BID SIGNATURE PAGE -· ----- -- -·--·. ---·-- I . I · Queried On Arkansas State Board of Pharmacy 322 South Main Street, Suite 600 Little Rock, AR 72201 P: 501.682.0190 F: 501.682.0195

BID SIGNATURE PAGE

Tvoe or Print the followina information.

PROSPECTIVE CONTRACTOR'S INFORMATION -·

I ----- -- -·--·. - ---·--

Company: Health C are Phar macy, Inc _____________

Address: \ J4_0l..A..li.v~ood Road, Suite F

. _ ~ I AR Veodo, # 1;1 koow~) 100051829

I City: L illie Rock State: AR I Zip Code: 72206 --Business 0 Individual := Sole Proprietorship □ Public Service Corp

Designation: 0 Parlnership ~ Corporation 0 Nonprofit - - - - -

Minority and I ~ Not Applicable □ American Indian D /\sian American D Service-Disabled Veteran

Women- U African American f7 Hispanic American n Pacific Islander American □ Women-Owned

Owned I Designation•: AR Cerlificalion #: • See Minority and Women-Owned Business Policy

PROSPECTIVE CONTRACTOR CONTACT INFORMATION Provide contact information to be used for bid sol/citation related matters.

- --Contact Person:

" 1isha...G.:abill Title: Pharmacist in C h arne

Phone: S0 1-RQ!L7S l 4 Alternate Phone: c;n t _r,;irn.3c;7 1

Email: I al ishalii)nharmacvlr.com

CONFIRMATION OF REDACTED COPY --- - 09 - 9 -

D YES, a redacted copy of submission documents is enclosed. rn NO, a redacted copy of submission documents is not enclosed. I understand a full copy of non-redacted submission

documents will be released if requP-sted.

Note: If a redacted copy of the submission documents is not provided with Prospective Contractor's response packet, ancl neither box is checked. a copy of the non-redacted documents, with the exception of financial data (other than pricing), will be released in response to any request made vnder /he Arkansas Freedom of Information Act (FOIA). See Bid Solicitation for oddilional information.

ILLEGAL IMMIGRANT CONFIRMATION ··-· . By signing and submitting a response to this Bid Solicitation , a Prospective Contractor agrees and certifies that they do not employ or contract w ith illegal immigrants. tr selected. the Prospective Contractor certifies that they will not employ or contract wit11 illegal immigrants during the aggregate term of a contract.

ISRAEL BOYCOTT RESTRICTION CONFIRMATION . . ·----

By checking the box below, a Prosrective Contractor aarees and certifies that they do not boycott Israel, and if selected, will not boycott Israel during the aggregate term of the contract.

XI Prospective Contractor does not and wil l not boycott Israel.

. ETHICAL STANDARDS CONFIRMATION ·- -- ·-- ·-

By signing and submitting a response to this Bid Solicitation, a Prospective Contractor guarantees that he has not retained a person to solicit or secure th is contract upon an agreement or understanding for a commission, percentage, brokerage or contingent fee, except for retention or bona fide employees or bona fide established commercial selling agencies maintained by the Contractor for the purpose of securing business.

An official authorized to bind the Prospective Con tractor to a resultant contract shall sign below.

The signature below signifies agreement thnt any exception that conflicts with a Requirement of this Bid Solicitation w ill cause the Prospective Cont ractor's bid to be rejected.

Authorized Signat~ ./-:.~- =-1Fµ..=::,,.,.,,...,,..- ---- T itle : ---"S'-'e:..::c:.:..re=-t'-"a:..:.r.;..y,_/1.:...'::..;r e::.oa:oes"'u:..::e.:_r _____ _

Printed/Typed Nam e: _._,R.,..o'-"b""e'-'rt....,S..,.,t"'e""12-'-'h""e.,_,n,,,_s __________ _ Date: 05/ ( 1/?0?0

8 1d Response Packet SP-20-0091 Page 2 of 4

ARKANSAS STATE BOARD OF PHARMACY 322 South l\l;iin, Sui le 600, Little Rock, ,\R 72201 l'honc: 501-682-0190 F;ix: 50'1-6U2•01 <J5

www.ph:irmacyho:ircl.arkansas.go\'

Queried on: May 04, 2020 7:28 am

License Verification General Information

Name: HealthCare Pharmacy, Inc.

Address Information Mailing Address

Address: 3401 Atwood Road Suite F

City/State/Zip: Little Rock, AR 72206

License Information

General Information Name: HealthCare Pharmacy, Inc.

Address Information Physical Address


City/State/Zip: Little Rock, AR 72206

Phone: (501)888-7514

Fax: (501)888-1717

License Information

Mailing Address


City/State/Zip: Little Rock. AR 72206

The Arkansas State Board of Pharmacy is responsible for maintaining all of the information on our website, including licensure information, disciplinary actions, and restrictions. The information provided in this license verification should be considered a primary source verification

and contains the same information that would be provided through other means: i.e. telephone, email, or mail and is true, accurate, and complete to the best of our knowledge. Information on this license verification is up-to-date as of the query date printed above.

License Type: Retail Pharmacy License

License Number: AR16215

Issue Date: 01 /31/1994 Expiration Date: 12/31/2021

Current Status: Active

Disciplinary Action: No

The Arkansas S1a1e Board of Pharmacy is responsible for maintaining all of the information on our website . including licensure information. disciplinary actions. and restrictions. The information provided in this license verification should be considered a primary source verification

and contains the same information that would be provided through other means: i.e. telephone, email, or mail and is true, accurate. and complete to 1he best of our knowledge. Information on this license verification is up-to-date as of the query dale printed above.

Queried On

Arkansas State Board of Pharmacy 322 South Main Street, Suite 600 Little Rock, AR 72201

P: 501.682.0190 F: 501 .682.0195

[email protected] • www.pharmacyboard.arkansas.gov

John Clay Kirtley, Pharm.D., Executive Director

May OS, 2020 7:44 am

License Verification

General Information

Name: Alisha Kay Crabill


Address: 7527 Palm Beach Ave Street 2:

City/State/Zip: Benton. AR 72019

License Information License Type: Pharmacist License

License Number: PD07850

Issue Date: O 1/21/1992

Expiration Date: 12/31/2021


Licensure Method: Exam Disciplinary Action: No

Preceptor: No

Nursing Home Consultant: Yes

Immunization Certification: No

The AAansa, SUltc Board of Ph.l~cy Is responsible tor m3in1alning :tll of the informDtion on our wcbsilo , lnelucling llc:e:n,urc information, d1scrplinary t1ct.OOs. ~nd rcs1ricbon.s. TM informa:ion provided in thi;S liconMt vcnf,c:nion should bo considered a primary source vcrifacion

ond cootmns tho same information that v.-ould be provided through other means: l.o. lclcphono. omall. or mail and is truo, accura!o, and complclo to the bo1t of our k.nowlodgo. Information on thls kcnso verification is up-to--d.iJtc as of tho query dale prin1ed abovo.

Queried On


P: 501.682.0190 F: 501 .682.0195



May 05, 2020 7:45 am


General Information Name: Jessica Ellen Holley


Address: 119 Pin Oak Cv Street 2:

City/State/Zip: Maumelle. AR 72113



Issue Date: 07/18/2018




Preceptor: No


Immunization Certification: Yes

The Af1.;ans.,s State Boord of Pharmacy is rc$pon~blc for maintaining an of the information on our web$.i1c . including fie.ensure information. drSop~oary sctk>nz:, and rcstriclions. Tho information providod in this iccnso vcrifacation should be COl'\Sidcrcd a primary sourco verification

and contains tho samo informatton thal would oo provided through other moons: I.e. tclophono, email. or mail omd is true, accurate. and complete to tho best or our knOYii1edgc. Information on this licon.so vonrication is up..to~ ato a, of tho Query dato pnntcd abovo.

Queried On


P: 501.682.0190 F: 501.682.0195



May 05, 2020 7:46 am


General Information Name: Kaitlin Mane Long


Address: 8514 Ranch Blvd Street 2:

City/State/Zip: Lillie Rock. AR 72223

License Information License Type: Phannac,st License

License Number: PD 1414 0





Preceptor: No


Immunization Certification: Yes

The An(ansos St.iltc Board of Pharm.ilcy is responsible for m3ir.ta1nlng all of the informallOn oo our wcbsllc , including l.ic:cnsurc lnformalion. d1Scipbnary actions. and rostnctions, Tho information prow:tod in tnis !Icon.so vcnf1Catioo should bo corutdcrod a pnmary source vonfteation

ond contains thO snmo tnformatton th31 would bo provided through 01her means: i.o. tolcphonc, email. or mall and is true. accurate, and complete to tho bost of our knowtodgo, lnfoo:natJOn on thtS license veriricahon is up•to-da10 as of lho Query dale priniO<I abo-.·o.

Queried On

Arkansas State Board of Pharmacy 322 South Main Street , Suite 600 Little Rock, AR 72201

P: 501 .682.0190 F: 501 .682.0195


John Clay Kirtley, Pharm.D., Execut ive Director

May 05, 2020 7:46 am


General Information Name: Tara Nikole Stoll


Address: 12125 Belle Terre Drive Street 2:

City/State/Zip: Alexander, AR 72002




Expiration Date: 12131/2021



Preceptor: No

Nursing Home Consultant: No Immunization Certification: No

The Ark~ns..,s Staie Bon.rd of PN trTl.3cy rs responsible for ~inloining .,n o f th<!, infOJmatioo on our website, Including l<cnsurc lnform.aoon. disciplinary octions, and rostrictions. Tho information provtdOd in this ltccnS(I vcnfication should be con.sidorod a primary source vcrif.calJOn

end contains tho same information thal "''ould bO provided through other mean,: l.o. tclcphono. omall. or rn..,,il and Is true, nccurato. and complete lo tho bcsl o f our know1odgo, lnformatJOO on l his liccnso vorif~tion i5 up-to--<ia!c as or lho query date printed above,

Queried On


P: 501.682.0190 F: 501 .682.0195


John Clay Kirtley, Pharm.D .. Executive Director

May 05. 2020 7:47 am


General Information Name: Pamela Dawn Fortner


Address: 4105 Old Oak Dr. Street 2:

City/State/Zip: Lillie Rock. AR 72212

License Information License Type: Pharmacisl License



Expiration Date: 12/31 /2021



Preceptor: No

Nursing Home Consultant: No Immunization Certification: No

The Arkansas State Board or Ph.lrrTIDcy i$ rcs.pon.siblc for m:tint.aining .>11 of the information on our wcb$itc , including liccn.sura inform:>tion, d1SC1plinary actJOOs, and ro:.ttictions. Tho information provtdod tn tnis l1ccnso venfica1,on shauld bo considered a primary source vcnfteatlOn

ond contains the same information that 1A-oold bO provided through other moans: l.o. 1olophonc, email, or mall And is trvo, :1ccurnto, nnd complolo to the best of our knowtodgo. Information on lhls k:onso vorirlClltion is up...to..doto a s of tho qoory dato printed nbovo.

Queried On


P: 501.682.0190 F: 501 .682.0195


John Clay Kirtley, Pharm.D. , Executive Director

May 05, 2020 7:48 am


General Information Name: Reba Chapman Strong


Address: 3124 Castle Valley Dr. Street 2:

City/State/Zip: Benton. AR 72015



Issue Date: 09101/1994

Expiration Date: 1213112021



Preceptor: No Nursing Home Consultant: No Immunization Certification: Yes

The Arknn:JtJ:. StJJtc Board of Ph.3rm.:acy is rc:.ponsible for m~int:iining a.II or me inlormaMn on our wcbsi1e , inckJding liccnsuro inlorma1ion, dtScipl,Mry actions, and rcstrichons. TM informahon provided in this k.cns.o vonfteallOO shoukt be considered e pnma.ry soun:.o vonfation

and contains the s.amo lnforma1K>n that "'-'OUld bo provided through other means: l.o. toktphonc, oma1l, or mall and is true. nccuralo, end com plcto lo tho best or our knowledge. lnlonnahon on this lic:onso verification ls up-to~ato as or tho Query Gato prin1cd abovo.

PROPOSED SUBCONTRACTORS FORM

• Do not include additional information relating to subcontractors on this form or as an attachment to this form.

PROSPECTIVE CONTRACTOR PROPOSES TO USE THE FOLLOWING SUBCONTRACTOR(S) TO PROVIDE SERVICES.

Type or Print the following information

Subcontractor's Company Name Street Address City, State, ZIP

L PECTIVE CONTRACTOR DOES NOT PROPOSE TO USE SUBCONTRACTORS

Bid Response Packet SP-20-0091 Page 3 of4

TO: FROM: DATE:

STATE OF ARKANSAS OFFICE OF STATE PROCUREMENT

1509 West 7th Street, Room 300 Little Rock, Arkansas 72201-4222

Vendors Addressed Brandi Schroeder, Buyer April 30, 2020

ADDENDUM 1

SUBJECT: SP-20-0091 Pharmacy Services

The following change(s) to the above-referenced IFB have been made as designated below:

Additional specification(s) ---

x Change of specification(s) Delete specification(s)

---

• Delete the last paragraph of Item 2.2 and replace with the following:

Page 1 of 1

Some Clients have Medicare Part D and/or primary insurance coverage for prescription drugs, and, as such, ADAP is a secondary payer. Between July 1, 2018, and June 30, 2019, ADAP was a secondary payer for 17,291, Medicare Part D prescriptions and 15,007 other primary insurance coverage. ADAP estimates that approximately 18,000 3408 prescriptions were dispensed during that time frame.

The specifications by virtue of this addendum become a permanent addition to the above referenced RFP. Failure to return this signed addendum may result in rejection of your proposal.

If you have any questions, please contact Brandi Schroeder at [email protected] or (501) 682-4169.

Date

~-\f¼\L~cwc ~V'\~«11 ~ Prospective Contractor's Name

ST A TE OF ARKANSAS OFFICE OF STATE PROCUREMENT

1509 West 7th Street, Room 300 Little Rock, Arkansas 72201-4222

ADDENDUM 2

TO: FROM: DATE:

Vendors Addressed Brandi Schroeder, Buyer May 7, 2020

SUBJECT: SP-20-0091 Pharmacy Services

The following change(s) to the above-referenced IFB have been made as designated below:

x Additional attachment(s) x Change of specification(s)

Delete specification(s) ---

~PDITIO~AL ATTACHMENT .

• Add the following attachment in reference to IFB Section 2.9:

Attachment D: Enhanced Patient Services Program

CHANGE OF .SPECIFICATION

• Delete IFB Item 3.1.A and replace with the following:

Arkansas Department of Health HIV/STD-Slot H-33 4815 W Markham Little Rock, AR 72205

Page 1 of 1

The specifications by virtue of this addendum become a permanent addition to the above referenced RFP. Failure to return this signed addendum may result in rejection of your proposal.

If you have any questions, please contact Brandi Schroeder at [email protected] or (501) 682-4169.

Date

H.QG.. l¼. CQ✓ G ~""-"'Cf I IV\ c__ Prospective Contractor's Name

Item

1

Item

DescriptJon1 ~ ~

-=--- · !!1:1!'-~

Official Bid Price Sheet SP-20-0091 I Pharmacy Services

E~timal~d ,# ,of. r 1P~r Pr~$Cri,ptton I P.res9ri)>tions ·1 co.st '

' ..,_ ..... _..,, . - -~stimaiedlAnnual1 to~st

Dispensing Fee 18,000 $ 0 .. 00 IS o.oo -

(per 340B prescription)

,..., ........ , ,-:. i"l"",1111. __ ,. ---· - .-~ I Per, ,enent .P,elT

Descrlption a ,,Esttmatecl1 # ·of 1€1i~nt_s, -- - 1 -,1: . .... ~ ,_

Enhanced Patient Service Fee

(per client per month)

,EstimatedlTeta'I Annua1reest .... ,. . . ~ . ~ 1 ' " - -

1,700 I$ 6, Cb

I ,Estima'.ted: Aruiµal f;ost

$ 0 .C>O

'$ ,6)-. ,0D

0.00

0.00

0.00

0.00

0.00

Official Bid Price Sheet SP-20-0091 I Pharmacy Services

Healthcare Pharmacy, Inc 3401 Atwood Road, Suite F

Little Rock, AR 72206 501-888-7514

Equal Opportunity Employment Healthcare Pharmacy, Inc provides equal employment opportunities to all employees and applicants, in accordance with state and federal laws. Our policy is to recruit, hire, promote, and compensate without regard to race, color, age, religion, sex, national origins, creed, handicap, or color. All qualified applicants shall receive consideration without regard to race, color, sex age, religion, handicap, or national origin. Furthermore, this policy applies to every subcontractor or contractor we hire.

EXECUTIVE ORDER E0-98-04 EXECUTIVE ORDER DISCLOSURE FORM

NAME:._~H=e=al~th~c~a~r~e~P~h~a~rm=a~cv~,~I~n~c ________________________ _

ADDRESS: 3401 Atwood Road Suite F Little Rock AR 72206 Street City State/Zip County

CONTRACT NO:_=SP"'----=2-"--0---"-0=09'"""1~---------- FEDERAL NO: ___,7'--"l_,-0"""6"'"8=22=9=3 _____ _

CONTRACT EFFECTIVE DATE: _....:.Jcc.:ul~l,:_:, 2::.;;0=-20-=---------------------

B. DISCLOSURE REQUIREMENTS

Agencies shall require, as a condition of obtaining or renewing a contract, lease, purchase agreement, employment, or grant with any state agency, that any individual desiring to contract with, be employed by, or receive grant benefits from, any state agency shall disclose whether that person is a current or former; member of the general assembly, constitutional officer, board or commission member, state employee, or the spouse or immediate family member of any of the persons described in this sentence. Agencies shall require that any non-individual entity desiring to contract with, or receive grant benefits from, any state agency shall disclose (1.) any position of control, or (2.) any ownership interests of 10% or greater, that is held by a current or former member of the general assembly, constitutional officer, board or commission member, state employee, or the spouse or immediate family member of any of the persons described in this sentence.

As a condition for obtaining funding through a contract, lease, purchase agreement, or a grant with the Department of Health and Human Services, the following information must be disclosed:

Individual contractor indicate below if you are: Current Former Term(s) of service

1. A member of the general assembly Yes/No Yes/No (circle one) ( circle one)

2. A constitutional officer Yes/No Yes/No ( circle one) (circle one)

3. A state employee Yes/No Yes/No ( circle one) (circle one)

4. Serving as a commission or board Yes/No Yes/No member ( circle one) ( circle one)

Individual contractor indicate below if you are a spouse or immediate family member of an individual that is;

C urren F ormer T () f enn s o service e a 1ve s name an re at10ns 1p R 1 f ' d l . h'

1. A member of the general Yes/No Yes/No assembly ( circle one) ( circle one)

2. A constitutional officer Yes/No Yes/No ( circle one) (circle one)

3. A state employee Yes/No Yes/No ( circle one) ( circle one)

4. Serving as a commission Yes/No Yes/No or board member ( circle one) (circle one)

(EO 98-04) l of 4

Non-individual entity list any individual who holds a position of control or ownership interest of 10% or greater in the entity if the individual is:

Current

1. A member of the Yes.@ general assembly ( circle one)

2. A constitutional officer Yes,@ ( circle one)

3. A state employee Yes@ (circle one)

4. Serving as a Yes~ commission or board (circle e) member

Former

Yes@ ( circle one)

Yes.@ (circle one)

Yes® ( circle one)

Yes© ( circle one)

Relative's name & Term(s) of Service Relationship Individual

Non-individual entity list any individual who holds a position of control or ownership interest of 10% of greater in the entity if the individual is a spouse or immediate family member of:

Current Former Term(s) of service Relative' s name & Relationship Individual

1. A member of the Yes@ Yes/~ general assembly ( circle one) ( circle one)

2. A constitutional officer Yes~ Yes@ (circle one) ( circle one)

3. A state employee Yes@ ( circle one)

Yes@g) ( circle one)

4. Serving as a Yese Yes@ commission or board (circle one) (circle one) member

Failure of any person or entity to disclose under any term of Executive Order 98-04 shall be considered a material breach of the terms of the contract.

~(- ~l _1 CV'S ~

Title SGe.-[T.t-e:PIJ

Date

TfflS FORM MUST BE COMPLETED AND RETURNED PRIOR TO EXECUTION OF THE CONTRACT

(EO 98-04) 2 of 4

NAME:-------------------------------------

ADDRESS:----------------------------------Street City State/Zip County

PHONE: _____________________ FAX: ______________ _

CONTRACT: ____________________________________ _

CONTRACT EFFECTIVE DATE: _____________________________ _ DISCLOSURE OF SUBCONTRACTORS

Agencies shall require, as a condition of obtaining or renewing a contract, lease, purchase agreement, or grant with any state agency, that any individual or entity desiring to contract with any state agency shall require that any subcontractor, sub-lessor, or other assignee (hereafter 'Third Party"), shall disclose whether such Third Party is a current or former; member of the general assembly, constitutional officer, board or commission member, state employee, or the spouse or immediate family member of any of the persons described in this sentence, or if any of the persons described in this sentence hold any position of control or any ownership interest of 10% or greater in the Third Party, and shall report any such disclosure by the Third Party to the agency. The disclosure requirements of this paragraph shall apply during the entire term of the contract, lease, purchase agreement, or grant, without regard to whether the subcontract, sublease, or other assignment is entered into prior or subsequent to the contract date.

Third Party shall indicate below if he/she is:

Current Former Term(s) of Service Relative's name & relationship Third Party

1. A member of the Yes/No Yes/No general assembly (circle one) (circle one)

2. A constitutional officer Yes/No Yes/No ( circle one) ( circle one)

3. A state employee Yes/No Yes/No (circle one) (circle one)

4. Serving as a Yes/No Yes/No commission or board (circle one) ( circle one) member

Third Party shall indicate below if he/she is a spouse or immediate family member of an individual that is

Current Former Terrn(s) of service Relative' s name & relationship Third Party

1. A member of the Yes/No Yes/No general assembly (circle one) (circle one)

2. A constitutional officer Yes/No Yes/No (circle one) ( circle one)

3. A state employee Yes/No Yes/No ( circle one) ( circle one)

4. Serving as a Yes/No Yes/No commission or board ( circle one) (circle one) member

Agencies shall require, as a further condition of obtaining or renewing any contract or agreement with any state agency, that the individual or entity desiring to contract shall incorporate into any agreement with a Third Party, previously defined, the below stated language, and any other necessary language as provided by rules and regulations promulgated to enforce Executive Order 98-04, which provides that failure of the Third Party to disclose the identity of any person or entity described previously shall be considered a material breach of the agreement.

(EO 98-04) 3 of 4

The failure of any person or entity to disclose as required under any term of Executive Order 98-04, or the violation of any rule, regulation or policy promulgated by the Department of Finance and Administration pursuant to this Order, shall be considered a material breach of the terms of the contract, lease, purchase agreement, or grant and shall subject the party failing to disclose or in violation to all legal remedies available to the Agency under the provisions of existing law.

Signature of Third Party

THIS FORM MUST BE COMPLETED AND RETURNED PRIOR TO EXECUTION OF THE CONTRACT

(EO 98-04) 4 of 4

Healthcare Pharmacy, Inc 3401 Atwood Road, Suite F

Little Rock, AR 72206

Arkansas Vendor Number: 100051829

Documents

BID SIGNATURE PAGE -· ----- -- -·--·. ---·-- I . I · Queried On Arkansas State Board of Pharmacy 322 South Main Street, Suite 600 Little Rock, AR 72201 P: 501.682.0190 F: 501.682.0195