IMPORTANT ADDENDUM #4. RFP # PHARMACY BENEFIT MANAGEMENT SERVICES Changes in Specifications and SHP Responses to Questions

Transcription

1 3200 Atlantic Avenue Raleigh, NC Phone: Fax: IMPORTANT ADDENDUM #4 RFP # PHARMACY BENEFIT MANAGEMENT SERVICES Changes in Specifications and SHP Responses to Questions Addendum Date: November 16, 2015 Proposals Opening Date & Time: December 7, :00pm., EST 1

2 Changes in Specifications 1. There is added to the RFP a current employee zip code census file attached as Exhibit H. and titled: Geo-Access CUS xlsx 2. There is added to the RFP the Plan s October membership report attached as Exhibit I. and titled: October Membership reports (Non-MAPDP). 3. Table X.D.2. Performance Guarantees- Implementation is amended and restated in its entirety as set forth below: 2

3 Table X.D.2. PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Administration Enrollment Administration Enrollment Administration Mail Order Claims Requirement Group Additions Contractor shall accurately and timely add new Employee Units within five (5) business days of receipt of the necessary documents.* Eligibility Posting Time Electronically transmitted eligibility files shall be accurately and timely posted within one (1) business days after receipt in specified format.* Mail Order Claims (a) No Intervention The Contractor shall dispense all prescriptions under mail service not requiring intervention within the time specified. Performance Standard 100% of All Employing Units are added within five (5) business days of receipt. 100% within two (2) business days of receipt (a) 100% within 2 business days of receipt Frequency of Measure Measured and reported within forty-five (45) calendar days following each quarter Measured and reported within forty-five (45) calendar days following each quarter. Measured and reported within forty-five (45) calendar days following each quarter. Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required 1.0% 1.0% 0.25%

4 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Paper Claims Administration Requirement (b) Intervention The Contractor shall dispense all prescriptions under mail service requiring intervention within the time specified dispensed with the incorrect drug or strength, divided by (ii) the number of all mail order pharmacy prescriptions dispensed. (c) Dispensing Accuracy The Contractor shall accurately dispense all mail order prescriptions as prescribed Dispensing Accuracy Rate means (i) the number of all mail order pharmacy prescriptions dispensed by Contractor in a Plan quarter less the number of those prescriptions dispensed by Contractor in such Plan quarter that are reported to and verified by the Contractor as having been dispensed. Paper Claim Process Time The Contractor shall respond to (process a check or reject notice) reimbursement paper claims. (1) Clean claim- a claim not needing additional information Performance Standard (b) 100% within 5 business days of receipt. (c) 99.9% or greater (1) 98% within 5 business days of the request Frequency of Measure Measured and reported within forty-five (45) calendar days following each quarter. Measured and reported within forty-five (45) calendar days following each quarter. Measured and reported within forty-five (45) calendar days following each quarter Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required (2) All paper claims (2) 100% within 10 Measured and 0.25% 0.25% 0.25% 0.25%

5 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Claims Administration Requirement Claim Adjudication Accuracy Claims Adjudication Accuracy Rate means (i) the number of retails claims, mail order claims and directly submitted paper claims, adjudicated by the Contractor in a Plan Year that do not contain a material adjudication error, divided by (ii) the number of all such claims adjudicated by the Contractor in such Plan year Performance Standard Frequency of Measure business days reported within forty-five (45) calendar days following each quarter 99% or greater. Measured and reported within forty-five (45) calendar days following each quarter by Bidder and audited by Plan Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required 1.0% Claims Administration Financial Accuracy - The Contractor shall guarantee that the average annual financial accuracy of paid claims will be 99% or higher. Financial accuracy is calculated as follows: the total dollars of audited claims paid minus the sum of the absolute dollar value of all overpayments and underpayments is divided by the total dollars of audited claims paid. Financial accuracy is calculated as follows: the total dollars of audited claims paid minus the sum of the 99% or higher. Measured and reported within forty-five (45) calendar days following each quarter by Bidder and audited by Plan 1.0%

6 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Member Services Member Services Member Services Availability Member Services Requirement absolute dollar value of all overpayments and underpayments is divided by the total dollars of audited claims paid Client Issue Resolution Issues initiated by the Plan Plan will receive an acknowledgement from the Contractor within twenty four (24) hours and a proposed resolution that is acceptable to the Plan within seventy-two (72) hours or three (3) business days. Performance measure to be tracked by open issues report.* The dedicated customer service toll-free line shall be staffed and available 24/7* Member Inquiry Response Time The Contractor shall respond to written concerns or complaints received by it in connection with its delivery of services within two (2) business days, and 99.8 % within 7 calendar days as calculated under the Time-to-Respond Formula. Time-to-Respond is calculated by counting the number of calendar days Performance Standard Frequency of Measure 100% Measured and reported within forty-five (45) calendar days following each quarter. 100% Measured and reported forty five (45) calendar days following each quarter. 99% s within two (2) business days, and 99.8 % within 7 calendar days Measured and reported within forty-five (45) calendar days following each quarter. Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required 1.0% 0.25% 0.5%

7 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Requirement from the day the complaint is received by the Contractor to, and including, the date a written response is mailed to the complainant. Time-to- Respond to written complaints shall be reported to the Plan Contract Manager quarterly. Performance Standard Frequency of Measure Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required Member Services Member Services Average Speed of Answer The Average Speed of Answer ( ASA ) of the Member service telephone line each Plan quarter will be on average thirty (30) seconds or less.* Call Abandonment Abandoned calls are defined as calls that have been connected or minimum of thirty (30) seconds and not answered by a live person before the call is connected.* 97% or greater Measured and reported within forty-five (45) calendar days following each quarter. 97% or greater Measured and reported within forty-five (45) calendar days following each quarter. 0.5% 0.5% Member Services Call Blocked Plan member calls will not be blocked. A blocked call is defined as any call made by the 100% Measured and reported within forty-five (45) 0.25%

8 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Member Services Member Services Requirement caller but not allowed into the Contractor s phone system First Call Resolution Rate First Call Resolution Rate means (i) the total number of telephone calls made by a Member and resolved by the Contractor Customer Service Representative on the first call as measured by the Member not calling back the Contractor customer service center within five (5) business days regarding the same inquiry, divided by (ii) the total number of telephone calls made by Members and received by the Contractor. Satisfaction Survey Percent of Plan member respondents very satisfied or satisfied with the Contractor services. Survey shall be conducted by an independent company Performance Standard Frequency of Measure calendar days following each quarter. 93% or greater Measured and reported within forty-five (45) calendar days following each quarter. 90% or greater Measured and reported ninety (90) calendar days following each contract year. Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required 1.0% 1.0%

9 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Network Network Access Requirement Retail Network Access- Urban Participating Members with an urban zip code shall reside within one (1) mile of a participating pharmacy, as measured on the first day of the contract year. Performance Standard Frequency of Measure Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required 98% or greater Measured and assessed first day of the contract year. 0.25% Network Access Retail Network On-line Availability Rate Retail Electronic Claim Timeliness Retail Claim Financial Accuracy Retail Network Access- Rural Participating Members with an urban zip code shall reside within fifteen (15) miles of a participating pharmacy, as measured on the first day of the contract year. 95% or greater Measured and assessed first day of the contract year. 0.25% The on-line system shall be available 24/7 99.8% or greater Measured 45 days after the close of the quarter The automated POS claims system shall process claims within twenty (20) seconds The payment accuracy rate shall be equal to the total dollars paid correct as a percent of the total dollars paid. Retail Claim Financial Accuracy is calculated as follows: The total dollars of audited retail claims paid 100% Measured 45 days after the close of the quarter 99.9% or greater Measured 45 days after the close of the quarter 0.25% 0.25% 0.25%

10 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Clinical Clinical Clinical Requirement minus the sum of the absolute dollar of all retail claim overpayments and underpayments is divided by the total dollars of audited retail claims paid. Utilization Management Programs Authorizations The Contractor will turn around all initial requests in accordance with N.C.G.S & Utilization Management PA, ST, and QLL requests and determinations will be made within 24 hours TAT. Performance Standard Frequency of Measure 100% Measured and reported within forty-five (45) calendar days following each quarter 95% within 24 Hours 99% within 48 Hours 100% within 72 Hours Measured and reported within forty-five (45) calendar days following each quarter Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required 0.5% 1.0% Clinical Formularies Changes to the Plan s formulary will be implemented within ten (10) business days after receipt of the Plan s formal request.* 100% Measured and reported within forty-five (45) calendar days following each quarter.. 1.0%

11 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Financial Financial Account Team Account Management Team Requirement Pharmacy Pricing The Contractor will guarantee one hundred percent (100%) of participating pharmacies will adhere to lower of U&C/MAC or actual price The Account Management Team assigned to the Plan shall respond to telephonic, , and other written inquires within the time period specified 1. Telephonic inquiries shall be responded to within one (1) business day. 2. inquiries shall be responded to within one (1) business day. 3. Written inquiries shall be responded to within three (3) business days Performance Standard Frequency of Measure 100% Measured and reported within ninety (90) calendar days following each quarter; reconciled annually % of all telephonic inquiries % of all inquiries % of all written inquiries Measured Quarterly and reported within 45 days of the close of the quarter Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required 1.0% 0.5% Account Management Team The Account Management Team assigned to the Plan shall co-manage with the Plan a work-plan with deliverables. The teams shall agree upon the deliverable dates. The Account Management Team 95% or greater Measured Quarterly and reported within 45 days of the close of the quarter 0.25%

12 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Account Management Team Performance Requirement shall meet the deliverable dates as approved by the Plan Performance of the Account Management Team shall be based on a semi-annual Report Card as developed by the Plan and Contractor Performance Standard Score of at least a 4 on a scale of 1 5 Frequency of Measure Semi-Annually Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required 0.5% Accuracy of Reports and deliverables Reports and deliverables to the Plan Each report shall be mathematically or otherwise accurate. The proposed amount at risk will apply to each report or deliverable. 100%. Measured Quarterly and reported within 45 days of the close of the quarter. 1.0% Ad hoc Reporting 1. Non-complex reports (reports that can be run by the account management team) Shall be deliverable to the Plan within the timeframe specified. 2. Complex reports (reports that cannot be run by the account management team) Shall be deliverable to the Plan within the timeframe specified. a. 100% Within 2 business days % Within 5 business days Measured Quarterly and reported within 45 days of the close of the quarter. 0.5% Reporting Quarterly Data Files Accurate and complete quarterly data files will be made available to the Plan within 30 calendar days following the end of the 100% Measured and reported within forty-five (45) 0.5%

13 PERFORMANCE GUARANTEES ON-GOING TO BE COMPLETED BY THE BIDDER All performance standards and results are Plan, not book of business specific. Total at risk fees least must be at least 25% with a maximum allocation of 2.0% and a minimum allocation of 0.25% for any given measure unless otherwise indicated Performance Indicator Requirement quarter. This applies to all claims, enrollment, utilization, financial, daily register, and rebate summary reports.* Performance Standard Frequency of Measure calendar days following each quarter. Risk: At least 25% of Quarterly Fees- Indicate Allocation Below Minimum Risk Required Reporting Reporting Performance Guarantee Reporting - A report that captures performance guarantees shall be provided to the Plan quarterly within forty-five (45) calendar days of the end of the quarter. Financial Guarantee Reporting - A report that captures all financial guarantees (discounts, fees rebates) shall be provided to the Plan within fortyfive (45) calendar days of the end of each quarter. 100% Measured and reported within forty-five (45) calendar days following each quarter. 100% Measured and reported within forty-five (45) calendar days following each quarter. 0.5% 0.5%

14 PBM RFP Vendor Questions 1.(a) Does the claim file include pharmacy claims from both the actives and EGWP retirees? Answer: The file contains all pharmacy claims paid from June 2014 through May Our EGWP program only ran during calendar year While it is possible that a few EGWP claims weren t paid until June 2014 or later, the number will be quite small. 1.(b) If yes, there is no way to identify if the claim is for an active or retiree. Would it be possible to get a new claims file that includes an indicator showing whether the claim is part of the commercial or EGWP plans? Answer: The file does not contain a retiree indicator. The Plan cannot provide a new claims file that includes and indicator showing whether the claim is a part of the commercial or EGWP plans. See the response provided to 1.(a) for additional clarification 2. The following additional information is requested for the claims data set: Answer: a. Formulary indicator (needed to provide requested formulary disruptions) b. Medicare Part D/RDS indicator (needed to provide the requested EGWP guarantees) a. Formulary indicator A new claims file will not be provided. The Plan currently has an open formulary with some excluded categories. For additional information visit: Prescription-Refill-Guidelines.aspx b. Medicare Part D/RDS A new claims file will not be provided. The Plan currently has an open formulary with some excluded categories. For additional information visit: Prescription-Refill-Guidelines.aspx 3. The RFP requires the Contractor to provide claims data to other Plan vendors and Partners on a monthly basis, within fifteen (15) calendar days of the end of the month. (See Sectioin viii.- Reporting) How many vendors and partners will there be and will they all get the same file layout or will each have their own custom formats? Answer: Claims data will most likely have to go to the Plan s Third Party Administrator, its Population Health Management vendor, and the Plan s Data Repository (SAS). Files may need to be sent to other vendors depending on the Plan s needs. A listing of the all of the Plan s contracted vendors is available at bottom of the page in the footer section, SHP Contracted 3

15 Vendors. The file layout is based upon the business needs of the Plan, therefore the file may not be the same for each vendor or partner. 4. Please provide member call volume from your current PBM for the last 12 months, broken out by hour segments, and if possible, breakouts that include call volume during business hours and after hours. Answer: The call volume from the Plan s current PBM for January 2015 through September 2015 is listed below. We do not have call volume by hour. Quarter Call Volume Jan 1, 2015 Mar 31, ,436 Apr 1, 2015 Jun 30, ,887 Jul 1, 2015 Sep 30, , Please provide actual Call Volume and Average Handle times for the previous plan year. Answer: The ASA was maintained at less than 30 seconds for the first three quarters of What are the total number of prior authorizations that were approved and the total number of prior authorizations that were denied in the previous plan year? Answer: From 1/1/14 to 12/31/14, there were a total of 70,942 PA/ST/QLL approved and 7,493 denied. 7. The pricing booklet only asks for an Open Formulary Quote and Closed Formulary quote. In the RFP there is a statement regarding custom formularies: Ability and willingness to support custom formularies. Current formulary link is provided below Can you confirm whether you are requesting a custom quote as well as based on the current formulary? Answer: The current formulary is an open formulary. Please provide quotes regarding Open and Closed Formularies both Broad and Narrow Network. The Bidder must be able to customize its formulary at the Plan s request. 8. Section 3.4.4B.iii Specialty Pharmacy Network states: Ability and willingness to subcontract with a Contractor developed blend of in-house and North Carolina based specialty network. Clearly outline which entity would provide each service, the exclusivity of each network, pricing advantages, member and physician advantages Please clarify the question is this in-house and in-house pharmacy? 4

16 Answer: In-house refers to the PBM s specialty service. The Plan is seeking bidder responses to what a blend of in-house and North Caroline based specialty networks would look like and how it will operate. 9. Please supply a current employee zip code census file (needed to provide requested GeoAccess reports). Answer: Attached as Exhibit H is a current employee zip code census file: Geo-Access CUS xlsx 10. Please provide the Plan s current formulary by NDC in Excel format. Answer: That information is not available. 11. Please provide the Plan s current specialty drug list by NDC in Excel format. Answer: That information is not available. 12. Within the claims data, are RDS eligible members included? If not, please supply an indicator within an updated data set that represents RDS eligible members. Answer: Yes, RDS eligible members claims are included. 13. What does your current PBM provide for RDS, Part B, and EGWP services to the Plan today? Answer: The Plan s current PBM provides RDS services on behalf of the Plan. 14. What is the Plan s expectation for your current formulary if the decision is made to move to a new PBM carrier? Answer: You must be able to support a custom formulary. The current formulary is an open formulary and the Plan s expectation is that bidder may suggest changes/updates to the current formulary. Bidders are requested to provide quotes regarding Open and proposed Closed Formularies utilizing both a Broad and Narrow Network. 15. Section iv. of the RFP states: Ability and willingness to provide view only access to Plan staff for all claims adjudication systems and AWP pricing and associated systems to be utilized for Plan claims. What viewing access does the Plan have to the current PBM s claim system and are all claim elements available for viewing? Answer: The Plan currently has viewing access to the claims adjudication platform, including limited UM PA authorization. The Plan receives screen shots from the PBM platform to view additional clinical and customer related calls. 16. Section 3.4.4b.iii states: Ability and willingness to subcontract with a Contractor developed blend of in-house and North Carolina based specialty network. Clearly outline which entity would provide each service, the exclusivity of each network, pricing advantages; member and physician 5

17 advantages (include IV treatments in the description). What arrangement does the Plan currently have in place where a network of specialty providers can be negotiated? Can the names of those providers be shared? Answer: The Plan s current specialty network arrangements are through the contracted PBM which uses Accredo. 17. Please advise if responses to the Performance Guarantee (PG) requests in Table X.D.1. and X.D.2. should be in included in the Technical Proposal or in the Cost Proposal. If bidders need to provide clarifications to the requested Performance Guarantees, how should we provide clarifications? Answer: PG responses should be included in the response to the Technical Proposal. This opportunity to ask questions and have the Plan provide responses would have been the appropriate way to seek clarification on the PGs. 18. Financial Statements for the past two years were provided to the Plan with the Minimum Requirements submission. Are bidders required to also include hard copies of these reports with our technical and redacted proposal submissions? Answer: Additional financial statements will not be required with the technical submission. 19. Can bidders submit pre-printed materials (e.g. annual reports, communication samples) on nonrecycled paper, or must all proposal materials be reprinted on recycled paper? Answer: Yes pre-printed materials and samples may be submitted. 20. The Technical Response form requests 2014 and first quarter 2015 call center services metrics including ASA, Abandon rate, First call resolution, and Quality. Please advise as to what you are looking for in response to Quality in this question. Answer: Quality is the ability to measure and ensure the member calls are handled appropriately. It is the Plan s expectation that Offeror has a program in place to measure the quality of the responses to members. 21. Please clarify the intent of the State health Plan as it relates to your Medicare Part D lives. We understand that the Plan chose to move the vast majority of their EGWP lives to an MA-PD plan through United/Humana. By requesting EGWP pricing in the Cost Proposal should we assume that the Plan is considering an EGWP for all of their Med D lives, including the lives now covered under the MA-PD? Please clarify exactly what population of Med D lives would potentially move to an EGWP in Answer: The Plan evaluates its benefit programs on a regular basis and needs to understand the Offeror s ability to administer an EGWP program. 22. Please provide a census file so we can provide the requested pharmacy maps and Geo Access reports. 6

18 Answer: Attached as Exhibit H is a census file: Geo-Access CUS xlsx. 23. The claims file does not include formulary flags which impact our ability to provide member disruption and/or detailed formulary comparisons. Can the Plan provide a revised claims file that includes this information? Answer: The Plan cannot provide a revised claims file. The Plan has previously provided information via the following link: Prescription-Refill-Guidelines.aspx 24. Please clarify the intent of Question b.vi. in the Formulary Management section. Is the Plan requesting information on the Bidder s commercial formularies only here? If Medicare formularies are required also, please clarify if you are requesting that we provide rebate/disruption impacts for the claims data provided with the RFP against our standard Medicare formularies. Answer: The Plan has requested information on the Bidder s commercial formularies. 25. Please clarify the intent of Question d in the Medicare Part D Coverage Options section. Is the Plan requesting that we compare our commercial formulary to our Medicare formulary and provide the top 10 drug classes for each formulary based on our book of business utilization? Answer: The question is seeking information comparing the Bidder s current PDP formulary and the formulary the Bidder would propose for a Plan EGWP formulary. 26. Page 7, item 6 - Historically Underutilized Businesses- is there a requirement to utilize HUB s? Or is there just an encouragement to utilize wherever possible? Answer: It is not required. 27. Page 9 - Bidder understands that the Plan is not under any obligation to agree to any alternate terms and conditions that a bidder may propose, as set forth in RFP Section II.B.1. This section seems to say that a bidder may not take any exceptions to or supplement any terms and conditions in its proposal if such exceptions or supplementing is not approved or permitted through the bidder question and answer process. However, Section II.B.1 goes on to say that a winning bidder may present revisions for the Plan s consideration after award. For avoidance of any doubt, can the Plan confirm that if a bidder believes an exception to an RFP term or condition, or a supplementary term is a necessary aspect of its proposal, the bidder may, at its own risk, present such term or condition in its proposal, so long as it is clearly stated? Answer: Failure to accept the Plan s terms and conditions as stated in the RFP is the basis for rejection of a Bidder s proposal. 28. Page 16, Section V, General Contract Terms & Conditions - Subsection H, Assignment, states that no assignment of a Contractor s obligation shall be permitted. Bidder, similar to other PBM s, utilizes 7

19 certain third-party vendors to support its ability to perform certain ancillary functions, such as ID card printing, help desk support for retail pharmacies in our network and performing medical necessity appeal reviews. We will disclose these vendors in our proposal; however, from time to time we may elect to switch vendors to obtain the best quality and/or value of support services. Can the Plan confirm that, with notice to the Plan, such vendor substitution will be permitted so long as the Plan has no objective concern about the new vendor and bidder remains 100% liable for proper performance of the function? Answer: The Plan will not unreasonably withhold approval of a subcontractor. 29. Page 16, Section V, General Contract Terms & Conditions, Subsection I, Audits and Access to Records - In order to provide the Plan with the specified access to records necessary to validate performance or cost, the PBM will need to provide the Plan with access to certain confidential information that is very competitively sensitive. Will the Plan permit bidders to propose for consideration certain protections around the manner and access to these records, such as requirements for third-party non-disclosure agreements, timetables to promote efficient auditing, etc.? Answer: The Plan will consider reasonable requests but cannot agree to anything that would inhibit the State Auditor s statutory rights. 30. Page 20, definition 8, Section V, General Contract Terms & Conditions, Subsection U, Defined Terms and References - Bidder defines a Biosimilar as a biological product that is highly similar to a U.S. licensed reference biological product notwithstanding minor differences in clinically inactive components, and for which there are no clinical meaningful differences between the biological product and the reference product in terms of the safety, purity, and potency of the product. We believe this definition is appropriate based on the emerging environment for these types of products, which generally do not contain an exact copy of the biological product that it is substituted for. Will the Plan consider Bidder s definition of biosimilar for this procurement? Answer: The Plan prefers to follow the FDA definition of biosimiliar products. 31. Page 20, definition 8, Section V, General Contract Terms & Conditions, Subsection U, Defined Terms and References - As of October 29, 2015, is Zarxio the only biologic launched in the US market place that meets your definition of biosimilar? Answer: Yes. 32. Page 24, Definition 47, Section V, General Contract Terms & Conditions, Subsection U, Defined Terms and References - Pass Through Pricing- Please confirm that the definition of Pass Through Pricing is for Retail Network prices and rebates, and does not apply to Mail Service and Specialty pricing for bidders that own and operate their own mail service and specialty pharmacies, which Definition 33 implies are locked and guaranteed rates to the Plan, but not an actual pass through of the bidder s wholesale acquisition pricing. Answer: Confirmed. 8

20 33. Page 25, definition 62, Section V, General Contract Terms & Conditions, Subsection U, Defined Terms and References - Rebates - The first sentence of this definition aligns with formulary rebates, as contracted in the PBM industry, however, the second sentence, can be construed as being much broader because the revenue is only described as being related to the Plan s utilization. Bidder may receive revenue from two sources that are indirectly related to utilization, consisting of fees or other compensation for services rendered and property provided in relations to the operation of our specialty drug pharmacies and related services, and prospective or retrospective discounts based on the purchase of products to stock Bidder-affiliated dispensing pharmacies. These fees and discounts are based on volume or services provided to manufacturers, rather than formulary or utilization decisions of clients, and are not allocated on a per claim or per client basis. These fees are retained by Bidder and help to support the mail order and specialty pharmacy discounts we are able to offer our clients. Please confirm that Bidder may make this clarification in its proposal for evaluation as part of the total proposal put forth. Answer: Confirmed. 34. Page 25, definition 63, Section V, General Contract Terms & Conditions, Subsection U, Defined Terms and References Manufacturer Service Fees - Bidder will not receive any Manufacturer Services Fees, as defined in the RFP, with respect to the Plan s business or members. However, Bidder expects to receive Manufacturer Administrative Fees collected by Bidder for administration services performed in relation to the formulary rebates collected. These fees will be passed through to the Plan and considered a component of Rebates. Please confirm that Bidder may make this clarification in its proposal for evaluation to avoid any potential confusion. Answer: Confirmed. 35. Page 30, Section V, General Contract Terms & Conditions - Subsection FF, Reimbursement for Claims specifies bi-weekly reimbursement for prescription drug claims. Bidder s systems are configured to generate invoices twice per month. This ensures that no invoice spans multiple months or multiple plan years. Can the Plan confirm that twice-monthly invoicing for claims is acceptable? Answer: Confirm: Twice-monthly invoicing for claims is acceptable. 36. Page 30, Section V, FF, Reimbursement for Claims - Can the Plan provide historical guidance for how quickly undisputed invoices are paid to the current PBM? Are they typically paid within 2-3 business days, which could be assumed to the standard referred to in the RFP? Answer: Payment generally occurs within seven (7) ten (10) days of receipt of the invoice. 37. Page 31, Section V, General Contract Terms & Conditions, Subsection JJ, Performance Bond - Does the Plan have a required format for the Performance Bond? If so, please provide a copy. Answer: No, we do not have a required format. 9

21 38. Page 39, Section VI, Scope of Work, section a.i - Question requests a dedicated customer call center. However, unlike the requirement for the account team, which states the team should be exclusively dedicated; section a.i does not require the customer call center to be exclusively dedicated. Is it acceptable to the Plan for the dedicated team to take calls from other plans members if they have excess capacity and are meeting the service level commitments? Answer: Yes. 39. Page 39, Section VI, Scope of Work, Section 3.2 Account Services - If the Customer Call Center is required to be dedicated and exclusive, please provide the number of manned phone calls received during a recent 12 month period for planning purposes Answer: The call volume from the Plan s current PBM for January 2015 through September Quarter Call Volume Jan 1, 2015 Mar 31, ,436 Apr 1, 2015 Jun 30, ,887 Jul 1, 2015 Sep 30, , Page 43, Section VI, Scope of Work, Section 3.4 Geo Access - Can the Plan send bidders a census file with member ZIP Codes to facilitate bidders ability to confirm member access requirements? Answer: Attached as Exhibit H is a census file with member ZIP Codes to facilitate bidder s ability to confirm member access requirements: Geo-Access CUS xlsx. 41. Page 44, d-2- Preferred and Non-Preferred 90 day networks - Can the Plan elaborate on what is meant by Preferred and Non-Preferred 90 day network? Is this design currently in place for the Plan? Would there be an incentive to the members to use a Preferred 90 day provider over a non-preferred 90 day provider? Answer: Preferred pharmacy networks could be a pharmacy in a narrow network offering better discounts than a non-preferred network. This design is currently not in place at the plan. There may be incentives for the member to use a preferred provider over a non-preferred. 42. Page 45, Section VI, Scope of Work, Section Q3.4.3.a.i in reference to a Preferred (Narrow) Network. Is this a 30 day network that excludes certain chains from the network? Answer: Yes, a narrow network may exclude certain chain pharmacies from the proposed narrow network. 43. Page 45, Section VI Scope of Work, question Please confirm if the Plan is currently Exclusive with the current PBM s Specialty pharmacy, meaning members are required to utilize the PBM s Specialty provider for Specialty medications? There are questions about being a preferred 10

22 vendor as well as a NC-based Specialty network. Is there currently a NC-based Specialty network in place? Answer: The PBM s Specialty pharmacy is exclusive with the exception of cancer drugs. A NC Specialty network is not currently in place. 44. Page 48, Section VI Scope of Work, question a,I Step Therapy - Can Plan confirm if existing users of drugs targeted by Step Therapy were grandfathered in perpetuity when the Step Therapy programs were implemented? Or were they subject to Step Therapy at time of program implementation/ after 1 year? Answer: This will vary depending on the medication. Members who are utilizing a Step 2 (non-preferred) product where the other products in that category have the same mechanism of action (eg. triptans, bisphosphonates) at the time of ST implementation may be grandfathered for a certain period of time and lettered regarding the change. Members who are utilizing a Step 2 product where the other products do not have the same mechanism (e.g inflammatory agents for RA, UC, etc) would be grandfathered in perpetuity if established on step 2 therapy. 45. Page 48, Section VI Scope of Work, question a.i- Step Therapy - Is the Plan s intent to exactly duplicate existing Step Therapy programs, or is Bidder allowed to propose utilizing Bidder s version of Step Therapy program, which might target similar or different medications? Answer: The Plan may require that a Bidder match the Plan s current step therapy programs. However, the Bidder is allowed to propose Bidder s version of Step Therapy programs. 46. Page 50, Section VI Scope of Work, question a.xix- Annual Business Plan- Can Plan confirm if this means a forward-looking document to identify future drugs for inclusion in UM programs? Answer: Confirmed. The Bidder is encouraged to propose Bidder s version of Step Therapy programs. 47. Page 51, Section VI, Scope of Work, Section Can the Plan send bidders a claims file containing formulary indicators to facilitate bidders ability to provide the necessary disruption analysis for Section 3.5.2? Answer: The Plan cannot send bidders a claims file containing formulary indicators to facilitate bidder s ability to provide the necessary disruption analysis for Section The Plan has previously provided information via the following link Prescription-Refill-Guidelines.aspx 48. Page 51, Section VI, Scope of Work, question Regarding formulary, can the Plan clarify if it is a requirement to exactly duplicate the existing Plan custom formulary? Or may bidder present a 11

23 formulary that is close to the existing custom Plan formulary, however with low disruption edits presented in order to maximize rebate value to the Plan? RFP question b.vi appears to imply that the Plan would adopt the Bidder s standard Open Formulary (with no drug exclusions) which would appear in Exhibit B W1 and W2 as Open Formulary. Answer: Bidder may be required to duplicate the Plan s custom formulary. However, the Plan encourages Bidders to propose a custom formulary. 49. Page 51, Section VI, Scope of Work, question a.v - Is the question referring to rebate implication referring to the negative implication to rebate guarantees if the Plan does not agree with the Bidder s placement of a new medication on a preferred tier? Answer: Yes. 50. Page 52, Section VI, Scope of Work, question a.i - Can the Plan send bidders a claims file containing formulary indicators to facilitate bidders ability to provide the necessary disruption analysis for Section 3.5.2? Disruption analysis based on a printed formulary as compared to a claims file containing a formulary indicator can lead to inaccuracies in analysis by both the Bidder and the Plan. Answer: No. The Plan is not able to provide a new claims file. 51. Page 52, Section VI, Scope of Work, question b.ii - Can the Plan confirm that the term Closed regarding formulary refers to the PBM industry practice of providing a Formulary which incorporates Exclusion of certain non-preferred drugs from coverage, subject to the ability to submit an exception request for medical necessity? Answer: Confirmed. 52. Page 55, Section VI, Scope of Work, Section Can the Plan provide a way to break out Retirees within the claims data? Since the RFP requires pricing for EGWP if the Plan implements EGWP for those retirees currently in RDS, and due to the different EGWP formulary/ corresponding rebates, bidder will be proposing different rebate guarantees for EGWP versus Commercial which necessitates the need to break out Retirees. Answer: No. 53. Page 55, Section VI, Scope of Work, Section 3.6.1, a., ii. - Please confirm that weekly is the desired frequency of submission of RDS eligibility feeds, as described in 3.6.1, a., ii. Due to the lifecycle and timing of RDS processing eligibility files, and the fact that CMS does not accept payment requests more frequently than monthly, it is not necessary to submit eligibility feeds more frequently than monthly. Our processes are automated on a monthly basis and this frequency continues to work well for our current RDS clients. Answer: Confirmed, however, pursuant to section 3.6.1, a., ii., the Plan may request more frequent files to ensure the eligibility is captured accurately during the Reconciliation process. 12

24 54. Page 57, Section VI, Scope of Work, a.i - Eligibility Files- can the Plan clarify if the current PBM is using the PBM s standard layout or if a custom layout provided by Plan s eligibility provider is used? If a Custom layout is required, please provide this layout so that programming estimates can be run. Answer: The Plan anticipates using a new custom file layout for the implementation of this contract and therefore the current file layout will not be provided. 55. Page 58, Section VI, Scope of Work, b.iii- 3rd Party Firms - are all those listed firms providing eligibility files to the current PBM? Or do some of them receive claims data from the PBM, which is the intent of their listing? Answer: No. The PBM may be required to interface with all of those vendors but the eligibility workflow will be defined during implementation. 56. Page 65, Section VI, Scope of Work, Subrogation - can the Plan detail what type of Medicare and/or Medicaid Subrogation is currently performed? Answer: We are interested in the Offeror s experience not the Plan s current workflow. 57. Page 67, Section VI, Scope of Work, a.ii - MAC list variance- can the Plan provide more information on the question here? There is confusion about what the intent is, if it is to provide detail on MAC reimbursement changes? Answer: The Bidder must have the ability and willingness to restrict MAC list variation and agree to no more than 1% variation from generic effective rate guarantee as measured on a quarterly basis-adjustments to conform to the discount guarantee agreed upon in the cost proposal. 58. Page 68, Section VI, Scope of Work, Rebate payment- Can the Plan clarify the requested timing for payment of minimum rebate guarantees? Typically this is 90 or 180 days after the quarter the claim is adjudicated. Answer: Financial guarantees (discounts, fees rebates) shall be provided to the Plan within fortyfive (45) calendar days of the end of each quarter. An annual reconciliation between the percentage of rebates paid and the guaranteed average amount. If the outcome of the reconciliation results in an amount due to the Plan, one hundred percent (100%) of the payment will be made by the Contractor within one hundred and eighty (180) calendar days after the contract year. 59. Page 76, Section IX.E- Cost Proposal/Scoring - Can the Plan clarify which of the three (3) buckets Rebate Guarantees will fall under? Bidder assumes it is part of the Network/Rx Fees bucket however seeks clarification. 13

25 Answer: Rebate Guarantees are included in Network/Rx Fees. 60. Section X, Performance Guarantees- In terms of the Plan s scoring of responses, are Performance Guarantees part of the Technical or Cost Proposal Section as described in Section IX.C? Answer: Performance Guarantees are included in the Technical Proposal. 61. Page 82, Section X Performance Guarantees, Table X.D.2. Enrollment Administration - Eligibility Posting Time The Requirement states Electronically transmitted eligibility files shall be accurately and timely posted within one (1) business days after receipt in specified format, but the Performance Standard states 100% within two (2) business days of receipt. Can the Plan confirm that the PG is 100% within two (2) business days of receipt? Answer: The Performance Standard should read 100% within one (1) business day of receipt 62. Page 83, Section X Performance Guarantees, Table X.D.2. Paper Claims Administration - What was the Plan s paper claim volume for the previous two contract years? Answer: The Plan s paper claim volume for the 1 st and 2 nd Quarters of 2015: Quarter Direct Claims Jan 1, 2015 Mar 31, ,365 Apr 1, 2015 Jun 30, Page 86, Section X Performance Guarantees, Table X.D.2. Network access - Is the following standard for Members residing in Suburban areas? Retail Network Access. Participating Members shall reside within (5) miles of a participating pharmacy, as measured on the first day of the contract year. Performance Standard: 97% or greater. Answer: Please see revised Section X Performance Guarantee, Table X.D.2 Network Access references included within this addendum. 64. Page 86, Section X Performance Guarantees, Table X.D.2. Retail Network On line Availability Rate - Does this standard exclude scheduled maintenance? Answer: Yes, this standard excludes scheduled maintenance. 65. Page 86, Section X Performance Guarantees, Table X.D.2. Retail Electronic Claim Timeliness - Does this standard exclude scheduled maintenance? Answer: Yes, this standard excludes scheduled maintenance. 66. Page 86, Section X Performance Guarantees, Table X.D.2 Claims Administration Financial Accuracy and Retail Claim Financial Accuracy - Please explain the difference between these two standards? 14

26 Answer: The Claims Administration Financial Accuracy guarantee relates to all claims (e.g. mail, retail, and direct paper claims). The Retail Claim Financial Accuracy guarantee relates only to retail claims. See the definition of Retail Claim Financial Accuracy included within this Addendum. 67. Exhibit B. Admin Fee PMPM- please confirm that the basis for the PMPM fee will be all eligible lives covered by the program, for example if Page 5 s data in Table I.B.4 were utilized, the basis would be 572,568 Answer: The basis for the PMPM fee will be all enrolled members based on the Plan s monthly membership report provided by the Plan s eligibility and enrollment vendor. 68. Exhibit B, Bundled Utilization Management Fee- please confirm that this incorporates all the standard fees for clinical UM programs as noted in the RFP, such as Prior Authorization, Step Therapy, Quantity Limit, Fraud Waste & Abuse, etc? Also, please confirm if it is optional to list a bundled UM fee? Exhibit B, W5 appears to allow for individual pricing for these UM programs. Answer: Confirmed. Standard UM fees should be bundled. It is optional for the bidder to list individual pricing for certain UM programs if applicable. 69. Exhibit B- UM Fee- in order to calculate a PMPM fee, please provide the number of prior authorization reviews processed by incumbent PBM over a most recent 12 month period. The number of PA s needed to assume for underwriting purposes is extremely unique to each individual client, hence the request. Answer: From 1/1/14 to 12/31/14, there were a total of 78,435 PA, ST, and QLL. 70. Exhibit B, W6- EGWP Proposal- Can the Plan provide a way to break out Retirees within the claims data? Since the RFP requires pricing for EGWP if the Plan implements EGWP for those retirees currently in RDS, and due to the different EGWP formulary/ corresponding rebates, bidder will be proposing different rebate guarantees for EGWP versus Commercial which necessitates the need to break out Retirees. Answer: No. 71. Exhibit E- Specialty Drugs- can the Plan clarify if the drugs listed as Provider Administered (Medical Benefit) Specialty Pharmacy Products are always adjudicated under the Medical Benefit? Or is there the chance that a member could send one of these medications in to the PBM Specialty Provider for filling? Answer: Drugs listed as Provider Administered (Medical Benefit) Specialty Pharmacy Products are currently always adjudicated under the Medical Benefit. 72. Can the Plan confirm that the utilization management information contained at is what is being used against the current formulary? 15

27 Answer: Confirmed. 73. Can the Plan confirm whether or not any prior authorizations have a step imbedded in them? Answer: Yes, there are prior authorizations that require step therapy. 74. Can the Plan clarify their Rheumatoid Arthritis/Psoriasis strategy? Some conflicting information is found when comparing the utilization management documents. The formulary doc has the below on the preferred specialty tier: Specialty Drugs tier 4 Enbrel Humira Stelara The Simponi utilization management document has this step strategy laid out: Preferred Products and Step Therapy Step 1: Enbrel, Humira Step 2: Actemra (SC), Cimzia, Orencia (SC), Otezla, Simponi (SC), Stelara Xeljanz The Stelara document wants members to step through Remicade which is not a preferred option. Answer: The specialty drug list also includes Orencia (SC) and Cosentyx as Tier 4 medications. The Simponi UM document is correct, however, it should clarify the differences between preferred and non-preferred as shown below. Stelara and Orencia do not require Enbrel and Humira specifically prior to the use of those agents but the use of Enbrel and Humira is contained within the coverage criteria. Step 1: Enbrel, Humira Step 2: Actemra (SC)-NP, Cimzia-NP, Cosentyx, Orencia (SC), Otezla-NP, Simponi (SC)-NP, Stelara Step 3: Xeljanz-NP NP=non-preferred For the Stelara document, it is not a requirement that members step through Remicade, but is an option for members along with Enbrel, Humira and other agents. Remicade is covered under the medical benefit for patients. 75. Will alternate language proposed for the Terms and Conditions section be considered? 16

28 Answer: Failure to accept the Plan s terms and conditions as stated in the RFP is a basis for rejection of a Bidder s proposal. 76. Section b: Would the State be willing to accept a 48 hour turnaround time for PAs? Our experience has shown a 24 hour window for prescribers to respond drastically increases denials due to insufficient support from provider and additional member frustration. Answer: Failure to accept the Plan s terms and conditions as stated in the RFP is a basis for rejection of a Bidder s proposal. 77. Section a.iv: Would the State be willing to include language that any payment made to the plan would be mutually agreed upon by both parties? Answer: No. Payment must be made in accordance with the cost proposal and other contract terms. 78. Section a.iv: Can the State confirm the total number of clinical Prior Authorizations performed over the most recent 12 month period available? Answer: From 1/1/14 to 12/31/14, there were a total of 78,435 PA, ST, and QLL. 79. Section a.vii: Can the State define what is meant by administrative Utilization Management (UM) programs? Answer: The Plan is referring to programs such as DUR, CDUR, ST, QLL and additional edits for age, gender, etc. 80. Section X: Performance Guarantees/Table X.D.1: In the Enrollment Administration Performance Indicator there appears to be 2 different targets in the Requirement section versus the Performance Standard section. Is the target 1 business day or 2 business days? Answer: The target is one (1) business day. 81. Section X: Performance Guarantees/Table X.D.1: Will alternate language proposed for the Performance Guarantees section be considered? Answer: Bidder must agree to Performance Guarantees as stated in the RFP. 82. Table X.D.1 Performance Guarantees: There are three different PGs surrounding financial accuracy, adjudication accuracy, and payment accuracy (see below). Please provide more information on how these three measures are distinguished between each other. Risk: At least Performance Indicator Requirement Performance Standard Frequency of Measure 25% of Quarterly Fees Indicate Allocation Below Minimum Risk Required 17

29 Claims Claim Adjudication Accuracy 99% or greater Measured and Administration Claims Administration Claims Adjudication Accuracy Rate means (i) the number of retails claims, mail order claims and directly submitted paper claims, adjudicated by the Contractor in a Plan Year that do not contain a material adjudication error, divided by (ii) Financial the number Accuracy of all - The such claims Contractor adjudicated shall guarantee by the Contractor that the average in such annual Plan year. financial accuracy of paid claims will be 99% or higher. Financial accuracy is calculated as follows: the total dollars of audited claims paid minus the sum of the absolute dollar value of all overpayments and underpayments is divided by the total dollars of audited claims paid. reported within forty- five (45) calendar days following each quarter by Bidder and audited by Plan 99% or higher Measured and reported within forty- five (45) calendar days following each quarter by Bidder and audited by Plan 1.0% 1.0% Retail Claim Financial The payment accuracy accuracy is rate 99.9% or Measured 45 days Financial calculated shall be equal as follows: to the total the total greater after the close of dollars of paid audited correct claims as a paid the 0.25% Accuracy dollar paid. value of all overpayments and underpayments is divided by minus percent the of sum the total of the dollars absolute quarter Answer: the The total Claims dollars Administration of audited Financial Accuracy guarantee relates to all claims (e.g. mail, retail, claims and paid. direct paper claims). The Retail Claim Financial Accuracy guarantee relates only to retail claims. The Claims Administration Adjudication Accuracy guarantee relates to whether or not the claim was appropriately adjudicated per plan edits, UM programs, pricing, etc. Please see the definition of Retail Claim Financial Accuracy included within this addendum as part of amended and restated Table X.D Please provide the most up to date membership numbers as of 11/1/15, including if possible, a breakout between Medicare Part D and non-medicare Part D lives, and between employees and household members. Answer: The Plan s most recent membership report is attached as Exhibit I. 18

30 84. Referring to Section Mail Order Service, Question b v. below: please provide information about the Plan s mandatory mail / retail-to-mail pilot program being run with your current PBM. What are your current mail utilization rates? v. The mail order incentive program you would propose for the Plan. Include information about how the program would be implemented. Answer: The Plan does not currently administer a mandatory mail order program. The current mail utilization rate is approximately 5%. 85. Referring to Section Mail Order Service, Question a. xv. below: please provide the actual number or percentage of home delivery users who fulfill prescriptions using U.S. mail or other carrier service versus filling a prescription online or calling a customer service representative? xv. Ability and willingness to provide postage paid envelopes to Member to mail prescriptions and to assume any postage/shipping increases. Answer: The actual number of home delivery claims for the first three quarters of 2015 is 342, Referring to Section Pharmacy Audits, Question ii. below: please share who the Plan s pharmacy audit vendor is? Please clarify what is meant by certain performance guarantees? To which guarantees are you referring? ii. Ability and willingness to accept the Plan s Pharmacy Audit Vendors findings to measure certain Performance Guarantees. Answer: Tricast is the Plan s pharmacy audit vendor. Discounts and rebates achieved on the Plan's behalf that exceed the financial guarantees are payable to the Plan. Dispensing fees that are paid lower than the guaranteed are also passed through to the Plan. 87. Referring to Section xii., please clarify what is meant by PAs in this question. Does it also include ST, QLL and all other Utilization Management programs? Answer: PAs should include all UM programs. 88. Referring to Section a.xiii, please provide a definition for low cost generic list at mail. Answer: A low cost generic list is a list of medications that may be provided to the member via mail order at a lower copayment/cost-share than what is depicted in the members plan design. These medications may be maintenance medications for chronic conditions. 89. Referring to the Plan s Brand Drug definition, please provide more information about the algorithm you reference and agree to allow for use in the cost proposal. What is the current Brand Algorithm? Answer: Plan s Brand Drug Definition The innovator drug product submitted to the FDA for approval. A Brand Drug is a drug produced and distributed with patent protection. (1) Single Source Brand Name Drug means a drug designated as a brand name drug by First DataBank, MediSpan or 19

31 another source agreed to by the Plan, by the Brand Name Code T and has a Multi Source Code of N or M. (2) Multi Source Brand Name Drug means a drug designated as a brand name drug by MediSpan by the Brand Name Code T and has a Multi Source Code O. The bidder may use a Brand Generic Algorithm (BGA) as approved by the Plan during implementation and reviewed and approved quarterly thereafter. 90. Referring to the Plan s Generic Drug definition, please provide more information about the algorithm you reference and agree to allow for use in the cost proposal. What is the current Generic Algorithm? Answer: Plan s Generic Drug A drug produced and distributed without patent protection. The generic drug may still have a patent on the formulation but not on the active ingredient. A generic must contain the same active ingredients as the original formulation. According to the U.S. Food and Drug Administration (FDA), generic drugs are identical or bioequivalent to the brand name counterpart with respect to pharmacokinetic and pharmacodynamic properties. Generic drugs are also referred to as "generics". (1) Single Source Generic Drug means a drug identified by the chemical or generic name, has a Brand Name Code B or G and a Multi Source Code N or M as determined by First DataBank, MediSpan or another source agreed to by the Plan. (2) Multi Source Generic Drug means a drug identified by the chemical or generic name by the Multi Source Code O or Y and the Brand Name Code B or G as determined by MediSpan. The Plan is looking for the Bidder to designate and move a drug as a generic classification whenever possible. Bidder may use a Brand Generic Algorithm(BGA) as approved by the Plan during implementation and reviewed and approved quarterly thereafter. 91. If the algorithm referenced in the Brand and Generic Drug definitions is proprietary, would you consider removing from the definition and also avoid its use in the cost proposal evaluation? Answer: No. 92. Do the Brand / Generic Algorithm impact guarantees that are currently in place? Answer: Yes, the Brand/Generic Algorithm impacts guarantees that are currently in place. 93. How is the adjudication of prescriptions impacted by the Brand / Generic Algorithm? Answer: Adjudication must follow the Plan Brand/Generic designation. 94. What is the process around getting the Brand / Generic Algorithm approved by the Plan? Answer: Bidder and Plan will mutually agree on the Brand/Generic Algorithm during implementation which will be reviewed and approved by the Plan quarterly thereafter. 95. What is the current membership that excludes the Medicare Advantage plans? 20

32 Answer: Based on the Plan s October membership report, membership that excludes the Medicare Advantage plans is 578, Is the Plan currently on a limited network? How many pharmacies are included in the current network? Are any major pharmacy chains excluded? Answer: The Plan does not currently offer a limited network. 97. Does the Plan currently have a Preferred 90 day at Retail Network in place? Is there a differential in copay that is being offered to members at certain pharmacies? Answer: The Plan does not currently offer a Preferred 90 day at Retail Network. 98. Are the maintenance medications required to go through the Preferred 90 day or mail benefit? Answer: The Plan does not currently offer a Preferred 90 day at Retail Network. 99. Can you define what kind of a Preferred 90 day network you are looking for? Is it a Narrow Network excluding certain pharmacies? Or is it a network that offers copay differential for members at specific pharmacies? Are there specific pharmacies you want to favor in a preferred 90 day network? Answer: Plan is looking for bidder to propose a Preferred 90 day network The RFP indicates mail utilization of 5% that is based on the 7/1/2013 to 6/30/2014 date range. is causing this reduction from 5% to 2%? Was there a change in the benefit design that caused the reduction? Please also supply the current mail utilization rate for YTD Answer: There were no benefit changes that caused the reduction. The 2% mail utilization represents July 1, 2014 December 31, 2014; a six (6) month period If the Plan decides to carve out Specialty, does that also include carving out specialty rebates? Answer: The Plan does not anticipate carving out specialty rebates at this time Is the Plan looking for an exclusive Specialty pharmacy arrangement? Answer: The Plan is lookiong for an exclusive Specialty pharmacy arrangement except for cancer medications Referring to Question b.iii below, please clarify what the Plan is asking for? 21

33 iii. Ability and willingness to subcontract with a Contractor developed blend of in-house and North Carolina based specialty network. Clearly outline which entity would provide each service, the exclusivity of each network, pricing advantages; member and physician advantages (include IV treatments in the description). Answer: The Plan is requesting the bidder to propose the specialty network inclusive of North Carolina based providers Can you confirm that the admin fee is 5% of the total evaluation? Answer: Confirmed. 22

34 October 20,

35 October 20,

36 October 20,

37 October 20,

38 October 20,

39 October 20,

40 October 20,

41 October 20,

42 October 20,

43 October 20,

44 October 20,

45 October 20,

46 October 20,

47 October 20,

48 October 20,

49 October 20,

50 October 20,

51 October 20,

52 October 20,

53 October 20,

54 October 20,

55 , , ,316 1, October 20,

56 ,092 1, , , ,261 1, ,136 1, ,189 1, ,587 2, ,698 2, ,010 1, October 20,

57 ,668 2, ,707 2, ,796 2, , ,574 2, ,273 1, ,311 1, ,931 2, ,866 2, October 20,

58 ,323 1, ,526 2, , , ,200 1, , ,352 1, ,364 3, ,493 2, ,439 3, October 20,

59 ,186 1, , ,841 3, , ,552 2, ,825 2, ,017 3, ,050 3, ,848 6, ,275 3, ,074 1, ,643 2, ,273 3, , , ,311 3, ,254 2, ,269 4, ,425 3, October 20,

60 ,859 2, , ,171 1, , ,482 2, ,701 2, , ,162 1, , ,948 2, , ,166 1, ,651 4, ,156 1, , ,254 October 20,

61 ,186 1, ,926 4, ,561 3, ,416 3, ,267 1, ,826 2, ,016 5, ,188 3, ,124 3, ,271 1, ,218 3, ,419 3, , ,278 3, ,721 2, ,649 2, ,358 3, ,222 1, ,791 5, October 20,

62 , ,211 1, ,103 4, October 20,

63 , ,080 6, , ,241 1, , ,584 2, ,008 1, ,339 1, October 20,

64 ,138 1, ,908 2, , October 20,

65 ,173 1, ,790 2, ,052 3, October 20,

66 , , ,055 1, , ,488 2, ,028 1, , , , ,157 1, , ,130 1, ,576 2, , ,005 1,583 October 20,

67 , , ,049 1, , ,036 1, , ,005 1, , ,034 October 20,

68 ,094 1, , ,470 2, ,404 1, , ,345 1, , ,429 3, , ,162 1, ,025 1, ,308 1, ,326 1,802 October 20,

69 ,311 1, , ,430 1, , ,287 1, , , ,391 1, , ,530 2, October 20,

70 , ,093 1, ,306 1, ,303 1, ,151 1, ,069 1, ,449 2, ,360 1, ,477 2, October 20,

71 , ,455 October 20,

72 ,055 1, ,650 2, ,355 1, , , October 20,

73 , , ,614 2, , , ,515 4, ,505 2, , ,226 3, , October 20,

74 ,328 1, , ,729 2, ,063 5, , , October 20,

75 , , , ,057 October 20,

76 , ,544 2, October 20,

77 ,144 1, , , , , ,284 1, October 20,

78 October 20,

79 October 20,

80 October 20,

81 October 20,

82 October 20,

83 October 20,

84 October 20,

85 October 20,

86 October 20,

87 October 20,

88 October 20,

89 October 20,

90 October 20,

91 October 20,

92 October 20,

93 October 20,

94 October 20,

95 October 20,

96 October 20,

97 October 20,

98 October 20,

99 October 20,

100 October 20,

101 October 20,

102 October 20,

103 October 20,

104 October 20,

105 October 20,

106 October 20,

107 October 20,

108 October 20,

109 October 20,

110 October 20,

111 October 20,

112 October 20,

113 October 20,

114 October 20,

115 October 20,

116 October 20,

117 October 20,

118 October 20,

119 October 20,

120 October 20,

121 October 20,

122 October 20,

123 October 20,

124 October 20,

125 October 20,

126 October 20,

127 October 20,

128 TOTALS: 403, ,129 October 20,

129 Enrollment Summary - Subscribers Only (Non-MAPDP) Monthly Membership by Product and Coverage Tier Enrollments as of: 10/31/2015 Reported as of: 11/1/2015 Relationship Type Subscriber Employing Unit Carrier Plan Name Coverage Total Subscribers Agencies BCBSNC Traditional 70/30 PPO Plan EMP ONLY 162 EMP/SPOUSE 10 EMP/CHILDREN 32 FAMILY 35 Enhanced 80/20 PPO Plan EMP ONLY 556 EMP/SPOUSE 20 EMP/CHILDREN 70 FAMILY 34 Consumer Directed Health Plan EMP ONLY 27 EMP/SPOUSE 4 EMP/CHILDREN 6 FAMILY 10 Charter Schools BCBSNC Traditional 70/30 PPO Plan EMP ONLY 1,302 EMP/SPOUSE 19 EMP/CHILDREN 303 FAMILY 154 Enhanced 80/20 PPO Plan EMP ONLY 1,397 EMP/SPOUSE 22 EMP/CHILDREN 329 FAMILY 116 EMP ONLY W/ MEDICARE 1 Consumer Directed Health Plan EMP ONLY 96 EMP/SPOUSE 7 EMP/CHILDREN 39 FAMILY 36 COBRA BCBSNC Traditional 70/30 PPO Plan EMP ONLY 159 EMP/SPOUSE 9 EMP/CHILDREN 23 FAMILY 24 Enhanced 80/20 PPO Plan EMP ONLY 272 EMP/SPOUSE 9 EMP/CHILDREN 25 FAMILY 37 EMP/CHILDREN 1 OR MORE CHILD WITH M/C 1 Consumer Directed Health Plan EMP ONLY 13 EMP/CHILDREN 3 FAMILY 5 Traditional 70/30 MA PPO Plan EMP ONLY W/ MEDICARE 3 Community Colleges BCBSNC Traditional 70/30 PPO Plan EMP ONLY 3,811 EMP/SPOUSE 251 EMP/CHILDREN 1,041 FAMILY 568 EMP ONLY W/ MEDICARE 3 EMP/SPOUSE EMP W/ MEDICARE 1 EMP/SPOUSE SPOUSE W/ MEDICARE 2 Enhanced 80/20 PPO Plan EMP ONLY 7,348 EMP/SPOUSE 290 EMP/CHILDREN 1,411 FAMILY 476 EMP ONLY W/ MEDICARE 5 FAMILY SPOUSE OR CHILD W/ MEDICARE 2 Consumer Directed Health Plan EMP ONLY 309 EMP/SPOUSE 53 EMP/CHILDREN 154 FAMILY 98 EMP ONLY W/ MEDICARE 1 Direct Bill BCBSNC Traditional 70/30 PPO Plan EMP ONLY 134 EMP/SPOUSE 5 EMP/CHILDREN 38 1 of 4

130 Enrollment Summary - Subscribers Only (Non-MAPDP) Monthly Membership by Product and Coverage Tier Enrollments as of: 10/31/2015 Reported as of: 11/1/2015 Relationship Type Subscriber Employing Unit Carrier Plan Name Coverage Total Subscribers Direct Bill BCBSNC Traditional 70/30 PPO Plan FAMILY 7 EMP ONLY W/ MEDICARE 1 EMP/CHILDREN 1 OR MORE CHILD WITH M/C 2 Enhanced 80/20 PPO Plan EMP ONLY 124 EMP/SPOUSE 4 EMP/CHILDREN 21 FAMILY 5 EMP/CHILDREN 1 OR MORE CHILD WITH M/C 1 Subscriber only 5 Consumer Directed Health Plan EMP ONLY 7 EMP/CHILDREN 1 Traditional 70/30 MA PPO Plan EMP ONLY W/ MEDICARE 438 EMP/CHILDREN EMP W/ MEDICARE 3 EMP/CHILDREN EMP + CHILD(REN) W/ MEDICARE 4 FAMILY EMP W/ MEDICARE 1 Municipalities BCBSNC Traditional 70/30 PPO Plan EMP ONLY 455 EMP/SPOUSE 18 EMP/CHILDREN 167 FAMILY 59 Enhanced 80/20 PPO Plan EMP ONLY 1,003 EMP/SPOUSE 35 EMP/CHILDREN 137 FAMILY 46 Consumer Directed Health Plan EMP ONLY 30 EMP/SPOUSE 3 EMP/CHILDREN 7 FAMILY 12 Public Schools BCBSNC Traditional 70/30 PPO Plan EMP ONLY 58,462 EMP/SPOUSE 1,418 EMP/CHILDREN 15,108 FAMILY 4,987 EMP ONLY W/ MEDICARE 14 EMP/SPOUSE EMP W/ MEDICARE 1 EMP/SPOUSE SPOUSE W/ MEDICARE 2 EMP/CHILDREN EMP W/ MEDICARE 1 FAMILY SPOUSE OR CHILD W/MEDICARE 1 Enhanced 80/20 PPO Plan EMP ONLY 64,955 EMP/SPOUSE 1,241 EMP/CHILDREN 13,953 FAMILY 3,286 EMP ONLY W/ MEDICARE 19 EMP/SPOUSE SPOUSE W/ MEDICARE 10 EMP/CHILDREN EMP W/ MEDICARE 3 FAMILY SPOUSE OR CHILD W/ MEDICARE 7 EMP/CHILDREN 1 OR MORE CHILD WITH M/C 4 Consumer Directed Health Plan EMP ONLY 2,161 EMP/SPOUSE 142 EMP/CHILDREN 1,032 FAMILY 541 Retirees BCBSNC Traditional 70/30 PPO Plan EMP ONLY 17,021 EMP/SPOUSE 1,232 EMP/CHILDREN 1,104 FAMILY 593 EMP/SPOUSE SPOUSE W/ MEDICARE 95 FAMILY SPOUSE OR CHILD W/ MEDICARE 18 EMP/CHILDREN 1 OR MORE CHILD WITH M/C 8 Enhanced 80/20 PPO Plan EMP ONLY 27,118 EMP/SPOUSE 1,391 EMP/CHILDREN 1,022 2 of 4

131 Enrollment Summary - Subscribers Only (Non-MAPDP) Monthly Membership by Product and Coverage Tier Enrollments as of: 10/31/2015 Reported as of: 11/1/2015 Relationship Type Subscriber Employing Unit Carrier Plan Name Coverage Total Subscribers Retirees BCBSNC Enhanced 80/20 PPO Plan FAMILY 438 EMP ONLY W/ MEDICARE 2 EMP/SPOUSE SPOUSE W/ MEDICARE 80 EMP/SPOUSE EMP + 1 OR MORE DEPENDENTS W/MEDICARE 9 FAMILY SPOUSE OR CHILD W/ MEDICARE 29 EMP/CHILDREN 1 OR MORE CHILD WITH M/C 13 Consumer Directed Health Plan EMP ONLY 526 EMP/SPOUSE 142 EMP/CHILDREN 60 FAMILY 42 EMP/SPOUSE SPOUSE W/ MEDICARE 1 EMP/SPOUSE EMP + 1 OR MORE DEPENDENTS W/MEDICARE 1 Traditional 70/30 MA PPO Plan EMP ONLY 4 EMP ONLY W/ MEDICARE 38,113 EMP/SPOUSE EMP W/ MEDICARE 502 EMP/SPOUSE SPOUSE W/ MEDICARE 1,157 EMP/CHILDREN EMP W/ MEDICARE 242 EMP/CHILDREN EMP + CHILD(REN) W/ MEDICARE 44 FAMILY EMP W/ MEDICARE 108 FAMILY EMP + 1 OR MORE CHILDREN W/ MEDICARE 48 Universities BCBSNC Traditional 70/30 PPO Plan EMP ONLY 11,202 EMP/SPOUSE 645 EMP/CHILDREN 2,811 FAMILY 1,901 EMP ONLY W/ MEDICARE 5 EMP/SPOUSE SPOUSE W/ MEDICARE 1 EMP/CHILDREN EMP W/ MEDICARE 1 FAMILY SPOUSE OR CHILD W/MEDICARE 1 FAMILY SPOUSE OR CHILD W/ MEDICARE 1 Enhanced 80/20 PPO Plan EMP ONLY 22,905 EMP/SPOUSE 1,193 EMP/CHILDREN 4,866 FAMILY 2,835 EMP ONLY W/ MEDICARE 5 EMP/SPOUSE SPOUSE W/ MEDICARE 3 FAMILY SPOUSE OR CHILD W/ MEDICARE 3 Consumer Directed Health Plan EMP ONLY 1,521 EMP/SPOUSE 184 EMP/CHILDREN 615 FAMILY 597 Beacon BCBSNC Traditional 70/30 PPO Plan EMP ONLY 20,812 EMP/SPOUSE 698 EMP/CHILDREN 5,202 FAMILY 1,899 EMP ONLY W/ MEDICARE 5 EMP/SPOUSE SPOUSE W/ MEDICARE 5 EMP/CHILDREN EMP W/ MEDICARE 1 FAMILY SPOUSE OR CHILD W/MEDICARE 1 Enhanced 80/20 PPO Plan EMP ONLY 30,115 EMP/SPOUSE 835 EMP/CHILDREN 4,770 FAMILY 1,397 EMP ONLY W/ MEDICARE 13 EMP/SPOUSE SPOUSE W/ MEDICARE 4 FAMILY EMP W/ MEDICARE 1 FAMILY SPOUSE OR CHILD W/ MEDICARE 3 Consumer Directed Health Plan EMP ONLY 1,162 EMP/SPOUSE 104 EMP/CHILDREN of 4

132 Enrollment Summary - Subscribers Only (Non-MAPDP) Monthly Membership by Product and Coverage Tier Enrollments as of: 10/31/2015 Reported as of: 11/1/2015 Relationship Type Subscriber Employing Unit Carrier Plan Name Coverage Total Subscribers Beacon BCBSNC Consumer Directed Health Plan FAMILY 355 Grand Total 401,626 Spouse Only Coverage Spouse/Child Coverage Child Only Coverage 1, Total Subscriber Count 403,613 4 of 4