ADDENDUM NUMBER ONE
THE UNIVERSITY OF NEW MEXICO HOSPITALS
Purchasing Department
933 Bradbury Dr. SE Ste 3165
Albuquerque, New Mexico 87106
Date: 4/8/15
Proposal Number: P319-15
Name of Procurement Specialist: Ed Ybarra
Due Date: 4/20/15 @ 2:00 pm MDT
Notice to all respondents:
Amend the Proposal: Employee Medical and Prescription Drug Plan
This addendum becomes part of the Proposal Documents and modifies, as noted below, the
original Bidding Documents.
Note 1:
It is permissible to submit a proposal for any of the following:
1. Utilization Review, Disease Management and Case Management services
independent of other services specified in this RFP. If you are proposing these
services (UR/DM/CM) on a stand-alone basis, you will need to complete ALL
applicable sections of the RFP including the applicable questionnaires and the
attached revised Cost Exhibit.
2. If you are quoting on all services specified in this RFP,
following:
you must do the
2.1. Complete the attached revised Cost Exhibit.
2.2. Indicate if you will allow UR/DM/ CM services to be carved out.
2.3. Clearly indicate any impact on fees for remaining services that you would
provide if UR/DM/CM services are carved-out.
2.4. Indicate if there are any other one-time or ongoing fees associated with
coordinating UR/DM/CM services that might be carved-out.
Note 2: Delete EXHIBIT O: COST EXHIBIT in the RFP in its entirety replace with the
attached attached EXHIBIT O-Revised: COST EXHIBIT.
Question 1: On page 4 of the RFP, Pharmacy Benefit Manager (Prescription Drug Coverage), it
states “Vendors must be willing to carve-out coverage for specialty drugs should they elect to
manage/contract separately for these services.”
o Please clarify what is meant by the term “carve-out” and what the intent is for the
requirement that “Vendors must be willing to carve-out coverage for specialty
drugs should they elect to manage/contract separately for these services.”




Does “carve-out” mean specialty services would be carved out to another
PBM or vendor?
Who is responsible for utilization management?
Would carve-out services apply to drugs that are typically covered through
the medical benefit?
Would carve-out services specifically mean the addition of a specialty
pharmacy to the health plan's specialty pharmacy network?
UNMH Response to Question 1: Carriers should quote services for bundled RX to include
specialty drugs. However, UNMH may want to entertain a discussion with the selected carrier at
a later date to potentially carve-out services for specialty drugs from the services. While no
decisions have been made at this time, management of specialty drugs may be brought in-house
to UNMH and UNM. No decision has been made as to whether this would include all specialty
drugs on only those purchased through the pharmacy benefit and future discussions would
include who would be responsible to handle the claims for these drugs.
Question 2: Appendix 4 – University of New Mexico Medical Group (UNMMG)
o Does UNMMG provide retiree coverage? If so is there coverage for both Pre 65
and Post 65 retirees?
UNMH Response: UNMMG does not provide coverage to retirees.
o Are there any additional providers included in the tier 1 benefits outside of the
Lobocare Network besides podiatry, audiology, urgent care and sleep study
centers?
UNMH Response: None have been identified at this time however, if a need
arises in the future, we will bring this up for discussion.
Acknowledge receipt of this Addendum in the space provided in Exhibit B. Failure to do so may
subject Offeror to disqualification.
All other provisions of the Proposal Documents shall remain unchanged. This addendum is
hereby made a part of the Proposal Documents to the same extent as those provisions contained
in the original documents and all itemized listing thereof.
EXHIBIT O-Revised: COST EXHIBIT
The Offeror should provide separately in this exhibit administration fees and rates for each of the
noted lines of service.
CLAIMS ADMINISTRATION / RX (PBM) SERVICES / NETWORK ACCESS /
UTILIZATION REVIEW / DISEASE MANAGEMENT / CASE MANAGEMENT
1
2
3
4
All rates should be quoted net of commissions. Commissions, contingencies, overrides or service fees are not to
be paid to any organization.
Fees/rates must be quoted based on scenarios as outlined on page 4 of this RFP.
This RFP include multiple cost scenarios. Be sure to complete each of the following tables.
Fees should be quoted on a PEPM and a 4-tier basis. At the time of contracting each entity must be allowed to
decide which basis they prefer.
CLAIMS ADMINISTRATION / RX (PBM) SERVICES / NETWORK ACCESS / UTILIZATION REVIEW /
DISEASE MANAGEMENT / CASE MANAGEMENT
Scenario 1A – Stand Alone
Each Entity Rated On Their Own Attributes
Each Entity May Select a Different Carrier
UNMH
8/1/15 Effective Date
Set Up Fee (1 time)
UNMH
SRMC
UNMMG
Monthly Claims Administration Fee *
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Services Provided (UR/DM/ CM services
along with Network access fees should be
quoted separately – see separate charts)
Claims Administration
Network Access
Utilization Review (UR)
Large/ Catastrophic Case Management (CM)
Disease Management (DM)
Banking Fees/ Financial Services
Information Technology
SPDs/ Plan Documents
SBCs
Claim Forms
Check Stock
ID Cards
Postage
Printing
Compliance
Communications Costs
Meeting Attendance (with client)
Upload deductible, out of pocket and other
SRMC
1/1/16 Effective Date
UNMMG
1/1/16 Effective Date
(must not include Utilization Review, Disease Management or Case
Management services or Network access Fees)
NOTE IF INCLUDED IN ADMINISRATION FEE / OTHERWISE
SPECIFY AMOUNT AND BASIS (PEPM / MONTHLY , ETC.)
Complete separate table below
Complete separate table below
Complete separate table below
Complete separate table below
CLAIMS ADMINISTRATION / RX (PBM) SERVICES / NETWORK ACCESS / UTILIZATION REVIEW /
DISEASE MANAGEMENT / CASE MANAGEMENT
Scenario 1A – Stand Alone
Each Entity Rated On Their Own Attributes
Each Entity May Select a Different Carrier
benefit accumulators upon take-over (UNMH
and UNMMG only)
Commissions
PPACA Appeals Process (Internal and
External)
Other
Rate guarantee (if offering rate cap, indicate
%)
Years 1 & 2
Year 3
Year 4
RX Rebates
How are rebates returned:
 Separate refund check or credit to claims
account
 Credit against monthly administration
fees (if this method is used, provide
estimates on projected rebates)
Other Fees/ Costs
Should entities elect to unbundle stop loss:
 Fee for claims reporting to stop loss
carrier:
 Impact to administration fees if stop loss
is carved-out.
Cost for biometric screenings
Cost for tobacco cessation program(s)
Cost to credit benefit accumulators
(deductible, out-of-pocket, visit limits) in the
event of mid-plan year takeovers
Impact to Core Administration fees if UR,
DM and CM services are carved out.
Cost for Coordination with another vendor if
UR, DM and CM Services are carved out
 On time fee
 Ongoing fee
UNMH
8/1/15 Effective Date
SRMC
1/1/16 Effective Date
UNMMG
1/1/16 Effective Date
NET
NET
NET
100% OF REBATES ARE TO BE RETURNED TO THE
CLIENT(S)
Network Access/Management
Fees to include LoboCare (Tier 1) and
Carrier Network (Tier 2)
UNMH
8/1/15 Effective Date
SRMC
1/1/16 Effective Date
UNMMG
1/1/16 Effective Date
UNMH
8/1/15 Effective Date
SRMC
1/1/16 Effective Date
UNMMG
1/1/16 Effective Date
No Carve-out Permitted
Network Access/Management Fee
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Utilization Review, Disease
Management & Case
Management Services,
Wellness & Nurse Line
(whether Carve-out or included in all
services)
Utilization Review
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Disease Management
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Case Management (per hour)
Wellness
Nurse Line
SUMMARY OF PRESCRIPTION DRUG GUARANTEES FOR SELF-FUNDED ARRANGEMENT
Scenario 1A
INSTRUCTIONS: Vendors must complete the following chart, showing the RX AWP discounts, rebates and
dispensing fees for you will guarantee for the self-funded ASO arrangement.
GUARANTEE CRITERIA
TRADITIONAL PRICING
GUARANTEE OF DISCOUNTS OFF AWP (Average Wholesale Price)
POST SETTLEMENT –QUOTED
BRAND
Retail
Mail Order
GENERIC
Retail
PASS THROUGH PRICING
SUMMARY OF PRESCRIPTION DRUG GUARANTEES FOR SELF-FUNDED ARRANGEMENT
Scenario 1A
INSTRUCTIONS: Vendors must complete the following chart, showing the RX AWP discounts, rebates and
dispensing fees for you will guarantee for the self-funded ASO arrangement.
GUARANTEE CRITERIA
TRADITIONAL PRICING
PASS THROUGH PRICING
Mail Order
SPECIALTY DRUGS
Retail
Mail Order
GUARANTEE OF DISPENSING FEES PER RX
BRAND
Retail
Mail Order
GENERIC
Retail
Mail Order
SPECIALTY DRUGS
Retail
Mail Order
ADMINISTRATIVE FEES
Retail
Mail Order
GUARANTEE OF REBATES PER RX
Retail
Mail Order

per script
per script
Please quote your administrative fees and any firm/illustrative stop-loss rates on a PEPM
basis. At the same time:
a. Provide a build-up of the PEPM fee by applying the following tier ratios to the
respective enrollment by tier:
i.
# of single enrollees times x (your unit cost for employee only)
ii. # of employee & spouse times 2.05x
iii. # of employee & child/ren times 1.85x
iv.
# employee & family times 2.9x
b. Indicate whether you will agree to honor the above fees (the PEPM fee or the unit
cost of x), regardless of which option the employer elects.
c. Confirm that these fees are net of any pharmacy rebates.
d. Confirm that you will effectively pass along 100% of rebates realized by actual
utilization, along with the options which are available:
i.
On a pure pass through basis – administrative fees are paid on a net basis,
and rebates are paid to the employer on a quarterly basis
ii. By crediting estimated rebates against your quoted admin fees, and then
accounting and reconciling actual rebates on a periodic basis
pepm
pepm
CLAIMS ADMINISTRATION / RX (PBM) SERVICES / NETWORK ACCESS / UTILIZATION REVIEW /
DISEASE MANAGEMENT / CASE MANAGEMENT
Scenario 1B – Joint
All Three Entities with Same Fees
UNMH (8/1/15 Effective Date)
SRMC (1/1/16 Effective Date)
UNMMG (1/1/16 Effective Date)
Set Up Fee (1 time)
UNMH
SRMC
UNMMG
Monthly Claims Administration Fee *
(must not include Utilization Review, Disease
Management or Case Management services or Network
access Fees)
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Services Provided (UR/DM/ CM services along with
NOE IF INCLUDED IN ADMINISTRATION FEE /
Network access fees should be quoted separately – see
OTHERWISE SPECIFY AMOUNT AND BASIS
separate charts)
(PEPM / MONTHLY, ETC.)
Claims Administration
Network Access
Complete separate table below
Utilization Review (UR)
Complete separate table below
Large/ Catastrophic Case Management (CM)
Complete separate table below
Disease Management (DM)
Complete separate table below
Banking Fees/ Financial Services
Information Technology
SPDs/ Plan Documents
SBCs
Claim Forms
Check Stock
ID Cards
Postage
Printing
Compliance
Communications Costs
Meeting Attendance (with client)
Upload deductible, out of pocket and other benefit
accumulators upon take-over (UNMH and UNMMG
only)
Commissions
NET
PPACA Appeals Process (Internal and External)
Other
Rate guarantee (if offering rate cap, indicate %)
Years 1 & 2
Year 3
Year 4
CLAIMS ADMINISTRATION / RX (PBM) SERVICES / NETWORK ACCESS / UTILIZATION REVIEW /
DISEASE MANAGEMENT / CASE MANAGEMENT
Scenario 1B – Joint
All Three Entities with Same Fees
UNMH (8/1/15 Effective Date)
SRMC (1/1/16 Effective Date)
UNMMG (1/1/16 Effective Date)
RX Rebates
100% OF REBATS ARE TO BE RETURNED TO
THE CLIENT(S)
How are rebates returned:
Separate refund check or credit to claims account
Credit against monthly administration fees (if this
method is used, provide estimates on projected rebates)
Other Fees/ Costs
Should entities elect to unbundle stop loss:
 Fee for claims reporting to stop loss carrier:
 Impact to administration fees if stop loss is
carved-out.
Cost for biometric screenings
Cost for tobacco cessation program(s)
Cost to credit benefit accumulators (deductible, out-ofpocket, visit limits) in the event of mid-plan year
takeovers
Impact to Core Administration fees if UR, DM and CM
services are carved out.
Cost for Coordination with another vendor if UR, DM
and CM Services are carved out
On time fee
Ongoing fee
Network Access/Management Fees to
include LoboCare (Tier 1) and Carrier Network (Tier
2)
No Carve-out permitted
Network Access/Management Fee
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
UNMH (8/1/15 Effective Date)
SRMC (1/1/16 Effective Date)
UNMMG (1/1/16 Effective Date)
Utilization Review, Disease
Management & Case
Management Services &
Wellness and Nurse Line
UNMH (8/1/15 Effective Date)
SRMC (1/1/16 Effective Date)
UNMMG (1/1/16 Effective Date)
(whether Carve-out or included in all
services)
Utilization Review
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Disease Management
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Case Management (per hour)
Wellness
Nurseline
SUMMARY OF PRESCRIPTION DRUG GUARANTEES FOR SELF-FUNDED ARRANGEMENT
Scenario 1B
INSTRUCTIONS: Vendors must complete the following chart, showing the RX AWP discounts, rebates and
dispensing fees for you will guarantee for the self-funded ASO arrangement.
GUARANTEE CRITERIA
TRADITIONAL PRICING
GUARANTEE OF DISCOUNTS OFF AWP (Average Wholesale Price)
POST SETTLEMENT –QUOTED
BRAND
Retail
Mail Order
GENERIC
Retail
Mail Order
SPECIALTY DRUGS
Retail
Mail Order
GUARANTEE OF DISPENSING FEES PER RX
BRAND
Retail
Mail Order
GENERIC
Retail
Mail Order
SPECIALTY DRUGS
PASS THROUGH PRICING
SUMMARY OF PRESCRIPTION DRUG GUARANTEES FOR SELF-FUNDED ARRANGEMENT
Scenario 1B
INSTRUCTIONS: Vendors must complete the following chart, showing the RX AWP discounts, rebates and
dispensing fees for you will guarantee for the self-funded ASO arrangement.
GUARANTEE CRITERIA
TRADITIONAL PRICING
PASS THROUGH PRICING
Retail
Mail Order
ADMINISTRATIVE FEES
Retail
Mail Order
GUARANTEE OF REBATES PER RX
Retail
Mail Order

per script
per script
pepm
pepm
Please quote your administrative fees and any firm/illustrative stop-loss rates on a PEPM
basis. At the same time:
e. Provide a build-up of the PEPM fee by applying the following tier ratios to the
respective enrollment by tier:
v.
# of single enrollees times x (your unit cost for employee only)
vi.
# of employee & spouse times 2.05x
vii.
# of employee & child/ren times 1.85x
viii. # employee & family times 2.9x
f. Indicate whether you will agree to honor the above fees (the PEPM fee or the unit
cost of x), regardless of which option the employer elects.
g. Confirm that these fees are net of any pharmacy rebates.
h. Confirm that you will effectively pass along 100% of rebates realized by actual
utilization, along with the options which are available:
iii. On a pure pass through basis – administrative fees are paid on a net basis,
and rebates are paid to the employer on a quarterly basis
iv.
By crediting estimated rebates against your quoted admin fees, and then
accounting and reconciling actual rebates on a periodic basis
UNMMG
FULLY INSURED RATES
(including RX, UR/ DM/CM services and Network)
Scenario 2A- Stand Alone
1
2
3
All rates should be quoted net of commissions. Commissions, contingencies, overrides or service fees are not to
be paid to any organization.
UNMMG is also soliciting quotes for fully insured coverage. Carriers are asked to provide a quote for a fully
insured plan that matches the current plan design as closely as possible.
Rates should be quoted on a 4-tier basis only.
Full Insured Rates:
Employee Only
Employee + Spouse / Domestic Partner
Employee + Child(ren)
Employee + Family
UNMMG ONLY
$
$
$
$
UNMMG
FULLY INSURED RATES
(including RX, UR/ DM/CM services and Network)
Scenario 2B- Joint
1
2
3
All rates should be quoted net of commissions. Commissions, contingencies, overrides or service fees are not to
be paid to any organization.
UNMMG is also soliciting quotes for fully insured coverage. Carriers are asked to provide a quote for a fully
insured plan that matches the current plan design as closely as possible.
Rates should be quoted on a 4-tier basis only.
Full Insured Rates:
Employee Only
Employee + Spouse / Domestic Partner
Employee + Child(ren)
Employee + Family
UNMMG ONLY
$
$
$
$
If you are deviating from the UNMMG current plan design under the fully insured
arrangement, please list all deviations in the following chart (you may add additional lines
as necessary).
Benefit
UNMMG Current
Deviation
STOP LOSS COVERAGE
1
2
3
4
5
6
All rates should be quoted net of commissions. Commissions, contingencies, overrides or service fees are not to
be paid to any organization.
Each entity should be rated separately based on their own demographics and stop loss coverage parameters.
Stop loss coverage should include Medical and RX.
Stop loss rates should be based on each entities own attributes (demographics, eligibility, plan design(s) and
claims data, but quoted on both a stand-alone and joint basis.
Fees should be quoted both as PEPM and on a 4-tier basis. At the time of contracting each entity must be
allowed to decide which basis they prefer.
Rates quoted for UNMH must be firm. Rates quoted for SRMC and UNMMG may be illustrative due to the
delayed effective date.
STOP LOSS COVERAGE
All Three Entities Select the Same Carrier
Scenario 1A - Stand Alone Coverage
Each Entity Rates on their Own Attributes – Each May Select a Different Vendor
UNMH
SRMC
UNMMG
(8/1/15)
(1/1/16)
(1/1/16)
Firm Rates
Illustrative
Illustrative
Illustrative
Individual Stop Loss
Rates
Rates
Rates
$430,000
$85,000
$85,000
$100,000
Deductible
Paid
Paid
12/12
12/12
Contract Basis
Premium Rates:
PEPM
4 Tier*
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
NET
NET
NET
NET
Commissions
Aggregate Stop Loss
12/12
12/12
Contract Basis
Premium Rates:
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Aggregate Factors:
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Commissions
NET
NET
NET
NET

Please quote your firm/illustrative stop-loss rates on a PEPM basis. At the same time:
i. Provide a build-up of the PEPM fee by applying the following tier ratios to the
respective enrollment by tier:
ix. # of single enrollees times x (your unit cost for employee only)
x. # of employee & spouse times 2.05x
xi. # of employee & child/ren times 1.85x
xii. # employee & family times 2.9x
j. Indicate whether you will agree to honor the above fees (the PEPM fee or the unit
cost of x), regardless of which option the employer elects.
k. Confirm that these fees are net of any pharmacy rebates.
l. Confirm that you will effectively pass along 100% of rebates realized by actual
utilization, along with the options which are available:
v.
On a pure pass through basis – administrative fees are paid on a net basis,
and rebates are paid to the employer on a quarterly basis
vi.
By crediting estimated rebates against your quoted admin fees, and then
accounting and reconciling actual rebates on a periodic basis
Individual Stop Loss
STOP LOSS COVERAGE
All Three Entities Select the Same Carrier
Scenario 1B- Joint
UNMH
SRMC
(8/1/15)
(1/1/16)
Firm Rates
Illustrative
Rates
$430,000
$85,000
Paid
Paid
Deductible
Contract Basis
Premium Rates:
PEPM
4 Tier*
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Commissions
Aggregate Stop Loss
Contract Basis
Premium Rates:
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Aggregate Factors:
PEPM
4 Tier *
Employee Only
Employee + Spouse/Domestic Partner
Employee + Child(ren)
Employee + Family
Commissions
NET
NET
NET
NET
UNMMG
(1/1/16)
Illustrative
Illustrative
Rates
Rates
$85,000
$100,000
12/12
12/12
NET
NET
12/12
12/12
NET
NET

Please quote your firm/illustrative stop-loss rates on a PEPM basis. At the same time:
m. Provide a build-up of the PEPM fee by applying the following tier ratios to the
respective enrollment by tier:
xiii. # of single enrollees times x (your unit cost for employee only)
xiv. # of employee & spouse times 2.05x
xv. # of employee & child/ren times 1.85x
xvi. # employee & family times 2.9x
n. Indicate whether you will agree to honor the above fees (the PEPM fee or the unit
cost of x), regardless of which option the employer elects.
o. Confirm that these fees are net of any pharmacy rebates.
p. Confirm that you will effectively pass along 100% of rebates realized by actual
utilization, along with the options which are available:
vii.
On a pure pass through basis – administrative fees are paid on a net basis,
and rebates are paid to the employer on a quarterly basis
viii. By crediting estimated rebates against your quoted admin fees, and then
accounting and reconciling actual rebates on a periodic basis