Oregon PEBB 2025 Medical and Pharmacy RFP_20251111.pdf

Oregon PEBB 2025 Medical and Pharmacy RFP

Confidential

1 Overview and Requirements Questionnaire

1.1 Introduction

This Request for Proposal (RFP) is to facilitate the selection of medical and pharmacy plans for the Oregon Public Employees’ Benefit Board effective January 1, 2027. Please refer to the main RFP document as well as supporting attachments to complete this questionnaire.

Unless the RFP explicitly requests or allows additional documents to be submitted in relation to a question, they will not be considered.

1.1.1 RFP Set Up

1.1.1.1 [TOGGLE] Which of the following proposals are you submitting?

Single, Pull-down list.

1: Combined medical and pharmacy, 2: Medical only, 3: Pharmacy only

1.1.1.2 [COMBINED & MEDICAL ONLY | TOGGLE] Which of the following plan options are you proposing?

Single, Pull-down list.

1: Statewide PPO, 2: Regional CCM, 3: Regional HMO

1.1.1.3 [REGIONAL ONLY] Confirm the region(s) where you are proposing a coordinated care plan.

Response

Portland Metro Single, Pull-down list.

1: Yes, 2: No

I-5 Corridor Single, Pull-down list.

1: Yes, 2: No

Oregon Coast Single, Pull-down list.

1: Yes, 2: No

Southwest Oregon Single, Pull-down list.

1: Yes, 2: No

Eastern Oregon Single, Pull-down list.

1: Yes, 2: No

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Central Oregon Single, Pull-down list.

1.1.1.4 [REGIONAL ONLY | TOGGLE] Which funding arrangement are you proposing?

Single, Pull-down list.

1: Fully-insured, 2: Self-insured

1.1.1.5 [COMBINED ONLY] Confirm you are submitting a combined medical and pharmacy proposal.

Single, Radio group.

1: Confirmed, 2: Not confirmed

1.1.2 Background Information

1.1.2.1 [COMBINED & MEDICAL ONLY] Please describe the plan you are proposing to Oregon PEBB. If you are not proposing both a Combined Medical and Pharmacy plan as well as a Stand-Alone Medical plan only, please explain your rationale for not submitting both.

500 words.

1.1.3 Minimum Requirements

1.1.3.1 [COMBINED & MEDICAL ONLY - REGIONAL ONLY] Confirm your proposal is not contingent upon being the only plan offered in the service area.

Single, Radio group.

2: Not confirmed, explain: [ 200 words ]

1.1.3.2 [MEDICAL ONLY] Confirm that your proposal is not contingent on being the Pharmacy Benefit Manager (PBM) as well.

Single, Radio group.

1.1.3.3 [PHARMACY ONLY] Confirm that your offer is not contingent on administering Oregon Public Employees' Benefit Board's medical plan.

Single, Radio group.

Confidential

1.1.3.4 [MEDICAL ONLY] Confirm your organization's ability to integrate with a PBM should PEBB chose a separate PBM vendor.

Single, Radio group.

1.1.3.5 Confirm your proposal does not include minimum participation or employer contribution requirements.

1.1.3.6 Confirm your plans will be offered to all eligible employees, as determined by PEBB, with no exclusions or waiting periods.

Single, Radio group.

1.1.3.7 Provide proof your company is licensed to provide health insurance in the State of Oregon. If not currently licensed, how and when will you be licensed?

Single, Radio group.

1: Licensed, 2: Not licensed, explain: [ 200 words ]

1.1.4 Organizational Information

1.1.4.1 Why should PEBB select you?

1000 words.

1.1.4.2 Please describe the insights your organization has gained from working with large and complex organizations (25K+ members) and public clients. Provide three accomplishments your organization is proud of regarding this experience, as well as three lessons learned. Include how your organization has incorporated these lessons learned into your business model or philosophy to provide the best possible services.

1.1.4.3 Include the names of the clients as well as potential contact information.

Client 1 Client 2 Client 3

Client Name 20 words. 20 words. 20 words.

Client Address 20 words. 20 words. 20 words.

Primary Contact 20 words. 20 words. 20 words.

Title 20 words. 20 words. 20 words.

Telephone Number 20 words. 20 words. 20 words.

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E-mail Address 20 words. 20 words. 20 words.

# of Employees & Retirees 20 words. 20 words. 20 words.

Scope of Services 100 words. 100 words. 100 words.

1.1.4.4 In a short summary, provide an overview of your organization. Key elements to include: Total annual revenue # of employees Headquarters and key locations Affiliated entities that you're proposing as part of the services for PEBB

200 words.

1.1.4.5 What are your top three strategic priorities in the next 2 - 3 years? How will these strategies improve the care provided to PEBB's members?

1.1.4.6 What are your top three challenges? How are you addressing these challenges?

1.1.4.7 Describe your company's vision and values and how they are demonstrated on an everyday basis.

1.1.4.8 [COMBINED AND PHARMACY ONLY] In what year was your PBM established?

To the year.

1.1.4.9 How many clients do you currently service by type based on the table below?

Response

Public Sector Integer.

Commercial Clients Integer.

Total Clients Integer.

1.1.4.10 Please provide your organization's most recent financial rating or filing from each of the following agencies. (Please provide rating or "not applicable".) Do not respond by providing information about your organization's credit ratings:

Response

A.M. Best 10 words.

Moody's 10 words.

Standard & Poor's 10 words.

Fitch 10 words.

1.1.4.11 What was your client retention rate?

Confidential

Response

YTD current year Percent.

Previous year Percent.

1.1.4.12 Provide information about your financial stability (financial ratings, annual reports, and financial statements, etc.).

1.1.4.13 Which services related to the requested scope of services will you subcontract? Provide brief details of how and by whom these services are provided and your role in managing their delivery.

1.1.4.14 Provide a description of any company initiatives, either current or planned, over the next 18 to 36 months, which will impact the delivery of services to PEBB during the contract period. Examples include system changes or migrations, call center opening/closing, mail service pharmacy opening/closing or network re-contracting.

1.1.4.15 If your organization has been involved in a merger or acquisition within the past three years, specify when the merger took effect, and how you have or will assimilate(ed) operations, account management and claims and clinical systems into your organization.

1.1.4.16 If your organization is involved in a merger or acquisition expected to close within the next 18 months, please provide the details of that transaction and expected close date.

1.1.4.17 What planned investments does your organization have for the next 3 years? Please indicate the amount of the planned investments, where resources will come from and what your expected outcome is. This should include any and all investments including M&A Activity.

1.1.4.18 Confirm you will provide any support required regarding any new groups or populations added to Oregon Public Employees' Benefit Board that may occur during the term of the contract.

Single, Radio group.

2: No; Explain [ 100 words ]

1.1.4.19 In the event of a group or population departing from Oregon Public Employees' Benefit Board, confirm Proposer will provide identical contracts to all remaining populations, including the current pricing arrangement, until the current contract term expires.

Confidential

Single, Radio group.

2: No; explain [ 100 words ]

1.1.5 Account Management

1.1.5.1 [COMBINED & MEDICAL ONLY] Please provide the following key personnel:

Account Manager

Physician Pharmacist Behavioral Health Clinician

Implementation Member Services

Claims

Name Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Title Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Location Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Years with company Integer. Integer. Integer. Integer. Integer. Integer. Integer.

Dedicated or designated?

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Current # of clients Integer. Integer. Integer. Integer. Integer. Integer. Integer.

Primary responsibilities

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Relevant experience with public sector clients

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

What does this team member specifically bring to PEBB?

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Please indicate the percentage of time that each assigned person will be dedicated to working with PEBB.

Percent. Percent. Percent. Percent. Percent. Percent. Percent.

Is your organization willing to guarantee this percentage?

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1.1.5.2 [PHARMACY ONLY] Please provide the following key personnel:

Executive Sponsor

Account/Operations Manager

Account Coordinator

Pharmacist/Clinical Program Director

Implementation

Name Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

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Title Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Location Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Years with company Integer. Integer. Integer. Integer. Integer.

Dedicated or Designated?

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Current # of clients Integer. Integer. Integer. Integer. Integer.

Primary responsibilities Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Relevant experience with public sector clients

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

What does this team member specifically bring to PEBB?

Unlimited. Unlimited. Unlimited. Unlimited. Unlimited.

Please indicate the percentage of time that each assigned person will be dedicated to working with PEBB.

Percent. Percent. Percent. Percent. Percent.

Is your organization willing to guarantee this percentage?

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1: Yes, 2: No

Single, Pull-down list.

1.1.5.3 [PHARMACY ONLY] Proposer confirms it will assign a designated financial analyst.

1.1.5.4 Confirm that the assigned Key Person will be no more than one time zone away from Oregon Public Employees' Benefit Board's location (Salem, Oregon).

Single, Radio group.

1.1.5.5 Confirm members of the account management team are expected to respond to all account inquiries from the PEBB staff within one business day.

Single, Radio group.

1.1.5.6 Describe the working relationship between your member service and account management teams.

1.1.5.7 Please identify the Key Person/Account Manager you are proposing for PEBB:

Confidential

Response

Name Unlimited.

Title Unlimited.

Role for PEBB Unlimited.

Anticipated # of meetings attended per year 20 words.

1.1.5.8 Proposer will not ask any PEBB participant to individually enter into any agreement with your organization or agree in any way to waive any legal rights or to obligate himself or herself to indemnify or hold harmless your organization in any way when interacting with the member website. This includes via click through, in consideration for using the member website, participating in any program, or otherwise. Any such language contained in the member website or in any materials provided by you shall be void and of no force and effect.

Single, Radio group.

1: Agree, 2: Disagree, explain: [ 200 words ]

1.1.5.9 Confirm PEBB will contract directly with your organization for all services. Any outsourcing agreements are made solely between your organization and the organization providing services.

Single, Radio group.

1.1.5.10 Confirm all employees working on and/or having access to PEBB data will be based in the U.S. In addition, any and all technology that will be used to administer these benefits will be accessible to the employees in the U.S. only, and all technology systems will be housed in the U.S. In the event your organization makes changes to the processes/systems access/location of the personnel that conflicts with the prior statements, PEBB will be notified in writing within 120 days' notice.

Single, Radio group.

1.1.5.11 Proposer agrees to provide necessary data files free of charge to PEBB in response to government requests or to respond to legal actions for the length of the contract. Such services shall be provided at the PEBB custom reporting rate after the contract has terminated.

Single, Radio group.

1.1.5.12 Confirm your organization reviews system access on a periodic basis to ensure proper maintenance procedures are in effect (e.g. terminated users no longer have system access, only senior staff are given sensitive systems access and no one person is given inappropriate combinations of system access).

Single, Radio group.

1.1.5.13 Confirm any material operational changes that result from a merger or acquisition will be communicated to PEBB by phone and in writing at least 90 calendar days prior to the effective date.

Single, Radio group.

1.1.5.14 Confirm that you will review and respond to any new supplier (program or company) forms, questionnaires, or other such documents that may be requested from you by PEBB.

Single, Radio group.

1.1.5.15 Has an employer/carrier partner terminated a contract with you due to your company's breach of the contract?

Single, Radio group.

1: Yes, explain: [ 200 words ] ,

1.1.6 Organizational Commitment to Health Equity

1.1.6.1 The following questions are meant to capture the commitment your organization has to diversity, equity, and inclusion.

Question Response

Confirm if your organization has a leader solely dedicated (1.0 FTE) to leading equity and inclusion internally.

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Do you have specific policies in place to address diversity, equity, and inclusion for your employees, such as a written diversity, equity, and inclusion plan?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Does your organization adhere to all 15 of the National Standards for Culturally and Linguistically Appropriate Services (CLAS)? If not, which of the 15 do you not currently adhere to and what is the plan to do so?

200 words.

Has your organization earned external accreditation or recognition for excellence in inclusive health or health equity (e.g. Human Rights Campaign Corporate Equality Index, EDGE certification, NCQA Health Equity Accreditation, etc.)?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

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If not, do you plan to seek accreditation or recognition? Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Other, please describe 200 words.

Nothing required

1.1.6.2 The following questions are meant to capture how your organization assesses and requires a commitment to diversity, equity and inclusion with vendor partners that you propose for PEBB:

Question Response

Do you assess or require vendor partners to have a leader solely dedicated (1.0 FTE) to leading equity and inclusion internally?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Do you assess or require vendor partners to have specific policies in place to address diversity, equity, and inclusion for your employees, such as a written diversity, equity, and inclusion plan?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Do you require vendor partners to adhere to all 15 of the National Standards for Culturally and Linguistically Appropriate Services (CLAS)? If not, what is the plan to do so?

200 words.

Do you assess or require vendor partners to earn external accreditation or recognition for excellence in inclusive health or health equity (e.g. Human Rights Campaign Corporate Equality Index, EDGE certification, NCQA Health Equity Accreditation, etc.)?

Compound, Pull-down list.

1: Confirmed, explain:

[ 200 words ], 2: Not confirmed, explain: [ 200 words ]

Provide any additional comments you have to demonstrate how your organization may or may not assess vendor partners’ commitment to diversity, equity, and inclusion.

1.1.6.3 Please define what health equity means to your organization and provide realized examples of how this is demonstrated.

1.1.6.4 Does your organization have an action plan in place to address at least one health disparity? Please describe.

1.1.6.5 Does your organization annually assess progress in reducing identified disparities?

1.1.6.6 What is your organization's commitment to achieving inclusive health for your clients' members?

Describe your inclusive health strategy including how you define inclusive health and what levels of investment have been made to reduce disparities.

1.1.6.7 Is there a solely dedicated (1.0 FTE leader within your organization working to address your clients' inclusive health needs? What responsibilities are included in their portfolio?

1.1.6.8 How does your organization promote inclusivity within the organization including training, policies and practices? Please also highlight any recognition your organization has received (e.g., Human Rights Campaign Corporate Equality Index).

1.1.6.9 To what extent does your organization develop and engage in community and multi-disciplinary partnerships to improve population health? Please describe relevant examples.

1.1.6.10 Describe how you are engaged locally and nationally in initiatives to address the key areas of social determinants of health (examples: insecurity, housing issues, and personal safety concerns).

1.1.6.11 Does your organization use its financing power internally or externally to support inclusive health or social drivers of health initiatives? Please describe.

100 words.

1.1.6.12 PEBB feels strongly that all members should be able to identify as the gender they choose and an “other” field should not be used for ease of grouping.

Question Response

Confirm if your system can accept and administer claims for members identified as non-binary or a gender other than M/F.

Compound, Pull-down list.

1: Confirmed, 2: Not confirmed

If your system can accept and administer claims for members identified as non-binary or a gender other than M/F, please confirm that the gender marker will not be labeled as “other.”

Compound, Pull-down list.

1: Confirmed, 2: Not confirmed, explain: [ 200 words ]

Does your member electronic health record have a distinct field that captures the various gender expressions (7 or more) separate from sex assigned at birth?

Compound, Pull-down list.

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2: Not confirmed, explain: [ 200 words ]

If yes, please describe the gender expressions. 200 words.

1.1.7 Open Enrollment Support

1.1.7.1 Proposer confirms it will provide Open Enrollment support at no charge that includes

Response

Call center services Single, Pull-down list.

1: Yes, 2: No

Printed pharmacy materials Single, Pull-down list.

1: Yes, 2: No

Virtual benefit fairs Single, Pull-down list.

1: Yes, 2: No

In-person support at onsite meetings (upon request) Single, Pull-down list.

1.1.7.2 Proposer will provide onsite resources at no charge to attend Oregon Public Employees' Benefit Board's annual benefit fairs and at locations determined by Oregon Public Employees' Benefit Board. Proposer resources must be core competent in Oregon Public Employees' Benefit Board's plan design and will not be outsourced.

Single, Radio group.

2: No; explain [ 100 words ]

1.1.8 Implementation Support

1.1.8.1 Attach a detailed project implementation work plan that illustrates all key activities and the person on your team who would be responsible for each activity and achieves successful completion by December 31, 2026. Call out any critical dates that must be met in order to keep the implementation on schedule. The file MUST be attached to this question.

Answer and attachment required

1: Yes, attached, explain: [ 200 words ]

1.1.8.2 Proposer confirms that the dedicated toll-free customer service number will be available (for use in printed materials, not for live calls) within 30 days of award of business.

Confidential

Single, Radio group.

2: No; Explain [ 50 words ]

1.1.8.3 Proposer confirms it will provide all customer service representatives and service staff with information and training regarding Oregon Public Employees' Benefit Board's plan design and program at least 10 business days prior to the open enrollment commencement date.

Single, Radio group.

1.1.8.4 All implementation support shall be provided to Oregon Public Employees' Benefit Board at no cost.

1.1.8.5 Proposer will maintain an implementation project plan and issue log documenting all implementation issues, actions, due dates and responsible parties.

Single, Radio group.

1.1.8.6 Proposer will proactively test plan design set-up and provide report of results including any elements that needed to be fixed to Oregon Public Employees' Benefit Board and Oregon Public Employees' Benefit Board's consultant for review at least three (3) weeks prior to Go-Live as long as plan documents are approved by Oregon Public Employees' Benefit Board 90 days in advance of Go-Live.

Single, Radio group.

1.1.8.7 Oregon Public Employees' Benefit Board and Oregon Public Employees' Benefit Board's consultant has the right to approve assigned implementation manager.

Single, Radio group.

1.1.8.8 Confirm ongoing account team--inclusive of account executive (strategist), account manager (day to day support), and clinical account executives--will be active participants in the implementation process to ensure understanding of why decisions were made during implementation.

Single, Radio group.

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1.1.9 Member Services and Communications

1.1.9.1 Proposer understands Public Employees' Benefit Board by way of their Staff reserves the right to review and approve all member-facing communications, whether digital, verbal, or written. This also includes communications from subcontracted vendors.

Single, Radio group.

1.1.9.2 Confirm you have provided a sample ID card with your RFP response and that it is compliant with the Transparency in Coverage and CAA requirements (42 USC 300-gg-111(e)) in place as of the effective date of coverage. The file MUST be attached to this question.

Single, Radio group.

Answer and attachment required

1: Attached

1.1.9.3 Explain your capabilities to customize ID cards to meet client's specification and include special wording for carved out vendors (as applicable). Also confirm that external carved-out phone numbers can be included.

1.1.9.4 Proposer will provide customization of ID cards at no additional cost.

2: No; explain [ 50 words ]

1.1.9.5 Please provide the font size for your ID cards. If smaller than size 12 font, please confirm what options are available to members who have vision impairments.

50 words.

1.1.9.6 How often do you issue new ID cards to members?

1.1.9.7 Are you moving away from physical ID cards and encouraging use of electronic ID cards via app? Will members have the option to obtain a physical card without cost if desired?

1.1.9.8 How many ID cards will families receive and who is listed on them? Does everyone in the family receive an ID card in the mail or is there a limit to the number of ID cards per family? Is there a cost difference?

1.1.9.9 Proposer will NOT charge for physical replacement ID cards.

Confidential

Single, Radio group.

1.1.9.10 Proposer confirms that due to its errors it will reproduce ID cards (including priority shipping) at no cost to Oregon Public Employees' Benefit Board.

Single, Radio group.

1.1.9.11 Proposer will provide ID cards to Oregon Public Employees' Benefit Board's Participants in compliance with all state and federal regulatory requirements at no cost to Oregon Public Employees' Benefit Board.

Single, Radio group.

1.1.9.12 Proposer will reissue physical and electronic ID cards at no cost to Oregon Public Employees' Benefit Board should state and/or federal regulations require changes.

Single, Radio group.

1.1.10 Data and Reporting

1.1.10.1 Confirm you will provide All-Payer, All Claims (APAC) reporting to the Oregon Health Authority (OHA), pursuant to ORS 442.373, with the ability to identify PEBB Members.

Single, Radio group.

1.1.10.2 Confirm you will provide PEBB's data warehouse vendor with medical and/or pharmacy claims feeds in the output required (see Attachment J - Medical and Attachment W - Pharmacy) and on a monthly basis.

PEBB's consultant will specify format changes and penalties may apply for missed reporting per contractual requirements.

Single, Radio group.

2: No, explain: [ 200 words ]

1.1.10.3 PEBB is often required to perform legislative analyses or pull data to respond to legal inquiries, public records requests, or other instances. Please confirm that there will be no additional charge for these requests, analysis, or reporting.

Single, Radio group.

1: Confirmed, explain: [ 200 words ] ,

1.1.10.4 Complete the following table regarding ongoing reporting to PEBB and their Consultant:

Report Detail Requested Frequency

Ability to Provide?

Comments / Response

Claims and Enrollment Claims:

- Must be reported on a paid basis

- Medical, Rx and Total per plan for medical coverage Enrollment:

- By plan

- Employee and Member count

Monthly Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Lag Triangles Medical and Rx Lag Triangles reporting split out as follows:

- Medical Plan

- Rx Plan

Monthly Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Large Claims Report

(YTD)

Claims above $50K

Include the following:

- Diagnosis

- Member Type

- Member Plan

- Amount by Individual Claimant per incident

- Likelihood of ongoing treatment

Monthly Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Variable Fee Reporting For all variable fees (e.g., OON shared savings):

- Identify expense components and estimated associated amounts that are NOT included in the claim or lag triangle reports

- Provide historical reporting, as applicable, summarizing variable fee amounts, separated by program

This is in addition to the annual requests by Consultant during the renewal process

Quarterly Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Large Claims over $250K Notification

The purpose of this communication is to provide early notification of potential high dollar claim payment in the future. This notification is based on detection of an inpatient confinement that satisfies pre-determined criteria for the possibility of a payment in excess of $250K.

Report should include:

- Pre-Authorizations

- Denied Claims

- Live Claims from Carrier

Ad Hoc & Quarterly

Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Confidential

- Diagnosis

- Comorbidities

- Ongoing claims potential

Online access to experience reports and ad-hoc reporting tools capable of reporting at plan or location level of detail

Always Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Provide regular and ad hoc reports covering claim detail, medical utilization and trends, operational activity, etc.

Ad Hoc Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

Custom reporting Ad Hoc Single, Pull-down list.

1: Yes, 2: No

200 words.

Nothing required

1.1.10.5 Confirm you will provide the other routine and ad hoc reports as defined in the Sample Contract.

Report Response

PDB Eligibility Discrepancy Report Single, Radio group.

1: Confirmed, 2: Not confirmed

Monthly Payment Discrepancy Report Single, Radio group.

1: Confirmed, 2: Not confirmed

Authorized Claims Payment Single, Radio group.

1: Confirmed, 2: Not confirmed

Health Program Invoices as outlined in Exhibit D Single, Radio group.

1: Confirmed, 2: Not confirmed

[COMBINED & MEDICAL ONLY] Alternate Payment Methodologies (APMs) Single, Radio group.

1: Confirmed, 2: Not confirmed

ID Card Mailing and Accuracy: PEBB Members will receive ID cards Single, Radio group.

1: Confirmed, 2: Not confirmed

Ad Hoc Reporting Single, Radio group.

1.1.11 Compliance

1.1.11.1 Proposer will comply with all applicable federal laws and regulations, including but not limited to HIPAA and CAA.

Single, Radio group.

1.1.11.2 Proposer will comply with all CAA transparency and reporting requirements for any year where Proposer provides services to Oregon Public Employees' Benefit Board at no additional cost. This confirms Proposer will provide required data reporting for the time period serviced even if Oregon Public Employees' Benefit Board terminates the contract with Proposer.

Single, Radio group.

1.1.11.3 Confirm Proposer will provide PEBB with the files submitted on their behalf to comply with Federal transparency requirements.

Single, Radio group.

1.1.11.4 Proposer agrees to provide machine readable files post-termination as required by the plan. Costs for file production and file hosting will be the same as the standard pricing for an active Oregon Public Employees' Benefit Board.

Single, Radio group.

1.1.11.5 Proposer will detail how the process works for its external Independent Review Organization (IRO) appeals.

1.1.11.6 Proposer will manage all process and resources related to the management of external IRO appeals and any costs are outlined in this Proposal.

Single, Radio group.

1.1.11.7 The Proposer agrees that as it relates to use and disclosure of PHI, electronic transaction standards and security of electronic PHI under the Health Insurance Portability and Accountability Act of 1996, as amended, Proposer is a “Covered Entity” and that it may, from time to time, enter into Subcontracts with a “Business Associate” as both such terms are defined under 45 CFR § 160.103. Accordingly, Proposer will ensure

Confidential it enters into Business Associate agreements with its Subcontractors when required under, and in accordance with, HIPAA. Notwithstanding the foregoing, Proposer and PEBB acknowledge that in providing services to Members, Proposer Specialty Pharmacy and the Mail Service Pharmacy are acting as separate health care provider covered entities under HIPAA and not as business associates to the plan covered by the Business Associate Agreement. In providing services, Proposer Specialty Pharmacy and the Mail Services Pharmacy shall abide by all HIPAA requirements applicable to covered entities and shall safeguard, use and disclose Member PHI accordingly.

Single, Radio group.

1.1.11.8 Confirm Proposer has attached a flow chart of Proposer claim denial appeals process (including post-service appeals, prior authorization, step therapy, safety, and other, if applicable) and address the following:

(a) Standard response time guidelines; (b) Notification of denial and appeal rights; (c) Qualifications for determining the need for pharmacist and/or physician review. The file MUST be attached to this question.

Single, Pull-down list.

Answer and attachment required

1: Attached

1.1.11.9 [SELF-INSURED ONLY] Proposer has a process for monitoring state and federal legislation that impacts Proposer's business models and/or Oregon Public Employees' Benefit Board and its members.

Single, Radio group.

1.1.11.10 Proposer will provide an interpretation of any new state or federal legislation and possible impact to Oregon Public Employees' Benefit Board within thirty (30) days of such legislation being passed.

Single, Radio group.

1.1.11.11 Proposer agrees to notify Oregon Public Employees' Benefit Board immediately if there is a violation of law or regulation, or systemic issue affecting Oregon Public Employees' Benefit Board.

Single, Radio group.

1.1.12 Contractual Requirements

1.1.12.1 [COMBINED ONLY] Combined Medical and Pharmacy

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1.1.12.1.1 Sample Group Benefits Contracts

1.1.12.1.1.1 Please confirm acceptance of the Contract Term section of Attachment I - Sample Group Benefits Contract as written.

CONTRACT TERM (Non-negotiable)

This Contract is effective on January 1, 2027 (“Effective Date”). Unless extended or terminated earlier in accordance with its terms, this Contract terminates on December 31, 2029. For the Contract's term to be extended, Contractor must satisfactorily perform the required services and meet annual PEBB requirements.

Single, Radio group.

1: Accept, 2: Do not accept (may result in disqualification), provide a rationale: [ 200 words ]

1.1.12.1.1.2 Please confirm acceptance of the Purpose section of Attachment I - Sample Group Benefits Contract as written.

PURPOSE

The purpose of this Contract is for Contractor to provide [Self-Insured or Fully Insured Regional or Statewide] Group Medical and Pharmacy Benefit Services to State employees who elect to participate in PEBB's Benefit Plans.

Single, Radio group.

1: Accept as written, 2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 200 words ]

1.1.12.1.1.3 Please confirm acceptance of the Contract Documents section of Attachment I - Sample Group Benefits Contract as written.

CONTRACT DOCUMENTS

This Contract consists of (a) this Group Benefits Contract without Attachments, together with (b) the following listed exhibits which are attached and are hereby incorporated into this Contract by reference:

Exhibit A - Legal Terms and Conditions

Exhibit B - Definitions

Exhibit C - Statement of Work

Exhibit D - Reporting and Performance Requirements

Exhibit E - Rates

Exhibit F - Data Sharing

Exhibit G - Insurance Requirements

Exhibit H - Independent Contractor Certification

Exhibit I - Companion Guide

Single, Radio group.

1: Accept as written, 2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 200 words ]

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1.1.12.1.2 Exhibit A - Legal Terms and Conditions

1.1.12.1.2.1 Please confirm acceptance of the Definitions section of Exhibit A - Legal Terms and Conditions as written.

1. Definitions

1.1 The following definitions apply to this Contract:

Please see Attachment B of the main RFP document. The Contract resulting from this RFP will include those definitions in Exhibit B of this Contract to the extent the defined terms are used in the future Contract.

1.2 Except for terms specifically defined in Exhibit B of this Contract, the definitions in PEBB's administrative rules in Chapter 101 of the Oregon Administrative Rules found at https://secure.sos.state.or.us/oard/displayChapterRules.action?selectedChapter=36 govern this Contract.

Single, Radio group.

2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 200 words ]

1.1.12.1.2.2 Please confirm acceptance of the Consideration section of Exhibit A - Legal Terms and Conditions as written.

2. Consideration

In consideration of the Work being performed under this Contract, PEBB shall pay Contractor consistent with Exhibit E, Rates. PEBB shall not pay for Work performed before this Contract is effective (except as provided herein) or after the Contract terminates.

Single, Radio group.

2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 200 words ]

1.1.12.1.2.3 Please confirm acceptance of the Default section of Exhibit A - Legal Terms and Conditions as written.

3. Default

3.1 Contractor shall be in default under this Contract if:

3.1.1 Contractor institutes or has instituted against it insolvency, receivership or bankruptcy proceedings, makes an assignment for the benefit of creditors, or ceases doing business on a regular basis;

3.1.2 Contractor no longer holds a license or certificate that is required for Contractor to perform its obligations under the Contract and Contractor has not obtained such license or certificate within 14 calendar days after PEBB's notice or such longer period as PEBB may specify in such notice;

3.1.3 Contractor commits any material breach or default of any covenant, warranty, obligation or agreement under this Contract, or fails to perform the Work under this Contract within the time specified under this Contract or any extension by PEBB of such time, or fails to pursue the Work as to endanger Contractor's performance under this Contract in accordance with its terms, and such breach, default or failure is not cured within 10 calendar days after PEBB's notice, or such longer period as PEBB may specify in such notice; or

3.1.4 Contractor has liquidated and delinquent debt owed to the State of Oregon or any department or agency of the State.

https://secure.sos.state.or.us/oard/displayChapterRules.action?selectedChapter=36

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3.2 If Contractor is in default under Section 3 , PEBB may pursue any or all of the remedies available to it under this Contract and at law or in equity, including, but not limited to:

3.2.1 Termination of this Contract under Section 4;

3.2.2 Withholding all monies due for Work and Work Products that Contractor has failed to deliver within any scheduled completion dates or has performed inadequately or defectively;

3.2.3 Initiation of an action or proceeding for damages, specific performance, or declaratory or injunctive relief;

3.2.4 Exercise of its right of setoff, and withholding of amounts otherwise due and owing to Contractor, without penalty;

3.2.5 Undertaking collection by administrative offset, or garnishment if applicable, of all monies due for Services and Deliverables to recover liquidated and delinquent debt owed to the State of Oregon or any department or agency of the State. Offsets or garnishment may be initiated after the Contractor has been given notice if required by law; or

3.2.6 All of them or any combination thereof.

3.3 These remedies described above in 3.2 are cumulative to the extent the remedies are not inconsistent, and PEBB may pursue any remedy or remedies singly, collectively, successively or in any order whatsoever.

3.4 PEBB will be in default under this Contract if:

3.4.1 PEBB fails to pay Contractor any amount pursuant to the terms of this Contract, and PEBB fails to cure such failure within 30 calendar days after Contractor's notice or such longer period as Contractor may specify in such notice; or

3.4.2 PEBB commits any material breach or default of any covenant, warranty, or obligation under this Contract, and such breach or default is not cured within 30 calendar days after Contractor's notice or such longer period as Contractor may specify in such notice.

Single, Radio group.

2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 500 words ]

1.1.12.1.2.4 Please confirm acceptance of the Termination section of Exhibit A - Legal Terms and Conditions as

4 Termination

4.1 PEBB's Right to Terminate at its Discretion. PEBB may terminate this Contract:

4.1.1 Upon 30 calendar days' prior written notice by Agency to Contractor;

4.1.2 Immediately upon written notice by PEBB to Contractor if PEBB fails to receive funding, appropriations, limitations, allotments or other expenditure authority at levels sufficient to pay for the Services or Work Products; or,

4.1.3 Immediately upon written notice by PEBB to Contractor if federal or state laws, regulations, or guidelines are modified or interpreted in such a way that the PEBB's purchase of the Services or Work Products under this Contract is prohibited or PEBB is prohibited from paying for such Services or Work Products from the planned funding source.

4.2 PEBB's Right to Terminate for Cause. In addition to any other rights and remedies PEBB may have under this Contract, PEBB may terminate this Contract immediately upon written notice by PEBB to

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Contractor, or at such later date as PEBB may establish in such notice, if Contractor is in default under Section 3.

4.3 Contractor's Right to Terminate for Cause. Contractor may terminate this Contract immediately upon written notice to PEBB, or at such later date as Contractor may establish in such notice, if PEBB is in default under Section 3.

4.4 Return of Property. Upon termination of this Contract for any reason whatsoever, Contractor shall immediately deliver to PEBB all of PEBB's property (including without limitation any Services or Work Products for which PEBB has made payment in whole or in part) that is in the possession or under the control of Contractor in whatever stage of development and form of recordation such PEBB property is expressed or embodied at that time.

4.5 Effect of Termination. Upon receiving a notice of termination of this Contract, Contractor shall immediately cease all activities under this Contract, unless PEBB expressly directs otherwise in such notice of termination.

Upon PEBB's request, Contractor shall surrender to anyone PEBB designates, all documents, research or objects or other tangible things needed to complete the Services and the Deliverables.

Single, Radio group.

2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 500 words ]

1.1.12.1.2.5 Please confirm acceptance of the Procedure upon Expiration section of Exhibit A - Legal Terms and Conditions as written.

5 Procedure upon Expiration

5.1 When this Contract expires (or in the event it is earlier terminated) and if requested by PEBB, Contractor shall administer all Benefits Claims through the applicable grace period and run out period. Contract termination will not extinguish or prejudice PEBB's rights to enforce this Contract with respect to any default by Contractor that has not been cured.

5.2 Upon expiration or termination of this Contract, Contractor shall:

5.2.1 Promptly deliver to PEBB all of PEBB's property (including, but not limited to any Work or Work Products for which PEBB has made payment in whole or in part) that is in the possession or under the control of Contractor in whatever stage of development and form of recordation such PEBB property is expressed or embodied at that time;

5.2.2 Cease all activities under this Contract, except for those activities and obligations that survive termination under Section 5.1, unless PEBB expressly directs otherwise in such notice of expiration or termination; and

5.2.3 Upon PEBB ‘s request, surrender to anyone PEBB designates, all documents, research, or objects or other tangible things needed to complete the Work and the Work Products.

Single, Radio group.

2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 200 words ]

1.1.12.1.2.6 Please confirm acceptance of the Rates section of Exhibit A - Legal Terms and Conditions as

6. Rates

Contractor guarantees all fees, rates, retention, discounts, and other compensation elements set forth in Exhibit E, Rates, for the Work performed under this Contract through the term date described in the

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Contract Term section of the Contract. If the Board makes substantive changes to the Plan Benefits provided under this Contract, PEBB will work with Contractor to determine whether any updates to Exhibit E, Rates, will also be appropriate. Contractor understands and agrees that payment of amounts under this Contract are contingent on PEBB receiving appropriations, limitations, allotments or other expenditure authority sufficient to allow them, in the exercise of reasonable administrative discretion, to continue to make payments under this Contract.

Single, Radio group.

2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 200 words ]

1.1.12.1.2.7 Please confirm acceptance of the Eligibility and Enrollment section of Exhibit A - Legal Terms and

7. Eligibility and Enrollment

Contractor shall provide services without discrimination to all Members, consistent with Exhibit C, Statement of Work. PEBB will furnish to Contractor a Member eligibility file in a manner consistent to that described in Exhibit C, Statement of Work.

Single, Radio group.

2: Accept with proposed deviations (please either provide specific language or a description of the deviation): [ 200 words ]

1.1.12.1.2.8 Please confirm acceptance of the Representations and Warranties section of Exhibit A - Legal Terms and Conditions as written.

8. Representations and Warranties (Non-Negotiable)

Contractor represents and warrants to PEBB that:

8.1 Contractor has the power and authority to enter into and perform this Contract.

8.2 This Contract, when executed and delivered, will be a valid and binding obligation of Contractor enforceable in accordance with its terms.

8.3 Contractor has the skill and knowledge possessed by well-informed members of its industry, trade, or profession and shall apply that skill and knowledge with care and diligence to perform the Work in a professional manner and in accordance with the highest standards prevalent in Contractor's industry, trade or profession.

8.4 Contractor shall, at all times during the term of this Contract, be qualified, professionally competent, and duly licensed to perform the Work.

8.5 Contractor prepared its proposal related to this Contract, if any, independently from all other Proposers, and without collusion, fraud, or other dishonesty.

8.6 The representations and warranties set forth in this section are in addition to, and not in lieu of, any other representations and warranties set forth elsewhere in this Contract.

8.7 Contractor (to the best of Contractor's knowledge, after due inquiry), for a period of no fewer than six calendar years preceding the Effective Date, faithfully has complied with:

8.7.1 All tax laws of this state, including but not limited to ORS 305.620 and ORS chapters 316, 317, and 318;

8.7.2 Any tax provisions imposed by a political subdivision of this state that applied to Contractor, to Contractor's property, operations, receipts, or income, or to Contractor's performance of or compensation for any work performed by Contractor;

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8.7.3 Any tax provisions imposed by a political subdivision of this State that applied to Contractor, or to goods, services, or property, whether tangible or intangible, provided by Contractor;

8.7.4 Any rules, regulations, charter provisions, or ordinances that implemented or enforced any of the foregoing tax laws or provisions; and

8.7.5 Contractor has no undisclosed liquidated and delinquent debt owed to the State or any department or agency of the State.

Single, Radio group.

2: Do not accept (may result in disqualification), provide a rationale: [ 500 words ]

1.1.12.1.2.9 Please confirm acceptance of the Ownership of Work Product section of Exhibit A - Legal Terms and Conditions as written.

9 Ownership of Work Product

9.1 All Work Product created by Contractor pursuant to the Work, including, but not limited to derivative works and compilations, and whether or not such Work Product is considered a work made for hire or an employment to invent, is the exclusive property of PEBB. PEBB and Contractor agree that such Work Product is “work made for hire” of which ORBB is the author within the meaning of the United States Copyright Act. If for any reason the Work Product is not “work made for hire,” Contractor hereby irrevocably assigns to PEBB any and all of its rights, title, and interest in all Work Product, whether arising from copyright, patent, trademark, trade secret, or any other state or federal intellectual property law or doctrine. Upon PEBB's reasonable request, Contractor shall execute such further documents and instruments necessary to fully vest such rights in PEBB. Contractor forever waives any and all rights relating to Work Product, including without limitation, any and all rights arising under 17 USC §106A or any other rights of identification of authorship or rights of approval, restriction or limitation on use or subsequent modifications.

9.2 Contractor Intellectual Property. In the event that a Deliverables delivered by Contractor under this Contract is or is a derivative work based on Contractor Intellectual Property, or is a compilation that includes Contractor Intellectual Property, Contractor hereby grants to PEBB an irrevocable, non-exclusive, perpetual, royalty-free license to use, reproduce, prepare derivative works based upon, distribute copies of, perform and display the pre-existing elements of the Contractor Intellectual Property employed in the Deliverables, and to authorize others to do the same on PEBB's behalf.

9.3 Third Party Intellectual Property. In the event that a Deliverables delivered by Contractor under this Contract is or is a derivative work based on Third Party Intellectual Property, or is a compilation that includes Third Party Intellectual Property, Contractor shall secure on the PEBB's behalf and in the name of the PEBB an irrevocable, non-exclusive, perpetual, royalty-free license to use, reproduce, prepare derivative works based upon, distribute copies of, perform and display the pre-existing elements of the Third Party Intellectual Property employed in the Deliverables, and to authorize others to do the same on PEBB's behalf.

9.4 No Rights. Except as expressly set forth in this Contract, nothing in this Contract may be construed as granting to or conferring upon Contractor any right, title, or interest in any intellectual property that is now owned or subsequently owned by PEBB. Except as expressly set forth in this Contract, nothing in this Contract may be construed as granting to or conferring upon PEBB any right, title, or interest in any Contractor Intellectual Property that is now owned or subsequently owned by Contractor.

9.5 Marks. Neither party grants the other the right to use its trademarks, trade names, service marks or other designations in any promotion or publication without prior written consent. Each party grants only the licenses and rights specified in this Contract.

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9.6 Competing Services. Subject to the provisions of this Section 10, and Contractor's obligations with respect to Confidential Information, including as defined in Section 10, nothing in this Contract precludes or limits in any way the right of Contractor to: (i) provide services similar to those contemplated in this Contract, or consulting or other services of any kind or nature whatsoever to any individual or entity as Contractor in its sole discretion deems appropriate, or (ii) develop for Contractor or for others, Deliverables or other materials that are competitive with those produced…