Table of Contents

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

 

Request For Proposals (RFP)
Section I: Introduction
Section II: Procurement Protocol and Process (Amended 7/31/17)
Section III: Administrative Proposal Requirements / Word Version (Amended 7/31/17)
Section IV: Technical Proposal Requirements / Word Version (Amended 7/31/17)
Section V: Cost Proposal Requirements / Word Version
Section VI: Evaluation and Selection Criteria (Amended 7/17/17)
Section VII.A: Draft Contract (DCS Version) (Amended 7/31/17)
Section VII.B: Draft Contract (NYSIF Version) (Amended 7/17/17)
Section VIII: Glossary of Terms (Amended 7/17/17)

 

Appendix
Appendix.A: Standard Clauses for New York State Contracts
Appendix.B: Standard Clauses for All DCS Contracts
Appendix.B: Standard Clauses for all NYSIF Contracts
Appendix.C: Third Part Connection and Data Exchange Agreement (DCS) / Word Version
Appendix.C: Third Part Connection and Data Exchange Agreement (NYSIF) / Word Version
Appendix C-1: Information Security Standards
Appendix D: Participation by Minority and Women-Owned Business Enterprises: Requirements and Procedures (Amended 7/17/17)
Appendix D-1: Minority and Women-Owned Business Enterprises - Equal Employment Opportunity Policy Statement (DCS) / Word Version
Appendix D-1: Minority and Women-Owned Business Enterprises - Equal Employment Opportunity Policy Statement (NYSIF) / Word Version
Appendix D-2: MWBE Utilization and Reporting Responsibilities Under Article 15-A

Exhibit I
Exhibit I.A: Proposal Submission Requirement Checklist / Word Version
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 / Word Version
Exhibit I.F: ST-220-TD
Exhibit I.G: Intentionally Left Blank
Exhibit I.H: Debriefing Guidelines
Exhibit I.I: Extraneous Terms Template / 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
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): DCS MWBE Utilization Plan (Form MWBE-100)
Exhibit I.O(B): NYSIF MWBE Utilization Plan (Form MWBE-100)
Exhibit I.P: Offeror's Certification of Compliance Pursuant to State Finance Law §139-k / Word Version
Exhibit I.Q.1: Vendor Profile (NYSIF)
Exhibit I.Q.2: NYSIF Vendor Security Survey
Exhibit I.R: Questions Template / Word Version
Exhibit I.S: Formal Offer Letter / Word Version
Exhibit I.T: Offeror Attestations Form / Word version
Exhibit I.U.1: Key Subcontractors or Affiliates / Word Version
Exhibit I.U.2: NYS Subcontractors and Suppliers / Word Version
Exhibit I.V: Program References / Word Version
Exhibit I.W: Compliance with NYS Workers' Compensation Law
Exhibit I.X: Vendor Assurance of No Conflict of Interest or Detrimental Effect / Word Version
Exhibit I.Y.1: Offeror’s Proposed Retail Pharmacy Network File (Amended 7/31/17)
Exhibit I.Y.2: File Layout Specifications for the Offeror's Proposed Retail Pharmacy Network File / Excel Version (Amended 7/31/17)
Exhibit I.Y.3: Offeror's Proposed Retail Pharmacy Network Access Prerequisite Worksheet / Excel Version (Amended 7/31/17)
Exhibit I.Y.4: Comparison of DCS Current Program Network Pharmacies and the Offeror's Proposed Retail Pharmacy Network / Word Version
Exhibit I.Z: Confidential Agreement and Certificate of Non-Disclosure / Word Version

Exhibit II
Exhibit II.A: Enrollment by Zip Code & Geo Access Network Report File (Amended 8/2/17)
Exhibit II.B: Enrollment by Month
Exhibit II.B.1: Total Empire Plan, Excelsior Plan and SEHP Enrollment by Age
Exhibit II.B.2: Covered Lives by Bargaining Group
Exhibit II.C: DCS-NYSIF Prescription Drug Program Copayment and Benefit Maximum Matrix
Exhibit II.C.1: DCS Benefit Program and Bargaining Unit Matrix
Exhibit II.D: Certificate of Insurance 2014 - NY Retiree
Exhibit II.D.1: NYSHIP General Information Book 2015 – NY Retiree
Exhibit II.D.2: At A Glance – SEHP
Exhibit II.D.3: At A Glance – MC; Legislature
Exhibit II.D.4: At A Glance – Excelsior
Exhibit II.D.5: 2017 NYSHIP Benefit Plan Comparison
Exhibit II.E: Empire Plan Health Plan Card
Exhibit II.E.1: Student Employee Health Plan Card (Amended 7/17/17)
Exhibit II.E.1a: Excelsior Health Plan Card
Exhibit II.E.1b: NYSIF PBM Claimant Card
Exhibit II.E.2: HCAP Providers for NYS Empire 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: Medical Exception Statistics Quarterly Report
Exhibit II.F.3: Empire Plan MAC List
Exhibit II.F.4: Cycle Claims Report
Exhibit II.F.5: Top 100 Drugs - Specialty
Exhibit II.F.6: Top 100 Brand Name and Generic Drugs - Retail Pharmacy
Exhibit II.F.7: Top 20 Therapeutic Categories – Retail and Mail
Exhibit II.F.8: Top 100 Brand Name and Generic Drugs – Mail Service Pharmacy
Exhibit II.F.9: MAC Alert Notice (Amended 7/17/17)
Exhibit II.F.10: Quarterly Performance Guarantee Report
Exhibit II.F.11: Quarterly Audit Report
Exhibit II.F.12: Quarterly Rebate Payment Detail and Other Pharma Revenue Report
Exhibit II.F.13: Monthly MAC Savings Report
Exhibit II.F.14: Drug Performance Report
Exhibit II.F.15: Annual Claims and Credits Paid by Agency
Exhibit II.F.16: Quarterly Summary of Participating Agency Claims
Exhibit II.F.17: Monthly Summary of Paid Claims by Month of Incurral
Exhibit II.F.18: Monthly Summary of Paid Claims by Pharmacy and Drug Type
Exhibit II.G: NYBEAS Enrollment Record Layout - Control Header
Exhibit II.G.1: NYBEAS Enrollment Record Layout - Transaction Set Header
Exhibit II.G.2: Feedback File Layout
Exhibit II.H: Drugs that Require Prior Authorization
Exhibit II.H.1: Prior Authorization Quarterly Report
Exhibit II.H.2: Prior Authorization Selected Statistics
Exhibit II.I: 2016 Flexible Formulary Drug List
Exhibit II.I.1: 2017 Flexible Formulary Drug List
Exhibit II.I.2: 2017 Excelsior Plan Drug List
Exhibit II.I.3: 2017 Empire Plan Excluded Drug List
Exhibit II.J: Generic Appeal Report
Exhibit II.J.1: Generic Appeal Selected Statistics
Exhibit II.K: Mail Service Pharmacy Claims
Exhibit II.K.1: Empire Plan Prescription Drug Program Website Statistics
Exhibit II.L: Empire Plan Prescription Drug Program Monthly Call Center Volume
Exhibit II.M: 2016 Vendor Attendance
Exhibit II.N: NYSIF Eligibility Process
Exhibit II.O: NYSIF Billing Process
Exhibit II.P: NYSIF Rebate File Processes (Quarterly – Yearly)
Exhibit II.Q: NYSIF Zip Codes (Excel Version)
Exhibit II.R: NYSIF Invoice
Exhibit II.S: NYSIF Aging Short Fill File Layout
Exhibit II.T: NYSIF Short Fill Process
Exhibit II.U: NYSIF Error Process
Exhibit II.V: NYSIF Paper Bills
Exhibit II.W: NYSIF PBM Prior Authorization Process
Exhibit II.X: NYSIF Report Fields
Exhibit II.Y: NYSIF Additional Reports
Exhibit II.Z: Call Statistics / Excel Version (added 7/17/17)

Exhibit III
Exhibit III.A: 2014 – 2016 Incurred Claims
Exhibit III.B: Intentionally Left Blank
Exhibit III.C: Selected Financial Data
Exhibit III.D: 2016 Incurred Claims by Month – Combined
Exhibit III.D.1: 2015 Incurred Claims by Month – Combined
Exhibit III.D.2: 2014 Incurred Claims by Month – Combined
Exhibit III.D.3: 2016 Incurred Claims by Month – EGWP
Exhibit III.D.4: 2015 Incurred Claims by Month – EGWP
Exhibit III.D.5: 2014 Incurred Claims by Month – EGWP
Exhibit III.D.6: 2016 Incurred Claims by Month – Commercial
Exhibit III.D.7: 2015 Incurred Claims by Month – Commercial
Exhibit III.D.8: 2014 Incurred Claims by Month – Commercial
Exhibit III.E: Current Brand-Generic Classification
Exhibit III.F: Paid Claims Per Cycle
Exhibit III.G: NYSIF Prescription Plan Payments
Exhibit III.H: NYSIF Quarterly Breakdown Payments
Exhibit III.I: Medical Exception Program Claims Experience
Exhibit III.J: External Appeal Review Fees
Exhibit III.K NYSHIP Compound Claims Summary / Excel Version (added 7/17/17)

Exhibit IV
Exhibit IV.A: Program Services Matrix
Exhibit IV.B: Diversity Practices Questionnaire / Word
Exhibit IV.C: NYS Diversity Practices Scoring Matrix

Exhibit V
Exhibit V.A: Proposed Claim Reimbursement Quote / Excel Version
Exhibit V.B: Layout Specifications for DCS Program Informational Claims Data File / Word Version
Exhibit V.B.1: Layout Specifications for NYSIF Program Informational Claims Data File / Word Version
Exhibit V.B.2: Designated Specialty Pharmacy Identifiers
Exhibit V.C: Retail and Mail Service Generic Drugs – MAC List Costs per GPI / Excel Version
Exhibit V.D: Specialty Pharmacy Program Dispensing Fees / Excel Version
Exhibit V.E: Pharma Revenue Guarantee Quote / Excel Version
Exhibit V.E.1: Documentation to Support Pharma Revenue Guarantee Quote
Exhibit V.F: Claims Administration Fee(s) Quotes / Excel Version (Amended 7/17/17)
Exhibit V.G: Vaccination Pricing / Excel Version (Amended 7/17/17)
Exhibit V.H: DCS Classified Generic Drugs


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