Table of Contents

(files on this site are in PDF and Excel, Word format)
(PDF files are controlling)

Pharmacy Benefit Services for The Empire Plan, Excelsior Plan, Student Employee Health Plan and New York State Insurance Fund Workers' Compensation Prescription Drug Programs

The Procuring Agencies have amended the language in certain sections of the Request For Proposal and Exhibits. Offerors should thoroughly examine each section of the Amended Request for Proposal and Exhibits to locate all changes. The yellow background with the date of the amendment identify the specific sections of the Request for Proposal and Exhibits that have been revised. Deleted language appears in strikethrough [--] and added language appears in underline [__].
 

A. Request For Proposals (RFP)
Section I: Introduction (Amended 4/4/12)
Section II: Procurement Protocol and Process (Amended 4/4/12)
Section III: Administrative Proposal Requirements / Word Version (Amended 4/4/12)
Section IV: Technical Proposal Requirement / Word Version (Amended 4/4/12)
Section V: Cost Proposal Requirements / Word Version (Amended 4/4/12)
Section VI: Evaluation and Selection Criteria
Section VII A: Draft Contract (DCS Version) (Amended 4/4/12)
Section VII B: Draft Contract (NYSIF Version) (Amended 4/4/12)
Section VIII: Glossary of Terms (Amended 4/4/12)
Appendix.A: Standard Clauses for New York State Contracts (Current version Inserted 4/4/12)
Appendix.B (DCS): Standard Clauses for All DCS Contracts (Amended 4/4/12)
Appendix.B (NYSIF): Standard Clauses for all NYSIF Contracts
Appendix.C (DCS): Third Part Connection and Data Exchange Agreement / Word Version
Appendix.C (NYSIF): Third Part Connection and Data Exchange Agreement / Word Version
Appendix D: Participation by Minority Group Members and Women With Respect to State Contracts: Requirements and Procedures

B. Exhibit I
Exhibit I.A: Proposal Submission Requirement Checklist
Exhibit I.B: Biographical Sketch Form / Word version
Exhibit I.C: Freedom of Information Law - Request for Redaction Chart / Word Version
Exhibit I.D: MacBride Statement and Non-Collusive Bidding Certification / Word Version
Exhibit I.E: ST-220-CA - Contractor Certification to Covered Agency / Word Version
Exhibit I.F: ST-220-TD - Contractor Certification
Exhibit I.G(A): Equal Employment Opportunity (EEO) Staffing Plan (form EEO-100 - DCS Version) / Word Version
Exhibit I.G(B): Equal Employment Opportunity (EEO) Staffing Plan (form EEO-100 - NYSIF Version) / Word Version
Exhibit I.H: Debriefing Guidelines
Exhibit I.I: NYS Standard Vendor Responsibility Questionnaire / Word Version
Exhibit I.J: Notice of Bidding Intention Form / Word version
Exhibit I.K: Offerors Affirmation of Understanding & Agreement / Word Version
Exhibit I.L: Procurement Lobbying Policy - Restrictions on Contacts During Procurement Process
Exhibit I.M: Compliance with Public Officers Law Requirements / Word Version
Exhibit I.N: Compliance with Americans with Disabilities Act / Word Version
Exhibit I.O(A): MWBE Utilization Plan (form MWBE-100 - DCS Version) / Word Version
Exhibit I.O(B): MWBE Utilization Plan (form MWBE-100 - NYSIF Version) / Word Version
Exhibit I.P: Offeror's Certification of Compliance Pursuant to State Finance Law 139-k - ADM 983 / Word Version
Exhibit I.Q(A): Certification of Good Faith Efforts (form MWBE-104 – DCS Version) / Word Version
Exhibit I.Q(B): Certification of Good Faith Efforts (form MWBE-104 – NYSIF Version) / Word Version
Exhibit I.R: Questions Template / Word Version
Exhibit I.S: Formal Offer Letter / Word Version
Exhibit I.T: Offeror Attestations Form / Word version (Amended 4/4/12)
Exhibit I.U: Key Subcontractors / Word Version
Exhibit I.V: Program References / Word Version
Exhibit I.W: Compliance with NYS Workers' Compensation Law / Word Version
Exhibit I.X: Information Security Policy
Exhibit I.Y.1: Participation-Non-Participation Status of Certain Chain Pharmacies / Excel
Exhibit I.Y.2: Offeror's Retail Pharmacy Network Record Layout / Excel
Exhibit I.Y.3:: Offeror's Proposed Retail Pharmacy Network File / Word Version
Exhibit I.Y.4: Offeror's Proposed Retail Pharmacy Network Access Prerequisite Worksheet / Excel
Exhibit I.Y.5: Comparison of Current Program Network Pharmacies and Proposed Retail Network / Word Version (Amended 4/4/12)
Exhibit I.Z: Confidentiality Agreement and Certificate of Non-Disclosure / Word Version

C. Exhibit II
Exhibit II.A: Enrollment by Zip Code & Geo Access Network Report File
Exhibit II.B: DCS Empire Plan - Enrollment by Month
Exhibit II.B.1: Enrollment by Age
Exhibit II.B.2: Covered Lives by Bargaining Unit or Other Group
Exhibit II.C: RFP Copay and Benefit Maximum Matrix (Amended 4/4/12)
Exhibit II.D.1: Certificate of Insurance - Traditional PDL
Exhibit II.D.2: Certificate of Insurance - Flexible Formulary
Exhibit II.D.3: Summary Plan Description - SEHP
Exhibit II.D.4: Empire Plan / Excelsior Plan Comparison Chart (2010)
Exhibit II.E.1: Intentionally Left Blank
Exhibit II.E.2a: Empire Plan Benefit Card
Exhibit II.E.2b: Student Employee Health Plan Benefit Card (SEHP)
Exhibit II.E.2c: Excelsior Plan Benefit Card
Exhibit II.E.2d: NYSIF Claimant Card
Exhibit II.E.3: Infusion Providers for Empire Plan
Exhibit II.E.4a: At A Glance 2012 - Traditional PDL
Exhibit II.E.4b: At A Glance 2012 - Flexible Formulary
Exhibit II.E.4c: At A Glance 2012 - Excelsior Plan
Exhibit II.F: Required Reports and Data Fields for MIS Reports
Exhibit II.F.1: NYS Detailed Claim File Layout (DCS)
Exhibit II.F.2: Intentionally Left Blank
Exhibit II.F.3: Retiree Drug Subsidy Quarterly Payment Files
Exhibit II.F.4: Empire Plan MAC List
Exhibit II.F.5: Cycle Claim Report
Exhibit II.F.6: Top 100 Drugs - Specialty
Exhibit II.F.7: Top 100 Brand Name and Generic Drugs - Retail Pharmacy
Exhibit II.F.8: Top 20 Therapeutic Categories
Exhibit II.F.9: Top 100 Brand Name and Generic Drugs - Mail Service Pharmacy
Exhibit II.F.10: MAC Alert Notice
Exhibit II.F.11: Quarterly Performance Guarantee Report
Exhibit II.F.12: Quarterly Audit Reports
Exhibit II.F.13: Quarterly Rebate and Other Pharma Revenue Report
Exhibit II.F.14: MAC Savings Report
Exhibit II.G: NYBEAS Enrollment Record Layout - Control Header
Exhibit II.G.1: NYBEAS Enrollment Record Layout - Transaction Set Header
Exhibit II.H: Drugs that Require Prior Authorization
Exhibit II.H.1: Prior Authorization Statistics Quarterly Report
Exhibit II.H.2: Prior Authorization Selected Statistics
Exhibit II.I: 2011 Preferred Drug List
Exhibit II.I.1: 2012 Preferred Drug List
Exhibit II.I.2: 2011 Flexible Formulary
Exhibit II.I.3: 2012 Flexible Formulary
Exhibit II.I.4: 2012 Excelsior Preferred Drug List
Exhibit II.J: Generic Appeal Report
Exhibit II.J.1: Generic Appeal Selected Statistics
Exhibit II.K: Mail Service and Specialty Pharmacy Claims
Exhibit II.K.1: Website Statistics
Exhibit II.L: Call Center Statistics
Exhibit II.M: Half Tablet Program - Drug List
Exhibit II.N: Vendor Attendance - Union Events, Conferences, Information Sessions
Exhibit II.O: Enrollment File Layout (NYSIF)
Exhibit II.P: Standard NPI Fixed-Length Billing File (NYSIF)
Exhibit II.Q: Rebate and Catch Up File Layout (NYSIF)

D. Exhibit III
Exhibit III.A: Intentionally Left Blank
Exhibit III.B: 2008-2011 Incurred Claims
Exhibit III.C: 2008-2011 Paid Claims
Exhibit III.D: Selected Financial Data
Exhibit III.E.1: 2011 Incurred Claims by Month
Exhibit III.E.2: 2010 Incurred Claims by Month
Exhibit III.E.3: 2009 Incurred Claims by Month
Exhibit III.E.4: 2008 Incurred Claims by Month
Exhibit III.E.5: 2007 Incurred Claims by Month
Exhibit III.E.6: 2006 Incurred Claims by Month
Exhibit III.F: Intentionally Left Blank
Exhibit III.G: Current Brand-Generic Classification / Excel
Exhibit III.H: Paid Claims Per Biweekly Cycle
Exhibit III.I: Prescription Plan Payments (NYSIF)
Exhibit III.J: Quarterly Breakdown Payments (NYSIF)

E. Exhibit IV
Exhibit IV.A: Program Services Matrix (Sections IV & V)

F. Exhibit V
Exhibit V.A: Proposed Claim Reimbursement Quote / Excel
Exhibit V.B: Re-Pricing Instructions for Offeror's Re-Priced Claims File
Exhibit V.B.1: File Layout Specifications for Offeror's Re-Priced Claims File (Amended 4/27/12)
Exhibit V.B.2: Offeror's Re-Priced Claim File
Exhibit V.C: Retail and Mail Service Generic Drugs – MAC List Costs per GPI / Excel
Exhibit V.C.1: Retail and Mail Service Generic Drugs – MAC List Costs per GCN / Excel
Exhibit V.D: Specialty Pharmacy Program Dispensing Fee / Excel
Exhibit V.E: Pharma Revenue Guarantee Quote / Excel
Exhibit V.E.1: Documentation to Support Pharma Revenue Guarantee Quote
Exhibit V.F: Claims Administration Fee(s) Quote / Excel


Return to Home Page