Table 1 2017 Plan Year Pharmacy Benefit Design – Table 2 2016 Enrollment Data (as of January 2016) – Table 3 Additional Background Information – Table 4 Format for Submission of Additional Clarification Questions – Table 5 Calendar of Events – Table 6 No Assumptions or Exceptions Allowed – Table 7 Evaluation Criteria – Exhibit 1 Pro Forma State of Wisconsin Contract (includes the Pro Forma Contract By – Authorized Board and the Pro Forma State of Wisconsin Pharmacy Benefit Program Agreement) Exhibit 2 Standard Terms and Conditions (DOA-3054) – Exhibit 3 Supplemental Standard Terms and Conditions for Procurement for Services – (DOA-3681) Exhibit 4 Department Terms and Conditions – Appendix 1 834 Companion Guide – Appendix 2 Data Specifications Pharmacy – – Appendix 3 Data Specifications Wellness – – Appendix 4 Data Specifications Medical – – Appendix 5 Data Specifications Dental – – Appendix 6 State Employer Group Roster (ET-1404) – Appendix 7 Local Employer Group Roster (ET-1407) – Appendix 8 Health Insurance Fact Sheet (ET-8902) – Appendix 9 Pharmacy Benefit Program Fact Sheet (ET-8933) – Appendix 10 Data Warehouse and Business Intelligence Data Flow – FORM A Proposal Checklist – FORM B Mandatory Proposer Qualifications – FORM C Subcontractor Information –
Table 1 – 2017 Plan Year Pharmacy Benefit Design Table 2 – 2016 Enrollment Data (as of January 2016) Table 3 – Additional Background Information Table 4 – Format for Submission of Additional Clarification Questions Table 5 – Calendar of Events Table 6 – No Assumptions or Exceptions Allowed Table 7 – Evaluation Criteria Exhibit 1 – Pro Forma State of Wisconsin Contract (includes the Pro Forma Contract By Authorized Board and the Pro Forma State of Wisconsin Pharmacy Benefit Program Agreement) Exhibit 2 – Standard Terms and Conditions (DOA-3054) Exhibit 3 – Supplemental Standard Terms and Conditions for Procurement for Services (DOA-3681) Exhibit 4 – Department Terms and Conditions Appendix 1 – 834 Companion Guide Appendix 2 – Data Specifications – Pharmacy Appendix 3 – Data Specifications – Wellness Appendix 4 – Data Specifications – Medical Appendix 5 – Data Specifications – Dental Appendix 6 – State Employer Group Roster (ET-1404) Appendix 7 – Local Employer Group Roster (ET-1407) Appendix 8 – Health Insurance Fact Sheet (ET-8902) Appendix 9 – Pharmacy Benefit Program Fact Sheet (ET-8933) Appendix 10 – Data Warehouse and Business Intelligence Data Flow FORM A – Proposal Checklist FORM B – Mandatory Proposer Qualifications FORM C – Subcontractor Information
ETG0013_RFP.docx