How To Write A Proposal For The Middlesex County Joint Health Insurance Fund

Transcription

1 MIDDLESEX COUNTY JOINT HEALTH INSURANCE FUND PHARMACY BENEFITS MANAGER REQUEST FOR PROPOSAL JUNE 16, 2015

2 Introduction Middlesex County Joint Health Insurance Fund (MCJHIF) self-insures Medical and Prescription Drug coverage. The inforce Prescription Drug Plan is administered through Express Scripts, Inc., and the current contract will expire December 31, This Request for Proposal provides information about MCJHIF and its self-insured Prescription Drug plan. You are invited to submit proposals for Pharmacy Benefit Management services in accordance with the specifications provided herein. We are seeking proposals based on the Traditional Self-insured Pricing Option for active and retired members. Please provide pricing guarantees for contract periods of one, two and three years. Respondents are requested to provide quotations based on RDS and EGWP retiree pricing. Overview of MCJHIF The Middlesex County Joint Health Insurance Fund is comprised of seven individual entities. Listed below are these entities and the PBM responsible for Rx administration. This RFP is limited to those entities with Rx administration provided through Express Scripts. Middlesex County Administration (Express Scripts) Middlesex County Board of Social Services (Express Scripts) Middlesex County Utilities Authority (Express Scripts) Middlesex County College (Embedded with the Medical Carrier) Middlesex County Mosquito Commission (Embedded with the Medical Carrier) Middlesex County Improvement Authority (CIGNA Rx) Roosevelt Care Center (CIGNA Rx) For 2015, Rx claims for Express Scripts are budgeted to be $30,000,000. MCJHIF offers eligible employees and retirees the option of enrolling in one of four medical plan options as outlined below: Horizon Choice (Self-funded POS) Aetna HMO (Self-Funded) CIGNA HMO (Self-Funded) Oxford (Conventionally Insured) 2

3 NOTE: This is a two part proposal process: Middlesex County Joint Health Insurance Fund Part 1 If you intend to provide a proposal, you must complete the DATA REQUEST FORM on page 6, and return it to North American Insurance Management via to David Hissey ([email protected]) no later than June 1, Upon receipt of the Data Request Form, census data and claim repricing data will be released. Part 2 Submit your completed proposal to the Middlesex County Joint Health Insurance Fund. Your completed proposal must include the required forms as instructed in this RFP, along with the completed pricing matrix and questionnaire. Your proposal response must include copies of your contractual definitions of each drug classification and method of calculating discounts and rebates. Six hard copies of your complete proposal and one CD containing your repriced claims file must be delivered to Joe Pruiti (Treasurer Middlesex County Joint Health Insurance Fund) no later than 10:00 a.m., June 16, Employee and Retiree Eligibility Active Member Enrollment 5,658 Retiree Member Enrollment (65 and over) 1,440 Retiree Member Enrollment (Under 65) 1,739 Currently, the MCJHIF receives reimbursement for retired members over age 65 through the Retiree Drug Subsidy (RDS) program. Responses to this RFP may be based on the continuation of the RDS program currently inforce or assume transition to an Employer Group Waiver Plan (EGWP). Respondents however, are encouraged to respond to both pricing options. Questions relative to the requirements for the EGWP are detailed later in this RFP. Employees who work at least 20 hours per week are eligible for benefits. Prescription coverage begins on the first of the month following sixty (60) days from date of hire. Children are covered until the end of the year during which they reach age twenty-six (26). Any changes in coverage due to a qualifying event must be done within sixty (60) days of the event. MCJHIF will pay the cost of coverage, which includes health insurance and the prescription drug plan, for retirees and their eligible dependents so long as the retiree has met the requirements as detailed in the Personnel Manual to be considered a Premium Free Retiree. There are approximately 130 Direct Bill Retirees (included in the totals above) who continue Rx coverage on a premium paying basis. Contributions Prescription drug coverage is automatically included with medical insurance for eligible employees and retirees. Employees and retirees are required to contribute in accordance with the contributions schedule set forth in NJ CH 78. 3

4 Middlesex County Joint Health Insurance Fund Details Client: Middlesex County Joint Health Insurance Fund Address: New Brunswick, NJ Covered members Covered Actives 5,658 Covered Retirees under 65 1,739 Covered Retiree over 65 1,440 Total Members 8,837 Current PBM: Expresss Scripts Inc. Effective Date of Renewal: January 1, 2016 Inquiries & Correspondence All correspondence, questions and responses are to be directed via to: David Hissey or Lynn Collins Phone (610) Fax (610) Vendor Selection An announcement of the selected vendor will be issued to all vendors who submitted responses to the RFP. Confidentiality No data or details of this RFP are to be shared with outside parties, for any purposes other than responding to the RFP, without the prior written approval of the MCJHIF. A statement of confidentiality must be returned with your proposal. Employee/Retiree Census An active employee and retiree census file has been created in excel. If you plan to provide a response to this RFP please use the form on page 6 to request the Census from David Hissey [email protected] Claims History If you plan to provide a response to this RFP please use the form on page 6 to request the claim history file from David Hissey [email protected] 4

5 Claims Data Repricing A sample selection of claims data has been developed in excel format. The data represents actual prescription drug fills for a recent 12 month period. Responding PBM s are to reprice the claims in accordance with the discount arrangements they are proposing using most current Average Wholesale Pricing. Identify the Average Wholesale Pricing database used. The repriced file is to be returned with your proposal response. The columns entitled Average Wholesale Price and Ingredient Cost (Discounted Cost) are to be completed by the responding PBM for each prescription included in the Claim File. Each prescription is to be repriced by the responding PBM according to the NDC applicable to each prescription. The file should be returned in the same format as provided. Classification of generic drugs, single source brand drugs and multi-source brand drugs in your repriced file should follow the definitions you apply to each drug class or fill volume in your proposal. For example, if you define multi source brand non-innovator drugs as generics then your repricing should reflect such. 5

6 IF YOU INTEND TO PROVIDE A PROPOSAL, RETURN A COPY OF THIS DATA REQUEST FORM TO: David Hissey, North American Insurance Management Item We intend to meet the specifications outlined and submit a proposal for the MCJHIF Prescription Drug Program by Tuesday, June 16, 2015 no later than 10:00 a.m. We intend to provide all items requested in this request for RFP including a repriced claim file as requested. Please provide the following information: Census, Claim Data, Claim Repricing File Check Yes or No We intend to provide a traditional self-insured model proposal Yes No In consideration of disclosure to us (Recipient) of claim data, census data and other relevant information (Evaluation Material), Recipient agrees that it will abide by such determination that the Evaluation Material is confidential, making all necessary and appropriate efforts to safeguard the Evaluation Material and keeping such Evaluation Material confidential and that, without the prior written consent of the Middlesex County Joint Health Insurance Fund, the Evaluation Material will not be disclosed by Recipient and will not be used by Recipient other than in connection with its evaluation of and consideration of this RFP and will not be used in any way detrimental to the MCJHIF or members herein. Moreover, Recipient agrees to transmit the Evaluation Material only to its representatives who need to know the Evaluation Material for the sole propose of assisting Recipient in reviewing the Evaluation Material and who are informed of this Agreement and who agree to be bound by the terms hereof as if a party here to. Finally, the Recipient specifically agrees not to use, publish, appropriate, photocopy or communicate, directly or indirectly, any confidential information relating to the claim or eligibility information of the MCJHIF. All costs associated with completing and preparing the project response will be borne by you and not the MCJHIF. Agreed and Completed by: Name: Title: Company: Address: Telephone: Signature: Date: Unless otherwise indicated the individual listed above will be considered the Point of Contact for this RFP. NOTE: Your typed name and date above will be considered a valid signature for this RFP. 6

7 UPON RECIEPT OF THIS FORM BY NORTH AMERICAN INSURANCE MANAGEMENT INDICATING YOUR INTENTION TO PROVIDE A PROPOSAL, WE WILL PROVIDE YOU WITH CENSUS DATA AND CLAIM REPRICING DATA NECESSARY FOR YOU TO COMPLETE YOUR SUBMISSION. SCHEDULE OF BENEFITS Benefits, Eligibility and Claim reporting must be broken by the sub groups as outlined below. Umbrella Group# MCJHIF1 Retail = Card and Direct - In and Out of Network for up to 34 DS or 100 units (whichever is greater) Mail (up to 90 DS) Group # Benefit Group Name Retail Generic Retail Brand Prepacks** Mail Generic Mail Brand MCJHIFCOU10 MCAFF $5 $10 MCJHIFCOU11 CWA 1082 Hlth $5 $10 MCJHIFCOU12 CWA 1082 Juv $5 $10 MCJHIFCOU13 Planning Pro $5 $10 MCJHIFCOU14 Planning Board $5 $10 MCJHIFCOU15 Engineers Pro $5 $10 MCJHIFCOU16 UPIU $5 $10 MCJHIFCOU17 Investigators CA $5 $10 MCJHIFCOU18 W & M 203 $5 $10 MCJHIFCOU19 I.A.F.F $5 $10 MCJHIFCOU20 Extension S $5 $10 MCJHIFCOU21 P.B.A. 214 $5 $10 MCJHIFCOU22 P.B.A. 214 Sup $5 $10 $5 $10 7

8 Copay MCJHIFCOU23 AP s $5 $10 MCJHIFCOU31 Sheriffs LO $5 $10 MCJHIFCOU32 Sheriffs SI $5 $10 MCJHIFCOU33 Sheriffs SO $5 $10 MCJHIFCOU34 Rangers PBA 156 $5 $10 MCJHIFCOU36 PBA 152 $5 $10 MCJHIFCOU37 PBA 152 Sup $5 $10 MCJHIFCOU40 AFSCME 3440 $5 $10 MCJHIFCOU41 AFSCME 3256 $5 $10 MCJHIFCOU42 AFSCME 3460 $5 $10 MCJHIFCOU43 AFSCME 3841 $5 $10 MCJHIFCOU44 AFSCME 2226 $5 $10 MCJHIFNONUA Non-Union Active $5 $10 MCJHIFCOCO03 County Cob 03 $5 $10 MCJHIFCOCO35 County Cob 35 $5 $10 MCJHIFCOU65DB03 County Pre-65 Direct-Bill 03 $0 $3 MCJHIFCOU65DB35 County Pre-65 Direct Bill 35 $3 $5 MCJHIFCOO65DB03 County Post-65 Direct-Bill 03 $0 $3 MCJHIFCOO65DB35 County Post-65 Direct Bill 35 $3 $5 Copay $0 $3 Copay $3 $5 Copay $0 $3 Copay $3 $5 8

9 MCJHIFCOU65PF03 County Pre-65 Prem Free 03 $0 $3 MCJHIFUCO65PF35 County Pre-65 Prem Free 35 $3 $5 MCJHIFCOO65PF03 County Post-65 Prem Free 03 $0 $3 MCJHIFCOO65PF35 County Post-65 Prem Free 35 $3 $5 Copay $0 $3 Copay $3 $5 Copay $0 $3 Copay $3 $5 MCJHIFSSACTU Soc Svcs Act Union $3 $5 MCJHIFSSACTNU Soc Svcs Act Non-Union $3 $5 MCJHIFSSCOBU Soc Svcs Cob Union $3 $5 MCJHIFSSCOBNU Soc Svcs Cob Non-Union $3 $5 MCJHIFSSU65DB03 Soc Svcs Pre-65 Direct Bill 03 $0 $3 Copay $3 $5 Copay $3 $5 Copay $3 $5 Copay $3 $5 Copay $0 $3 MCJHIFSSU65PF03 MCJHIFSSO65DB03 MCJHIFSSO65PF03 Soc Svcs Pre-65 Prem Free 03 $0 $3 Soc Svcs Post-65 Direct Bill 03 $0 $3 Soc Svcs Post-65 Prem Free 03 $0 $3 Copay $0 $3 Copay $0 $3 Copay $0 $3 MCJHIFUTACT Util Active $5 $10 MCJHIFUTCOB Util Cobra $5 $10 MCJHIFUTU65DB Util Pre-65 Direct Bill $5 $10 MCJHIFUTU65PF Util Pre-65 Prem Free $5 $10 MCJHIFUTO65DB Util Post-65 Direct Bill $5 $10 MCJHIFUTO65PF Util Post-65 Prem Free $5 $10 Copay $10 $20 Copay $10 $20 Copay $10 $20 Copay $10 $20 Copay $10 $20 Copay $10 $20 9

10 Note: Your proposal response must detail any deviations from the current plan design. For example, if your PMB has a mandatory formulary which limits or excludes any drugs, or deviates in any way from the current configuration, it must be noted. Also upon implementation of the program the successful PBM must agree that the plan design and formulary in place at the time of award will remain unchanged for the Contract Period, unless changed by MCJHIF. GENERAL 1. Please give a brief company background/history, including how long your company has been providing the services outlined in this RFP. 2. Indicate the number of any outstanding legal actions pending or lawsuits yielding court decision or settled in the past two years against or involving your organization, if any. Explain the nature and current status of the action(s). Can you assure these actions will not disrupt business operations? 3. Indicate the number and percentage of employer clients your organization contracts with, within the tiers defined below. 4. Confirm that designated MCJHIF staff may have access to your system for eligibility updates and viewing. Public Sector Less than 5,000 employees 5,000 to 10,000 employees 10,000 to 25,000 employees 25,000 to 50,000 employees More than 50,000 employees Number of Current Clients Percentage of Current Clients ACCOUNT SERVICE 5. What office would handle the general servicing of this account? Will dedicated account team representatives be assigned to this account? Please provide resumes for each member of the team. 6. Do account service representatives have online access to real-time claim processing information? Do these representatives have authority to approve and/or override claims? 7. Provide a proposed implementation plan and timetable, beginning with the award of business on August 1, 2015, to the effective date of coverage on January 1, Outline your file transfer process for claims and eligibility. 10

11 9. Confirm your systems will allow a breakdown of eligibility into multiple sub classifications (40 plus). 10. MCJHIF will transmit all data electronically via the Unicorn HRO Benefit Eligibility System. Please provide detailed specifications relative to your system requirements and the parameters required to accept an electronic data feed of all initial and ongoing eligibility. Provide your file layout format. 11. How is the client billed? Do you provide electronic invoicing? MEMBER SERVICES 12. Will dedicated customer service representatives be assigned to MCJHIF Members? Will customer service representatives receive client-specific training? 13. Do customer service representatives have online access to real-time claim processing information? Do these representatives have authority to approve and/or override claims? 14. Is your telephone response data audited? Please provide the following information regarding telephone response data: Measurement Time to answer Talk-time Abandonment rate 15. How are plan members and clients notified (phone, written document, other) of plan changes, new drug additions/formulary changes, and drug recalls? 16. What services are available to members via the Internet? (Provide brief detail of service & function). REPORTING 17. What is your standard reporting cycle for client cost and utilization analysis? 18. Are customized reports available at the request of the client? 19. Do you provide clients with a comparison of financial data to your book of business? 20. Do you provide access to claims experience through PC or internet based software to client and consultant's office? 21. Describe your ability to report rebates at line of business level. Also provide the level of detail available on the rebate reports, (e.g. NDC level, drug level, manufacturer level). 22. Provide a sample of your performance report package and any additional reporting (i.e., DUR, clinical management reports, audit reports, formulary reports, etc.) and outline the frequency they are generated and in what format (electronic, hard copy or both)? 11

12 CLAIMS PROCESSING / NETWORK 23. What are the normal hours of operation of the claim operation, customer service, and mailorder facility? Include extended or weekend shifts. 24. What national drug database will be utilized for claims processing? What is your position and strategy for potential changes in the national drug databases? 25. Provide a brief description of your disaster recovery plan for claims processing and for computer/communications systems. Can you guarantee a system recovery time in case of disaster? 26. Describe security systems and protocols in place to protect confidential patient records (HIPAA compliance). 27. Describe your policy regarding lost/broken medication, early refills, and emergency medication fills. 28. Provide a copy (or URL) of your current New Jersey provider directory. What number and percent of available retail pharmacies (nationally) are in your network? Do you have a staff that addresses pharmacy relations issues? 29. What percent of erroneous or fraudulent payments to pharmacies are discovered through your audit efforts? Do you return 100% of all monies you recover based on the incurred claim experience? If not, explain what portion (if any) is returned. GENERIC DRUG MAXIMUM ALLOWABLE CHARGE (MAC) PROGRAM 30. Describe your MAC program for generic substitution, and include your MAC list as of January 1, What percentage of all generics dispensed does this represent? 32. Does your MAC price apply to EVERY pharmacy in your network, without exception? If not, please explain. MAIL ORDER 1. Describe the mail order service facility you are proposing. If the mail order service is not owned by your company, identify the name of the supplier and explain why this supplier was selected and how long the relationship has been in place. 2. Please describe your ability to accept electronically prescribed medications within your mail service pharmacies. 12

13 3. What form of payment can you accept from the enrollee? For purchases made by credit card, can refills be phoned in or submitted via the Internet? How many days advance notice must an enrollee provide in order to guarantee that their supply is received before the existing supply is depleted? What is the average time in days between receipt of claim and delivery to enrollee (include delivery time)? 4. Are shipping costs included in the dispensing fee? If not, define the additional cost (include rush order cost, if applicable. SPECIALTY 5. Is your specialty pharmacy owned by your company? From what location do you dispense specialty medications? 6. What are the criteria used to designate a prescription as a specialty medication for your program? Describe the list of drugs and drug categories currently included in your specialty program. PROSPECTIVE AND RETROSPECTIVE DRUG UTILIZATION REVIEW 7. Please describe your prescription drug utilization review program and the qualifications of the staff that performs the review. 8. Describe your system for fraud and abuse. Once detected how you do intervene? Is there an additional cost? 9. Please describe your assessment and intervention process for dealing with prescribing physicians and pharmacies. Who is responsible for communication? To whom are these communications directed? 10. What was the annual dollar cost savings generated by your utilization review program for the twelve-month period ending December 31, 2013? How is this cost savings calculated? What percentage does this represent of your total scripts paid (Mail and Retail)? DISEASE MANAGEMENT 11. Please list any Disease Management programs that your company offers. 12. Does your disease management program interface with the medical carrier? Please describe your capability to integrate medical and pharmacy data. 13. For each of the clinical programs discussed, identify the methods of quantifying and reporting program impact and subsequent savings. FORMULARY 14. Provide a copy of your current drug formulary. Include a listing of any excluded drugs in your formulary. 13

14 15. Describe if your formulary including excluded drug list is mandatory? CLIENT REFERENCES 16. Please list 3 client references of similar size and/or industry. 17. Please list 3 terminated client references. EMPLOYER GROUP WAIVER PLAN (EGWP) 18. Do you provide the full services associated with EGWP programs within your firm or do you subcontract services? 19. If the answer was no to question 18, please identify the primary subcontractors and the role they would play in providing services to customers such as MCJHIF. 20. What is your CMS Star Rating? 21. How may EGWP plans does your firm manage? 22. How many members participate in the EGWP plans that you service? 23. Does your firm administer your own Prescription Drug Plan? 24. Does your firm have the ability to identify non-covered part D drugs in the claim system? 25. Does your firm collect these in the prescription drug event (PDE) data report? 26. Does your firm report PDE events to CMS directly or is there a separate reporting system firm that is subcontracted? 27. How often do you file the PDE with CMS? 28. Will your system provide for MCJHIF to review Out of Pocket reports for members? 29. Identify three Medicare product clients that would serve as references for our firm s services. 30. What has been the growth rate in costs for EGWP clients that you manage after the conversion to an EGWP relative to the standard RDS population? 31. Please confirm that your firm will assume responsibility for all CMS required reporting for the group as well as the member. 14

15 PROPOSAL PRICING The MCJHIF Rx plan is currently a traditionally priced self-insured program. REBATES AND DISCOUNT GUARANTEES Description 1 Year Guarantee 2 Year Guarantee 3 Year Guarantee Retail rebate guarantee per paid claim* Mail rebate guarantee per paid claim* Confirm that your organization will never switch for a medication with a lower cost AWP to a higher cost AWP regardless of rebate impact. Retail Brand Discount Guarantee 1 Retail Generic Discount Guarantee 1 Retail Dispensing Fee Guarantee 1 Mail Brand Discount Guarantee 1 Mail Generic Discount Guarantee 1 Guaranteed Percentage of Generic Drugs that will receive MAC Discount MAC Discount Guarantee NON MAC Discount Guarantee 90 Day Supply at Retail Brand Discount Guarantee 1 90 Day Supply at Retail Brand Discount Guarantee 1 Compound Drugs 1 Specialty Medications 1 15

16 Please complete the matrix above. 1. Provide your contract definition for each drug type that goes into each repricing guarantee class. For example if you define multi source brand differently than single source brand for purposes of applying different discount rates, it is important to reflect that in the above schedule. Make certain that your claim file repricing is consistent with your contract definitions, percentage discounts and rebates above. Include any and all specific definitions related to how you define Generic Drug, Multi Source Brand Drugs, Source Brand Drugs, Specialty Medications etc., and any sub classifications, i.e. number of equivalents, as well as dispensing volumes, for purposes of discounts and rebates. If you are selected as the successful bidder your contract definitions of your drug classifications must match those above as well as those used for repricing the claim file. 2. Confirm that your organization will never switch a medication with a lower cost AWP to a higher cost AWP regardless of rebate impact. 3. Confirm that all claims will adjudicate at the lesser of the discounted AWP, U & C, MAC pricing or the member copay. CLAIM FILE REPRICING Use the following methods in repricing: [1-(total discounted AWP ingredient cost divided by total undiscounted AWP ingredient cost (use AWP as of the proposal response date)]. For the purposes of calculating discounts, costs do not include dispensing fees and claims with ancillary charges. 16

17 ADMINISTRATIVE CHARGES AND OTHER FEES Per Employee Per Month Fee Retail Claims Administrative Fee Per Claim Mail Claims Administrative Fee Per Claim Paper Claims Administrative Fee Per Claim Are reversals and denials subject to an administrative fee? If a claim is reversed, is the administrative fee for that claim reversed? Please provide your charges or note Included in Administrative Fees as applicable Implementation/Account Servicing Initial data import of open mail order and specialty pharmacy refills, prior authorization histories and up to six months of historical claims data Manual/Hard Copy Eligibility Electronic Eligibility/Data transfer Online Eligibility Software Training for access to online system Initial Enrollment Identification Cards Replacement ID Cards Monthly Reporting Electronic Reporting Online Ad Hoc Reporting (Custom) Administrative Prior Authorization Custom Prior Authorization Member Education Programs Explanation of Prescription Benefits Member Communications mailed to Member Customized Member Communication Materials 17

18 Postage cost for Member Communication Materials Dedicated account management team Toll-free member services telephone access for Members Toll-free telephone service for benefits personnel Network Management/Network compliance monitoring Toll-free Help Desk assistance and Interactive Voice Response (IVR) unit access for participating pharmacies. Dedicated Clinical pharmacist Electronic Data File in NCPDP format reflecting all Claims Activity Is there a limit to the number of data feeds that can be routinely sent to client and/or vendors at no charge Audit /COB Recovery Are 100% of recovered costs returned to the Client? External Appeal Process Medicare Part D Services (see below) Middlesex County Joint Health Insurance Fund Report Name CMS PBM Provides to Client Required Enrollment/Disenrollment Yes No Reversals Yes Yes Medication Therapy Management Programs Yes Yes Generic Dispensing Rate Yes Yes Grievances Yes Yes (if PBM provides Grievance Service) Prior Authorization, Step Edits, and Non-Formulary Yes Yes Exceptions Appeals Yes Yes (if PBM provides Appeals Service) Call Center Measures Yes Yes (if PBM provides Call Center Service) Overpayment Yes Upon request Pharmaceutical Manufacturer Rebates, Discounts, Yes Yes and Other Price Concessions Licensure and Solvency, Business Transactions Yes No and Financial Requirements Monthly EOB Statements Yes Yes Prescription Data Event (PDE) Yes Yes Plan Comparison Files Yes Yes PBM will provide directly to CMS Formulary File (HPMS) on behalf of Part D clients Plan Master Beneficiary Cost Pharmacy Cost Pricing File Plan Formulary Overrides 18

19 1. Detail all additional fees/charges not covered (postage, printings, booklets, start up costs, etc). List any other related services that the Respondent offers that have not been specifically requested in this RFP. Provide charges and fees for these services. 2. Confirm client can perform a market check during the second year of the contract and may opt out of the third year with no penalties. 3. PBM s routinely sell detailed drug utilization data to outside firms, including database managers, marketing firms, drug manufacturers and others. Does your company sell drug utilization data? If so, please provide detail on this. 4. Please provide a signature ready contract with the pricing and terms outlined within this RFP, including all proposed definitions, performance guarantees, financial guarantees and audit provisions. PERFORMANCE GUARANTEES Service Standard Guarantee (Provide Fees) Reporting and Account Management Timeliness of production Standard reports to be delivered within 15 business days of end of period 19 $ per day per report after 15 business days at the end of period over time period. Accuracy of data 100% accuracy $ per month if error rate > 1% over time period. Paper Claim Processing Turnaround time for claims Turnaround time for claims requiring additional review Claims adjudication accuracy Generic Utilization Generic dispensing rate National Network Generic dispensing rate- Mail Service Pharmacy 100% of claims requiring no intervention handled within 5 days. Define basis for measuring turnaround time. 97% of claims requiring intervention handled within 5 days with remainder within 10 days. Define basis for measuring turnaround time. 99% of all claims to be paid with no errors. % generic dispensing by national pharmacy network. % generic dispensing by mail service pharmacy. $ per day for each day beyond 5 days per claim requiring no intervention over time period. $ per day for each day beyond 5 days per claim requiring intervention over billing cycle time period. $ per month if error rate > 1% over each one month time period. $ per each percent lower per quarter than generic dispensing rate guaranteed. $ per each percent lower per quarter than generic dispensing rate guaranteed. Generic substitution- National % generic substitution by national $ per each percent lower per

20 Service Standard Guarantee (Provide Fees) Network pharmacy network. quarter than generic substitution rate guaranteed. Generic Substitution- Mail Service Pharmacy % generic substitution by mail service pharmacy. $ per each percent lower per quarter than generic substitution rate guaranteed. Mail Service Processing Turnaround time Turnaround time for receipt of Rx until ship date for in-stock items with no intervention. *Federal programs may require more stringent timeframes. $ per day for each day beyond 2 business days over time period. Turnaround time Accuracy Mail Service Call Center response time On-Line Claim Processing Turnaround time for claims processing Claims adjudication accuracy Turnaround time for receipt of Rx until ship date for in-stock items with intervention. *Federal programs may require more stringent timeframes. 99% of all medications to be dispensed at mail order without error. Average speed of answer (ASA) within 20 seconds. Define basis for measuring response time. 98% response within 4 seconds. Define basis for measuring turnaround time (e.g. from receipt of claim in claims processing system). 99.9% of all claims to be paid with no errors. $ per day for each day beyond 3 business days over time period. $ per error if error rate > 1%. To be evaluated by DVHCC every months. $ per month if ASA > 20 seconds over time period. $ per incidence if > 2% of turnaround time for claims processing exceeds 4 seconds over time period. $ per month if error rate > 0.10% over time period. System downtime 99.9% system availability. $ per tenth of percentage point variance if system downtime > 0.1% per day over time period. Customer Service Call response time Average speed of answer (ASA) within 20 seconds. Define basis for measuring response time. Abandonment rate Abandonment rate will average 5% or less. Define how call is classified as abandoned. $ per month if ASA > 20 seconds over time period. $ per month if abandonment rate > 5% over time period. 20

21 PRICING DEFINITIONS. DISCOUNT GUARANTEES TRADITIONAL SELF INSURED Discounts will be calculated as follows: [1-(total discounted AWP ingredient cost divided by total undiscounted AWP ingredient cost for the annual period)]. (both amounts calculated as of the date of adjudication) For the purposes of calculating discounts, costs do not include dispensing fees and claims with ancillary charges, and are calculated prior to application of Copayments. PBM will pay the difference for any shortfall between the actual result and the guaranteed result. Guarantees for claims adjudicated at 90 day supply discount at retail are calculated separately from Retail discounts. CLINICAL PROGRAM DEFINITIONS Retrospective DUR: PBM reviews members claims to identify inappropriate therapy patterns and ensure the clinical appropriateness and cost-efficiency of the drugs prescribed to include letters to physicians offering suggestions. The Retrospective DUR program will focus on drug-induced diseases, noncompliance, over utilization, suboptimal dosing, not approved indications and abuse. Physician Profiling: PBM educates physicians about prescribing issues and identifies physicians that are high-cost outliers, among other categories. In addition to physician profiles, based upon data collected from the prospective, concurrent and Retrospective DUR review, PBM will also focus on physicians using a high percentage of second line agents. Examples of therapeutic classes where inappropriate second line use will be evaluated are antibiotics, non-steroidal anti-inflammatory drugs, gastrointestinal agents, anti-diabetic agents... High Utilization Management (including intervention): PBM tracks high utilizing members and review these profiles to identify opportunities for intervention. Interventions may include correspondence or direct communication with patients, pharmacists or the physician. High utilizing members will be tracked based upon the number of prescriptions within a quarter, total dollars within a quarter, total physicians in a quarter, and total pharmacies in a quarter. Physician Compliance Programs: PBM tracks physician compliance to protocol management initiatives, disease management initiatives, and formularies. Based upon data collected through the claims processing system, PBM will identify providers who are not compliant with these programs and perform interventions including both correspondence and direct communication to physicians. 21