6414 - Administrative Servies Only (ASO) for Medical and Pharmacy Benefits, 1.Pricing SheetExhibit 1
RFP 6414 Pricing Sheet for Medical & PBM Administration
The respondent shall complete the following section, which directly corresponds to the specifications. The contractor shall not make changes to this format.
Section MA - Medical Services Proposal Pricing
ITEM
1
2
3
4
Total Medical ASO Cost
ITEM
1
2
3
4
Total Medical ASO Costs for Years 2-5
*Assumes a 2% increase to employee count each year.
Section MB - Credits and Additional Fees Proposal Pricing
ITEM
1
2
3
4
5
Total Credits and Additional Cost
ITEM
1
2
3
4
Total Credits and Additional Costs for Years 2-5
Section MC - Cost of Additional Medical ASO Miscellaneous Services:
ITEM
1
2
3
4
Total Additional Medical ASO Miscellaneous Services
ITEM
1
2
3
4
Total Additional Medical ASO Misc Services Costs for Years 2-5
This below listed equipment, software, license, and services are representative of the City's of Denton requirements
for the identified project. The request pricing shall be utilized in determination of the "cost of service", of the various phases of the project, and any additional needs that may become
known to the City during the contract period.
Complete Additional Pricing on Sheet B Labeled "RX Discounts"
QTY
1500
1500
1500
1500
QTY*
1530
1560.6
1591.812
1623.64824
QTY
QTY
QTY
QTY
*NOTE: PLEASE EMAIL THIS EXHIBIT 1 AS AN EXCEL FILE TO EBIDS@CITYOFDENTON.COM
UOM
PEPM
PEPM
PEPM
PEPM
UOM
PEPM
PEPM
PEPM
PEPM
UOM
EA
EA
EA
EA
EA
UOM
EA
EA
EA
EA
UOM
UOM
Respondent's Business Name
Principal Place of Business (City and State)
Type of Service Requested
Claims Administration
Network Access Fee
Pre-Certification
Disease Management Administration Costs
Total Medical ASO Costs Years 2-5:
CY 2019
CY 2020
CY 2021
CY 2022
Type of Service Requested
Wellness Credits
Implementation Credits
Third Party Stop Loss Integration Fee
Third Party Pharmacy Integration Fee
EDI File Feed set up costs for eligibility file transfer
Total Credits and Additional Costs Years 2-5
CY 2019
CY 2020
CY 2021
CY 2022
DESCRIPTION
Total Additional Medical ASO Misc Costs Years 2-5:
CY 2019
CY 2020
CY 2021
CY 2022
Cost of Service
Cost of Service
Cost of Service
Cost of Service
Cost of Service
Cost of Service
Total Cost of Service
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
Exhibit 1
RFP 6414 Pricing Sheet for Medical & PBM Administration
The respondent shall complete the following section, which directly corresponds to the specifications. The contractor shall not make changes to this format.
Section PA - PBM Services Proposal Pricing
ITEM
Retail
1
2
Mail Order
1
2
Total PBM Dispensing Cost
ITEM
1
2
3
4
Total PBM Dispensing Costs for Years 2-5
*Assumes a 2% increase to employee count each year.
ITEM
Retail
1
2
Total PBM Administrative Cost
ITEM
1
2
3
4
Total PBM Administrative Costs for Years 2-5
*Assumes a 2% increase to scripts (to coincide with employee count increase) each year.
Section PB - Estimated Annual Rebates to City
ITEM
1
Total Rebates
ITEM
1
2
3
4
Total Estimated Rebates Costs for Years 2-5
Section PC - Cost of Additional PMB Miscellaneous Services:
ITEM
1
2
3
4
5
Total Additional PBM Miscellaneous Services
ITEM
1
2
3
4
Total Additional PBM Misc Services Costs for Years 2-5
This below listed equipment, software, license, and services are representative of the City's of Denton requirements
for the identified project. The request pricing shall be utilized in determination of the "cost of service", of the various phases of the project, and any additional needs that may become
known to the City during the contract period.
Sheet C Labeled "ASO-Total Pricing Sheet" is Autofilled--Please do not make changes
Complete Additional Pricing on Sheet D Labeled "RX Discounts"
QTY
3300
37142
125
1608
QTY
43018.5
43878.87
44756.4474
45651.576348
QTY
42175
25
QTY*
43044
43904.88
44782.9776
45678.637152
QTY
QTY
QTY
QTY
UOM
SCRIPTS
SCRIPTS
SCRIPTS
SCRIPTS
UOM
SCRIPTS
SCRIPTS
SCRIPTS
SCRIPTS
UOM
SCRIPTS
SCRIPTS
UOM
SCRIPTS
SCRIPTS
SCRIPTS
SCRIPTS
UOM
EA
UOM
EA
EA
EA
EA
UOM
UOM
*NOTE: PLEASE EMAIL THIS EXHIBIT 1 AS AN EXCEL FILE TO EBIDS@CITYOFDENTON.COM
Respondent's Business Name
Principal Place of Business (City and State)
Type of Service Requested
Brand dispensing fee
Generic dispensing fee
Brand dispensing fee
Generic dispensing fee
Total PBM Dispensing Costs Years 2-5
CY 2019
CY 2020
CY 2021
CY 2022
Type of Service Requested
Administrative fee for electronic claims
Administrative fee for paper claims
Total PBM Administrative Costs Years 2-5
CY 2019
CY 2020
CY 2021
CY 2022
Rebates
Total Estimated Rebates Years 2-5:
CY 2019
CY 2020
CY 2021
CY 2022
DESCRIPTION
Total Additional PBM Misc Costs Years 2-5:
CY 2019
CY 2020
CY 2021
CY 2022
0
0
Cost of Service
Cost of Service
Cost of Service
Cost of Service
Rebate Credit
Rebate Credit
Cost of Service
Cost of Service
Total Cost of Service
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
Total Cost of Service
0
0
0
Total Cost of Service
0
0
0
0
0
Total Rebate Credit
0
0
Total Rebate Credit
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
Exhibit 1
RFP 6414 Pricing Sheet for Medical & PBM Administration
The respondent shall not complete changes to the following section, which directly corresponds to the specifications. The contractor shall not make changes to this format.
Section Total A - Medical-PBM Services Proposal Pricing
ITEM
1
2
3
4
5
Total Costs
ITEM
1
2
3
4
5
Total Costs
ITEM
1
2
3
4
5
Total Costs
SECTION A -- TOTAL MEDICAL-PBM SERVICE PRICING COSTS
Section Total B - Medical-PBM Credits/Rebates to City
ITEM
1
2
3
4
5
SECTION B -- TOTAL MEDICAL-PBM CREDITS/REBATES/ADD'L FEES PRICING COSTS
Section Total C - Medical-PBM Costs of Additional Miscellaneous Services:
ITEM
1
2
3
4
5
SECTION C -- TOTAL MEDICAL-PBM COSTS OF ADD'L MISC PRICING COST
TOTAL MEDICAL-PBM SERVICE PRICING COSTS (SECTION A + B + C TOTALS)
This below listed equipment, software, license, and services are representative of the City's of Denton requirements
for the identified project. The request pricing shall be utilized in determination of the "cost of service", of the various phases of the project, and any additional needs that may become
known to the City during the contract period.
Complete Additional Pricing on Sheet D Labeled "RX Discounts"
Respondent's Business Name
Principal Place of Business (City and State)
Total Medical ASO Costs
Total Medical ASO Costs 2018
Total Medical ASO Costs 2019
Total Medical ASO Costs 2020
Total Medical ASO Costs 2021
Total Medical ASO Costs 2022
Total PBM Dispensing Costs
Total PBM Dispensing Costs 2018
Total PBM Dispensing Costs 2019
Total PBM Dispensing Costs 2020
Total PBM Dispensing Costs 2021
Total PBM Dispensing Costs 2022
Total PBM Administrative Costs
Total PBM Administrative Costs 2018
Total PBM Administrative Costs 2019
Total PBM Administrative Costs 2020
Total PBM Administrative Costs 2021
Total PBM Administrative Costs 2022
Total Medical-PBM Credits/Rebates
Total Medical-PBM Credits/Rebates/Additional Fees Costs 2018
Total Medical-PBM Credits/Rebates/Additional Fees Costs 2019
Total Medical-PBM Credits/Rebates/Additional Fees Costs 2020
Total Medical-PBM Credits/Rebates/Additional Fees Costs 2021
Total Medical-PBM Credits/Rebates/Additional Fees Costs 2022
Total Medical-PBM Additional Miscellaneous Costs
Total Medical-PBM Additional Miscellaneous Services Costs 2018
Total Medical-PBM Additional Miscellaneous Services Costs 2019
Total Medical-PBM Additional Miscellaneous Services Costs 2020
Total Medical-PBM Additional Miscellaneous Services Costs 2021
Total Medical-PBM Additional Miscellaneous Services Costs 2022
*NOTE: PLEASE EMAIL THIS EXHIBIT 1 AS AN EXCEL FILE TO EBIDS@CITYOFDENTON.COM
0
0
Total Cost of Service
0
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
0
0
Total Credit
0
0
0
0
0
0
Total Cost of Service
0
0
0
0
0
0
0
Exhibit 1
RFP 6414 Pricing Sheet for Medical & PBM Administration
The respondent shall complete the following section, which directly corresponds to the specifications. The contractor shall not make changes to this format.
Section D - PBM Services Discounts
ITEM
Retail
1
2
3
4
5
Mail Order
1
2
3
4
5
6
Complete Supplemental Questions on Sheet E Labeled "Supplemental Questions"
UOM
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
EA
*NOTE: PLEASE EMAIL THIS EXHIBIT 1 AS AN EXCEL FILE TO EBIDS@CITYOFDENTON.COM
Respondent's Business Name
Principal Place of Business (City and State)
Type of Service Requested
Single-source brand ingredient cost discount off AWP (Discount may not include savings from DUR; formulary savings; clinical savings; or DAW penalties)
Multi-source brand ingredient cost discount off AWP
Effective brand discount (combined total of brand discount (excluding the items above) & U&C only
MAC generic discount off AWP
Non-MAC generic discount off AWP
Single-source brand ingredient cost discount off AWP
Multi-source brand ingredient cost discount off AWP
Effective brand discount (combined total of single-source and multi-source)
Brand ingredient cost discount off AWP
Non-MAC generic discount off AWP
Effective generic discount (combined total of MAC and non-MAC) including ALL-in generics, e.g. SSGs
0
0
Percentage
Exhibit 1
RFP 6414 Pricing Sheet for Medical & PBM Administration
The respondent shall complete the following section, which directly corresponds to the specifications. The contractor shall not make changes to this format.
Technical Requirements: Please respond to the questions below.
Medical ASO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Pharmacy Benefits Administration
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
For the purposes of this RFP response, ALL Generics are defined as SSGs, zero balance generics, MAC and NON-MAC generics, U&C generics, authorized generics or originator generics.
For purposes of this RFP response, SSGs are defined as: “Single-Source Generic Drug” means a prescription medication that is: (i) licensed and then currently marketed by one (1) Generic
Drug manufacturer; (ii) is subject to patent litigation; or (iii) is not available in sufficient supply.
________ Initial here that you have read and understand and will AGREE to the definition of Overall Network Generic Effective Rate Guarantee (OGER); as “all in” and the SSG definition
as provided on the left.
Contractor will provide a single point-of-contact account manager and representative. This person shall be available through a toll-free telephone number and a direct telephone number.
For each type of plan administered, the benefits will be interpreted and claims processed in accordance with the summary plan description.
No loss/No gain: No covered member shall lose or gain benefits as a result of a vendor change. All pre-existing condition limitations, actively-at-work and non-confinement provisions
must be expressly waived for the initial enrollment for covered members who have already satisfied the limitations under the current plan.
Provider must assume all existing subscribers, including Consolidated Omnibus Reconciliation Act of 1985 (COBRA) and Family Medical Leave Act (FMLA) subscribers.
CITY OF DENTON does not guarantee a minimum participation in the plans. Employees have the option to decline dental, medical and pharmacy (one plan). Contractors shall indicate any
specific restrictions if awarded contracts for less than the current enrollment.
The contract shall contain a clause or clauses assuring the following: No clerical error made by the Contractor or the CITY OF DENTON shall invalidate insurance otherwise validly in
force, nor continue insurance otherwise validly terminated.
If an eligible employee, before date of eligibility or within 30 days of hire, has made written application for coverage and has authorized the premium contributions, the insurance,
if otherwise entitled to, shall not be invalidated solely because of the failure of the CITY OF DENTON, due to clerical error, to give proper notice to the Contractor of such employee’s
application.
Contractor will accept and deliver electronic eligibility and enrollment data to any CITY OF DENTON contracted carve-out contractor (i.e., prescription drug contactor, online enrollment
system
Contractor will assist in annual plan communication and enrollment.
Contractor will develop and provide a summary handout/overview of plan benefits for initial annual enrollment, employee orientation and annual enrollment for any renewal term.
Contractor agrees that any major network changes will be brought to the immediate attention of CITY OF DENTON representation.
Contractor agrees to performance guarantees in connection with the implementation of services and for those services that are to be provided on an ongoing basis. The details of these
guarantees will be negotiated during the finalist selection process. The City Will require performance Guarantees on issuance of ID Cards. Contractor will be expected to conduct regular
internal audits and report the results back to the CITY OF DENTON for use in enforcing performance guarantees.
CITY OF DENTON has the right to have an audit performed annually or on an “as needed” basis if circumstances warrant, including but not limited to: compliance with contractual obligations;
compliance with CITY OF DENTON summary plan document; and accuracy of computer reports, claims payments, and records.
Turnover plan - Contractor agrees to transmit test data to a new contractor no less than 30 days prior to the termination of a contract and to provide a final verified transition data
file to the new contractor within 30 days after the termination.
Notwithstanding “no Default for Causes Beyond Reasonable Control”, Contactor will provide security and emergency protection for all data, records, forms, and data processing operations
devoted to the CITY OF DENTON contract, in whole or in part.
Contractor will comply with the Health Insurance Portability and Accountability Act (HIPAA) privacy, security and standard transactions regulations according to the terms of a HIPAA
business associate agreement with CITY OF DENTON.
Contractor agrees to provide a full claim and eligibility file annually at no cost to the City.
PBM will agree to minimum guarantees for rebates and network discounts.
City requires 100% pass-through of all rebates (base, incentive) administrative fees, manufacturer fees and financial benefits received.
PBM will agree that a zero-balance due (ZBD) claims is one where the City pays no part of the pharmacy reimbursement because the pharmacy reimbursement is equal to or below the member’s
co-pay amount. For ZBD claims, it is a requirement that the member pay the lower of: 1) sum of the discounted ingredient cost + dispense fee; 2) participating pharmacy’s U&C; or 3)
the member’s co-payment. This requirement extends to both retail and mail order pricing. Reflecting a pharmacy reimbursement rate of 100% is not appropriate or acceptable.
PBM agrees that if any changes in contracted network discounts and fees, or in Pharmacy contracts concerning rebates earned, occur during the course of the contract term, these discounts
and/or rebate improvements will be passed along to the City immediately upon implementation.
The City requires that the Average Wholesale Price (AWP) used to calculate the claim is the current, post-settlement AWP as published AND VERIFIABLE by a nationally-recognized pricing
reference, and that a single AWP pricing source is used (i.e., First Databank or Medi-Span).
PBM agrees that AWP is based on 11-digit National Drug Code (NDC) as supplied by a nationally recognized AND VERIFIABLE pricing source (i.e., First DataBank or Medi-Span) on the date
of service for retail-30, retail-90, and mail claims.
If a proprietary AWP pricing system is used by the PBM, PBM will allow full audit access to verify that the amount billed to the City is the same as the amount reimbursed to the network
pharmacy, and that the AWP basis is the 11-digit NDC as supplied by a nationally recognized AND VERIFIABLE pricing source (First DataBank or Medi-Span) on the date of service.
The City requires that the definition of generic drugs are those drug products for which there is an approved application under Section 505(j) of the Federal Food, Drug, and Cosmetic
Act (21 USC 355(j)). If a drug product approval is based upon an abbreviated new drug application (ANDA), that drug is a generic drug. Single-source generic drugs are included in
the definition of “generic drugs.” This definition must be used when adjudicating claims and when quoting generic discounts and guarantees.
Discounts & Discount Guarantee Calculations Requirements:
1. Bidder agrees to exclude the following from all contract discounts and discount calculations:
a) DAW 5 claims
b) Member co-pays for “member pay the difference” claims
c) Zero balance claims (ZBCs)
d) Claim audit recoveries
e) Therapeutic substitution savings
f) COB claims
g) DMR Claims
2. Bidder agrees that no discount value will be derived from:
PBM agrees that Single-Source Generics (SSG) will be excluded from the Brand Drug discounts and the Brand Discount Guarantee.
The PBM must offer ONE MAC list, which must be an identical MAC pricing list at retail-30, retail-90, mail order and specialty providers.
The City will accept only a pass through financial proposal that is PMPM-based (not a proposal based on claims).
PBM agrees that the City members will pay the lowest of (i) co-pay, (ii) U&C or (iii) contracted rate. In no event will the member pay full co-pay if the contracted cost is lower.
The City will require a quarterly report demonstrating that pass-through pricing has been achieved in all network channels.
PBM agrees that 100% of audit recoveries from all network pharmacies will be returned to the City.
The City, at its sole expense, may conduct an annual audit of PBM’s records of claims processed on the City’s behalf, including, but not limited to, paid, reversed, and denied claims,
and any other data or algorithms required to reconcile the amount that the City paid for adjudicated claims, for claims processing, for PBM’s performance, and for measurement of PBM’s
representations, promises, and guarantees with the City.
At PBM’s expense, PBM shall make available to the City’s auditor at the PBM’s location, any and all records containing the City information and any other records reasonably necessary
for the auditor to evaluate PBM’s performance, including, but not limited to, paid, reversed, and denied claims, manufacturer rebate contracts, pharmacy contacts, and any other data
or algorithms required to reconcile the amount that the City paid for adjudicated claims, for claims processing, and to measure PBM’s representations, promises, and guarantees with
The City. Wherever applicable, PBM will provide such data in the form of a direct source system extract, such that the data are consistent with the actual transactions processed. PBM
will provide this data in such format that neither the City nor the City’s auditor will be required to purchase any third-party licenses or incur any external costs in order to complete
a thorough audit. PBM also will provide, either within the data or by means of supporting data tables and algorithms, data-based definitions for all criteria described in this contract,
(e.g., what claims were adjudicated as brand or generic).
PBM agrees that the City will have FULL audit rights as follows:
a) Claim-level detail to verify that PBM is billing exactly the amount it is reimbursing to network providers.
b) Full access to all pharma manufacturer contracts and rebate-level detail to verify 100% of all pharmacy manufacturer rebates, monies and financial benefits are passed through
in full to the City.
Full access to all provider reimbursement contracts for all networks, including retail, 90 day retail, mail order and specialty.
PBM will agree to minimum guarantees for rebates, network discounts and dispensing fees and will immediately pass through to the City all upside improvements through the term of the
contract, which will be verifiable by annual audit or when deemed necessary by City or City’s representative.
PBM agrees that its only revenue source earned on this account will be the administrative fee charged.
If your MAC price is lower than the pharmacy’s Usual & Customary (U&C) price, will the MAC price prevail?
Overall Network Generic Effective Rate Guarantee (OGER) will include ALL generics. No exceptions.
a) Usual and Customary (U&C) claims greater than the member’s co-pay
b) The AWP value from any compound claims for compound claims that are labeled and adjudicated under U&C, and the AWP value from pharmacy input errors
*NOTE: PLEASE EMAIL THIS EXHIBIT 1 AS AN EXCEL FILE TO EBIDS@CITYOFDENTON.COM
Respondent's Business Name
Principal Place of Business (City and State)
0
0
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Agree
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
Do Not Agree
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No