| 3.0 Administrative Requirements & Questionnaire | | | |
| Directions: The following are the TUHSD's core requirements that must be explicitly included in your proposed signature ready contract. Bidders' responses to this section will be heavily weighted in the selection process. Please include your responses within this form. Indicate 'Confirmed' or 'Not Confirmed' as to your organization's ability to comply. Please keep your Deviation or Explanations brief and complete such that they fit within the cell space provided. | | | |
| 3.1. Formulary Management | | Confirmation | Deviation or Explanation |
| 3.1.1 | a.) Provide the name of the Formulary you are proposing for the Commercial plan and the number of drug exclusions. | | |
| b.) In TAB14_Preferred Drug List, provide as a list of the each drug by NDC, Drug Name and Therapeutic Class. | Select One | |
| 3.1.2 | a.) Provide the name of the Specialty Formulary you are proposing for the Commercial plan and the number of drug exclusions, if applicable. | | |
| b.) In TAB15_Specialty Drug List, provide a list of the each specialty drug by NDC, Drug Name and Therapeutic Class. | Select One | |
| 3.1.3 | In TAB16_Excluded Drug List, provide as a list of the excluded non-specialty and specialty drugs and the therapeutic alternatives for the commercial plan. | Select One | |
| 3.1.4 | Confirm the PBM will allow members to obtain formulary excluded drugs with a prior authorization for medical necessity under your proposed offer without impacting the proposed rebates. | Select One | |
| 3.1.5 | Provide information of the PBM's process to implement new non-specialty and specialty drug formulary exclusions. | | |
| 3.1.6 | Confirm the TUHSD has the right to opt in or opt out of any additional non-specialty/ specialty formulary drug exclusions during the term of the contract without penalty or an impact to the contractual pricing. | Select One | |
| 3.1.7 | a.) Confirm that the PBM agrees to notify the TUHSD and its designee 90 days in advance of when a drug is targeted to be excluded from coverage or moved to/from the non-specialty and specialty preferred drug list. | Select One | |
| b.) Confirm that the PBM will provide a detailed disruption and financial impact analysis at the same time. | Select One | |
| 3.1.8 | Confirm that the PBM agrees to notify members 60 days in advance of when a member's utilized drug is targeted to be removed from the non-specialty and specialty preferred drug list and thus become excluded from coverage. The PBM must provide at least two notifications to the member with the formulary alternative. | Select One | |
| 3.1.9 | Confirm that the PBM agrees to notify physicians of affected members 60 days in advance of when a member's utilized drug is targeted to be removed from the non-specialty and specialty preferred drug list and thus become excluded from coverage. | Select One | |
| 3.1.10 | Confirm that the PBM agrees to notify the TUHSD or its designee 90 days in advance of when a drug is targeted to change tiers or be moved to or from a preferred or non-preferred non-specialty/ specialty formulary tier. The PBM must provide a detailed disruption and financial impact analysis at the same time. | Select One | |
| 3.1.11 | Confirm that the PBM agrees to notify members 30 days in advance of when a member's utilized drug is targeted to be moved to a higher cost tier. The PBM must provide at least one (1) notification to the member with the formulary alternative. | Select One | |
| 3.1.12 | Confirm that the PBM agrees to notify physicians of affected members 30 days in advance of when a member's utilized drug is targeted to be moved to a higher cost tier. | Select One | |
| 3.1.13 | Confirm that the PBM will be able to provide a list of the non-preferred brand drugs that are covered by the TUHSD upon request at any time during the term of the commercial contract. | Select One | |
| 3.1.14 | Confirm the PBM agrees to grandfather the TUHSD's current formulary for up to 90 days following the contract effective date with no impact on rebate guarantees if the TUHSD requests it. | Select One | |
| 3.1.15 | Confirm no new drug therapies will be covered for the first six (6) months a drug is available in the market. | Select One | |
| 3.1.16 | Confirm that the PBM agrees to remove drugs from the formulary (other than FDA recalls and other safety reasons) at most two-times per year. | Select One | |
| 3.1.17 | All bidders must complete and submit a formulary disruption based on your proposed commercial plan formulary. Please confirm that you have completed both Table 1 (Summary of PBM Disruption Analysis) and Table 2 (Detailed Disruption Results) in TAB08_Formulary Disruption, using the most recent four (4) months of claims data provided. | Select One | |
| 3.1.18 | For the commercial plan, indicate below potential disruption due to utilization management rules such as quantity, prior authorization, and step therapy that are built into your proposed formulary. If none apply, please indicate as such by entering “0” into the chart. Please provide a summary of your formulary disruption analysis using the table below limited to the most recent four (4) months of claims data provided. | | |
| Type of Change | Total Number of Unique Utilizers Impacted | Total Number of Unique Prescriptions Impacted |
| Prior Authorization: Impacted by formulary required prior authorizations | | |
| Step Therapy: Impacted by formulary required step therapy | | |
| Quantity Limits: Impacted by formulary required quantity limits | | |
| Total Number of Unique Utilizers Impacted | | |
| 3.1.19 | For the commercial plan, please provide the top 10 excluded maintenance drugs and their formulary alternatives. Please use format below for top 10 products. | | |
| a.) #1 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| b.) #2 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| c.) #3 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| d.) #4 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| e.) #5 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| f.) #6 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| g.) #7 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| h.) #8 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| i.) #9 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| j.) #10 Drug that is Moving from Covered to Not Covered/Excluded | | |
| w Name of Drug | | |
| w # Distinct members impacted | | |
| w # Claims impacted | | |
| w Name of Preferred alternative | | |
| 3.1.20 | Please attach the formulary disruption detail supporting the summary provided in TAB08_Formulary Disrupton. The detail must include at a minimum drug name impacted, patient count, Rx count, generic or brand indicator, maintenance indicator, specialty indicator, Drug Class or common indication, and formulary alternative provided in excel format. Provide the name(s) of the attachments. | Select One | |
| 3.2. Clinical Programs | | Confirmation | Deviation or Explanation |
| 3.2.1 | In TAB18_Clinical Programs, provide a complete list of your clinical programs with pricing and projected savings associated with each program and highlight those programs recommended for the plan. Describe the type of impact members will face for each of these programs. | Select One | |
| 3.2.2 | Confirm all pricing submitted is NOT contingent on participation in any proposed clinical management programs, group medical or behavioral health programs proposed by you or any other vendor other than programs that are requested by the TUHSD. | Select One | |
| 3.2.3 | a.) Confirm the PBM offers an optional Comprehensive Utilization Management program that includes all of the PBM's Prior Authorization, Drug Quantity Management and Step Therapy edits for all non-specialty and specialty drugs. | Select One | |
| b.) Confirm that the TUHSD is able to enroll in this program or is able to elect not to enroll in this program without affecting the proposed financial guarantees. | Select One | |
| c.) Provide the name of the program and the applicable fees whether the fees are on a Per Member Per Month basis or on a per occurrence basis. | | |
| 3.2.4 | Confirm the PBM will keep accurate and detailed information regarding every prior authorization the PBM approves and such information will be available for the TUHSD's review or its auditor's review upon request. | Select One | |
| 3.2.5 | Confirm the PBM will only charge a Prior Authorization fee one time for the review of a member's single prescription and will not charge a fee multiple times if the member/provider does not respond in a timely manner to requests for additional information or if the member/provider makes the request to review the drug again. | Select One | |
| 3.2.6 | Confirm the PBM will guarantee the total Prior Authorization fee charges will not be greater than the TUHSD's Net Cost (before rebates) for the claim that is ultimately filled. | Select One | |
| 3.2.7 | Provide descriptions of the PBM's capabilities to use medical claims data and prescription claims data to identify safety and health risks. | | |
| 3.2.8 | Provide descriptions of the PBM's programs to better manage high cost non-specialty generics and brands, including Auto-Immune, Diabetes and Oncology products. | | |
| 3.2.9 | Provide descriptions of the PBM's process to better manage drug inflation and hyperinflation drugs. | | |
| 3.2.10 | a.) Confirm the PBM will provide TUHSD with a utilization management program for every non-specialty drug with an ingredient cost of over $1,000 per 30 days' supply. | Select One | |
| b.) Confirm the PBM guarantees to refund TUHSD for every non-specialty drug over $1,000 that adjudicates that was not properly reviewed by the PBM. | Select One | |
| 3.2.11 | a.) Do you have edits or programs in place designed to detect, address potential drug fraud and/or abuse and notify TUHSD? | | Select One |
| b.) If yes, explain and include a listing of the specific drugs targeted by this program. | | |
| c.) If yes, describe the enrollee outreach after fraud or abuse is identified. | | |
| d.) If yes, detail the controls put into place after fraud or abuse is identified. | | |
| 3.2.12 | a.) Do you require two generic products in order for a brand drug with a DAW 1 or 2 code to get the DAW penalty? | | Select One |
| b.) Does the DAW penalty process apply to just DAW 1 and 2 or all DAW codes? | | Select One |
| c.) Describe any additional details on how your organization's DAW penalty process works. | | |
| d.) Does your process allow an appeals process that allows a member's doctor to provide information showing that the brand name drug is medically necessary? | | Select One |
| e.) If so, how does that process work? Would the regular brand discount, fee, rebate and member copay apply to that drug? | | |
| 3.2.13 | Confirm the PBM's proposal reflects the TUHSD's current strategy for HIV PrEP in which it only covers generic Truvada and excludes Descovy, brand Truvada and Apretude and only covers those excluded products via medical exception. If not, confirm the TUHSD can continue this strategy without an impact to the financial guarantees. | Select One | |
| 3.2.14 | What program does the PBM have in place for members that enroll in the PBM's automatic mail order refill program to ensure members still need that medication and are not stock-piling unused medication? | Select One | |
| 3.2.15 | a.) Describe the PBM's Cash Card Program/ Discount Card Program that compares the discounted ingredient cost against the cost using the discount cards in the marketplace and uses lesser of logic to calculate the member copay. | | |
| b.) Indicate if this program only applies to generic drugs and if it applies to excluded products. | Select One | |
| c.) Confirm that medications not covered by the TUHSD, including OTC products, will not count towards the member's yearly out-of-pocket limit or deductible. | Select One | |
| 3.3. Retail Network Management | | Confirmation | Deviation or Explanation |
| 3.3.1 | Confirm the pricing guaranteed in this RFP for the Commercial plan reflects the PBM's Broad Retail 30 national network similar to what is currently in place. Indicate the name of the proposed Retail 30 network. | Select One | |
| 3.3.2 | Confirm the pricing guaranteed in this RFP for the Commercial plan reflects a broad Retail 90 network similar to what is currently in place. Indicate the name of the proposed Retail 90 network and the participating retail pharmacies. | Select One | |
| 3.3.3 | The commercial Plan's current plan design encourages members to fill maintenance medications at mail/Retail90, but does not apply a penalty if the member continues to fill a 30 day supply. Is the PBM able to administer this plan design? | | Select One |
| 3.3.4 | The PBM agrees that it will not remove any participating pharmacies that impact greater than 2% of the TUHSD's prescriptions without communicating to the TUHSD at least sixty (60) days in advance of the scheduled change. If the change is not agreeable to the TUHSD, the TUHSD will have the right to terminate the agreement without penalty with 30 days' notice. | Select One | |
| 3.3.5 | a.) Confirm the PBM will not withhold any financial recoveries from audits performed on the contracted pharmacy network including retail, mail order and specialty pharmacies. | Select One | |
| b.) Confirm any recoveries will be disclosed and credited to the TUHSD. | Select One | |
| c.) Confirm the PBM will provide, on a quarterly basis, a summary of the TUHSD's retail network audits and recovery payments provided to the TUHSD. | Select One | |
| 3.3.6 | Confirm the PBM will not charge the TUHSD or offset any costs from a pharmacy audit recovery even if the PBM has to pursue additional collection action to recover pharmacy audit discrepancies. | Select One | |
| 3.3.7 | Confirm the PBM will maintain the retail pharmacy audit recovery fee paid to the PBM at 0% of the collections throughout the life of the contract. | Select One | |
| 3.3.8 | Confirm the PBM will recover all outstanding payments from retail pharmacies as a result of incorrect charges and pay all the amounts owed from these audits to the client regardless of whether the PBM is able to recover all of these amounts from the delinquent retail pharmacies. | Select One | |
| 3.3.9 | Provide a description of the escalation process for urgent drug claim issues in which a claim is rejecting at the pharmacy and members need immediate assistance and resolution. | | |
| 3.3.10 | All bidders must complete and submit a retail network disruption based on your proposed retail network for the Commercial plan. Results to be included are the number of members that will be required to change the utilized retail pharmacy as well as the number of prescriptions associated with the retail pharmacy change. Do NOT include claims processed at either the incumbent's exclusive specialty, the incumbent's mail order pharmacy or closed pharmacies within your counts. Please confirm that you have completed both Table 1 (Summary of PBM Disruption Analysis) and Table 2 (Detailed Disruption Results) in TAB07_Retail Network Disrupt, using the full 12 months of claims data provided. | Select One | |
| 3.3.11 | For the commercial plan, please complete the table below based on your retail network disruption analysis. | | |
| Type of Change | Total Number of Unique Utilizers Impacted | Total Number of Unique Prescriptions Impacted |
| Retail Pharmacies that are NOT Part of Proposed Retail 30 Network but are Eligible to Solicit | | |
| Retail Pharmacies that are NOT Part of Proposed Retail 30 Network and are NOT Eligible to Solicit | | |
| Total Number of Unique Utilizers, Script Counts Negatively Impacted | | |
| 3.4. Audit Rights | | Confirmation | Deviation or Explanation |
| 3.4.1 | Confirm the TUHSD will have the right to use an auditor of its choice, not restricted to a mutually agreed upon CPA accounting firm, and will be required to have an active executed confidentiality agreement on record. | Select One | |
| 3.4.2 | The TUHSD or its designee will have the right to audit (claims, performance guarantees, rebates, clinical performance, administrative fees, eligibility, and/or benefit design set up) annually for up to two (2) complete Contract/Plan Periods, with an auditor of its choice, with full cooperation of the PBM as defined within the PBM's audit protocols clearly defined within the proposed contract at no additional charge from the PBM. PBM's audit protocols in the proposed contract must reflect all agreed upon Audit Rights in this RFP. | Select One | |
| 3.4.3 | The TUHSD will not be held responsible for time or miscellaneous costs incurred by the PBM in association with any audit process including, but not limited to, all costs associated with provision of data, audit finding response reports, or systems access, provided to the TUHSD or its designee by the PBM during the life of the contract. Note: This includes any data required to transfer the business to another vendor and money collected from lawsuits and internal audits. | Select One | |
| 3.4.4 | The PBM will not set a maximum number of claim samples per audit. The TUHSD or the auditor, on behalf of the TUHSD, will be able to provide all claims in question (e.g., claim samples separately without limit). | Select One | |
| 3.4.5 | The PBM agrees to a 30-day turnaround time to provide the fully researched and complete responses to all the sample claims and claims audit findings or a mutually agreeable reasonable turnaround time. | Select One | |
| 3.4.6 | a.) TUHSD or its designee will have the right to audit the greater of 10 pharmaceutical manufacturer contracts or the pharmaceutical manufacturer rebate contracts that account for 70% of the total rebate payments during the selected audit period during an on-site and/or monitored remote rebate audit. | Select One | |
| b.) Confirm these are actual pharmaceutical manufacturer contracts and not contracts with a rebate aggregator. | Select One | |
| 3.4.7 | Confirm that the PBM will correct any errors from inception of the errors through error resolution date that TUHSD, or its representative, brings up to the PBM's attention whether identified by an auditor or otherwise within 30 days of audit closure. Any errors found financially impacting TUHSD member(s) or TUHSD, will be reimbursed to TUHSD member(s) or TUHSD based on TUHSD's preferred method of credit or payment within 30 days of audit closure. | Select One | |
| 3.4.8 | Confirm Audit Rights shall survive the termination of the agreement between the parties for a minimum of 12 months past the termination effective date. | Select One | |
| 3.4.9 | TUHSD will have the right to initiate an audit at any time during the calendar year and the PBM agrees to assign a dedicated audit staff for the duration of the audit request. | Select One | |
| 3.4.10 | Confirm that only TUHSD, or the auditor on behalf of TUHSD, can formally close an audit initiated by TUHSD or the auditor on behalf of TUHSD. | Select One | |
| 3.4.11 | Confirm the TUHSD is able to initiate a new audit even if all parties have not agreed that the prior audit is closed. | Select One | |
| 3.4.12 | The PBM will provide claims data and audit documentation required by TUHSD, or the auditor on behalf of TUHSD, within 14 days upon final agreement of the audit scope and having an active executed confidentiality agreement on record. | Select One | |
| 3.4.13 | The PBM agrees to a 15-day turnaround time to respond to the audit report, so far as the audit report does not introduce any new issues not raised during the initial review/sample claims, or a mutually agreeable reasonable turnaround time. | Select One | |
| 3.4.14 | The PBM and/or PBM's group purchasing organization (GPO) will provide unredacted access to pharmaceutical manufacturer rebate contracts during an on-site and/or monitored remote rebate audit. | Select One | |
| 3.4.15 | Confirm the TUHSD can audit the contracts between the PBM and the Participating Retail Pharmacies to ensure the TUHSD is only paying the PBM the amount the PBM pays Participating Retail Pharmacies without any spread as part of this Transparent Pricing Arrangement at Participating Retail Pharmacies. | Select One | |
| 3.5. Implementation (Applies to both the Commercial and EGWP with enhanced plan design contracts) | | Confirmation | Deviation or Explanation |
| 3.5.1 | Confirm that the PBM agrees to load all current prior authorizations, open mail order refills, specialty transfer files, claim history files, and accumulator files that exist for current members from the existing PBM at NO charge to the TUHSD (with no charges being deducted from the implementation allowance for file loading or IT). | Select One | |
| 3.5.2 | Confirm that the PBM agrees to send at least 12 months of claims history data, all current prior authorizations, open mail order refills, specialty transfer files, and accumulator files that exist for the TUHSD members to the next/successor PBM at NO charge if the TUHSD terminates the contract with or without cause. | Select One | |
| 3.5.3 | Confirm that the PBM agrees to waive any charges to the TUHSD or the TUHSD's medical plan claims administrators such as a set-up fee, a programming fee, or a monthly fee, for establishing a connection with a Third Party Administrator/Claims processor for real-time, bi-directional data integration, including non-standard data integration formats. | Select One | |
| 3.5.4 | Confirm that the PBM agrees to work with the TUHSD's auditor during a pre/post implementation audit to run test claims in a test environment utilizing the TUHSD's actual plan parameters. | Select One | |
| 3.5.5 | Confirm that the PBM will provide draft SPD language for any clinical programs that are to be implemented. | Select One | |
| 3.5.6 | Confirm that the PBM will have a member-friendly website as well as the TUHSD's specific 800-telephone number available to all plan members prior to the go-live date. | Select One | |
| 3.6. Member Services and Account Management | | Confirmation | Deviation or Explanation |
| 3.6.1 | a.) Confirm that the PBM agrees to provide appropriately trained designated account resources including, but not limited to, an implementation manager, strategic account executive, clinical director - pharmacist, account manager, claims advocate, customer service manager, an underwriter/financial analyst and a member communications coordinator that are familiar with the TUHSD’s industry. | Select One | |
| b.) In addition to completing TAB02_Rx Account Team, please confirm that you have included biographies in attachments. | Select One | |
| 3.6.2 | a.) Confirm the PBM's Account Team will be available to meet with the TUHSD quarterly, upon request, to review utilization reports and service performance metrics. | Select One | |
| b.) Confirm the Account Manager will be responsible for overseeing the task log and ensuring each identified issue is addressed until resolution is achieved. | Select One | |
| c.) Confirm the PBM will include a Performance Guarantee on the Account Team's responsiveness. | Select One | |
| 3.6.3 | Confirm that the PBM agrees to obtain the TUHSD's approval for all member communication materials before distribution to members. | Select One | |
| 3.6.4 | The TUHSD reserves the right to review, edit, or customize any communication from the PBM to its membership. | Select One | |
| 3.6.5 | Confirm that the PBM agrees to obtain the TUHSD's approval for all member communication materials before distribution to members. | Select One | |
| 3.6.6 | Confirm that the PBM will not automatically enroll the TUHSD in any programs that involve any type of communications with members or alterations of members' medications, without express written consent from the TUHSD. | Select One | |
| 3.6.7 | Confirm that the PBM include the TUHSD's logo on member communications if requested by the TUHSD? | Select One | |
| 3.6.8 | Describe how the PBM will personalize member communications based on the TUHSD's various demographics (e.g., age, new hires) and type of enrolled plan (e.g., Actives, Pre-65 Retirees). | | |
| 3.6.9 | Confirm that postage is included when mailing new ID cards and replacement cards. | Select One | |
| 3.6.10 | Confirm members will be able to print out ID Cards from the PBM's website. In addition, confirm the member will be able to see the ID card from the PBM's mobile App. | Select One | |
| 3.6.11 | Confirm the PBM will not outsource member calls to a third-party. | Select One | |
| 3.6.12 | Confirm that all member service call recordings and notes between the PBM and the TUHSD's members will be the TUHSD's property. | Select One | |
| 3.6.13 | a.) Confirm that the PBM agrees to document 100% of the TUHSD's member service calls through call recordings and call notes. | Select One | |
| b.) Confirm that the PBM will forward written transcripts of calls at the TUHSD's request within two business days of the request being made. | Select One | |
| 3.6.14 | a.) The TUHSD reserves the right to access all call recordings or call notes from member service calls with its members. | Select One | |
| b.) Confirm that the PBM agrees to allow the TUHSD the right to request call recordings and/or notes at any time. | Select One | |
| c.) Confirm that the PBM agrees to allow the TUHSD to listen to any recorded calls within 24 hours of the TUHSD's request. | Select One | |
| 3.6.15 | Confirm that all customer service operations requiring verbal communication with the TUHSD and the TUHSD's members will be performed in the United States (i.e., will not be provided offshore). | Select One | |
| 3.6.16 | Confirm that multi-language communication phone line support is included in the base administrative fee. List the languages available to the TUHSD members speaking to your customer service representatives. | Select One | |
| 3.6.17 | a.) How do you track member complaints? | | |
| b.) List the top five (5) member complaints related to retail, mail order, and the specialty pharmacy program. | | |
| c.) What processes/ remedies have been put into effect to resolve these complaints? | | |
| 3.6.18 | The PBM agrees to, at minimum, quarterly calls to review member service issues. The PBM agrees to allow the TUHSD to review member service quality issues to the resolution endpoint. | Select One | |
| 3.6.19 | Can members view real time discount price by drug and pharmacy via your website, mobile app or call center? | | Select One |
| 3.6.20 | a.) Provide a demo website, link, or informational materials highlighting the capabilities as well as the look and feel of the client self-service tools that will be available to TUHSD administrators. Tools includ reporting capabilities and basic member services/detail information such as eligibility, claims, and prior authorization views. Provide name of attachment(s) within the space provided. | | |
| b.) Please provide the TUHSD with a dummy login so that the TUHSD can access the PBM's member website. If not possible, please provide an attachment with images of the PBM's member website layout. | | |
| 3.6.21 | a.) Is a member able to store credit card information on the PBM's member website and see amounts due and payments made on the website? | Select One | |
| b.) If a member continues to see a balance on the website despite having a payment, what is the process the member should take and how long does it take to have a resolution? | | |
| 3.6.22 | a.) Provide standard report package sample the TUHSD will receive and note frequency. | | |
| b.) Confirm the standard reporting package will be sent to the TUHSD on a quarterly or annual basis at the TUHSD's request. | Select One | |
| 3.6.23 | The PBM agrees that all future edits required because of plan design changes implemented by the TUHSD shall be completed, after testing, by the PBM within 45 days of request/advisory by the TUHSD. | Select One | |
| 3.6.24 | In TAB04_Rx Subcontractors, list all functions you currently outsource to any third party and name sub-contractor for the following functions. | Select One | |
| 3.6.25 | Confirm the PBM will provide the TUHSD with a 90-day advance notice of any changes in suppliers or sub-contractors for services such as specialty pharmacy, mail-order facility and/or other products and services. | Select One | |
| 3.6.26 | What is the PBM's process if a member calls the customer care service line to inquire for a status on a prior authorization? | Select One | |
| 3.6.27 | a.) Describe the PBM's process if a member calls the customer care service line because the doctor's office has not completed the prior authorization form, has filled out the incorrect prior authorization form and/or there is a delay in reviewing the doctor's prior authorization form. | | |
| b.) Do customer care representatives offer to call the doctor's office on the member's behalf to ensure the doctor has completed the proper documentation? | Select One | |
| c.) Does the PBM's prior authorization team call a doctor's office, on the member's behalf, to collect the requested prior authorization information via the phone? | Select One | |
| 3.6.28 | a.) Describe the PBM's process if a member calls the customer care service line because the generic product that the member was prescribed is out of stock? | | |
| b.) Will the customer care representative offer a branded medication at the member's generic cost but the brand cost to the TUHSD without the TUHSD's approval? | Select One | |
| 3.7. Legal Responsibilities | | Confirmation | Deviation or Explanation |
| 3.7.1 | General Compliance: All bidder services must adhere to relevant federal and state laws and regulations. | Select One | |
| 3.7.2 | HIPAA Compliance: All bidder systems and services must be in compliance with the HIPAA EDI, Privacy, and Security regulations on the appropriate dates established by the Department of Health & Human Services. | Select One | |
| 3.7.3 | The PBM shall indemnify, defend and hold harmless the TUHSD, its officers, directors, employees and agents and affiliates from and against any and all claims, actions, demands, costs, and expenses, including reasonable attorney fees and disbursements, as a result of a breach by the PBM of any of its obligations under the Commercial and EGWP with enhanced plan design Agreements or arising out of the negligent act or omission or willful misconduct of the PBM or its employees or agents. | Select One | |
| 3.7.4 | The indemnification set forth above shall cover a breach of protected health information. | Select One | |
| 3.7.5 | Confirm the PBM agrees to hold the TUHSD harmless for any HIPAA Violations made by the PBM or its Network Pharmacies. | Select One | |
| 3.7.6 | Confirm that the PBM will agree to be claims fiduciary for clinical based determinations. | Select One | |
| 3.7.7 | Confirm that the PBM Agreement will contain provisions which prevent the PBM from assigning any duties or functions without the written consent of the TUHSD. | Select One | |
| 3.7.8 | Confirm that the PBM agrees that in the event of a dispute between the parties, about the payment or entitlement to receive payment, or any administrative fees hereunder, the PBM and the TUHSD shall endeavor to meet and negotiate a reasonable outcome of said dispute. In NO event shall PBM undertake unilateral offset against any monies due and owed the TUHSD, whether from manufacturer rebates, credit adjustment or otherwise. | Select One | |
| 3.7.9 | Confirm that the PBM agrees to provide the PBM's alternative mediation or appeal options for conflict resolution to help the TUHSD resolve disputes. This appeal option should provide a simple, efficient and fair method of providing resolutions to the member and TUHSD's issues. | Select One | |
| 3.7.10 | What general and professional errors and omissions cybersecurity liability coverage does the PBM currently have in place? Include name of insurer, per occurrence dollar limits and total policy coverage limits. | | |
| 3.7.11 | Confirm the TUHSD will have the option of choosing legal counsel to defend claims litigation based on decisions made by the PBM to deny coverage for clinical reasons, and that PBM will be fully involved in said defense, the cost of which shall be borne by the PBM to the extent the PBM is found to have been negligent or at fault in the denial decision. | Select One | |
| 3.7.12 | Confirm the PBM will respond to and timely incorporate future Health Care Reform changes in full compliance with the law and at no additional cost to the TUHSD. | Select One | |
| 3.7.13 | Confirm the PBM will agree to handle claims/appeals processing in accordance with the minimum requirements of ERISA as amended by the Patient Protection and Affordable Act (PPACA). | Select One | |
| 3.7.14 | Confirm the PBM will agree to be responsible for selecting and contracting the external review organizations sufficient to allow the TUHSD to comply with ERISA as amended by the PPACA. | Select One | |
| 3.7.15 | Confirm the Agreement will be governed in all respects according to the laws in the State of which the TUHSD resides (Arizona). | Select One | |
| 3.7.16 | Confirm the PBM will agree to provide data and reporting information for drug manufacturer lawsuits and settlements and will agree to list out their responsibilities regarding these class actions (e.g., notify TUHSD about them, and provide the appropriate information). | Select One | |
| 3.7.17 | Confirm your organization meets all federal and state benefit laws including all relevant provisions of ACA, HIPAA and Mental Health Parity laws. | Select One | |
| 3.7.18 | a.) Confirm the PBM’s liability to the TUHSD shall not be limited to the total claims processing fees paid to the PBM by the Fund for the twelve (12) months prior to the date the claim is asserted. | Select One | |
| b.) Confirm the PBM will be liable for any claim asserted by the TUHSD, not limited to a time period that the TUHSD was aware of such claim and not limited to a time period after the event giving rise to the claim. | Select One | |
| 3.8. Federal No Surprises Act, Final Transparency Rule, No Surprises Act | | | Answer |
| 3.8.1 | a.) Describe how your company will ensure that the TUHSD is in compliance with federal law and regulations concerning surprise billing and transparency with respect to the services provided by your company. | | |
| b.) Confirm your company will incorporate language in good faith regarding the Federal No Surprises Act and Final Transparency Rule. | Select One | |
| 3.8.2 | List any subcontractors or third-parties who are providing assistance to you in complying with the law and regulations, or who will be involved in work you may perform on behalf of the TUHSD. | | |
| 3.8.3 | List any technical specifications that the TUHSD will need to meet to use any solution you intend to offer to comply with the law and regulations, including software, hardware, or other information technology. | | |
| 3.8.4 | a.) Are you fully compliant with the regulations and statutory law? | | Select One |
| b.) If not, please explain. | | |
| 3.8.5 | a.) Are your existing fees inclusive of all services related to the law and regulations? | | Select One |
| b.) If not, please explain what additional costs the TUHSD may incur. | | |
| c.) Please also state when and how the TUHSD would be notified of any fee modification proposals. | | |
| 3.8.6 | Do you intend to propose revisions to the existing pharmacy benefit manager agreement? | | Select One |
| Transparency Rules (Not Applicable to grandfathered Plans) | | | |
| 3.8.7 | a.) Will you provide the TUHSD with a machine-readable file on a monthly basis including prescription drug negotiated rates? | | Select One |
| b.) If so, state whether you will send information to the TUHSD or provide another service to the TUHSD that allows the TUHSD to link to another website? | | |
| c.) Describe the information technology requirements necessary for transmitting files and/or posting them. | | |
| d.) If the TUHSD uses multiple service providers for pricing, will you provide assistance in consolidating the information into one file? | | |
| Gag Clause | | | |
| 3.8.8 | a.) Do any contracts you are a party to contain a clause prohibiting disclosure of pricing terms (“gag clause”) which is prohibited under the Consolidated Appropriations Act (CAA), 2021? | | Select One |
| b.) If yes, please describe and state how you will ensure they are removed. | | |
| c.) Indicate your timeline for removing gag clauses from contracts. | | |
| d.) On behalf of the TUHSD, will you attest to not having gag clauses in applicable contracts and submit the attestation to the Departments in a timely manner. | | Select One |
| No Surprises Act | | | |
| 3.8.9 | The Act requires ID cards to contain information about deductibles and out-of-pocket maximums. | | |
| a.) Have you updated your ID cards to include at a minimum the major medical deductible and out-of-pocket maximum; a telephone number and internet website address for participants to seek consumer assistance, and access additional applicable deductibles and maximum out-of-pocket limits? | | Select One |
| b.) Please provide a copy of a template ID card. | | |
| 3.8.10 | a.) For grandfathered and non-grandfathered plans, please describe how you will support the additional External Appeals requirements for Covered Services? | | |
| b.) Do you provide a contract with an Independent Review Organization for external review? | | Select One |
| 3.8.11 | a.) Do you provide a price comparison tool via an internet website, via telephone, and in paper form upon request, that allows a participant to compare the amount of cost sharing that they will be responsible for by participating provider and geographic region? | | Select One |
| b.) Describe the price comparison tool in detail, and whether any subcontractors are used to produce it. | | |
| c.) Describe who will provide the telephone tool and at what location. | | |
| d.) Is there a dedicated team for the TUHSD’s participants to provide the tool and assist with its use? | | Select One |
| e.) What internet website will be used for the price comparison tool, and will the TUHSD need to provide its own website to link to the tool or will your company provide that site? | | |
| f.) What is the source of the rate information provided by the tool? | | |
| g.) With which benefits software vendors is your tool integrated? | | |
| h.) Please provide screenshots of the web portal to be used for the participant cost-sharing disclosure. | | Provide as an attachment named "PBM-Name_No Surprises Act" |
| i.) How will you respond to individuals who request the information on paper instead of through the website? | | |
| j.) Describe what, if any, features are available beyond the requirements of the No Surprises Act. Is the TUHSD able to opt out of any such features? | | |
| k.) Describe any additional costs for the tool. | | |
| 3.8.12 | Describe your process for addressing participant or provider complaints that may be made against the plan under the Act. | | |
| 3.8.13 | Do you provide the plan’s external review services for prescription drug benefits? | | Select One |
| 3.8.14 | a.) How will you assist the TUHSD in annually reporting prescription drug costs and other information to the federal government? | | |
| b.) Describe your process for reporting prescription drug cost information to the federal government. | | |
| c.) On behalf of the TUHSD, will you submit to the Departments each of the following files on an aggregated basis, including the cost data of the TUHSD? If not, please indicate files which will/will not by submitted by the PBM. | | Select One |
| i. P2 File | | Select One |
| ii. D1 File | | Select One |
| iii. D3 File | | Select One |
| iv. D4 File | | Select One |
| v. D5 File | | Select One |
| vi. D6 File | | Select One |
| vii. D7 File | | Select One |
| viii. D8 File | | Select One |
| d.) If you will submit on an aggregated basis including TUHSD data, what information will the TUHSD need to provide? | | |
| - Please describe your process for gathering any such information, including any technology specifications. | | |
| e.) If you will submit on an aggregated basis including TUHSD data, will you provide confirmation of timely submission to the TUHSD? | | Select One |
| - Will you provide a copy of your submission to the TUHSD? | | Select One |
| f.) If you will not submit on an aggregated basis including TUHSD data, will you provide cost data to the TUHSD sufficient for the TUHSD to submit the required reporting? | | Select One |
| - In what format will the cost information be provided? | | |
| g.) Describe whether you will accept responsibility for fulfilling all cost reporting obligations and if not which ones you will not fulfill. | | |
| h.) State any additional costs for this reporting service. | | |
| 3.8.15 | a.) The Act requires ID cards to contain information about deductibles and out-of-pocket maximums. Describe what changes are needed to ID cards and how you will provide the new cards. | | |
| b.) Describe any charges for the cards. | | |
| c.) Describe when and how new ID cards will be delivered to Plan participants. | | |
| 3.8.16 | Describe what benefits you administer through the TUHSD's pharmacy benefit, including specialty drugs, that you expect to be subject to the requirement to provide plan participants with an Advanced Explanation of Benefits (as required under ERISA Section 716(f); PHSA Section 2799A-1(f)). | | |
| 3.8.17 | What process will be used to accept provider notification of expected charges and services? | | |
| 3.8.18 | Describe how you will provide the Advanced EOB to participants, i.e., via electronic means or mail as requested by the participant. | | |
| 3.8.19 | Describe how you will provide reports assuring that the Advanced EOB process is performing as required by law. | | |
| 3.9. Eligibility | | Confirmation | Deviation or Explanation |
| 3.9.1 | Confirm that the PBM agrees to the specified eligibility rules established by the TUHSD for covered parties. | Select One | |
| 3.9.2 | Confirm that the PBM will receive quarterly full eligibility file match from the TUHSD's administrators. Confirm the PBM will not use this file for card re-issuing. | Select One | |
| 3.9.3 | Confirm the PBM will only use this file to ensure both entities have the same members enrolled. | Select One | |
| 3.9.4 | a.) How does the PBM define “ID Card Reissues”. | | |
| b.) Confirm how the PBM will determine which ID Card Reissues require a fee. | | |
| 3.10. Invoicing | | Confirmation | Deviation or Explanation |
| 3.10.1 | Confirm that the PBM shall promptly process and fill all prescriptions submitted from eligible, covered members. The PBM will process the prescription and pay pharmacy fees using its own resources and will be reimbursed by the TUHSD on regular basis (e.g., twice monthly, bi-weekly, other). | Select One | |
| 3.10.2 | a.) Confirm that the PBM will invoice the TUHSD twice monthly for claims (e.g., weekly, twice monthly or bi-weekly) and once monthly for the administrative services. | Select One | |
| b.) The District will pay all undisputed claim invoice amounts to the PBM within ten (10) business days after the District receives such invoice from the PBM and all undisputed administrative services invoice amounts to the PBM within fifteen (15) calendar days after the District receives such invoice from the PBM. | Select One | |
| c.) Confirm that if the District disputes all or a portion of any invoice, the District will pay the undisputed amount timely and notify the PBM in writing, of the specific reason and amount of any dispute before the due date of the invoice. The PBM and the District will work together, in good faith, to resolve any dispute. The District will not be charged interest or late penalties. Upon resolution, the District or the PBM will remit the amount owed to the other party, if any, within five (5) business days as the parties agree based on the resolution. | Select One | |
| 3.10.3 | a.) The PBM shall provide the TUHSD with an invoice for administration fees on a monthly basis. PEPM and PMPM fees will be based on eligibility counts determined by the TUHSD. | Select One | |
| b.) Confirm the PBM will provide an itemized list of administrative fee charges, including both unit cost and number of units, with each monthly invoice. | Select One | |
| 3.10.4 | a.) How will the PBM give money back to the TUHSD in instances in which the PBM overcharges the TUHSD for services that the PBM then agrees has overcharged and/or inappropriately charged? | | |
| b.) Will the PBM be able to provide this as a transfer back into the TUHSD's bank account instead of a credit to the TUHSD's invoices upon the TUHSD's request? | | Select One |
| 3.10.5 | Confirm the PBM agrees that all reporting submitted by the PBM must be reconciled to the billing. | Select One | |
| 3.11. Cybersecurity | | Confirmation | Deviation or Explanation |
| 3.11.1 | Does the PBM conduct periodic risk assessments to identify cybersecurity threats, vulnerabilities, and potential business consequences? | Select One | |
| 3.11.2 | Describe the PBM's processes and systems for dealing with cybersecurity threats and protection of personal identifiable information? | | |
| 3.11.3 | Does the PBM have an annual independent assessment made of your cybersecurity processes? | Select One | |
| 3.11.4 | Does the PBM have a Chief Information Security Officer or equivalent position? | Select One | |
| 3.11.5 | Does the PBM have a privacy and security policy, and does the policy apply to personal identifiable information of health plan clients? | Select One | |
| 3.11.6 | a.) Does the PBM have policies on storing personal identifiable information including where it is stored, how long it is stored, and how it is eliminated? | Select One | |
| b.) Describe the training process. | | |
| 3.11.7 | a.) Is the PBMs policy clear with respect to storing personal identifiable information on laptops and portable storage devices? | Select One | |
| b.) Describe the PBM's policy. | | |
| 3.11.8 | a.) Confirm that all personnel who come in contact with personal identifiable information are trained on adequate protection of the information? | Select One | |
| b.) Describe the training process. | | |
| 3.11.9 | Does the PBM have carry cybersecurity insurance? | Select One | |