | ||
| Attachment H2 - Data Use Agreement.pdf | ||
| HMO_Attachment C - Network.xlsx | XLSX spreadsheet | |
| HMO_Attachment F - BAA.pdf | ||
| Questions and Answers HMO.pdf | ||
| DMS-2223-072_Addendum No. 1.pdf | ||
| HMO Addendum No. 2.pdf | ||
| HMO_Attachment A - Administrative Requirements_07.27.2022.xlsx | XLSX spreadsheet | |
| HMO_Attachment D - Cost_09.12.2022.xlsx | XLSX spreadsheet | |
| Revised Attachment A - Administrative Requirements_9.9.22.xlsx | XLSX spreadsheet | |
| Revised Attachment B - Technical_9.9.22.xlsx | XLSX spreadsheet |
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ASO HMO Fees
| Invitation to Negotiate (ITN) for the State of Florida, Department of Management Services (Department) |
| HMO Medical |
| Medical Pricing - Self-Insured HMO with Carve-in / Carve-out Rx Services |
| Respondent Name: |
| [Insert Respondent Name Here] |
| Indicate Carve-in or Carve-out |
| [Indicate Carved-in / Carved-out] |
| ■ Fees must be provided for an initial three year contract (entirety of 2024 - 2026) plus up to three optional one year renewals (occurring in 2027, 2028 and 2029). |
| ■ Self-Insured Administrative Services Only (ASO) fees should be input in this tab. Below fees should assume pharmacy benefit is carve-out to a separate PBM and NO commissions are paid to any broker or consultant. |
| ■ Base fees assuming administration of current two plan options - Standard and HDHP HMOs. See Attachment A - Administrative Requirements, Read Me First tab for additional information on how to access detailed plan designs. |
Fixed Core Administrative Fees (PEPM)
Please note, yellow shaded cells below are formula driven. When adding rows for additional services, please follow instructions on where to add additional rows so costs are captured in calculations
| In the event the Respondent doesn’t properly add necessary information in the rows as instructed, such provided information may be considered in calculating the total fixed core administration fees. | ||
| Plan Year 1/1/2024 through 12/31/2024 | ||
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2025 through 12/31/2025 | |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2026 through 12/31/2026 | |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2027 through 12/31/2027 | |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2028 through 12/31/2028 | |
| (Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract) | Plan Year 1/1/2029 through 12/31/2029 |
(Incurred - fees to cover administering claims incurred after the effective date of the plan year, even if paid after the end of the contract)
| Core Administration Fee = Includes Claims Adjudication + Customer Service + Network Access/ Management + Care Management |
| Region 1 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Region 2 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Region 3 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Region 4 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Region 5 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Region 6 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Region 7 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Region 8 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Region 9 |
| <10,000 Subscribers |
| 10,000 - 19,999 Subscribers |
| 20,000 - 34,999 Subscribers |
| 35,000+ Subscribers |
| Standard Reports |
| Nurse Line |
| Telemedicine Service Fee for any available services from external vendor |
(PCP, Behavioral Health, Dermatology) Any Other Administrative or Carve-Out Vendor Fees (For example, radiology precertification, etc.)
Add additional rows as necessary below this row.
Any Other Service/Program Included in Core Administration Fee above Add rows as necessary above this row
| Total of Fixed Core Administration Fees = core administration fee + standard reports + nurse line + telemedicine service + administrative fees + carve-out fees. | ||||||
| Region 1 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Region 2 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Region 3 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Region 4 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Region 5 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Region 6 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Region 7 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Region 8 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Region 9 | ||||||
| <10,000 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 10,000 - 19,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 20,000 - 34,999 Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| 35,000+ Subscribers | $0 | $0 | $0 | $0 | $0 | $0 |
| Claims Per Subscriber Per Month |
| Capitation Claim Amounts (if applicable). |
| To what services do these amounts pertain? |
| Do these amounts vary by any counties in FL, GA or AL? If so, describe how. |
| Case Management and Utilization Management |
Confirm each of the below services are included in the core fee provided above.
| Asthma case management | |||||||||
| Back case management/discounts | |||||||||
| Cancer case management | |||||||||
| Chronic condition case management | |||||||||
| Congestive heart failure case management | |||||||||
| Diabetes case management | |||||||||
| Depression and anxiety case management | |||||||||
| Family planning case management | |||||||||
| Heart disease case management. | |||||||||
| Hypertension case management. | |||||||||
| Low back pain/injury case management. | |||||||||
| Lung conditions (except asthma) case management. | |||||||||
| Muscle or joint problems case management. | |||||||||
| Neonatal intensive case management | |||||||||
| Patient management | |||||||||
| Prenatal case management | |||||||||
| Rheumatoid arthritis case management | |||||||||
| Complex Comorbidities case management | |||||||||
| Catastrophic injury case management | |||||||||
| Hospice case management | |||||||||
| Behavioral health case management | |||||||||
| Pre-admission verification/authorization | |||||||||
| Pre-admission outreach | |||||||||
| Inpatient admission/concurrent review | |||||||||
| Discharge planning | |||||||||
| Post discharge outreach | |||||||||
| Retrospective review | |||||||||
| Outpatient surgical review/prior authorization | |||||||||
| Outpatient imaging review/prior authorization | |||||||||
| Home health care (include scope of services covered in Explanation) | |||||||||
| Durable medical equipment review | |||||||||
| Physical therapy review | |||||||||
| Occupational therapy review | |||||||||
| Speech therapy review | |||||||||
| Predictive technology | |||||||||
| High-risk outreach | |||||||||
| Episodic case management | |||||||||
| Complex case management | |||||||||
| Demand management/nurse triage | |||||||||
| Impact to Administrative Fees | PY 2024 | PY 2025 | PY 2026 | PY 2027 | PY 2028 | PY 2029 | |||
| If Respondent is NOT awarded pharmacy benefits as part of its HMO response, what impact, if any, will there be to the above HMO administrative fees? If so, detail (as a PEPM offset). | |||||||||
| Provider Networks | Reply | Explanation | |||||||
| Confirm the provider network that you are proposing and basing your above quoted premiums, represents your broadest provider network? | |||||||||
| Do you have an alternative (e.g., narrower) provider network that would be available? If so, describe in "Explanation" column basis/ fundamentals for this alternative. | |||||||||
| If so, what would the impact be on the above proposed fees should the State choose to offer a broad network? | |||||||||
| If so, what would the impact be on the above proposed fees should State choose to offer a narrow network? | |||||||||
| If so, what approximate impact on claims under this alternative network should Department expect, for the counties in which you are proposing to be offered? | |||||||||
| Any Additional Programs Available Not Identified Above | |||||||||
| Include Fees and Any ROI Guarantees | Reply | Explanation | |||||||
| Insert here and describe in "Explanation" column. | |||||||||
| Insert here and describe in "Explanation" column. | |||||||||
| Add Rows as Needed | |||||||||
| Broker Commissions | Reply | Explanation | |||||||
| Confirm proposed fees are net of commissions (no commissions) |
| Service Area | |||
| Confirm the service areas to which your above proposed HMO fixed core administrative fees apply based on the Department defined HMO service areas. The Department allows employees to elect HMO coverage utilizing either their listed "work county" or the county in which their permanent residence is located. (Note - enrollment in a Respondent's option is limited to the regions Respondent is awarded as a result of this ITN, but a Respondent's plan access will be "opened" beyond the counties included in each awarded region. For example, a Respondent's plan is awarded HMO services for region 3 only; however, the Respondent's plan operates in every county in FL and members who reside or work in region 3 and are enrolled in the Respondent's plan may seek care from network providers in any county in the state or outside of the state when network physicians and facilities are available.) | |||
| Regions | Confirm Access in Responding Regions | Explanation (e.g., access only available in portions of the indicated county) | |
| Region 1 | Bay | ||
| Calhoun | |||
| Escambia | |||
| Gulf | |||
| Holmes | |||
| Jackson | |||
| Okaloosa | |||
| Santa Rosa | |||
| Walton | |||
| Washington | |||
| Region 2 | Franklin | ||
| Gadsden | |||
| Jefferson | |||
| Leon | |||
| Liberty | |||
| Madison | |||
| Taylor | |||
| Wakulla | |||
| Region 3 | Alachua | ||
| Bradford | |||
| Columbia | |||
| Dixie | |||
| Gilchrist | |||
| Hamilton | |||
| Lafayette | |||
| Levy | |||
| Marion | |||
| Suwannee | |||
| Union | |||
| Flagler | |||
| Region 4 | Baker | ||
| Clay | |||
| Duval | |||
| Nassau | |||
| Putnam | |||
| St Johns | |||
| Volusia | |||
| Region 5 | Brevard | ||
| Indian River | |||
| Lake | |||
| Orange | |||
| Osceola | |||
| Seminole | |||
| Region 6 | Citrus | ||
| Desoto | |||
| Hardee | |||
| Hernando | |||
| Highlands | |||
| Hillsborough | |||
| Manatee | |||
| Pasco | |||
| Pinellas | |||
| Polk | |||
| Sarasota | |||
| Sumter | |||
| Region 7 | Martin | ||
| Okeechobee | |||
| Palm Beach | |||
| St Lucie | |||
| Region 8 | Charlotte | ||
| Collier | |||
| Glades | |||
| Hendry | |||
| Lee | |||
| Region 9 | Broward | ||
| Miami-Dade | |||
| Monroe | |||
| Georgia | Brooks | ||
| Camden | |||
| Charlton | |||
| Clinch | |||
| Decatur | |||
| Echols | |||
| Grady | |||
| Lowndes | |||
| Seminole | |||
| Thomas | |||
| Ware | |||
| Alabama | Baldwin | ||
| Covington | |||
| Escambia | |||
| Geneva | |||
| Houston | |||
| Mobile |
| Cost Questions | Reply | Explanation | ||
| Please enter your reply in the "Reply" column and any explanation in the "Explanation" column. Written Replies and Explanations within this excel Attachment must be limited to 400 characters or less. Written Replies and Explanations beyond 400 characters will not be evaluated. | ||||
| 1 | Confirm this reply to which Respondent is submitting: | |||
| a. | Self-insured HMO option(s) with prescription drug benefit (i.e., Rx carve-in) | |||
| b. | Confirm your HMO response will still apply as submitted if the proposed Rx services are ultimately NOT awarded? | |||
| c. | Response includes Department HMO Service Region 1? | |||
| d. | Response includes Department HMO Service Region 2? | |||
| e. | Response includes Department HMO Service Region 3? | |||
| f. | Response includes Department HMO Service Region 4? | |||
| g. | Response includes Department HMO Service Region 5? | |||
| h. | Response includes Department HMO Service Region 6? | |||
| i. | Response includes Department HMO Service Region 7? | |||
| j. | Response includes Department HMO Service Region 8? | |||
| k. | Response includes Department HMO Service Region 9? | |||
| 2 | Confirm that administrative fees will be paid monthly and that the administrative cost will be assessed on a per-employee-per-month (PEPM) basis based on Departments enrollment counts (self-bill), with no subsequent accounting or year-end reconciliation. The PEPM fee can differ by plan type but not by enrollment tier (e.g. single/family). | |||
| 3 | Have you identified the costs for any services beyond those specified that you recommend Department consider that are not included in your quoted fees in the Additional Programs section in the chart above? Please outline a description of any service, the charge of said service and your best estimate of the annual cost in the Explanation column. | |||
| 4 | Confirm that the pricing submitted within this reply (as well as provider network disruption and stats exhibits provided in Attachment C - Network) is based on your broadest provider networks, both in FL and the US. | |||
| a. | What is the name of this network? | |||
| Self-Insured Plan - Ongoing Services, Renewals | Reply | Explanation | ||
| 5 | Respondent will provide a definition of all terms and an itemization of all assumptions used, including projected claims, trend factors and the formula involved, plus a complete explanation of the logic inherent in the final renewal rate/fee package. | |||
| 6 | Respondent will provide annual actuarial services including estimated or actual identification of expenses, including the change in IBNR, claim administration expenses, other expenses (such as, number of transactions/EOBs), and a detailed allocation of administrative cost projections. | |||
| Self-Insured Plan - Guaranteed Claim Discounts | Reply | Explanation | ||
| 7 | Is Respondent willing to guarantee medical claim discounts off normal charges? If so, indicate below for what types of services and in the "Explanation" column describe how these guarantees will be measured - you can expand on your description in the additional Cost Explanation section below. | |||
| a. | Hospital Inpatient Discount | |||
| b. | Hospital Outpatient Discount | |||
| c. | Physician Discount | |||
| d. | Out of Network Discount | |||
| e. | Other Services Discount - please describe | |||
| Self-Insured Plan - Guaranteed Claim Trend Rates | Reply | Explanation | ||
| 8 | Is Respondent willing to guarantee PEPM medical trend? | |||
| a. | If so, what is Respondent's PEPM medical trend guarantee? | |||
| 9 | Provide the percentage of ASO fees the Respondent would put at risk for the guaranteed discount/medical trend guarantee. |
Wellness ASO HMO
| Invitation to Negotiate (ITN) for the State of Florida, Department of Management Services (Department) |
| HMO Medical |
| Wellness Services - Self-Insured HMO with Carve-in / Carve-out Rx Services |
| Respondent Name: |
| [Insert Respondent Name Here] |
| Indicate Carve-in or Carve-out |
| [Indicate Carved-in / Carved-out] |
| Proposed Program Fees |
| Confirm the wellness or care management programs that are available via your proposed self-insured HMO plan. |
| Health Improvement Programs - Please review the below programs and confirm if these programs are included in your self-insured HMO Plan. Please add rows for additional programs offered, as necessary. | Year 1 | ||
| (Effective January 1, 2024) | Year 2 | ||
| (Effective January 1, 2025) | Year 3 | ||
| (Effective January 1, 2026) | Year 4 | ||
| (Effective January 1, 2027) | Year 5 | ||
| (Effective January 1, 2028) | Year 6 |
(Effective January 1, 2029)
| Wellness Services |
| Online Health Risk Questionnaire |
| Onsite Biometric Screenings - Includes: |
| Total Cholesterol (LDL & HDL) |
| Glucose |
| Blood Pressure |
| Waist Measurement |
| BMI |
| Other (Add Rows as Necessary) |
| Health Coaching |
| Telephonic-based coaching - Includes: |
| Weight Management |
| Nutrition |
| Smoking Cessation |
| Exercise |
| Healthy Pregnancy |
| Back Pain |
| Stress Management |
| Other (Add Rows as Necessary) |
| Tobacco Cessation Services |
| Tobacco Cessation Program with: |
| Specialized Tobacco Cessation Coaching |
| Nicotine Replacement Therapy |
| Prescription Medications |
| Other (Add Rows as Necessary) |
| Immunizations |
| Organize and sponsor onsite flu shots |
| Physical Activity |
| Conduct team-based corporate challenges |
| Weight loss discount programs |
| Fitness club membership reimbursement |
| Other (Add Rows as Necessary) |
| Online Wellness Tools |
| Personalized Portal with: |
| Health scores |
| Screening results |
| Program recommendations |
| Health library |
| Other (Add Rows as Necessary) |
| Online behavior change modules addressing: |
| Physical activity |
| Tobacco cessation |
| Nutrition |
| Weight management |
| Stress/energy |
| Sleep |
| Living with a condition |
| Other (Add Rows as Necessary) |
| Online tracking tools for: |
| Physical activity |
| Healthy eating and living well |
| Living well |
| Other (Add Rows as Necessary) |
| Telephonic-based Disease Management - Includes: |
| Asthma - Adult and Pediatric |
| Diabetes |
| Coronary Artery Disease |
| Chronic Obstructive Pulmonary Disease |
| Heart Failure |
| Chronic Low Back Pain |
| Osteoarthritis |
| Cerebrovascular/Peripheral Artery Disease |
| Behavioral |
| Low Back Pain |
| Other (Add Rows as Necessary) |
| Other |
| Insert Here (Add Rows as Necessary) |
ASO Medical Repricing
| Invitation to Negotiate (ITN) for the State of Florida, Department of Management Services (Department) |
| HMO Medical |
| Medical Repricing - Self-Insured HMO with Carve-in / Carve-out Rx Services |
| Respondent Name: |
| [Insert Respondent Name Here] |
| Indicate Carve-in or Carve-out |
| [Indicate Carved-in / Carved-out] |
| Please complete the below charts using the data from the State repricing file obtained by contacting the Procurement Officer. A separate worksheet should be completed for each HMO service area that you are proposing. Provide an electronic copy of actual Excel workbook for each HMO service area with your firm's repricing data with the response. Name the file: Respondent's Name_ Medical Repricing_HMO_Service Area # |
| Proposed HMO Service Area: | Insert Here |
| Proposed Network Name: | Insert Here |
| Claim Types | Network Charges | Network Discount (%) | Network Discount ($) | Network Allowed |
| Inpatient | ||||
| Outpatient | ||||
| Professional | ||||
| Repriced Subtotal | $0 | 0% | $0 | $0 |
| Unmatched Claims | $0 | $0 | ||
| Grand Total | $0 | 0% | $0 | $0 |
Proposed Network Name: Insert Here
| Claim Types | Network Charges | Network Discount (%) | Network Discount ($) | Network Allowed |
| Inpatient | ||||
| Outpatient | ||||
| Professional | ||||
| Repriced Subtotal | $0 | 0% | $0 | $0 |
| Data Issues | $0 | $0 | ||
| Grand Total | $0 | 0% | $0 | $0 |
Out of Network (OON) Charges
FI HMO Premium
| Invitation to Negotiate (ITN) for the State of Florida, Department of Management Services (Department) |
| HMO Medical |
| Medical Pricing - Fully-Insured HMO with Carve-in / Carve-out Rx Services |
| Respondent Name: |
| [Insert Respondent Name Here] |
| Indicate Carve-in or Carve-out |
| [Indicate Carved-in / Carved-out] |
| ■ Rates must be provided for the initial three year contract period (entirety of 2024 - 2026) in the chart below. The contract for this ITN includes an additional three - one or multiyear year extension (each of 2027, 2028 and 2029). Please refer to the Cost Questions towards the end of this tab to confirm any rate guarantees or caps Respondent is offering for the additional years. |
| ■ If replying to a fully-insured HMO option, premium rates should be input in this tab. Below premium should assume NO commissions are paid to any broker or consultant. |
| ■ Premiums should assume administration of current two plan options - Standard and HDHP HMOs. See Attachment A - Administrative Requirements for additional information on how to access detailed plan designs. It is assumed these plans will be used in Florida. |
| 2024 | 2025 | 2026 | ||||||
| Instructions: Provide premium rates for those regions in which you have a full service area/robust offering and wish to submit a fully-insured proposal. Submit rates for Medicare retirees on a RDS basis. | Monthly Premium Rates Effective for Calendar Year 2024 | Monthly Premium Rates Effective for Calendar Year 2024 | Monthly Premium Rates Effective for Calendar Year 2025 | Monthly Premium Rates Effective for Calendar Year 2025 | Monthly Premium Rates Effective for Calendar Year 2026 | Monthly Premium Rates Effective for Calendar Year 2026 | ||
| Medical with Pharmacy Carve-In | ||||||||
| Actives, COBRA, & Early Retirees | Medical with same Pharmacy Carve-In as Actives for | |||||||
| Medicare Retirees (EGWP) | Medical Only with Pharmacy Carve-Out | |||||||
| Actives, COBRA, & Early Retirees | Medical Only with Pharmacy Carve-Out | |||||||
| Medicare Retirees | Medical with Pharmacy Carve-In | |||||||
| Actives, COBRA, & Early Retirees | Medical with same Pharmacy Carve-In as Actives for | |||||||
| Medicare Retirees (EGWP) | Medical Only with Pharmacy Carve-Out | |||||||
| Actives, COBRA, & Early Retirees | Medical Only with Pharmacy Carve-Out | |||||||
| Medicare Retirees | Medical with Pharmacy Carve-In | |||||||
| Actives, COBRA, & Early Retirees | Medical with same Pharmacy Carve-In as Actives for | |||||||
| Medicare Retirees (EGWP) | Medical Only with Pharmacy Carve-Out | |||||||
| Actives, COBRA, & Early Retirees | Medical Only with Pharmacy Carve-Out |
Medicare Retirees
| Region* | Total Coverage Tier | Current HMO Active/COBRA, Early Retiree Enrollment* | Current HMO Medicare-eligible Retiree Enrollment* | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP | HMO Standard Plan | HMO HDHP |
| Region 1 | Employee/Retiree Only | 966 | 224 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 1,645 | ||||||||||||||||||||||||||
| Region 2 | Employee/Retiree Only | 9,657 | 5,757 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 14,065 | ||||||||||||||||||||||||||
| Region 3 | Employee/Retiree Only | 3,556 | 314 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 6,185 | ||||||||||||||||||||||||||
| Region 4 | Employee/Retiree Only | 2,604 | 388 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 3,879 | ||||||||||||||||||||||||||
| Region 5 | Employee/Retiree Only | 3,169 | 237 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 4,629 | ||||||||||||||||||||||||||
| Region 6 | Employee/Retiree Only | 4,777 | 405 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 7,097 | ||||||||||||||||||||||||||
| Region 7 | Employee/Retiree Only | 1,158 | 42 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 1,533 | ||||||||||||||||||||||||||
| Region 8 | Employee/Retiree Only | 794 | 26 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 1,154 | ||||||||||||||||||||||||||
| Region 9 | Employee/Retiree Only | 5,861 | 143 | ||||||||||||||||||||||||
| Employee/Retiree + Family | 6,541 | ||||||||||||||||||||||||||
| * Based on county where Department employee resides or works. Current enrollment in HMO plans, includes enrolled COBRA participants. |
| Service Area |
| Confirm the service areas to which the above proposed HMO premium rates apply based on the Department defined HMO service areas. The Department allows employees to elect HMO coverage utilizing either their listed "work county" or the county in which their permanent residence is located. (Note- enrollment in a Respondent's option is limited to the regions Respondent is awarded as a result of this ITN, but a Respondent's plan access will be "opened" beyond the counties included in each awarded region. For example, a Respondent's plan is awarded HMO services for region 3 only; however, the Respondent's plan operates in every county in FL and members who reside or work in region 3 and are enrolled in the Respondent's plan may seek care from network providers in any county in the state or outside of the state when network physicians and facilities are available.) |
Regions Confirm Access in Responding Regions Explanation (e.g., access only available in portions of the indicated county)
| Region 1 | Bay | ||
| Calhoun | |||
| Escambia | |||
| Gulf | |||
| Holmes | |||
| Jackson | |||
| Okaloosa | |||
| Santa Rosa | |||
| Walton | |||
| Washington | |||
| Region 2 | Franklin | ||
| Gadsden | |||
| Jefferson | |||
| Leon | |||
| Liberty | |||
| Madison | |||
| Taylor | |||
| Wakulla | |||
| Region 3 | Alachua | ||
| Bradford | |||
| Columbia | |||
| Dixie | |||
| Gilchrist | |||
| Hamilton | |||
| Lafayette | |||
| Levy | |||
| Marion | |||
| Suwannee | |||
| Union | |||
| Flagler | |||
| Region 4 | Baker | ||
| Clay | |||
| Duval | |||
| Nassau | |||
| Putnam | |||
| St Johns | |||
| Volusia | |||
| Region 5 | Brevard | ||
| Indian River | |||
| Lake | |||
| Orange | |||
| Osceola | |||
| Seminole | |||
| Region 6 | Citrus | ||
| Desoto | |||
| Hardee | |||
| Hernando | |||
| Highlands | |||
| Hillsborough | |||
| Manatee | |||
| Pasco | |||
| Pinellas | |||
| Polk | |||
| Sarasota | |||
| Sumter | |||
| Region 7 | Martin | ||
| Okeechobee | |||
| Palm Beach | |||
| St Lucie | |||
| Region 8 | Charlotte | ||
| Collier | |||
| Glades | |||
| Hendry | |||
| Lee | |||
| Region 9 | Broward | ||
| Miami-Dade | |||
| Monroe | |||
| Georgia | Brooks | ||
| Camden | |||
| Charlton | |||
| Clinch | |||
| Decatur | |||
| Echols | |||
| Grady | |||
| Lowndes | |||
| Seminole | |||
| Thomas | |||
| Ware | |||
| Alabama | Baldwin | ||
| Covington | |||
| Escambia | |||
| Geneva | |||
| Houston | |||
| Mobile | |||
| Cost Questions | |||
| Please enter your reply in the "Reply" column and any explanation in the "Explanation" column. Written Replies and Explanations within this excel Attachment must be limited to 400 characters or less. Written Replies and Explanations beyond 400 characters will not be evaluated. | Reply | Explanation |
| 1 | Confirm the replies which Respondent is submitting: | ||
| a | Fully-Insured HMO option(s) with prescription drug benefit (i.e., Rx carve-in) | ||
| b | Response includes Department HMO Service Region 1? | ||
| c | Response includes Department HMO Service Region 2? | ||
| d | Response includes Department HMO Service Region 3? | ||
| e | Response includes Department HMO Service Region 4? | ||
| f | Response includes Department HMO Service Region 5? | ||
| g | Response includes Department HMO Service Region 6? | ||
| h | Response includes Department HMO Service Region 7? | ||
| i | Response includes Department HMO Service Region 8? | ||
| j | Response includes Department HMO Service Region 9? | ||
| Proposed Premiums | Reply | Explanation | |
| 2 | Are above rates guaranteed and firm as of your proposal submission? | ||
| a | If not, when will firm rates for 2024 be available? | ||
| 3 | Please confirm if the above rates for years 2024 - 2026 include a rate guarantee or rate increase caps for the additional years in which the contract may be extended: | ||
| a | 2027? If so, describe in "Explanation" column. | ||
| b | 2028? If so, describe in "Explanation" column. | ||
| c | 2029? If so, describe in "Explanation" column. | ||
| 4 | Are you willing to update your proposed rates if Department modifies the service area on which you have initially developed your rates? Note in "Explanation" column any limitations on Department modifying this baseline service area. | ||
| 5 | How did you select the service area in which you are proposing for your fully-insured option? | ||
| 6 | Confirm that rates for Medicare Retiree plans coordinate with Medicare on the same basis as current (see Attachment A - Administrative Requirements for instructions on how to obtain details on current plan designs). Note any caveats in "Explanation" column. | ||
| 7 | Confirm that if you have submitted rates for a fully-insured HMO then you will be able to provide the State with all the data it requires to annually file for RDS. | ||
| Underwriting Assumptions | Reply | Explanation | |
| 8 | a) Minimum enrollment assumptions? | ||
| 9 | b) Minimum employer contribution levels? | ||
| 10 | d) Please disclose other caveats or assumptions for the Department's consideration in the explanation column. | ||
| Provider Networks | Reply | Explanation | |
| 11 | Confirm the provider network that you are proposing and basing your above quoted premiums represents your broadest provider network? | ||
| 12 | Do you have an alternative (e.g., narrower) provider network that would be available? If so, describe in "Explanation" column basis/ fundamentals for this alternative. | ||
| 13 | If proposing an alternative, what would be the impact on above proposed premiums should Department choose to offer instead? | ||
| Member Service | Reply | Explanation | |
| 14 | Identify which of the below services are included in Member Services on which your proposal is based. | ||
| a | General customer service via toll free number to address questions on plan designs, provider networks, ID cards, etc. | ||
| b | Advocacy, including claim resolution support | ||
| c | Assist members in selecting quality providers within network for specific care situations, including leverage the State's cost transparency tool | ||
| d | Help schedule provider appointments for members | ||
| e | Assist with use of State's health care cost and quality tool | ||
| f | Provide expert medical second opinions | ||
| g | Offer other member services? Describe in "Explanation" column. | ||
| h | Offer other member services? Describe in "Explanation" column. | ||
| i | Offer other member services? Describe in "Explanation" column. | ||
| j | Offer other member services? Describe in "Explanation" column. | ||
| Additional Services - Not included in quoted fees | Reply | Explanation | |
| 15 | Please identify any services beyond those specified that you recommend Department consider that are not included in your quoted fees. Please outline a description of any service, the charge of said service and your best estimate of the annual cost in the Explanation column. | ||
| a | Additional Services (add rows as necessary) | ||
| b | Additional Services (add rows as necessary) | ||
| c | Additional Services (add rows as necessary) | ||
| d | Additional Services (add rows as necessary) | ||
| Broker Commissions | Reply | Explanation | |
| 16 | Confirm proposed fees are net of commissions (no commissions) |
Wellness FI HMO
| Invitation to Negotiate (ITN) for the State of Florida, Department of Management Services (Department) |
| HMO Medical |
| Wellness Services - Fully-Insured HMO with Carve-in / Carve-out Rx Services |
| Respondent Name: |
| [Insert Respondent Name Here] |
| Indicate Carve-in / Carve-out |
| [Indicate Carved-in / Carved-out] |
| Proposed Program Fees |
| Confirm the wellness or care management programs that are available via your proposed fully-insured HMO Plan. |
| Health Improvement Programs - Please review the below programs and confirm if these programs are included in your fully-insured HMO Plan. Please add rows for additional programs offered, as necessary. | Year 1 | ||
| (Effective January 1, 2024) | Year 2 | ||
| (Effective January 1, 2025) | Year 3 | ||
| (Effective January 1, 2026) | Year 4 | ||
| (Effective January 1, 2027) | Year 5 | ||
| (Effective January 1, 2028) | Year 6 |
(Effective January 1, 2029)
| Wellness Services |
| Online Health Risk Questionnaire |
| Onsite Biometric Screenings - Includes: |
| Total Cholesterol (LDL & HDL) |
| Glucose |
| Blood Pressure |
| Waist Measurement |
| BMI |
| Other (Add Rows as Necessary) |
| Health Coaching |
| Telephonic-based coaching - Includes: |
| Weight Management |
| Nutrition |
| Smoking Cessation |
| Exercise |
| Healthy Pregnancy |
| Back Pain |
| Stress Management |
| Other (Add Rows as Necessary) |
| Tobacco Cessation Services |
| Tobacco Cessation Program with: |
| Specialized Tobacco Cessation Coaching |
| Nicotine Replacement Therapy |
| Prescription Medications |
| Other (Add Rows as Necessary) |
| Immunizations |
| Organize and sponsor onsite flu shots |
| Physical Activity |
| Conduct team-based corporate challenges |
| Weight loss discount programs |
| Fitness club membership reimbursement |
| Other (Add Rows as Necessary) |
| Online Wellness Tools |
| Personalized Portal with: |
| Health scores |
| Screening results |
| Program recommendations |
| Health library |
| Other (Add Rows as Necessary) |
| Online behavior change modules addressing: |
| Physical activity |
| Tobacco cessation |
| Nutrition |
| Weight management |
| Stress/energy |
| Sleep |
| Living with a condition |
| Other (Add Rows as Necessary) |
| Online tracking tools for: |
| Physical activity |
| Healthy eating and living well |
| Living well |
| Other (Add Rows as Necessary) |
| Telephonic-based Disease Management - Includes: |
| Asthma - Adult and Pediatric |
| Diabetes |
| Coronary Artery Disease |
| Chronic Obstructive Pulmonary Disease |
| Heart Failure |
| Chronic Low Back Pain |
| Osteoarthritis |
| Cerebrovascular/Peripheral Artery Disease |
| Behavioral |
| Low Back Pain |
| Other (Add Rows as Necessary) |
| Other |
| Insert Here (Add Rows as Necessary) |
Rx Definitions
| Invitation to Negotiate (ITN) for the State of Florida, Department of Management Services (Department) |
| HMO Medical | Carve-In Rx |
| Rx Definitions |
| Respondent Name: |
| [Insert Respondent Name Here] |
Instructions: Enter the answer to each Definition in the column provided. Use the "Explanation" columnm to provide a brief explanation. Written Replies and Explanations within this excel Attachment must be limited to 400 characters or less. Written Replies and Explanations beyond 400 characters will not be evaluated.
| Definitions | Do you agree with the stated definition? If not, please explain. | Explanation | |
| 1. | "340B Claim(s)" means a Claim that receives 340B program pricing and is dispensed from a 340B program covered entity. 340B claims are identified by the submission of “20” in the ‘Submission Clarification Code’ field (420-DK) AND includes a covered entity owned pharmacies 340B status coded as “38” or “39” in the NCPDP DataQ database. | ||
| 2. | “Adjusted Rx” means a 30-day supply claim equivalent, that shall be calculated as follows: Adjusted Rx = [Claim Days Supply] / [30 days]. For avoidance of doubt, a Claim with a 90-day supply would constitute three (3) Adjusted Rx. A claim with a 10 (ten) day supply would constitute 1/3 (one-third) of an Rx. | ||
| 3. | "Administrative Fee(s)" means the fee paid to PBM for agreed upon PBM services. | ||
| 4. | "PBM Affiliates" of a party shall mean an entity: |
(i) which is directly or indirectly, through one or more intermediaries, controlling such party;
(ii) which is under the same direct or indirect ownership or control as such party; or
(iii) which is directly or indirectly, through one or more intermediaries, owned or controlled by such party.
For purposes of this definition and the Agreement, “control” (including the terms controlling, controlled by or under common control with) means (a) the possession, direct or indirect, (b) the power to direct or cause the direction of the management or policies of an entity, or (c) the ability to direct an entity’s affairs or to control the composition of its board of directors or equivalent body, whether through (i) 50% of more of voting securities, (ii) partnership or membership interests, (iii) by contract or (iii) any other means.
Further, a Group Purchasing Organization shall also be considered a PBM Affiliate to the extent the GPO meets the above definition.
| 5. | “Average Wholesale Price” or “AWP” means the average wholesale unit price for a product on the date the product is dispensed as set forth from the most current pricing information provided to PBM by Medi-Span Prescription Guide including supplements multiplied by the Fill Quantity. For determining the AWP, the actual 11-digit NDC package size dispensed on the date the product is dispensed will be used. |
| 6. | "Authorized Generics" means an approved Brand Drug that is marketed without the brand name on its label. Other than the fact that it does not have the brand name on its label, it is the exact same drug product as the branded product. An Authorized Generic may be marketed by the brand name drug company, or another company with the brand company’s permission. Authorized Generics will be identified using Medi-Span Multisource Code of “M” (co-branded product) with a Brand Drug Code of “B” (Branded Generic Name) or “G” (generic). |
| 7. | “Biosimilar Product” or “Biosimilar” means a Specialty Drug that is a biological product that is highly similar to a US-licensed reference biological product notwithstanding minor differences in clinically inactive components, and for which there are no clinically meaningful differences between the biological product and the reference product in terms of the safety, purity, and potency of the product as defined in the Biologics Price Competition and Innovation Act of 2009 at 42 U.S.C. §262(i)(2) and approved under Section 351(k) of the Public Health Services Act and as identified in the Purple Book. |
| 8. | "Brand Drug" or "Brand Product" means an FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy Study Implementation) drug, or product, which is manufactured and distributed by an innovator drug company, or its licensee , set forth in Medi-Span’s National Drug Data File (MS) as a brand drug identified by all of the products meeting at least one of the following criteria: |
1. Brand Name code of “T” (trademarked) and Multisource Code “M”
2. Brand Name code of “B” or “T” and Multisource Code of “N”
3. Brand Name code of “B” or “T” and Multisource Code “O” and a DAW code of 0, 1, 2, 7, 8, or 9
For avoidance of doubt, Brand Drugs may include, but are not limited to: vaccines, supplies, medical devices, kits, diabetic supplies, OTCs and test strips.
| 9. | “Claim(s)” means any electronic or paper request for payment or reimbursement processed through PBM’s on-line claims adjudication system or otherwise transmitted or processed in accordance with the terms of an agreement in connection with Department’s Plan, including claims in which the Member pays the full cost and Department has no cost liability, but does not include requests for payment or reimbursement that (i) rejected due to system edits designed to enforce Department’s pharmacy benefit programs or were reversed or cancelled from the claim payment system. |
| 10. | “Compound Drug” shall mean a mixture of two (2) or more ingredients when at least one of the ingredients in the preparation is an FDA approved federal legend drug, and the mixture of which is not otherwise generally available in an equivalent commercial form or strength in response to a physician’s prescription to create a medication tailored to the specialized medically required need for an individual patient. |
| 11. | "Coordination of Benefits or COB Claim(s)" means a Claim where more than one health insurance program, policy, or other form of coverage, including governmental or non-governmental coverage, has payment and a primary and secondary carrier liability is determined. |
| 12. | "Data Fees" means fees received by PBM for the sale of aggregate blinded data to a limited group of third parties including nationally recognized data integration firms. |
| 13. | "Days of Supply" means the number of days supplied for a Claim as submitted to PBM by the dispensing Pharmacy. |
| 14. | "Dispensing Fee(s)" means the fee paid to the dispensing pharmacy for the professional service of filling a claim and is equal to the Total Claim Cost less the Ingredient Cost and less the applicable sales tax. U&C Claims will always have a zero dollar Dispensing Fee. |
| 15. | "Fill Quantity" means the number of units dispensed for a Claim as submitted to PBM by the dispensing Pharmacy. |
| 16. | "Formulary Rebate(s)" or "Access Rebate(s)" means a rebate collected by PBM or PBM Affiliates from pharmaceutical companies for products where the implemented formulary encourages Member use over other products and is attributable to Department' specific utilization. |
| 17. | "Generic Drug" or "Generic Product" means an FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy Study Implementation) drug, or product, that is therapeutically equivalent to other pharmaceutically equivalent products, as set forth in Medi-Span’s National Drug Data File (MS) as a generic drug identified by all products meeting at least one of the following criteria: |
1. Brand Name code of “G” (generic) for all Multisource Codes (M, N, O, and Y)
2. Multisource Code of “Y” (generic)
3. Multisource Code of “M” (co-branded product) with a Brand Drug Code of “B” (Branded Generic Name)
4. “O” (originator brand) with a DAW code of 3, 4, 5, or 6.
For avoidance of doubt, Generic Drugs may include, but are not limited to: drugs, vaccines, supplies, medical devices, kits, diabetic supplies, OTCs and test strips.
18. “Group Purchasing Organization” or “GPO” is an entity that aggregates the purchasing power of a group of businesses to obtain discounts or rebates from pharmaceutical manufacturers. These services may include contracting with manufacturers for Manufacturer Payments or any similar service conducted on behalf of the PBM. Any entity who provides the same or similar services as the PBM on behalf of the PBM under this Agreement shall also be considered a GPO. For purposes of this Agreement, rebate aggregators or any similar/competing entity shall also be a GPO.
PBM represents and warrants that PBM’s agreements with a Group Purchasing Organization shall contain (and will continue to contain through the term of this Agreement) provisions or obligations that are substantially similar to any provision or obligation contained in this Agreement which directly or indirectly relates to any service under this Agreement that is or may be performed by a GPO as defined herein. A breach of this representation and warranty shall be considered a material breach of this Agreement.
| 19. | “Guaranteed Minimum Manufacturer Payment” or “Rebate Guarantee” is the average Rebate per Brand Claim or per Claim. The performance will be calculated for the annual period using the following formula for each dispensing Channel independently: [Total Rebate payable to Department] / [Total Brand Drug Rx Count] OR [Total Rebate payable to Department] / [Total Paid Claim Count] |
| 20. | "Home Infusion Pharmacy or HIF" means a Retail Pharmacy-based, decentralized patient care organization with expertise in USP 797-compliant sterile drug compounding that provides care to patients with acute or chronic conditions generally pertaining to parenteral administration of drugs, biologics and nutritional formulae administered through catheters and/or needles in home and alternate sites. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of 6. |
| 21. | "House Generics" means a Brand Drug submitted with a Dispense As Written (DAW) 5 code in place of the generic equivalent and where the pharmacy is reimbursed at a Generic Drug rate, including MAC, as applicable. For reconciliation of the Generic Drug discount guarantees, the AWP of House Generic drugs shall be the per unit AWP of the generic equivalent and not the AWP of the Brand Drug. House Generics will be identified using Medi-Span Multisource Code M, N, O, or Y and a Dispense as Written (DAW) code of 5. |
| 22. | "Incentive Rebate(s)" means a rebate collected by PBM from pharmaceutical companies for products where restrictions on competitor products have been put in place and is attributable to Department' specific utilization. |
| 23. | "Indian Health Services, Tribal or Urban Indian Health or I/T/U" means a Retail Pharmacy operated by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization as defined in Section 4 of the Indian Health Care Improvement Act, 25 U.S.C. 1603. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of 8. |
| 24. | “Inflation Protection Payments” means payments received by Respondent (if any; and whether separately made or in the form of increased Rebates) from a pharmaceutical manufacturer for the purpose of adjusting for year over year price inflation of the manufacturer’s price to Respondent for prescriptions on which Rebates are paid; in accordance with and pursuant to applicable pharmaceutical manufacturer agreements. |
| 25. | "Ingredient Cost" means the discounted AWP cost of a claim and is equal to the Total Claim Cost less the applicable Dispensing Fee and less the applicable sales tax. |
| 26. | "Limited Distribution Specialty Drugs" are those Specialty Drugs only available through select pharmacy providers as determined by the drug manufacturer. |
| 27. | "Long Term Care Pharmacy or LTC" means a Retail Pharmacy that dispenses medicinal preparations delivered to patients residing within an intermediate or skilled nursing facility, including intermediate care facilities for mentally disabled, hospice, assisted living facilities, group homes, and other forms of congregate living arrangements. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of 4. |
| 28. | "Mail Order Pharmacy" means a Pharmacy that is owned, licensed, operated or identified by PBM, where Claims are filled and delivered through the mail to Members. |
| 29. | "Manufacturer Administrative Fee(s)" or "Rebate Administrative Fee(s)" means fees for services rendered to pharmaceutical manufacturers in relation to administrative duties in connection with aggregation, allocating, collecting, and invoicing for rebates. |
| 30. | "Manufacturer Payments" includes Rebates, Manufacturer Administrative Fees, Inflation Protection Payments, and Data Fees, but excludes Other Pharma Revenue. |
| 31. | "Market Share Rebate(s)" or "Performance Rebate(s)" means a rebate collected by PBM from pharmaceutical companies that is based on the utilization of a rebated product compared to the utilization of competitor products and is attributable to SMD' specific utilization. |
| 32. | "Maximum Allowable Cost or MAC" means the price that has been established by PBM for a Brand Drug or Generic Drug included on its MAC drug list, which may be amended from time to time by PBM. A copy of such MAC drug list shall be provided to Department, prior to execution and upon Department’s reasonable request, and shall be updated by PBM in its sole discretion. The same MAC list will be used for a Retail Pharmacy, a Mail Order Pharmacy, and a Specialty Pharmacy (i.e. same number of drugs, same drugs). The Mail Order Pharmacy and Specialty Pharmacy MAC list price points for individual drugs/generic class numbers shall be equal to or less (i.e., more deeply discounted) than the Retail Pharmacy MAC price points for the same drugs/generic class numbers. |
| 33. | "Member(s)" means each individual who Department identifies in the eligibility file to be eligible for prescription drug benefits under its plan. |
| 34. | "Member Cost Share" means the amount which a Member is required to pay for a Claim in accordance with Department' benefit design, which may be a deductible, a percentage of the Claim price, a fixed amount and/or other charge or penalty. |
| 35. | "Member-Submitted Claim(s) or Paper Claim(s)" means a Claim submitted to PBM for reimbursement by a Member for which the Member paid cash. |
| 36. | "Military Pharmacy" means a Retail Pharmacy whose primary function is to store, prepare and dispense pharmaceuticals and other associated items to uniformed services beneficiaries. These pharmacies may be associated with Department of Defense or U.S. Coast Guard clinic, Department of Defense hospital or freestanding. Usually associated with outpatient services. Associated with taxonomy code “332000000X”. These Pharmacies are identified by a National Council for Prescription Drug Program’s (NCPDP’s) dispenser type code of 17. |
| 37. | "Open Preferred Drug List or Open Formulary" will be defined as a listing of all FDA-approved prescription drugs. No FDA-approved prescription drugs will be excluded from an open formulary without the express written consent of Department. |
| 38. | "Other Pharma Revenue" means Pharmacy Purchase Discounts (i.e.. Mail Order Volume Discounts), Transmission Fees, and Specialty Service Fees. |
| 39. | "Over-the-Counter" or "OTC" Claim(s) means a Claim for items that do not require a prescription for a Member to purchase that Department has chosen to or has been required to include as covered products under the prescription drug benefit. OTC Claims are defined as having an ‘O’ or 'P" indication in Medi-Span’s Rx-OTC Indicator Code. |
| 40. | “Participating Pharmacy” means a Retail Pharmacy, Mail Order Pharmacy, Specialty Pharmacy, non-traditional pharmacy (such as I/T/U, LTC, HIF, Military, TER or VA) or other Pharmacy that participates in the PBM’s network of Participating Pharmacies pursuant to an agreement between the Participating Pharmacy and PBM or between the Participating Pharmacy and Department for such Pharmacy’s dispensing of Covered Drugs to Members. |
| 41. | "Pass Through Pricing”, "Pass through", or "Transparent Pricing" means a pricing structure comprised of fixed guaranteed discounts at PBM's Mail Order Pharmacy and Specialty Pharmacy and a full pass through of PBM's contracted rates with Participating Pharmacies and pharmaceutical manufacturers. In this arrangement, PBM retains the difference between Mail Order and specialty acquisition costs and the amounts guaranteed to Department. PBM passes through (1) its contracted rates with Participating Pharmacies and (2) all Manufacturer Payments it receives from pharmaceutical manufacturers in excess of the Department’s guaranteed Manufacturer Payments. The amount billed to Department at Retail Pharmacies will be equal to the amount paid by PBM to the Retail Pharmacies. |
| 42. | "Pharmacy" means a pharmacy that participates in the PBM network pursuant to an agreement between the pharmacy and PBM. |
| 43. | "Pharmacy Purchase Discount(s)" or "Mail Order Volume Discount(s)" means discounts, paid at time of purchase, or retrospectively, received by PBM or its affiliates from pharmaceutical manufacturers, which are attributable to or based on products purchased by PBM affiliated dispensing pharmacies. |
| 44. | “Preferred Specialty Network” means a network arrangement where a copay/coinsurance Member Share differential distinguishes preferred versus non-preferred Specialty Pharmacies. |
| 45. | “Pricing Source” means Medi-Span Prescription Guide including supplements. |
| 46. | "Rebates" means the return of partial payments from a pharmaceutical manufacturer, pursuant to the terms of a rebate contract, negotiated directly or indirectly with a pharmaceutical company by PBM, PBM Affiliates, or a GPO, on behalf of all plan sponsors, and directly or indirectly attributable to the utilization of certain prescriptions by members. Rebates shall include Formulary Rebates (i.e. Access Rebates), Market Share Rebates (i.e. Performance Rebates), Incentive Rebates, Value-Based Rebates, Medical Drug Rebates (if carve-in with a Health Plan), and Non-Preferred Rebates. Rebates do not include the value of manufacturer coupons applied at the pharmacy or other patient assistance programs. |
| 47. | "Retail Pharmacy" means a Pharmacy that is not a Mail Order Pharmacy nor a Specialty Pharmacy. |
| 48. | "Sales Tax" means a tax imposed by local, state, or federal government at the point of sale on a Claim that is collected by the dispensing Pharmacy |
| 49. | "Single Source Generic(s) or SSG(s)" are Generic Drugs that are manufactured by one generic drug manufacturing company. |
| 50. | “Specialty Drugs” are defined as certain pharmaceuticals, biotech or biological drugs, that are used in the management of complex or genetic disease that meet at least one of the first two criteria (a and b) and all of the last three criteria (c-e) in order to be placed on Respondent's specialty drug list: |
a) Produced through DNA technology or biological processes
b) Targets a complex disease caused by a combination of genetic, environmental and lifestyle factors
c) Unique handling, distribution, and/or administration requirements such that the drug cannot be safely dispensed from a mail service pharmacy
d) Requires a customized medication management program that includes medication use review, patient training,…
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