P-364
ATTACHMENT 3
PRESCRIPTION DRUG QUESTIONNAIRE
MEDICAL/RX VENDORS MUST COMPLETE THIS SECTION.
INSERT YOUR COMPANY’S NAME HERE
Retail Pharmacy Network
1.
Identify your PBM.

Is your PBM internal or external?
2.
Are networks of varying size available? Please clearly
describe differences in participating pharmacies, differences
in discount arrangements, and estimated overall impact on
drug spending.
3.
Is your list of participating pharmacies available online?
Internal
External
Yes
No
Yes
No
Yes
No
Yes
No

4.
If you are selected as a finalist, please be prepared to
submit a current listing of participating pharmacies in
New Mexico.
Do your pharmacies provide flu shots?

5.
How is the reimbursement / payment handled?
How do you handle specialty drugs?

Are there any prior authorization requirements?

If yes, please describe.
6.
Describe your process for Rx protocol of dosage and refill
frequency.
7.
Outline/explain any and all dosage or quantity limitations.
8.
Are there any specific situations where you would override or
deny a physician’s prescription?

If yes, provide details?
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P-364
ATTACHMENT 3
PRESCRIPTION DRUG QUESTIONNAIRE
Formularies and Rebates
9.
How is your formulary established?
10.
Do all drug manufacturers whose products are included in
your formulary provide your network with rebates?
Yes
No
Yes
No


11.
If so, how are the rebates shared with the plan sponsor?
If so, are the rebate dollars paid to the plan sponsor or
are credits given prospectively?
 Do you provide minimum rebate guarantees?
 If so, please describe.
How often do the drugs on the formulary change?
12.
Is your formulary available on the Internet?
Yes
No
13.
Will you agree to remit or credit back to premium 100% of
manufacturers’ rebates and incentives of any kind to the
employer?
Yes
No
Yes
No
Yes
No
Yes
No

14.
15.
16.
If not, what percentage?

How often?
Does the formulary rebate program apply to the mail order
program?
Do you guarantee that ingredient cost charges made by
network pharmacies will be based on the lesser of the
discount offered, actual retail paid, MAC price or your actual
acquisition costs?

If not, explain.
Does the PBM receive rebates or other forms of
reimbursement from the manufacturers that is not disclosed
or shared with the client?
17.
Do you have a specialty drug tier plan provision (i.e., 4th tier)?
Yes
No
18.
Are specialty drugs available through mail order?
Yes
No
19.
Outline the categories of medications considered “specialty
drugs.”
Mail Order Prescription Drug Program
2
P-364
ATTACHMENT 3
PRESCRIPTION DRUG QUESTIONNAIRE
20.
Do you have your own mail order prescription drug program?
If not, skip to following question.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No


21.
If so, is it fully integrated with your retail network?
Where is your mail order pharmacy located?
Do you subcontract with an outside mail order vendor?

22.
If so, which mail order vendor do you use?
Is there an internet pharmacy available through your PBM?

If so, please describe.

Please confirm that members can order prescriptions
online.
Pharmacy Contracting
23. Do you maintain the same pricing contracts for all network
pharmacies?

If not, explain.
Eligibility / Maintenance Services
24. Is there an additional / separate ID card required for
prescription drug coverage? If so, describe.
25.

Are dependents listed by name on the pharmacy card?
Do you charge a fee for card preparation?
Reporting
26. Describe the claim and utilization reports that will be made
available as part of your quoted fee. Provide samples of all.
3
P-364
ATTACHMENT 3
GENERAL QUESTIONNAIRE
ALL VENDORS MUST COMPLETE THIS SECTION.
ENTER VENDOR NAME:
Firm / Organization Questions
1. Do you carry an Errors & Omissions policy?
2. Do you carry a comprehensive general liability
policy?
3. Does your company carry a fidelity bond?
4. Will you agree to offer a Performance Guarantee with
financial penalties?
 If yes, include your proposed performance
guarantee in your proposal, including the total
amount you are willing to put at risk.
5.
No
No
Yes
Yes
No
No
Please provide the following information. (New
Mexico public sector employers or higher
education organizations are preferred.)


6.
Yes
Yes
Three (3) current client references
At least one of these references should be from a
client of similar size. Provide  Client Name
 Contact
 Contact’s email address
 Address
 Telephone number
 Type of coverage (e.g., medical, life)
 Approximate # of employees covered by
each contract
Please provide the following information. (New
Mexico public sector employers or higher
education organizations are preferred.)


Two (2) former clients, who may be contacted.
Provide  Client Name
 Contact
 Contact’s email address
 Address
 Telephone number
 Type of coverage (e.g., medical, life)
 Approximate # of employees covered by
each contract
 Reason for termination
Implementation, Enrollment, Eligibility and Maintenance Questions
4
P-364
ATTACHMENT 3
GENERAL QUESTIONNAIRE
7.
What is the normal lead-time required to implement a
group?
8.
What mediums do you accept for plan enrollment?
9.
Do you offer online eligibility maintenance for all
clients?
 If so, is there a charge?
 Is there a charge for hard copy maintenance?
10. Finalists will be required to provide a formal and
detailed implementation plan.
Yes
Agree
No
Disagree
General Administration Questions
11. For insured coverages: for the first and each renewal
year, what periods of time will be used as the basis
for determining renewal recommendations?
12. When are premiums/fees due under your policy?


What is the grace period?
If premium is paid after the grace period, is a
penalty and/or interest charge assessed?
 If yes, explain in detail.
Customer Service / Satisfaction Questions
13. Do you complete customer service surveys?



Yes
No
Yes
No
Yes
No
How frequently do you conduct satisfaction
surveys?
What percentage of participants is surveyed?
What is your performance standard for patient
satisfaction survey results?
14. Will you provide a foreign language interpreter service for
participants as needed?

Are there any charges associated with this
service? If so, specify.
15. Describe your company’s client management team
structure.
16. Describe how your company handles client
management responsibilities and transition when a
member of the team:
 Goes out on extended leave (more than 2
weeks)
 Leaves the company
17. Provide a brief bio detailing the experience and
background of each individual that would be
assigned to the CNM account.
18. Provide the office location (city) that each member of
the account management team works from.
5
P-364
ATTACHMENT 3
GENERAL QUESTIONNAIRE
19. Does your company have a local office in the
Albuquerque area?
 If not, what is the closest office?
20. How many onsite meetings does the account team
commit to attending throughout the year for:
 Implementation
 Ongoing account management and reporting
 Open enrollment
 Health and Wellness Fair
21. Will CNM be assigned a dedicated representative?
 How many other accounts will this individual
service?
 What amount of time will the representative’s
time will be available to service the CNM
account?
Technology Questions
22. Which of the following tasks can members and plan
sponsor representatives perform online? You may
indicate N/A if not applicable to the line of coverage
you are quoting.
Members
 Enrollment (New Hires and Open Enrollment)
 Changes in Status
 Billing (Plan Administrators only)
 Claim inquiry
 Provider search
 Access provider directories
 Physician/provider cost and quality comparison
 ID card request
 Electronic EOB
 Terminations
 Other
23. Is there an additional cost for online services?
 If yes, describe.
24. What percentage of claims is auto-adjudicated
through your system?
25. BRIEFLY describe the services you offer to support
the client’s human resources / benefits team.
Reporting Questions
26. Are you able to provide data that benchmarks the
client’s experience against the following :
 Your book of business
 National norms
 Similar sized municipalities
Please provide cost to provide benchmark reports, if
any.
27. Provide a list of all standard and optional reports
available and associated costs (if any). Please
provide sample reports.
Report
Frequency Additional Cost? If
so, indicate amount.
6
Plan Sponsors
N/A
Yes
Yes
Yes
Yes
Standard?
Optional?
No
No
No
No
Comments
P-364
ATTACHMENT 3
GENERAL QUESTIONNAIRE
28. What is the lag time on reports from your firm?
29. Does the client/consultant have the ability to access
your database in real time for purposes of:
 Tracking plan experience
 Utilization patterns
 Other available plan information
 How is this ability provided?
 Is there an additional charge to the client?
 If so, what is the charge?
7
Yes
Yes
Yes
No
No
No
Yes
No
P-364
ATTACHMENT 3
PRESCRIPTION MINIMUM REQUIREMENTS
ALL VENDORS MUST COMPLETE THIS SECTION.
The following are proposal specifications. Please complete the following chart by responding in the righthand column. If you disagree with any of the criteria, you may not be considered. If the criteria do not
apply to the services you are quoting, please indicate “N/A.”
ENTER VENDOR NAME:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
You have reviewed and accept the Plan’s eligibility provisions
outlined in the RFP.
You must be licensed in New Mexico or willing to obtain a
license in New Mexico.
Agree
Disagree
Agree
Disagree
Self-funded Quotes: ASO fees must be guaranteed for a
minimum of two (2) years from the effective date. A third year
rate guarantee is preferred. Fees must be the same for Years
1 and 2.
The rates/fees/premiums should be calculated NET of
commissions.
Renewal rates and fees must be submitted 120 days prior to
the contract renewal date.
You have included detailed plan summaries for all quoted
plans.
You currently have a provider network in Albuquerque, NM.
The vendor will be responsible for producing the
Booklet/Certificate of Coverage / Summary Plan
Description/Summary of Benefits and Coverage. The client
reserves the right to review/revise the Booklet/COC/SPD/SBC
prior to finalization.
Vendor agrees to provide a booklet draft within 60 days of the
effective date.
Vendors may be required to attend open enrollment meetings.
Vendor agrees to provide all standard reports to the client.
The client must be able to access reports online.
You must agree to waive the “actively at work” provision for
the currently enrolled. The master contract will reflect the
elimination of the actively at work restriction or deferred
effective date for all initially enrolled active or inactive
employees and dependents. This will include only initial
eligibles (those eligible on the effective date of the contract)
including COBRA continuees.
You are in compliance with all HIPAA Privacy, Electronic Data
Interface (EDI) and Security requirements.
With regard to the Patient Protection and Affordable Care Act
(PPACA) please confirm your understanding and agreement
with the following:
 Vendors must agree to be in compliance with, and able to
administer, PPACA’s required administration processes
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Agree
Disagree
Disagree
Agree
Disagree
Agree
Agree
Agree
Agree
Disagree
Disagree
Disagree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Disagree
8
P-364
ATTACHMENT 3
PRESCRIPTION MINIMUM REQUIREMENTS
16.
17.
18.
19.
20.
and reporting requirements (e.g., nondiscrimination
testing, etc.), as outlined in the law.
 Vendors must agree to be in compliance with, and able to
administer, PPACA’s claims appeal process (both internal
and external) and must be willing to take the steps
necessary to ensure that the client/plan is in full
compliance. This includes your agreement to contract
with at least three (3) URAC-accredited IROs
(Independent Review Organizations).
Your contract must require no more than a 30-day notice of
termination. Your contract cannot prohibit the group from
terminating coverage at any time. There must be no penalties
for late notification or for termination off anniversary.
Vendor agrees to provide performance guarantees. Provide
details within your proposal.
You have specifically listed all deviations from the RFP and
coverage requirements on Attachment 11, Deviations from
RFP Terms and Conditions and Coverage Requirements.
NOTE: Deviations MUST be listed; you cannot simply make
a “general” reference to section(s) of the proposal.
You completed all questionnaires and exhibits in full and in
the format requested (e.g., Word or Excel – not PDF).
Insurance premium tax does not apply to public entity
employers including, but not limited to, cities, counties, school
districts, etc. If selected, premium tax will not be charged.
9
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Disagree
Agree
Disagree