Exhibit 1 Pro Forma State of Wisconsin Contract – 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 – Exhibit 5 State of Wisconsin Department of Employee Trust Funds Regional Map – Appendix 1 834 Companion Guide – Appendix 2 Pharmacy Data Specifications – Appendix 3 Wellness Data Specifications – Appendix 4a - Claims Data Specifications Medical – Appendix 4b - Claims Data Specifications - Dental Appendix 5 Provider Data Specifications – Appendix 6 Guidance for Department Initiatives – Appendix 7 State Employer Group Roster (ET-1404) – Appendix 8 Local Employer Group Roster (ET-1407) – Appendix 9 Health Insurance Fact Sheet (ET-8902) – Appendix 10 Financial and Utilization Data – Appendix 11 Health Care Performance Metrics – Appendix 12 Data Warehouse and Business Intelligence Data Flow – FORM A Proposal Checklist – FORM B Mandatory Proposer Qualifications – FORM C Subcontractor Information – FORM D Proposer Verification of Data Submission to Board Actuary – FORM E ETG0003 Designation of Confidential and Proprietary Information – FORM F ETG0003 Non-Disclosure Agreement (NDA) – FORM G DOA-3261 Request for Proposal – FORM H DOA-3477 Vendor Information – FORM I DOA-3478 Vendor References –
Exhibit 1 – Pro Forma State of Wisconsin Contract 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 Exhibit 5 – State of Wisconsin Department of Employee Trust Funds Regional Map Appendix 1 – 834 Companion Guide Appendix 2 – Pharmacy Data Specifications Appendix 3 – Wellness Data Specifications Appendix 4a - Claims Data Specifications – Medical Appendix 4b - Claims Data Specifications - Dental Appendix 5 – Provider Data Specifications Appendix 6 – Guidance for Department Initiatives Appendix 7 – State Employer Group Roster (ET-1404) Appendix 8 – Local Employer Group Roster (ET-1407) Appendix 9 – Health Insurance Fact Sheet (ET-8902) Appendix 10 – Financial and Utilization Data Appendix 11 – Health Care Performance Metrics Appendix 12 – Data Warehouse and Business Intelligence Data Flow FORM A – Proposal Checklist FORM B – Mandatory Proposer Qualifications FORM C – Subcontractor Information FORM D – Proposer Verification of Data Submission to Board Actuary FORM E – ETG0003 Designation of Confidential and Proprietary Information FORM F – ETG0003 Non-Disclosure Agreement (NDA) FORM G – DOA-3261 Request for Proposal FORM H – DOA-3477 Vendor Information FORM I – DOA-3478 Vendor References
RFP_ETG0003.docx