OMESformCP076.pdf
PDF 286 KB Posted
- Attached to
- RFP for Pharmacy Benefit Manager
- Solicitation number
- EV00000953
- Issued by
- Oklahoma
About this file
This is a Responding Bidder Information form (OMES Form CP076) issued by the Oklahoma Office of Management and Enterprise Services (OMES) Central Purchasing division in connection with a Pharmacy Benefit Manager (PBM) services solicitation for the Oklahoma Health Care Authority Employees Group Insurance Division (EGID). The form serves as a certification document that bidders must submit along with their response to the RFP. The solicitation seeks qualified suppliers to provide comprehensive PBM services, including pharmacy claims adjudication, customer service, reporting, and related services through EGID. The document does not specify response deadlines, site visits, bidders conferences, award dates, or contract terms within its content.
The form requires bidders to provide general company information, including FEIN/SSN, Supplier ID, company name, and contact details, as well as certifications addressing specific Oklahoma statutory requirements. Bidders must disclose whether they are engaged in boycotts of Israeli goods or services, verify registration with the Oklahoma Secretary of State (or provide exemption documentation), provide workers' compensation insurance certificates or exemption statements, and declare whether they qualify as service-disabled veteran businesses under Oklahoma law. The form does not address pricing terms, set-asides, incumbent information, funding sources, or other financial details within its scope, as it functions primarily as a bidder certification and eligibility verification document rather than a comprehensive solicitation summary.
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Other files
| File | Type | Posted |
|---|---|---|
| Exhibit_6_Current_Plan_Designs.xlsx | XLSX spreadsheet | |
| Exhibit_1_Bidder_Reference_Worksheet.docx | DOCX document | |
| Exhibit_2_ThirdPartySupplierInfo.xlsx | XLSX spreadsheet | |
| Agency_Bidder_Instructions.pdf | ||
| Pre-Proposal_Conference_Agenda.docx | DOCX document | |
| Exhibit_7_-_Deviation_Explanations.xlsx | XLSX spreadsheet | |
| Exhibit_8_-_OHCA_EGID_Standard_Business_Associate_Agreement.docx | DOCX document | |
| Exhibit_9_-_Additional_Services_Cost_Proposal.docx | DOCX document | |
| Exhibit_3_Financial_Questionnaire-Price_Sheet.xlsx | XLSX spreadsheet | |
| 4_Attachment_C_EGID_Agency_Terms.docx | DOCX document | |
| 5_Attachment_D_IT_Terms.docx | DOCX document | |
| omes-form-cp004.docx | DOCX document | |
| Exhibit_5_Formulary___Network_Disruption.xlsx | XLSX spreadsheet | |
| Exhibit_4_Performance_Guarantees.xlsx | XLSX spreadsheet | |
| Q_A_Amendment_1.docx | DOCX document | |
| Exhibit_10_-_SB_1447_Certification.docx | DOCX document | |
| 3_Attachment_B_State_Terms.docx | DOCX document | |
| Attachment_A.pdf |
Show all 18
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Text version
OMES Form CP076 (11/2024) RESPONDING BIDDER INFORMATION | Page 1 of 1
Central Purchasing
RESPONDING BIDDER INFORMATION
You must submit a Certification for Competitive Bid and Contract along with the response to the solicitation.
1. SOLICITATION
Solicitation #
2. BIDDER GENERAL INFORMATION
FEIN/SSN Supplier ID
Company name
3. BIDDER CONTACT INFORMATION
Address
Contact name Title
Email Phone Website Fax
4. BIDDER IS ENGAGED IN BOYCOTT OF GOODS OR SERVICES FROM ISRAEL
Yes No
5. REGISTRATION WITH THE OKLAHOMA SECRETARY OF STATE
Yes Filing number:
No Prior to the contract award, the successful bidder is required to register with the Secretary of State or must attach a signed statement that provides specific details supporting the exemption the supplier is claiming (sos.ok.gov or 405- 521-3911).
6. WORKERS’ COMPENSATION INSURANCE COVERAGE
Bidder is required to provide a certificate of insurance showing proof of compliance with the Oklahoma Administrative Workers’ Compensation Act.
Yes Include a certificate of insurance with the bid.
No Exempt from the Administrative Workers’ Compensation Act pursuant to 85A O.S. § 2(18)(b)(1-11). (Attach a written, signed and dated statement on letterhead stating the reason for the exempt status. For frequently asked questions concerning workers’ compensation insurance, visit wcc.ok.gov.)
7. DISABLED VETERAN BUSINESS ENTERPRISE ACT
Yes I am a service-disabled veteran business as defined in 74 O.S. § 85.44E.
Include the following with the bid response:
1. Certification of service-disabled veteran status as verified by the appropriate federal agency.
2. Verification of not less than 51% ownership by one or more service-disabled veterans.
3. Verification of the control of the management and daily business operations by one or more service-disabled veterans.
No I do not meet the criteria as a service-disabled veteran business.
8. SIGNATURE
Authorized signature Date
Name Title https://www.sos.ok.gov/ https://www.wcc.ok.gov/
| Central Purchasing |
| RESPONDING BIDDER INFORMATION |
| Solicitation: |
| FEINSSN: |
| Supplier ID: |
| Company name: |
| Contact name: |
| Title: |
| Email: |
| Phone: |
| Website: |
| Fax: |
| 4 BIDDER IS ENGAGED IN BOYCOTT OF GOODS OR SERVICES FROM ISRAEL: Off |
| Prior to the contract award the successful bidder is required to register with the Secretary of State or must attach a: Off |
| Compensation Act: Off |
| 7 DISABLED VETERAN BUSINESS ENTERPRISE ACT: Off |
| Date: |
| Name: |
| Title_2: |
| Filing number: |
| Address: |
File details come from the government source that posted it. Updated .