Revised Forms 5b and 6b.pdf

FORM 5a – MANDATORY RESPONSIVENESS REQUIREMENTS - Medical

The Respondent certifies that it is in compliance with the requirements of this ITN, including subsection 3.2, section 9.

The Respondent certifies that neither it, nor its affiliates, is a convicted vendor or a discriminatory vendor as described in section 287.133 and section 287.134, F.S., respectively.

The Respondent certifies that the Respondent is not on the Scrutinized Companies with Activities in Sudan List, the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or the Scrutinized Companies that Boycott Israel List, and is not participating in a boycott of Israel.

The Respondent certifies that, if awarded a Contract, it will provide the Department with a PDF file of its current and active registration with the Florida Department of State, Division of Corporations (www.sunbiz.org), prior to execution of a Contract or, if exempt from registration, a statement to that effect noting the basis for the exemption. Respondents should note that foreign entities are required to obtain a Florida Certificate of Authorization pursuant to applicable Florida Statutes, from the Florida Department of State, Division of Corporations (www.sunbiz.org), to transact business in the State of Florida.

The Respondent certifies that it will provide all required services contemplated within this ITN, and as modified during negotiations.

The Respondent certifies that the Respondent is in compliance with section 448.095(2)(a), F.S., and that within the last year (i.e., within the last 365 days), it has not had a contract terminated under section 448.095(2)(c), F.S., by a public employer, as defined by section 448.095(1)(i), F.S.

The Respondent certifies its proposed health plan(s) and benefits provided under each plan shall adhere to all applicable requirements set forth in Florida or Federal law.

Signature below certifies that the signatory has the authority to respond to this solicitation on the Offeror’s behalf and certifies conformance with all Responsiveness Requirements listed above.

Name of Respondent’s Organization

Printed Name of Organization’s Authorized Representative

Signature of Organization’s Authorized Representative Date

REVISED FORM 5b – MANDATORY RESPONSIVENESS REQUIREMENTS - Pharmacy Carve-In

The Respondent certifies that certifies that the entity the Respondent will utilize to provide Carve-In pharmacy services (Respondent’s “Carve-In Pharmacy”) is in compliance with the requirements of this ITN, including section 3.2, section 9.

The Respondent certifies that neither its Carve-In Pharmacy, nor its Carve-In Pharmacy’s affiliates, is a convicted vendor or a discriminatory vendor as described in section 287.133 and section 287.134, F.S., respectively.

The Respondent certifies that its Carve-In Pharmacy is not on the Scrutinized Companies with Activities in Sudan List, the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or the Scrutinized Companies that Boycott Israel List, and is not participating in a boycott of Israel.

The Respondent certifies that, if awarded a Contract, it will provide the Department with a PDF file of its Carve-In Pharmacy’s current and active registration with the Florida Department of State, Division of Corporations (www.sunbiz.org), prior to execution of a Contract or, if exempt from registration, a statement to that effect noting the basis for the exemption. Respondents should note that foreign entities are required to obtain a Florida Certificate of Authorization pursuant to applicable Florida Statutes, from the Florida Department of State, Division of Corporations (www.sunbiz.org), to transact business in the State of Florida.

The Respondent certifies that it will provide, in conjunction with its Carve-In Pharmacy, all required services contemplated within this ITN, and as modified during negotiations.

The Respondent certifies that its Carve-In Pharmacy is in compliance with section 448.095(2)(a), F.S., and that within the last year (i.e., within the last 365 days), it has not had a contract terminated under section 448.095(2)(c), F.S., by a public employer, as defined by section 448.095(1)(i), F.S.

The Respondent certifies the proposed health plan(s) and benefits provided under each plan through its Carve-In Pharmacy shall adhere to all applicable requirements set forth in Florida or Federal law.

Signature below certifies that the signatory has the authority to respond to this solicitation on the Respondent’s and its Carve-in Pharmacy’s behalf and Respondent certifies its Carve-in Pharmacy’s conformance with all Responsiveness Requirements listed above.

Name of Respondent’s Organization

Printed Name of Organization’s Authorized Representative

FORM 6a – Minimum Qualifications - Medical

The Respondent certifies that it has at least ten (10) years' experience providing medical administrative services in the State, including administration of a network.

The Respondent certifies that it currently has at least one hundred thousand (100,000) covered lives across the Respondent's book of business as of the Reply submission date.

The Respondent certifies that it is registered with the Florida Office of Insurance Regulation to conduct business within the State.

The Respondent certifies that it currently has at least three (3) government/public entity employer groups.

The Respondent certifies that it agrees to administer the self-insured and fully-insured plans in accordance with the plan designs specified in the ITN. Please go to https://www.mybenefits.myflorida.com/health/resources to obtain copies of the plan descriptions.

The Respondent certifies that it agrees that the Department reserves the right to award medical and prescription drug coverages independently, or in any combination, if it so chooses.

The Respondent certifies it is willing, if awarded a contract for HMO, to offer its plans alongside another Respondent also offering HMO and/or PPO options.

The Respondent certifies their Response will still apply if the Department selects Respondent for fewer service areas than initially proposed, besides ASO fees that may vary based on existing enrollment bands as outlined in Attachment D – Cost.

Signature below certifies that the signatory has the authority to respond to this solicitation on the Offeror’s behalf and certifies conformance with all Responsiveness Requirements listed above.

Name of Respondent’s Organization

Printed Name of Organization’s Authorized Representative

REVISED FORM 6b – Minimum Qualification - Pharmacy

The Respondent certifies that the entity the Respondent will utilize to provide Carve-In pharmacy services (Respondent’s “Carve-In Pharmacy”) has at least ten (10) years' experience providing pharmacy benefit management services in the State, including administration of a retail pharmacy network.

The Respondent certifies its Carve-In Pharmacy is registered with the Florida Office of Insurance Regulation to conduct business within the State as a pharmacy benefit manager pursuant to section 624.490, Florida Statutes.

The Respondent certifies its Carve-In Pharmacy has current URAC Specialty Pharmacy (formerly Utilization Review Accreditation Commission) accreditation.

The Respondent certifies its Carve-In Pharmacy has a retail pharmacy network within the State of Florida.

The Respondent certifies its Carve-In Pharmacy has administered at least two hundred fifty million dollars ($250,000,000) in annual pharmacy benefit claims, services, or product income in calendar year 2020 within the State of Florida.

The Respondent and its Carve-In Pharmacy agree that only the Department will determine, as part of its benefit design, if or when a drug class or drug product will be subject to prior authorization or step therapy or be excluded from coverage except for implementation of Respondent's or its Carve-In Pharmacy’s formulary design.

The Respondent certifies that its Carve-In Pharmacy currently has at least five hundred thousand (500,000) commercial covered lives (excluding discount card programs) across the Carve-In Pharmacy’s pharmacy benefit management book of business as of the Reply submission date.

The Respondent certifies its Carve-In Pharmacy currently has at least one (1) employer group of similar size (three hundred thousand (300,000) covered lives or more) and composition (both Medicare and non-Medicare) as the State of Florida.

The Respondent certifies that its Carve-In Pharmacy’s pricing will not be based on the use of prior authorization or preferred drug step therapy programs, unless requested by the Department during the negotiation of this procurement.

The Respondent certifies that its Carve-In Pharmacy can support on a monthly basis a minimum of nine (9) health claims data file transfers, one (1) pharmacy data file transfer, and one (1) eligibility file transfer.

The Respondent certifies that it and its Carve-In Pharmacy agree that the Department reserves the right to award medical and prescription drug coverages independently, or in any combination, if it is in the best interest of the State.

The Respondent certifies its Carve-In Pharmacy is willing, if Respondent is awarded a contract for HMO, to offer its plans alongside another Respondent also offering HMO and/or PPO options.

Signature below certifies that the signatory has the authority to respond to this solicitation on the Respondent’s and its Carve-in Pharmacy’s behalf and Respondent certifies its Carve-in Pharmacy’s conformance with all Responsiveness Requirements listed above.

Name of Respondent’s Organization

Printed Name of Organization’s Authorized Representative