042-1616186-JFC_-_Pharmacy_Benefits_Services.pdf

County of Orange

Health Care Agency

Request for Proposals

RFP No.: 042-1616186-JFC

Pharmacy Benefits Management Services

Released

December 26, 2023

Request for Proposals 2 of 44 Pharmacy Benefits Management Services

TABLE OF CONTENTS

SECTION PAGE

I. Introduction and General Information

A. Proposal Focus and Background

B. Contract Term and Funding Availability

C. Time Proposals will Remain Valid

D. Timeline

E. Withdrawal of Proposals

F. Questions Regarding the RFP Process and Requirements

G. General Instructions for Submittal

H. County Rights

I. Use of Lobbyists

J. Protest Process

K. Change of Ownership/Name and Litigation Status

L. Conflict of Interest

M. Confidentiality

N. Modifications to the RFP

O. Insurance Requirements

II. Description of Services

A. Target Population

B. Services to be Provided

C. Performance Objectives

D. Staffing Requirements

III. Proposal Preparation and Evaluation

A. Proposers Eligibility to Contract with the County

B. Rejection of Proposals

C. Minor Irregularities and Deficiencies in Proposal(s)

D. Non-Responsive Proposals

E. Evaluation of Proposals and Selection of Provider(s)

IV. Minimum Submission Requirements

V. Proposal for Pharmacy Benefits Management Services

A. Provider Experience and Qualifications

B. Services

C. Performance Objectives

D. Staffing

E. Budget

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Attachments

Attachment I – Contract Template

Attachment II – Form A-E

Attachment III – Budget Forms

Campaign Contribution Form

NOTE: Forms and attachments in PDF and/or Excel format are posted on The County’s online bidding system as separate attachments to this solicitation.

INTRODUCTION AND GENERAL INFORMATION SECTION I

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A. PROPOSAL FOCUS AND BACKGROUND

The County of Orange (County) Health Care Agency (HCA) is seeking proposals from qualified organizations to provide Pharmacy Benefits Management Services. The primary goal of this program is to provide medication distribution services to Orange County residents of all ages who meet medical necessity criteria, and who have no other financial resources for these services, to the extent resources are available.

B. CONTRACT TERM AND FUNDING AVAILABILITY

The County plans to contract with a qualified organization to provide the services described in this

Request for Proposals and reserves the right to make multiple awards to proposers for services requested in the solicitation. At the discretion of County, the initial term of the contract resulting from this solicitation may be renewed for an additional term or terms. Any renewal is contingent upon available funding, contractor performance, need for services, and County policies.

Successful proposers are expected to accept the terms and conditions of Attachment I - Contract

Template, which contains the contracting requirements between the County and the proposer regarding the provision of services solicited under this Request for Proposals (RFP). The selected proposer(s) proposal will be retained and incorporated into the contract by reference and made part thereof, except for assurances and promises that are unlawful.

Contract resulting from this solicitation shall be a cooperative Contract and may be utilized by all

County of Orange departments.

The provisions and pricing of any Contract resulting from this solicitation will be extended to other governmental entities. Governmental entities wishing to use this Contract will be responsible for issuing their own purchase documents, providing for their own acceptance, and making any subsequent payments. Contractor shall be required to include in any subordinate Contract entered into with another governmental entities pursuant to this Contract, a Contract clause that will hold harmless the County of Orange from all claims, demands, actions or cause of actions of every kind resulting directly or indirectly, arising out of, or in any way connected with, the use of this Contract.

Failure to do so will be considered a material break of this Contract and grounds for immediate

Contract termination. Governmental entities are responsible for obtaining all certifications of insurance, endorsements, and bonds required. The Parties agree that any other governmental entity utilizing this Contract shall not be deemed to be an agency or employee of County for any purpose whatsoever. The Contractor is responsible for providing each governmental entity a copy of this

Contract upon request. The County of Orange makes no guarantee of usage by other users of this

Contract.

The Contractor shall be required to maintain a list of the County of Orange departments and governmental entities using this Contract. The list shall report dollar volumes spent annually and shall be provided on an annual basis to the County, at the County’s request.

Subordinate Contracts must be executed prior to the expiration or earlier termination of this Contract and may survive the expiration of this Contract up to a maximum of one year; however, in no case shall a subordinate Contract exceed five (5) years in duration.

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The contract awarded through this solicitation is anticipated to be a hybrid of actual cost and fee-for-service. The funding source for these services is planned to be from Net-County Cost funds.

Any contract resulting from this solicitation is contingent upon sufficient funds being made available by federal, state, and/or county governments for the term of the contract. County reserves the right to revise the contract terms stated in this solicitation. Start-up funds are not available for these services.

C. TIME PROPOSALS WILL REMAIN VALID

Proposals will remain valid for 365 days from the solicitation due date. If for any reason a selected proposer is unable, unavailable or unwilling to begin the Services on July 1, 2024, the County reserves the right to award the contract to the next ranked proposal without conducting another solicitation/RFP or otherwise proceed as deemed in the best interest of the County

D. TIMELINE

The following timelines are approximations only and do not constitute any commitment or guarantee by the County.

Activity Date

RFP Released December 26, 2023

The County’s online bidding system Question and Answer Deadline January 16, 2024

Proposals Due January 23, 2024

Interview (if applicable) Last week of February

Services Commence July 1, 2024

E. WITHDRAWAL OF PROPOSAL(S)

A proposal may be withdrawn by the proposer or an authorized representative, provided his or her identity is made known, but only if the withdrawal is made prior to the date submission of the proposals are due.

F. QUESTIONS REGARDING THE RFP PROCESS AND REQUIREMENTS

All questions regarding this RFP are to be posted online via The County’s online bidding system

Question and Answer (Q&A) Section and will only be accepted and answered during the Q&A period that lasts until approximately one (1) week prior to the RFP closing date.

All proposers are expected to thoroughly read through the entire RFP package before posting questions. All participating proposers will simultaneously receive a notification via The County’s online bidding system that a question has been posted related to this RFP and will be available for view by all participating proposers. The County’s responses to the questions asked will be posted as

Request for Proposals 6 of 44 Pharmacy Benefits Management Services promptly as possible to The County’s online bidding system and will be available for view by all participating proposers.

The Q&A Section will close on January 16, 2024 at 4:00 P.M. Pacific Time. All proposers are encouraged to post any questions regarding the RFP by this deadline. After the close of the Q&A period, bidders may only contact the Procurement Administrator with questions related to uploading proposals to the County’s online bidding system. No other specific solicitation-related questions will be answered.

It is up to each individual proposer to determine if their organization meets the eligibility criteria stated in the RFP prior to submitting a proposal. The County does not provide any assistance to that effect.

Proposers are to strictly follow the directions above for questions regarding this RFP. During the entire RFP process, no County representative may be contacted for questions or information regarding this RFP with the exception of the assigned Procurement Administrator, Joseph Cook-

Giles at jcook-giles@ochca.com. Any violation of this direction may be deemed non-responsive with the RFP process and shall form a basis for the rejection of the proposal.

G. GENERAL INSTRUCTIONS FOR SUBMITTAL

All proposals must clearly meet all of the requirements of this solicitation. Proposers should review all requirements and instructions to ensure that each requirement is clearly addressed in the proposal.

The County shall not be responsible for any oral instructions given by any employees of the County in regard to the proposal instructions, specifications, or proposal documents described in this RFP.

1. Prepare the proposal with the reviewer in mind; do not assume reviewers know your program. Proposal must be detailed and self-explanatory.

2. Proposals should be carefully proofread and include the following:

a) Table of Contents with page numbers, for each file.

b) Reference(s) to any appendices.

c) Placement of required forms immediately after the text they support in the proposal.

d) Numbered pages.

e) Text must be at least one and one-half (1½) line-spaced.

f) Times New Roman, 12 point font.

g) Each section is to be separated by a titled cover page and each question as it appears in the solicitation is to precede its corresponding response.

h) All requested information is to be in the sequence and format specified in the solicitation.

3. Use the Proposal Preparation Checklist Form (Form A - Attachment II) to plan and monitor proposal preparation, as well as to verify completion of all materials before submission.

4. Provide accurate and honest information. Information that is inaccurate may prompt an investigative review and will affect the evaluation of the proposal.

5. Ensure that information provided on the forms is consistent with the narrative and the information provided on other forms.

6. If you omit any required information or data, explain why.

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7. Ensure compliance with contract requirements and all applicable laws/regulations related to privacy and security pertaining to disclosure of confidential and/or private client information.

Such information may be redacted in any material submitted in response to this RFP.

8. Do not use appendices for information that is required in the body of the proposal. Use appendices to provide documentation or examples of activities mentioned in the proposal.

9. Do not include home addresses, home phone numbers, and/or personal email addresses for any employee, volunteer, board member, etc. in your proposals.

10. Electronic Submission: Proposals and requested documents must be electronically uploaded in PDF format, via The County’s online bidding system. Responses to Section IV and Section

V of the RFP must be submitted in separate files. If proposing more than one (1) Project/Service

Area/Region, upload a separate Section V for each Project/Service Area/Region, but only one

(1) Section IV needs to be uploaded.

a) Section IV must be uploaded in one (1) file labeled “[Services]-[Proposer Name]-Agency

Description.”

b) Section V must be uploaded in one (1) file labeled “[Services]-[Proposer Name]-Proposal.”

c) Allow sufficient time to upload all required files. After the 4:00 P.M. Pacific Time proposal deadline, The County’s online bidding system will not allow any uploads, e.g., if file #1 uploaded successfully at 3:58:23 P.M. and file #2 is in progress of being uploaded at 4:00:01

P.M., file #2 will not upload successfully.

11. Proposal Delivery Instructions: Proposals are due on or before January 23, 2024 no later than

4:00 P.M. Pacific Time.

H. COUNTY’S RIGHTS

The County reserves the right to:

1. Modify this RFP prior to the time proposals are due, provided proposers are granted such extensions as necessary to allow sufficient time for submission of proposals in response to the modified RFP.

2. Cancel this RFP at any time, but prior to award of a contract by the Board of Supervisors, in whole or in part, when it is determined that cancellation is in the best interest of the County.

3. Reject any or all proposals.

4. Reject a proposal at any time during the RFP process for reasons stated in this RFP or for false information submitted in response to the RFP.

5. Enter into a contract for all or some of the stated services.

6. Award single or multiple contracts.

7. Based on the County’s needs and availability of funds, modify the scope of service described herein, provided proposers are allowed to re-submit modified proposals within a reasonable time.

8. Ask proposers for additional information or documentation.

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I. USE OF LOBBYISTS

The County of Orange does not require, and neither encourages nor discourages, the use of lobbyists or other consultants for the purpose of securing business.

J. PROTEST PROCESS

Any actual or prospective proposer who alleges a grievance by the solicitation or award of a contract may submit a grievance or protest that this solicitation is unfairly restrictive, ambiguous or contains conflicting provisions.

Protest of Solicitation Specifications

All protests related to solicitation specifications must be submitted to HCA Procurement and

Contract Services no later than five (5) business days prior to the close of the solicitation period.

Protests received after the five (5) business day deadline will not be considered by the County. In the event the protest of specifications is denied and the protester wishes to continue in the solicitation process, it must still submit a proposal prior to the close of the solicitation in accordance with the proposal submittal procedures provided in the solicitation.

Protest of Award of Contract

In protests related to the award of a contract, the protest must be submitted no later than five (5) business days after the “Notice of Intent to Award Contract” is provided by HCA Procurement and

Contract Services. Protests relating to a proposed contract award, which are received after the five

(5) business day deadline will not be considered by the County. Upon receipt of a timely protest, the

Procurement and Contract Services Division Manager will, within 10 business days, issue a decision in writing which shall state the reasons for the actions taken.

The County may, after providing written justification to be included in the procurement file, make the determination that an immediate award of the contract is necessary to protect the substantial interests of the County. The award of a contract shall in no way compromise the protester’s right to the protest procedures outlined herein.

Procedure

All protests shall be typed under the protester’s letterhead and submitted in accordance with the provisions stated. All protests shall include at a minimum the following information:

1. The name, address, and telephone number of the protester.

2. The signature of the protester or the protester’s authorized representative.

3. The name of the solicitation or number of the RFP.

4. A detailed statement of the legal and/or factual grounds for the protest.

5. The form of relief requested.

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Written protests must be sent to: County of Orange/Health Care Agency

Procurement and Contract Services

400 W Civic Center Drive, 3rd floor

Santa Ana, CA 92701

Attn: Joseph Cook-Giles

Jcook-giles@ochca.com

Appeal Process

If the protester disagrees with the decision of the Procurement and Contract Services Division

Manager, the protester may submit a written notice within three (3) business days from receipt of the Procurement and Contract Services Division Manager’s decision to the Office of the County

Procurement Officer requesting an appeal to the Procurement Appeals Board.

Written appeals must be sent to: County of Orange/County Procurement Office

400 W Civic Center Drive, 5th floor

Santa Ana, CA 92701

Attn: County Procurement Officer

CPOAppeals@ocgov.com

Within 15 business days, the County Procurement Officer will review all materials in connection with the protest, assess the merits of the protest and provide a written determination that shall contain his or her decision on whether the protest shall be forwarded to the Procurement Appeals Board.

The decision of the County Procurement Officer on whether to allow the appeal to go forward will be final and there shall be no right to any administrative appeals of this decision.

K. CHANGE OF OWNERSHIP/NAME AND LITIGATION STATUS

If a contract is awarded as a result of this solicitation, proposer agrees that if there is a change or transfer in ownership of proposer’s organization prior to the completion of a contract, and the County agrees to an assignment of the Contract, the new owners shall be required under the terms of sale or other instruments of transfer to assume Contractor’s duties and obligations contained in the Contract and complete them to the satisfaction of the County.

The County reserves the right to immediately terminate the Contract in the event the County determines that the assignee is not qualified or is otherwise unacceptable to the County for the provision of services under the Contract.

L. CONFLICT OF INTEREST

Proposer shall exercise reasonable care and diligence to prevent any actions or conditions that could result in a conflict with County interests. In addition to the proposer, this obligation shall apply to the proposer’s employees, agents, and subcontractors associated with the provision of goods and services provided under the Contract. The proposer’s efforts shall include, but not be limited to establishing rules and procedures preventing its employees, agents, and subcontractors from mailto:CPOAppeals@ocgov.com

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The County reserves the right to disqualify any proposer on the basis of any real or apparent conflict of interest that is disclosed by the proposal submitted or any other information available to the

County. This disqualification is at the sole discretion of County. Any proposer submitting a proposal herein waives any right to object to the County’s exercise of this right, now or at any future time, before anybody or agency including, but not limited to, the County Board of Supervisors or any court of competent jurisdiction.

M. CONFIDENTIALITY

California Public Records Act

Pursuant to California law, all information contained in a proposal may be public record, subject to disclosure to any member of the public who requests it through the California Public Records Act

(CPRA). If it is necessary to include proprietary/trade secret information in a response, the County recommends that the proposal clearly and prominently marks the information believed to fall within such categories.

Names of Members of the Evaluation Panel and Communications with Panel Members

The names of the evaluation panel members will not be disclosed unless ordered by a court.

To assure a fair process, members of the evaluation panel will be instructed not to discuss the information in the proposal or the solicitation process with any proposer(s) or other individuals. All communications between the proposer and County must be through the County’s online bidding system Q&A Section prior to the close of the Q&A period and through Procurement Administrator after the close of the Q&A period. Any violation of this direction will be deemed non-responsive with the RFP process and shall form a basis for the rejection of the proposal.

N. MODIFICATIONS TO THE RFP

The County reserves the sole right to interpret or change any provision of the solicitation at any time prior to the proposal submission date. Any and all interpretations or changes will be in the form of a written addendum, which will be furnished to all proposers through The County’s online bidding system. All addendums issued will become part of the solicitation and resultant Contract. Proposers hereby acknowledge their receipt of any addendum by being registered in The County’s online bidding system and acknowledge it is the proposer’s responsibility to check for, and read all addendums posted in The County’s online bidding system.

Should such addendum require information not previously requested, the County at its sole discretion, may determine that a time extension is required for the submission of proposals, in which case an addendum will indicate the new proposal submission date.

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O. INSURANCE REQUIREMENTS

Insurance coverage and limits for the awarded Contract will vary based upon the identified services and will be determined during contract negotiations. The baseline amounts and key requirements are as follows:

COVERAGE MINIMUM LIMITS

Commercial General Liability $1,000,000 per occurrence

$2,000,000 aggregate

Automobile Liability, including coverage for owned or scheduled, non-owned and hired vehicles

$1,000,000 combined single limit each accident

Workers’ Compensation Statutory

Employer's Liability Insurance $1,000,000 per accident or disease

Network Security & Privacy Liability $1,000,000 per claims-made

Professional Liability

$1,000,000 per claims-made or occurrence

$1,000,000 aggregate

Sexual Misconduct Liability $1,000,000 per occurrence

1. Increased insurance limits may be satisfied with Excess/Umbrella policies. Excess/Umbrella policies when required must provide Follow Form coverage.

2. REQUIRED COVERAGE FORMS

a. The Commercial General Liability coverage shall be written on occurrence basis utilizing

Insurance Services Office (ISO) form CG 00 01, or a substitute form providing liability coverage at least as broad.

b. The Business Auto Liability coverage shall be written on ISO form CA 00 01, CA 00 05, CA

0012, CA 00 20, or a substitute form providing coverage at least as broad.

3. REQUIRED ENDORSEMENTS

The Commercial General Liability policy shall contain the following endorsements, which shall accompany the Certificate of Insurance:

a. An Additional Insured endorsement using ISO form CG 20 26 04 13, or a form at least as broad naming the County of Orange its elected and appointed officials, officers, employees, and agents as Additional Insureds, or provide blanket coverage, which will state As Required by Written Contract.

b. A primary non-contributory endorsement using ISO form CG 20 01 04 13, or a form at least as broad evidencing that the Contractor’s insurance is primary, and any insurance or self-insurance maintained by the County shall be excess and non-contributing.

4. The Workers’ Compensation policy shall contain a waiver of subrogation endorsement waiving all rights of subrogation against the County of Orange, its elected and appointed officials, officers, employees, and agents or provide blanket coverage, which will state As Required by

Written Contract.

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5. The Network Security and Privacy Liability policy shall contain the following endorsements which shall accompany the Certificate of Insurance:

a. An Additional Insured endorsement naming the County of Orange, its elected and appointed officials, officers, employees, and agents as Additional Insureds for its vicarious liability.

b. A primary and non-contributory endorsement evidencing that the Contractor’s insurance is primary, and any insurance or self-insurance maintained by the County shall be excess and non-contributing.

6. All insurance policies required by this Contract shall waive all rights of subrogation against the

County of Orange, its elected and appointed officials, officers, employees, and agents when acting within the scope of their appointment or employment.

7. Contractor shall provide thirty (30) days prior written notice to the County of any policy cancellation or non-renewal and ten (10) days prior written notice where cancellation is due to non-payment of premium and provide a copy of the cancellation notice to County. Failure to provide written notice of cancellation may constitute a material breach of the Contract, upon which the County may suspend or terminate this Contract.

8. If Contractor’s Professional Liability and/or Network Security & Privacy Liability are “Claims-

Made” policy(ies), Contractor shall agree to the following:

a. The retroactive date must be shown and must be before the date of the Contract or the beginning of Contract services.

b. Insurance must be maintained, and evidence of insurance must be provided for at least three (3) years after expiration or earlier termination of Contract services.

c. If coverage is canceled or non-renewed, and not replaced with another claims-made policy form with a retroactive date prior to the effective date of the contract services, Contractor must purchase an extended reporting period for a minimum of three (3) years after expiration of earlier termination of the Contract.

9. The Commercial General Liability policy shall contain a severability of interests clause also known as a “separation of insureds” clause (standard in the ISO CG 0001 policy).

10. Insurance certificates should be forwarded to the agency/department address listed on the solicitation.

11. If the Contractor fails to provide the insurance certificates and endorsements within seven (7) days of notification by CEO/Purchasing or the agency/department purchasing division, award may be made to the next qualified vendor.

12. County expressly retains the right to require Contractor to increase or decrease insurance of any of the above insurance types throughout the term of this Contract. Any increase or decrease in insurance will be as deemed by County of Orange Risk Manager as appropriate to adequately protect County.

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13. County shall notify Contractor in writing of changes in the insurance requirements. If Contractor does not provide acceptable Certificates of Insurance and endorsements to County incorporating such changes within thirty (30) days of receipt of such notice, this Contract may be in breach without further notice to Contractor, and County shall be entitled to all legal remedies.

14. The procuring of such required policy or policies of insurance shall not be construed to limit

Contractor's liability hereunder nor to fulfill the indemnification provisions and requirements of this Contract, nor act in any way to reduce the policy coverage and limits available from the insurer.

Prior to the provision of services, the successful proposer will be required to purchase insurance at the above minimum standards at proposer’s expense, and to deposit with the County, Certificates of

Insurance including all endorsements necessary to satisfy the provisions identified above.

If Self-Insured, the successful proposer will be required to provide a Certificate of Self-Insurance that meets at minimum, the requirements identified above.

Failure of the proposer to meet these requirements after the proposer has been selected, and prior to the

Contract start date, shall result in forfeiture of the proposer’s Contract award.

PROPOSAL PREPARATION AND EVALUATION SECTION III

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A. TARGET POPULATION

Pharmacy Benefits Management Services shall be provided to the following populations:

1. Children and youth with Serious Emotional Disturbance (SED);

2. Transitional-aged youth (TAY);

3. Adult and older adults with Serious and Persistent Mental Illness (SPMI);

4. Children and adults with substance use disorders;

5. Children and adults enrolled in Prevention and Early Intervention (PEI) programs; and

6. Substance Use Disorder clients (SUD)

B. SERVICES TO BE PROVIDED

The successful bidder will be responsible for administering and processing pharmacy claims for eligible services in accordance with the BHS/MSN program guidelines. BHS and MSN utilize separate formularies to adjudicate claims in their respective programs. MSN utilizes a four (4) tiered medication co-payment structure while BHS has no tiered medication designations or co-pay requirements because BHS pays all out-of-pocket cost for our clients.

The provider shall not be a plan fiduciary and shall not exercise discretion, authority, or control regarding administration of the Benefit Plan Design. The provider shall provide the services as stated and required by the Benefit Plan Design with responsibilities including, but not limited to:

1. Benefit Plan Design

a. Make modifications to Benefit Plan Design, as specified by BHS/MSN Program Manager or designee(s), to meet federal, state, or BHS/MSN requirements. The provider is expected to establish a Benefit Plan Design and assist with financial modeling of Benefit Plan Design modifications and formulary changes.

1) Upon signed request by BHS/MSN to provider, BHS/MSN may initiate Benefit Plan

Design changes, network modifications, or add other services. Dependent on the complexity and breadth of the Benefit Plan Design parameter change, provider will implement a change as soon as possible or practicable but shall not take longer than five

(5) working days without written consent of the BHS/MSN Program Manager or designee(s).

2) Services shall be provided in accordance with the modified Benefit Plan Design.

Reimburse only those medications that are on the BHS or MSN formularies, unless otherwise authorized. BHS/MSN is the payer of last resort for medications prescribed by

BHS/MSN authorized prescribers. BHS/MSN maintains formularies restricted to generic substitution formulations when available. Generic formulations, whether they are available from one or more manufacturers, must be covered by successful bidder from the authorized BHS or MSN formulary list.

The BHS formulary is posted on the BHS website at:

http://ochealthinfo.com/bhs/about/formulary.

http://ochealthinfo.com/bhs/about/formulary

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The MSN formulary can be found at:

http://www.ochealthinfo.com/civicax/filebank/blobdload.aspx?BlobID=23977

Reimbursement of any medications adjudicated by the PBM outside the scope of the BHS or MSN formularies, without a proper prior authorization will result in an audit exception and funds withheld from the successful bidder.

b. Obtain all medications through successful bidder’s network of pharmacies. PBM services must be provided based on the following program guidelines, benefits, BHS/MSN formularies and formulary rules. Failure to do so without proper authorization will result in an audit exception and funds withheld from the successful bidder.

1) All medications available in generic formulation must be prescribed as generic.

Specifically, all generic, multisource, store brand, over-the-counter (OTC), and private label products must be dispensed as generic and priced as a generic. If a physician prescribes a brand name product, the pharmacy is expected to substitute with a generic formulation when one is available unless a prior authorization is provided by the

BHS/MSN Medical Director or designee(s).

2) All medications on the formularies have a quantity limit on the number of units covered in a month’s supply. These quantity limits are formulary limits on the usual dosage for each medication. Prescriptions for quantities in excess of the quantity limits require a prior authorization.

3) BHS/MSN typically cover only a 30-day supply of medications at a time. The formularies contain days’ supply limits on all medications. Any prescriptions that contain days’ supplies different from the formulary limits require a prior authorization.

4) Early refill requirements: Appointment times vary depending on the acuity of the patient and the next available appointments. Accordingly, successful bidder should have means to allow multiple prescriptions for one (1) or two (2) week’s duration of the same medication within a one (1) month period. These early refill prescriptions require a prior authorization.

c. Process and Adjudicate Prior Authorizations.

The BHS Prior Authorization and Manual Client Addition procedures are:

1) Client Authorization Request (CAR). Used by BHS when a client is approved for medication and the client is not in the database. The client is manually entered into the database by BHS staff once the CAR has been approved.

2) Prior Authorization Request (PAR). Used by BHS when a medication is prescribed that is outside of the authorized BHS formulary and in situations where the client has lost or had their medication stolen or is leaving the area for a set period of time. Any in-network physician is authorized to prescribe outside of the formulary for a period of no greater than 30 days. PARs are entered into the database by BHS staff once approved, and the

PAR should override a denial by the database due to the prescription being outside of the formulary.

http://www.ochealthinfo.com/civicax/filebank/blobdload.aspx?BlobID=23977

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3) Treatment Authorization Request (TAR). Used by BHS when a medication is prescribed that is outside of the authorized BHS formulary beyond 30 days. A TAR requires the approval of the BHS Medical Director or designee(s). Once approved, TARs are entered into the database by BHS staff, and the TAR should override a denial by the database.

d. Process Medicare Part D and Medi-Cal with a Share of Cost

1) BHS is payer of last resort, however, when it is determined that the client being served qualifies for any other programs sponsored by state and federal agencies (i.e. Medi-Cal, Medicare, MSN, etc.), also known as coordination of benefits (COB), services provided by BHS do not exclude persons with other coverage. As a result, BHS authorized prescribers prescribe medications for these persons as well.

2) With the Medicare Prescription Drug Coverage Benefit, specifically Part D, BHS desires to ensure that its clients with this coverage are not financially deterred from obtaining their medications and decompensating as a result of not maintaining their medication regimens. Therefore, BHS will cover any out of pocket expenses for clients receiving

Medicare benefits as well as deductibles for clients with private insurance. The desired

Benefit Plan Design for these populations is that in all cases the cost of the medication should be billed to Medicare, Medi-Cal and/or 3rd party payers as appropriate and BHS will only be billed for any remaining out of pocket expenses.

3) When a client has Medi-Cal, Medi-Cal is expected to pay for the medications and not

BHS. However, if a client has a share of cost, BHS will cover the client’s share of cost.

4) MSN does not participate in the Medicare Part D benefit. All program costs are covered by the County of Orange General Fund.

e. MSN Prior Authorization Process - Prior authorization requests, for non-formulary medications, are processed in-house by the care coordination unit (CCU). Requesting prescriber or pharmacist will complete the MSN Drug Authorization form which is reviewed by the CCU nurse for approval/denial.

2. Pharmacy Network Management

a. Prior to May 1, 2019, and as required thereafter, the successful bidder will work with

BHS/MSN Program Managers or designee(s) on written communications to the successful bidder’s network pharmacies, located in the geographical area of Orange County unless otherwise specified, regarding the change from BHS/MSN’s current Pharmacy Benefits

Manager to the successful bidder. The successful bidder’s network contracting and management department shall follow up with written communications, electronic communication (fax, emails, etc.), and phone calls to ensure each participating network pharmacy is aware of the change and has all the necessary information to ensure a smooth transition for BHS/MSN and its clients.

b. The successful bidder is expected to routinely communicate policies and procedures regarding new drugs, therapeutic substitutions, utilization management, adjudication standards and practices (particularly relating to coordination of benefits), periodic informational material, Benefit Plan Design changes or other network changes to the network pharmacies. All such communications requires BHS/MSN Program Manager’s approval prior to distribution.

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1) The successful bidder will ensure that all communication referencing the BHS/MSN

Program, including financial responsibility, clinical issues, or educational materials, with client/patient/member will occur only with the express approval of BHS/MSN. Education materials that may be specifically related to BHS/MSN include, but are not limited to:

a) Formulary and preferred drug lists

b) Policies and procedures related to claims submission

c) New product notifications

d) Communication of new clinical guidelines

e) Policies and procedures related to prior authorizations

f) Patient compliance reminders

g) Policies and procedures related to member grievances

h) Benefits of optimizing generic drugs

c. The successful bidder will manage network pharmacy relationships, including credentialing and contracting, which encompasses pharmacy program compliance, contractual disputes, and re-credentialing.

1) The successful bidder may be requested by BHS/MSN to visit network pharmacies to better communicate with and educate pharmacists on issues that directly impact the BHS clients’ access to medications through the benefit managed by the successful bidder.

2) The successful bidder shall survey pharmacies to better monitor client satisfaction and needs of network pharmacies and shall share the results of these surveys with BHS/MSN at least on a bi-annual basis.

3) If an analysis of the pharmacy network uncovers any pockets of clients who need better access to pharmacies, any local pharmacies not already contracted shall be invited to join the network, if qualified and meets credentialing criteria. Copies of all pharmacy network contracts must be available to BHS/MSN at contract initiation and subsequently at

BHS/MSN discretion for review to ensure compliance with the Contract.

d. The successful bidder is expected to manage and monitor its pharmacy network in order to ensure compliance with respect to:

1) Drug utilization review (DUR) messages

2) Formulary compliance

3) Non-standard Benefit Plan Design (e.g., direct paper program, limited refills, etc.)

4) Usual and customary (U&C) submissions for all claims including all discount pharmacy prices at point of sale.

e. The successful bidder shall conduct at least quarterly audits to determine the accuracy of claims adjudication and to detect potential fraud and abuse. These audits shall also review

BHS/MSN Program formulary compliance. The successful bidder must conduct on-site audits of at least one (1) percent of participating network pharmacies annually and desktop audits of at least 75 percent. From the 75 percent total desktop audits, at least 10 percent

Request for Proposals 18 of 44 Pharmacy Benefits Management Services must be selected for follow-up on-site audits. Successful bidder shall advise BHS of any audit findings.

1) The successful bidder’s desktop audits shall include certain financial variances, formulary and DUR compliance, U&C compliance, and dollar per prescription limits in addition to system parameters.

2) The majority of network pharmacies shall be selected on the basis of their performance history versus other pharmacies servicing the same customer and national averages. If a pharmacy’s performance is outside of the norm, a desktop audit will be performed. If the desktop audit is unable to provide a satisfactory resolution the pharmacy will be scheduled for an on-site audit.

3) Audit criteria used shall include, but not be limited to:

a) Members’ complaints

b) BHS/MSN requests

c) Lower than average generic substitution rate

d) Lower than average formulary compliance

e) High controlled substance percent

f) Higher than average number of prescriptions per BHS client

g) Higher than average days’ supply per prescription

h) Higher than average ingredient cost per prescription

i) Higher than average quantity billed per prescription

4) If an on-site audit is required, successful bidder shall notify the pharmacy and schedule the audit. Successful bidder shall notify BHS/MSN in advance of any on-site audit visits to successful bidder network pharmacies. On-site audits shall include a general review for the following:

a) Compliance with governmental regulations

b) Review of insurance signature logs

c) Formulary awareness

d) Consultations provided

e) Records retention

f) Expired medications

g) Verification of prescription-specific information including:

(1) Patient name

(2) Drug name and strength

(3) Directions for use

(4) Quantity

(5) Number of authorized refills

Request for Proposals 19 of 44 Pharmacy Benefits Management Services

(6) Allowance of generic substitution Dispense as Written (DAW notation)

(7) Quality of service provided to customers

(8) Authorized prescriber identifiers (Name, National Provider Identification

Number, etc.)

5) Based on data analysis during desktop audits, or in the event that a pattern of behavior is seen in the processed claims, successful bidder shall visit selected pharmacies on-site as a follow-up, to provide additional education and guidance to the pharmacy staff.

6) The successful bidder is expected to audit and/or provide information, as directed, on pharmacies identified by BHS/MSN as poor performers or outliers.

7) In the event of fraud detection, successful bidder shall immediately notify BHS/MSN.

After consultation with BHS/MSN, and depending on the severity of the offense, successful bidder shall either provide additional education about the infraction to the offending pharmacy or remove the pharmacy from the network.

8) Any monies recovered from pharmacy audits are to be credited to the appropriate party.

f. The successful bidder must provide a pass through arrangement with BHS/MSN, and therefore, shall not keep any spread on drugs, including brands and generics paid on the maximum allowable cost (MAC) fee schedule, purchased through network pharmacies and the amount billed to BHS/MSN.

1) The successful bidder shall provide regular reports designed to ensure that the pass through arrangement is appropriate and provides value to BHS/MSN and the County

Quality Assurance (QA) contractor.

2) The successful bidder must provide complete and clean claims to BHS/MSN and the

County QA contractor including, but not limited to, valid prescriber National Provider

Identification (NPI) identifiers, valid and active National Drug Code (NDC) numbers, valid pharmacy NPI numbers, etc. Clean claim means a claim that has no defect, impropriety, or special circumstance, including incomplete documentation that delays timely payment. Claims data must be provided with each invoice in National Council for

Prescription Drug Program (NCPDP) D.0 and/or 2.2 batch formats (including the submit and response parts of the data) as directed by BHS/MSN and the County QA contractor.

Claims data must include support for every PA, DUR, and early refill.

3) The successful bidder shall allow the County pharmacy consultant/quality assurance/auditor to audit payments and contracts to ensure compliance with all contract provisions. This shall include any services that are performed on behalf of BHS/MSN.

Successful bidder may require the County pharmacy consultant/quality assurance/auditor to sign non-disclosure agreement and said agreement shall not require signature of

BHS/MSN.

g. The successful bidder will provide a pharmacy network located within the borders of Orange

County to allow for filling prescriptions of eligible clients, unless otherwise specified by

BHS/MSN.

1) Payment shall be limited to successful bidder’s network pharmacies.

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2) All pharmacy claims to successful bidder must be submitted within 60 days of the date of service. Claims submitted after this timeframe will be denied at BHS/MSN discretion.

3) The successful bidder will pay pharmacies in accordance with its contracts with its network pharmacies.

3. Customer Service

a. The successful bidder will maintain a call center with telephone numbers dedicated to facilitating communication with the BHS/MSN, BHS/MSN contractors and pharmacy successful bidders submitting claims for BHS/MSN. Successful bidder must have a call center with toll-free telephone number(s) for the purpose of answering pharmacy related questions, client and BHS/MSN questions, troubleshooting issues and giving general information to BHS/MSN clients and staff.

b. The successful bidder’s customer service call center shall manage pharmacy communications. Customer service call center must feature live agents who answer the phone

24 hours a day, seven days a week, 365 days a year. Pharmacists shall be available during regular business hours to take calls that are transferred from the customer service area.

Successful bidder will ensure emergency access to a registered pharmacist 24 hours a day.

The call center shall handle inquiries from network pharmacies to clarify coverage and prescription information for the BHS/MSN Programs. Successful bidder will also ensure immediate response to pharmacy questions through access to Benefit Plan Design data, patient profiles and drug history, online and in real time.

c. The successful bidder is expected to use a call management tracking system to log calls and establish an escalation procedure to handle caller inquiries. Each call must be logged and given a code that translates into the type of call received (e.g. eligibility, pharmacy location, co-pay or benefit question, etc.). Information to be collected and documented by the customer services representative will include the name of the pharmacy, the name of the caller, the problem and the solution. Any issue dealing with the potential blocking of access to eligible clients will be treated with the utmost urgency until resolved as these issues are the most likely to create liability for BHS/MSN. The successful bidder must have procedures for handling client concerns including timeline for solution and method for communicating issue and results to BHS/MSN.

d. The successful bidder shall train the customer service representatives in the intricacies of the

Benefit Plan Design. The successful bidder will provide the customer service representatives written reference information regarding the Benefit Plan Design, as approved by the

BHS/MSN Program Managers or designee(s). Specific documentation for the customer service department shall be created by the successful bidder based upon the needs of

BHS/MSN and corresponding Benefit Plan Design. The successful bidder shall provide follow-up refresher training at regular intervals to ensure that all staff members can accurately resolve all issues pertaining to medication access to eligible clients. In addition, successful bidder shall track all calls and monitor random calls for quality assurance purposes and provide BHS/MSN with quarterly statistics on call performance.

e. The successful bidder must have the ability to access AT&T’s Language Line or other

County approved contractor for immediate interpreter services for non-English speaking

Request for Proposals 21 of 44 Pharmacy Benefits Management Services clients. For the hearing and speech impaired, successful bidder must provide TDD-TTY telecommunications.

f. The successful bidder shall hold monthly meetings with BHS/MSN in the first quarter and quarterly meetings thereafter.

g. The successful bidder shall provide BHS/MSN with a quarterly performance guarantee report card.

h. The successful bidder shall provide guarantees and financial penalties for failure to meet time commitments in providing data, web page capabilities, reports, etc.

i. The successful bidder shall provide guarantees and financial penalties for failure to provide complete electronic claims detail to support each invoice. BHS/MSN expects that administrative fees will be waived for failure to provide required data.

j. The successful bidder shall provide BHS/MSN with guarantees and financial penalties for eligibility inaccuracy.

k. The successful bidder shall screen all invoices for accuracy and deny payment for invalid claims. The provider will provide a performance guarantee for resolution of the denied claims by the next invoice cycle.

l. Provider is expected to minimize turnover of the account management team. BHS/MSN requires to be informed within 30 days of an account management team member change

m. The successful bidder must be able to provide written communication in threshold languages (Spanish, Vietnamese, Korean, Arabic, Farsi, etc.). BHS/MSN retains the option to translate necessary materials into other languages and provide said materials to successful bidder for use and distribution to BHS/MSN clients as appropriate.

1) All patient communication, other than appropriate for dispensing/refilling a prescription, must be approved by the BHS/MSN Program Managers or designee(s).

2) The BHS/MSN Program Managers or designee(s) retains the right to determine if communications are of marketing or other nature that is inconsistent with BHS/MSN

Program policies.

4. IT Requirements regarding the BHS/MSN Eligibility Files

a. The successful bidder must have the capacity to receive from BHS/MSN, via a secure file transfer method, daily eligibility files.