RFP Intake Form

Legal Company Name

Client Status

Street Address

City/St/Zip

Eligible Employees

Employees on Plan

SIC Code

Renewal Month

Current Carrier

Plan Type

Fully Insured

Level Funded

Self Funded

Other

Broker

Agency

Advisor PEPM

Requested Spec Deductible(s)

Monthly Aggregate Accommodation?

Current Contract Term

Requested Due Date

Include Network Disruption Analysis?

If a Network Disruption Analysis is requested, you must submit the following report criteria in Excel:

Primary RFP Contact Email & Phone

Are you aware of any HCC below?

Specialty Drugs

Cancer

Dialysis

Other Chronic Conditions

Can you confirm a call with the decision makers?

Yes

RFP Requirements

Census- Must have dependent info on separate rows from subscriber and include all of the following fields: Name, DOB, Relationship, Gender, Street Address, City, State, Zip, Tier (EE, ES, EC, FAM, WAIVE), Plan Choice, Active/COBRA/Retiree
Current SPD/SBC
Monthly Claims- Current & Prior Plan Year
Large Claims
Rx Claims
Top Drugs Report
Current Renewal

Drop your files here

Notes

Send me a copy of my responses