122436 O5 - Attachment C1 - Confirmations & Questionnaire.xlsx
XLSX spreadsheet 49 KB Posted
- Solicitation number
- 122436 O5
- Issued by
- Blaine County, Nebraska
About this file
This document is a Confirmations & Questionnaire attachment (Attachment C1) for RFP #122436 O5, issued by the State of Nebraska for Administrative Support Services for the state's employee health care prescription drug benefit plans. The solicitation seeks a Pharmacy Benefit Manager (PBM) to provide comprehensive administrative services for approximately 13,600 enrolled members, including active employees, pre-65 retirees, COBRA participants, and their dependents. The RFP was released on June 9, 2025, with proposal responses due by July 18, 2025, and an anticipated contract award in October 2025. The initial contract term will run through June 30, 2029, with options to renew for two additional one-year periods, with the benefit plan year commencing on July 1, 2026.
The procurement focuses on a self-funded PBM administrator with transparent pricing models, including guaranteed minimum AWP discounts for brand and generic medications, and comprehensive rebate guarantees. The cost structure includes per member per month (PMPM) administrative fees, with an estimated consistent enrollment of around 28,386 members throughout the contract period. Evaluation criteria include 25 points for Corporate Overview, 55 points for Technical Response, and 20 points for Cost, with potential additional points for vendor demonstrations. The state requires a dedicated Account Management Team, HIPAA compliance, and performance guarantees with potential financial penalties ranging from $2,000 to $50,000 per occurrence, emphasizing a rigorous and performance-driven procurement process.
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Instructions
| ATTACHMENT C - CONFIRMATIONS & QUESTIONNAIRE | Bidder: | NAME |
| SOLICITATION NUMBER - 122436 O5 |
| Instructions for Completing this Questionnaire Workbook |
| • Provide succinct yet informative responses. |
| • Bidder should complete all questions in this Questionnaire. |
Confirmations
| ATTACHMENT C - CONFIRMATIONS & QUESTIONNAIRE | Bidder: |
| SOLICITATION NUMBER - 122436 O5 | NAME |
| All Bidders must comply with the following conditions regarding the RFP. Confirm your capability to meet each of the following with a response of Confirmed or Not Confirmed. If your response varies by the plan option(s) you are quoting, please explain. If a Bidder takes exception to any of these confirmations, it must be clearly noted. These confirmations will also explicitly apply to any subcontractors used. | ||
| Confirmations | Vendor Response | |
| A. | GENERAL | Response (Confirmed/Not Confirmed) |
| A.1 | PBM agrees the State has the right to terminate the contract for any reason without penalty of any kind upon ninety (90) days-notice. The State will receive all rebates accrued during the tenure of the contract. | |
| A.2 | PBM agrees the State reserves the right to audit the State’s PBM claim records, and any other financial records as they pertain to the pharmacy benefit program, whenever the State deems it appropriate, using whatever methodology and vendor they choose. Such claim audits may be performed by the State’s personnel or by outside auditors selected by the State. | |
| A.3 | PBM agrees if selected as a finalist, to provide a signature ready contract and that your responses to the RFP, including all attachments, will be included as an attachment to the contract. The State reserves the right to negotiate additional changes to the final contract. | |
| A.4 | PBM agrees it shall provide a fully pass-through network, meaning it will bill the State the same as it reimburses network pharmacies for retail, mail order, and specialty drug claims. The PBM shall also pass-through 100% of Rebates to the State. All business practices, processes, and sources of revenue must be fully disclosed upon request. | |
| A.5 | PBM agrees the State reserves the right to carve-out specialty and mail order drug fulfillment and/or utilization management if it determines it is financially advantageous to do so. | |
| A.6 | PBM agrees to develop a member satisfaction survey approved by the State to be sent to each plan member, conduct the survey, and collect and report respondent results on an annual basis at no additional cost to the State. | |
| A.7 | PBM agrees to provide easy-to-access management reports approved by the State in Excel or in a format that can be exported to Excel at least quarterly and as otherwise requested by the State. | |
| A.8 | PBM agrees to abide by all Federal and State laws and requirements throughout the contract term. | |
| A.9 | PBM will not render or administer services off-shore, and all work performed will be in the contiguous United States. | |
| B. | CONTRACT DEFINITIONS | Response (Confirmed/Not Confirmed) |
| B.1 | Contract Definitions | |
| a. AWP (Average Wholesale Price) –The actual reported "AWP" from Medi-Span for the specific NDC-11 on the Day of Service for all channels (i.e., Retail, Mail, and Specialty). Claims will not use an average AWP or pre-settlement AWP, nor will the AWP be externally calculated, altered, or adjusted. Claims at Mail and Specialty pharmacies will use the AWP of the actual package size and NDC-11 used to dispense (not the package size of the prescription dispensed or alternative package sizes). | ||
| b. Brand Drug - For adjudication purposes, a drug that is approved by the U.S. Food and Drug Administration (FDA) and is distributed under an FDA Application Type of new drug application (NDA) or biologic license application (BLA), and which is not an Authorized Generic and which is not a House Generic. In instances where the Brand or Generic status of a drug, as determined by the Contractor relying on an independent published source, differs from this definition, the Contractor may rely on its standard drug classification system for operational purposes of claim adjudication. All Brand Pricing Guarantees will be reconciled based on Medi-Span multi-source code field M, N, or O, excluding House Generics, as defined herein, and shall mean drugs or devices for which the Medi-Span Multisource Code field contains “M” (co-branded product), or “N” (single source brand), or “O” (originator). If the multi-source code in Medi-Span is "O", and there is a DAW code of 3, 4, 5, 6, or 9, the drug shall be considered a generic. | ||
| c. Biosimilar - A FDA-approved type of biological product that is highly similar to and has no clinically meaningful differences in terms of safety and effectiveness from its respective FDA-approved biological reference product, under Section 351(k) of the Public Health Service Act, as added by the Biologics Price Competition and Innovation Act of 2009. | ||
| d. Claim - Prescription drugs, over the counter (OTC) products, drug products, medical supplies, or medical devices that are processed and paid through PBM's adjudication system or otherwise transmitted/processed by the PBM in accordance with State's applicable benefit plan design. Bidder agrees its financial bid is based on approved and Paid Claims only and will exclude all rejected, withdrawn, denied and/or reversed Claims. | ||
| e. Compound Drug - A medication that requires compounding by pharmacists because it is not available from a pharmaceutical manufacturer in the prescribed form or strength. Compound drugs consist of two or more solids, semi-solids, or liquids where at least one of which is a Covered Product. | ||
| f. Covered Product – The prescription drugs, supplies, and other items that are covered under the Benefit or treated as covered pursuant to a coverage determination appeal. | ||
| g. Generic Drug - For adjudication purposes, a drug that is approved by the U.S. Food and Drug Administration (FDA) and is distributed under an FDA Application Type of abbreviated new drug application (ANDA), or which is an Authorized Generic or which is processed as a House Generic. In instances where the Brand or Generic status of a drug, as determined by the Contractor relying on an independent published source, differs from this definition, the Contractor may rely on its standard drug classification system for operational purposes such as claim adjudication. All Generic Pricing Guarantees will be reconciled based Medi-Span multi-source code filed of Y or House Generic, as defined herein. | ||
| h. Authorized Generic Drug - Any drug sold, licensed, or marketed under a new drug application (NDA) approved by the Food and Drug Administration (FDA) under section 505(c) of the Federal Food, Drug, and Cosmetic Act (FFDCA) that is marketed, sold or distributed under a different labeler code, product code, trade name, trademark, or packaging (other than repackaging the listed drug for use in institutions) than the Brand Drug. | ||
| i. House Generic Drug - A drug with the multi-source code field in Medi-Span of O when there is a DAW code of 5. | ||
| j. Ingredient Cost - The total cost for a Covered Product on a Paid Claim, excluding Administrative Fees, Copay, Dispensing Fees, POS Rebates, government-imposed service fees, and taxes, in accordance with the terms of the Plan. | ||
| k. MAC – maximum allowable cost. | ||
| l. Rebates – Compensation or remuneration of any kind received or recovered from a pharmaceutical manufacturer or rebate aggregator attributable to the purchase or utilization of covered drugs by eligible persons, including, but not limited to, incentive rebates categorized as mail order purchase discounts; credits; rebates, regardless of how categorized; market share incentives; promotional allowances; commissions; educational grants; market share of utilization; drug pull-through programs; implementation allowances; clinical detailing; rebate submission fees; and administrative or management fees. Rebates also include any fees that PBM receives from a pharmaceutical manufacturer for administrative costs, formulary placement, and/or access. | ||
| m. Manufacturer Administrative Fees - Those fees received by PBM or PBM's Affiliate(s) from pharmaceutical manufacturers or intermediaries pursuant to a contract between PBM or PBM's Affiliate(s) and a drug manufacturer to manage placement of Covered Products on PBM's Formulary and administering, invoicing, allocating and collecting Rebates that are attributable to Covered Products dispensed to Members. | ||
| n. Formulary – The list of clinically appropriate Covered Products covered by the State, organized into different tiers or levels indicating potential member cost share for each Covered Product. | ||
| o. Copay – The portion of the charge for each Covered Product dispensed to a Member that is the responsibility of such enrollee (e.g., copayment, coinsurance, cost sharing, and/or deductibles under initial coverage limits and up to annual out-of-pocket thresholds) as provided under the Benefit. | ||
| p. Paid Claims – Defined as all transactions made on eligible members that result in a payment to pharmacies or members from the State or State member copays. (Does not include reversals and adjustments.) Each unique prescription that results in payment shall be calculated separately as a paid claim. | ||
| q. Member – All eligible employees and their eligible dependents enrolled under the State prescription benefit program. | ||
| r. Market Check – An evaluation of prescription drug pricing based on benchmarks derived from existing market PBM agreements of comparable plans. | ||
| s. 340B Claim - A Claim identified by the submission of "20" in the Submission Classification Code field 420-DK and/or a Claim submitted by a pharmacy owned by a covered entity, as defined in Section 340B(a)(4) of the Public Health Services Act, whose 340B status is coded as "39" in the NCPDP DataQ database. Claims incurred at a PBM owned, operated, or affiliated mail or specialty pharmacy are not included in this definition. | ||
| t. GCN – A five-character numeric figure that represents the clinical formulation; it is specific to active ingredient list, route of administration, dosage form, and drug strength. | ||
| u. GPI or GP14 - Generic Product Identifier reported by Medi-Span. It is a 14-character hierarchical classification that identifies drugs from their primary therapeutic use down to the unique interchangeable product regardless of manufacturer or package size. | ||
| v. U&C Price (Usual and Customary) – The actual retail price charged by a Participating Pharmacy for a specified drug if purchased in a cash transaction on the date the drug is dispensed, as reported to Supplier by the Participating Pharmacy. | ||
| w. ZBD Claim (Zero Balance Due) – Any claim for which the Member is response under the applicable Benefit Plan for the full amount of the Claim's Gross Drug Cost and State is responsible for no portion of the Claim's Gross Drug Cost. | ||
| B.2 | Minimum Brand and Minimum Generic Discount Guarantees for both mail and retail shall be defined as follows: (1 – Aggregate Ingredient Cost/Aggregate AWP) | |
| a. Aggregate Discounted Ingredient Cost prior to application of plan specific copayments will be the basis of the calculation. | ||
| b. Aggregate AWP will be sourced from Medi-Span. | ||
| c. Dispensing Fees are not included in the Aggregate Ingredient Cost. | ||
| d. Zero Balance Due claims will be included in the guaranteed measurement for AWP, ingredient cost, achieved discounts or dispensing fee calculations at the discounted cost before copay. | ||
| e. All guarantee measurements shall be calculated prior to the Copay being applied. Entire dollar-for-dollar shortfalls, prior to the application of Copay, will be reimbursed to the State without any adjustments to remove zero balance due or excess copayment claims. | ||
| f. Both the Aggregate Ingredient Cost and Aggregate AWP from the actual date of claim adjudication will be used. | ||
| g. Aggregate AWP will be the date sensitive, 11-digit NDC of the actual product dispensed at both retail and mail and specialty. | ||
| h. Non-MAC, MAC, single-source, and multiple source generic products are to be included in the generic guarantee measurement (regardless of the exclusivity period and/or number of manufacturers) and excluded from brand guarantee measurement. | ||
| i. Compounds, OTC claims, and claims with ancillary charges will be excluded from the guarantee measurements for retail and mail order components. | ||
| j. The guarantee measurement must exclude the savings impact from DUR programs, formulary programs, utilization management programs, and/or other therapeutic interventions. | ||
| k. Measurement will be performed annually via independent audit utilizing date-sensitive AWP derived from a single, nationally recognized price source for all claims. | ||
| B.3 | PBM agrees to provide upon request any proprietary algorithms, hierarchy or other logic employed to define a prescription drug as generic or brand. | |
| C. | FINANCIAL - GENERAL | Response (Confirmed/Not Confirmed) |
| C.1 | PBM will invoice the State weekly for claims and once monthly for administrative services. | |
| C.2 | PBM agrees to bill administration fee on a fixed-fee, per Member per month basis. | |
| C.3 | There are NO additional fees (beyond those outlined in the financial section) required to administer the services outlined in this Proposal. Any mandatory fees, including clinical and formulary programs fees, must be clearly outlined in the Financial Section. | |
| C.4 | All fees include the cost of claims incurred/filled during the effective dates of this contract regardless of when they are actually processed and paid (run-out). | |
| C.5 | PBM agrees to review and negotiate the pricing applied to newly introduced generic drugs annually. | |
| C.6 | PBM agrees to adjudicate prescription claims for compound medications with the same dispensing fees and logic associated with traditional claims. | |
| C.7 | All pricing will be effective and guaranteed for the term of the agreement and will not include adjustments for claims volume shifts amongst the various provider channels (e.g., mail utilization rates decline or 90-day retail utilization increases). | |
| C.8 | Confirm all pricing will be effective and guaranteed for the term of the agreement and will not be modified or amended if the State’s membership decreases by 20% or less. | |
| C.9 | All applicable administrative fees will be on a per member per month basis. | |
| C.10 | Each distinct pricing guarantee (including rebates) will be measured and reconciled on a component (e.g. retail brand, retail generic, retail 90 brand, retail 90 generic, mail order brand, mail order generic, specialty brand drugs at participating retail pharmacies, specialty brand drugs at the PBM’s Specialty Pharmacy, specialty generic drugs at retail, specialty generic drugs at PBM’s Specialty Pharmacy) basis only and guaranteed on a dollar-for-dollar basis with 100% of any shortfalls recouped by the State. Surpluses in one component will not be utilized to offset deficits in another component. | |
| C.11 | PBM will provide a financial reconciliation report within 60 days after the end of each measurement period, and the report will include the contractual and actual discounts and dispensing fees for each component (e.g., retail brands, retail generics, mail brands, mail generics, specialty drugs via Participating Retail Pharmacies, specialty drugs via the PBM’s Specialty Pharmacy). | |
| C.12 | PBM agrees that any shortfall between the actual result and the minimum guarantee will be paid, dollar-for-dollar, to the State within 90 days of the end of the measurement period. | |
| C.13 | PBM ’s financial reconciliation that occurs after the end of the measurement period will use the lower of the AWP pricing at the point of adjudication or the retroactive AWP pricing, if the pricing source the PBM uses issues retroactive AWP pricing for that annual reconciliation time period. | |
| C.14 | PBM agrees to the use of a single, consistent Maximum Allowable Cost (MAC) list for each drug (NDC-level). PBM agrees to share the MAC list with the State for pricing verification on a quarterly basis, and whenever new drugs are added or upon request. | |
| C.15 | All pricing submitted will NOT be 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 State. Further, the pricing guaranteed in the Financial Section of this RFP reflects a) the PBM’s broadest national network and b) the PBM’s proposed formulary, without mandated utilization management unless otherwise authorized or requested by the State. | |
| C.16 | All pricing will NOT be contingent on specific utilization patterns. For instance, pricing terms contingent on limited utilization in a specific geographic location (e.g., Nebraska) is unacceptable. | |
| C.17 | PBM will NOT implement or administer or allow any program that results in the conversion from lower discounted ingredient cost drug products to higher ingredient cost drug products without the prior written consent of the State or its designee. | |
| C.18 | PBM agrees to annual Market Checks conducted by an independent third party (of the State’s choosing) to ensure the State is receiving market competitive pricing terms within the industry based on its volume and membership and will improve pricing in the event that the State’s contract terms are less than market competitive. | |
| C.19 | PBM agrees to implement new pricing to commence at the beginning of the following plan year. Acceptance of the new pricing will NOT result in extension of the contract, unless requested by the State. | |
| C.20 | Mail order pricing and rebates will apply to all claims that adjudicate at mail regardless of days’ supply. | |
| C.21 | PBM agrees that mail order and specialty drug dispensing fees will remain constant throughout the contract term and will not be increased for any increases in postage charges. | |
| C.22 | PBM will guarantee Retail/Mail Order unit cost equalization, meaning that Mail Order unit costs prior to member cost sharing, dispensing fees, and sales taxes charged to the State will be no greater than the unit cost for the same NDC-11 at Retail. | |
| C.23 | PBM agrees to produce a date-sensitive comparison report showing unit costs charged to the State at a GCN-level, and reimburse the State on a dollar-for-dollar basis for all instances where mail order unit costs exceed retail unit’s costs. Report and reconciliation will be provided on an annual basis. | |
| C.24 | The State will be notified of any switch in the AWP source at least 180 days prior to the change. In the event that the AWP source change is not determined by a third party to be price neutral for the State, the State will have the right to terminate the contract with no penalty. | |
| C.25 | PBM will be responsible for collecting any outstanding member cost shares for prescriptions dispensed through the mail order facility. The PBM will not invoice the State for any uncollected member cost shares. | |
| C.26 | The State will have the ability to adjust “refill-too-soon” limits at both retail and mail without any modifications to the guaranteed pricing. | |
| C.27 | PBM agrees to provide weekly and/or monthly data transmissions to any other relevant State vendors at no charge, and two full, annual electronic claims files, in NCPDP format, at NO charge. PBM will also interact/exchange data with all vendors as required at no additional charge. | |
| D. | FINANCIAL - REBATES | Response (Confirmed/Not Confirmed) |
| D.1 | Guaranteed rebates per brand will be based on all Brand prescriptions dispensed, not only on formulary prescriptions dispensed. | |
| D.2 | Rebates are guarantees on a minimum (i.e., not fixed) basis, and the PBM will pass through 100% of the rebates through to the State. | |
| D.3 | Over-performance of minimum rebate guarantees will not be used to offset performance guarantee shortfalls in any other pricing guarantees. | |
| D.4 | Rebates will not be withheld for execution of any contract amendments. The State is entering into a three-year agreement and needs no annual renewals/amendments signatures for payment of rebates. | |
| D.5 | PBM will reconcile rebate guarantees to verify that the State is receiving the guaranteed rebates and provide rebate payments and reports listing detailed rebate utilization and calculations to the State quarterly, within sixty (60) calendar days of the quarter’s close, without a request being made by the State. | |
| D.6 | PBM will provide the annual rebate report within 180 days of the end of each contract year. Any shortfall between the actual result and the minimum rebate guarantees will be paid, dollar-for-dollar, to the State within 180 calendar days of the end of the contract year. | |
| D.7 | All rebate revenue earned by the State will be paid to the State regardless of its termination status as a client. Lag rebates will continue to be paid to the State after termination until 100% of earned rebates are paid. | |
| D.8 | PBM agrees to produce an auditable quarterly report demonstrating pass-through rebates. PBM will attach a sample of the report they intend to use as part of their response. | |
| E. | FORMULARY MANAGEMENT | Response (Confirmed/Not Confirmed) |
| E.1 | PBM agrees to provide written notification to the State or its designee at least 90 days in advance when a Formulary drug is targeted to be moved to or from the Formulary drug list. PBM must provide a detailed disruption and financial impact analysis at the same time. No greater than five percent (5%) of Members will be disrupted by any formulary deletions or all deletions in total, on an annual basis. | |
| E.2 | PBM agrees to send timely notification letters to affected Members and their prescribing physicians of drug formulary changes or other changes where there is a negative impact to Member at no additional fee. | |
| E.3 | PBM agrees to remove drugs from coverage or the Formulary at most two times per year (7/1 and 1/1) and no greater than five percent (5%) of participants will be disrupted by any formulary deletions or all deletions in total, on an annual basis (except where a Generic drug is replacing a Brand drug). | |
| F. | PHARMACY NETWORK MANAGEMENT | Response (Confirmed/Not Confirmed) |
| F.1 | PBM will not withhold any financial recoveries from audits performed on the contracted pharmacy network including mail order and specialty pharmacies. Any recoveries will be disclosed and credited to the State. | |
| F.2 | PBM agrees that it will not remove any participating network pharmacies that impact greater than 2% of the State’s prescriptions without communicating to the State at least sixty (60) days in advance of the scheduled change. If the change is not agreeable to the State, the State will have the right to terminate the agreement without penalty. | |
| F.3 | PBM agrees to provide network geo-access reporting to the State upon request and to maintain targeted access levels throughout the contract term and such access shall include independent pharmacies throughout the State and nationally. | |
| F.4 | PBM agrees to not introduce any new drug or therapeutic category limitations to any participating network pharmacies during the term of the contract. | |
| G. | AUDITING & AUDIT RIGHTS | Response (Confirmed/Not Confirmed) |
| G.1 | PBM agrees that all financial pricing components (discounts, dispensing fees, rebates) are subject to independent, electronic audit utilizing date sensitive AWP information on an NDC level from a nationally recognized pricing source (e.g., MediSpan). | |
| G.2 | The State or its designee will have the right to audit annually, with an auditor of its choice, (for both claims and rebates), with full cooperation of the selected PBM, the claims, services and pricing and/or rebates, including the manufacturer or aggregator rebate contracts held by the PBM, to verify compliance with all program requirements and contractual guarantees with no additional charge from the PBM. | |
| G.3 | The State or its designee will have the right to audit up to 36 months of claims data at no additional charge from the PBM. | |
| G.4 | The State or its designee will have the right to audit, with an auditor of its choice, at any time provided the State gives 90-days advance notice. | |
| G.5 | PBM will provide complete claim files and documentation (i.e., full claim files, financial reconciliation reports, inclusion files, and plan documentation) to the auditor within 30 days of receipt of the audit data request as long as a non-disclosure agreement is in place between the auditor and the PBM. | |
| G.6 | PBM agrees to a 30-day turnaround time to provide the full responses to all of the sample claims and claims audit findings. | |
| G.7 | PBM agrees to financial guarantees for turnaround times for each stage of the audit process. | |
| G.8 | PBM will correct any errors that the State, or its representative, brings to the PBM’s attention whether identified by an audit or otherwise. | |
| G.9 | The State or its designee will have the right to audit up to 12 pharmaceutical manufacturer contracts during an on-site rebate audit. | |
| G.10 | The State’s right to audit shall survive the termination of the agreement between the parties for a period of 3 years. | |
| G.11 | The State will not be held responsible for time or miscellaneous costs incurred by the PBM in association with any audit process including, all costs associated with provision of data, audit finding response reports, or systems access, provided to the State 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. | |
| H. | HIPAA COMPLIANCE | Response (Confirmed/Not Confirmed) |
| H.1 | PBM certifies that all personnel/staff in PBM's organization have completed their initial HIPAA training and will continue to complete HIPAA training on an annual basis. | |
| H.2 | PBM will provide a copy of their most recently completed HIPAA assessment with their RFP submission. | |
| H.3 | In the event of a privacy violation or data breach, PBM will provide any required remedies to resolve the violation/breach. | |
| H.4 | PBM agrees to hold the State harmless for any HIPAA Violations made by the PBM and its Network Pharmacists. | |
| I. | PLAN DESIGN | Response (Confirmed/Not Confirmed) |
| I.1 | PBM agrees to duplicate the plan features and level of coverage presently offered to the State’s covered member population. | |
| I.2 | PBM will ensure its proposal is issued in accordance with the specifications and information, including the full Summary Plan Descriptions (SPD) of each plan offered by the State, referenced in this RFP. PBM is required to review each plan SPD provided online at the State of Nebraska website for plan design and coverage provisions. | |
| I.3 | All deviations of your ability to administer the current plan designs and coverage provisions must be CLEARLY identified. The State reserves the right to modify and/or change plan designs on an annual basis at no additional cost to the State. All deviations from the plan design requirements will be scored accordingly. | |
| J. | IMPLEMENTATION, OPEN ENROLLMENT, AND COMMUNICATION | Response (Confirmed/Not Confirmed) |
| J.1 | PBM shall provide an implementation plan assuming a December 1, 2025 contract award. At a minimum, the Implementation Project Plan must provide specific details on the following: |
a. Identification and timing of significant responsibilities and tasks
b. Names, titles, and experience of key implementation staff and time dedicated to the State during implementation
c. Identification and timing of the State's responsibilities
d. Transition requirements with the incumbent vendors
e. Staff assigned to attend and present (if required) at Open Enrollment
f. Data and timing requirements from current vendors to ensure transition of care and transfer of any open-refill, prior authorization, or other necessary files
| J.2 | Confirm implementation will be completed prior to the State’s Annual Open Enrollment period in May 2026. The implementation plan(s) shall also define responsibilities assigned to the contractor and responsibilities assigned to the State. Failure to provide this information may be grounds to reject a proposal. | |
| J.3 | After J.2, please add: Confirm that, if awarded the business, you will be prepared to start implementation work as of the contract award date due to the lead time needed for open enrollment. | |
| J.4 | PBM must provide a dedicated implementation manager whose sole account is the State, who in coordination with the dedicated account manager and account management team, will effectively manage the implementation of this program. The dedicated implementation manager must continue to support the State a minimum of 60 days after the Go Live date of July 1, 2026, should the State desire. Such support includes, but is not limited to: weekly calls with the State and the designated Account Management team; maintenance of issue tracking logs; and issue resolution. This support must be provided as part of the base administrative fees with no additional cost to the State. | |
| J.5 | The State requires that the PBM will be available and participate in the State’s Open Enrollment communications campaign. | |
| J.6 | PBM shall provide detailed information on its procedures and time frame to prepare for annual Open Enrollment. The State will offer an annual Open Enrollment period during which time covered members may switch their plan of coverage. The successful contractor shall provide staff to assist State HR Personnel and Administrative Services – State Employee Benefits with annual Open Enrollment meetings in various locations throughout the State. The successful contractor shall have certificate books ready for distribution prior to the State’s annual Open Enrollment; State will provide plan designs electronically to Contractor 30 days prior to annual Open Enrollment. Describe your company's timelines and deadlines for Open Enrollment (system updates due to plan changes or file formats, new divisions, manual work arounds, dates for last pre-OE updates, OE file updates, etc.). | |
| J.7 | PBM shall incur all costs for printing and distribution of all communications, including but not limited to: | |
| a. Identification Cards (ID) printed | ||
| b. Booklets electronic copy provided | ||
| c. Certificates electronic copy provided | ||
| d. Summary Plan Descriptions (SPDs) electronic copy provided | ||
| J.8 | PBM shall incur all costs for additional open enrollment materials, including but not limited to: | |
| a. Additional custom printing | ||
| b. Web hosting | ||
| J.9 | When customized printing is required, the PBM shall present a proof to the State for approval in a timely manner. | |
| J.10 | PBM agrees that if they become the successful contractor that no external communications material that mentions the State's benefit plans may be circulated without written approval from the State. The State reserves the right to review, edit, or customize any communication from the PBM to its membership. | |
| J.11 | PBM shall provide detailed information on how it will communicate to the members. PBM must provide sample communication materials such as certificate of coverage booklets, up-to-date-provider network directories, request letters for clinical programs, and sample EOBs. | |
| J.12 | PBM shall provide members access to written or electronic EOB statements at no cost to the State or member. | |
| J.13 | PBM shall produce ID cards and/or temporary proof of benefit letters in “real time”. Identification cards will be subject to final approval by the State. | |
| J.14 | PBM agrees that 100% of ID cards will be distributed within 10 business days of being notified of the new or changed enrollment by the State. | |
| J.15 | PBM agrees that replacement ID cards must be mailed within ten (10) business days of notification. | |
| J.16 | Confirm that ID cards will be subject to final approval by the State. | |
| J.17 | PBM agrees to in-person meetings with the State as required to discuss plan performance, present utilization and financial results, etc. at PBM’s expense. At a minimum, the State expects that the Account Executive and Clinical Pharmacist attend these meetings. | |
| J.18 | Confirm you will provide a dedicated 24-hour toll-free customer service phone line available during Open Enrollment as well as throughout the year. | |
| K. | VENDOR ACCOUNTABILITY AND PERFORMANCE GUARANTEES | Response (Confirmed/Not Confirmed) |
| K.1 | Minimum performance standards are included in Attachment D – Performance Guarantees. PBM must provide these standards measured on State specific data. Confirm agreement. | |
| K.2 | The State requires that 30% of the Administrator’s annual PBM Fees be placed at risk annually as a financial penalty for failure to meet the administrative performance guarantees in accordance with Attachment D, as established by the State of Nebraska. All penalties will be assessed based on these pre-established guarantees against actual State-specific performance results annually, not the bidder’s book of business. Confirm agreement. | |
| K.3 | The State requires that 30% of the Administrator’s PBM Fees be placed at risk as a financial penalty for network discount guarantees provided by the PBM. All penalties will be assessed based on the State-specific annual performance results only. Confirm agreement. |
&F Page &P of &N
Questionnaire
| ATTACHMENT C - CONFIRMATIONS & QUESTIONNAIRE | Bidder: | NAME |
| SOLICITATION NUMBER - 122436 O5 |
| Questionnaire Section | Section | Response | |
| A | EXPERIENCE AND REFERENCES | Experience | RESPONSE |
| A.1 | Provide three references of clients. At least one reference should include a Public Sector group with at least 15,000 lives. | Experience | |
| Reference #1: | Experience | ||
| a. Company Name | Experience | ||
| b. Contact Person | Experience | ||
| c. Title | Experience | ||
| d. Telephone # | Experience | ||
| e. E-mail Address | Experience | ||
| f. Total Membership | Experience | ||
| g. Tenure (Years) | Experience | ||
| Reference #2: | Experience | ||
| a. Company Name | Experience | ||
| b. Contact Person | Experience | ||
| c. Title | Experience | ||
| d. Telephone # | Experience | ||
| e. E-mail Address | Experience | ||
| f. Total Membership | Experience | ||
| g. Tenure (Years) | Experience | ||
| Reference #3: | Experience | ||
| a. Company Name | Experience | ||
| b. Contact Person | Experience | ||
| c. Title | Experience | ||
| d. Telephone # | Experience | ||
| e. E-mail Address | Experience | ||
| f. Total Membership | Experience | ||
| g. Tenure (Years) | Experience | ||
| A.2 | For your entire book of business, provide the total year-end national group members. Please also provide statistics for your Public Sector clients. | Experience | |
| Total Covered Lives (excluding non-insured discount programs) | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| Public Sector Covered Lives (excluding non-insured discount programs) | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| Number of Public Sector Clients | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| Number of Public Sector Clients with 15,000+ lives | Experience | ||
| 2024 | Experience | ||
| 2023 | Experience | ||
| A.3 | Explain your revenue model | Experience | |
| A.4 | Do you consider your solution a transparent PBM model? | Experience | |
| a. If yes, how long have you offered a transparent PBM model? | Experience | ||
| b. Do you have accounts that are not a transparent PBM model? | Experience | ||
| c. If yes, what percentage of your book of business in on a non-transparent PBM model? | Experience | ||
| A.5 | What has your average trend (claim inflation rate) been for the last 4 years, by year, for middle and enterprise market segments. | Experience | |
| A.6 | Does your firm participate in the business model of "claw backs" for any commercial / public plans? Please elaborate. | Experience | |
| B | ACCOUNT MANAGEMENT | Acct Mgmt | RESPONSE |
| B.1 | Confirm that the proposed account management team has at least three (3) years working with Public Sector group pharmacy drug benefit plans having at least 15,000 employees. | Acct Mgmt | |
| B.2 | Confirm you will provide an Account Executive and a backup account staff member that will handle ALL service matters related to the operation of the program. | Acct Mgmt | |
| B.3 | Confirm you will respond to all State inquiries within one (1) business day. | Acct Mgmt | |
| B.4 | The State may require that the PBM’s Account team to attend The State's Board meetings at the PBM’s expense. Confirm understanding. | Acct Mgmt | |
| B.5 | How do you assess the Account Team’s performance and quality of service? Provide a sample of an annual score card or template used. | Acct Mgmt | |
| C | MEMBER SERVICES | Member Svcs | RESPONSE |
| C.1 | The State requires a dedicated toll free number and Customer Service for this contract. This line should be dedicated solely for the use of State members. | Member Svcs | |
| a. Confirm member service representatives are available 24 hours a day, 365 days a year. | Member Svcs | ||
| b. Where will this unit be located? | Member Svcs | ||
| C.2 | Describe the process members use to transfer from the interactive voice response unit (IVR) to speak to a live representative. | Member Svcs | |
| C.3 | Describe your clinical pharmacist support to members, hours available, and how members reach a pharmacist. | Member Svcs | |
| C.4 | Confirm all member services calls are recorded and are accessible for the purposes of resolving member issues. | Member Svcs | |
| C.5 | Describe the system by which the Member Service unit tracks and documents calls. | Member Svcs | |
| a. Describe the process to review the findings of the call tracking and documentation process with the State. | Member Svcs | ||
| b. Confirm this system is able to produce State-specific member service statistics. | Member Svcs | ||
| C.6 | Describe your appeals procedures for denied claims or authorizations and time frames that a member would follow. | Member Svcs | |
| C.7 | Describe the escalation process for Member Service satisfaction and complaints. | Member Svcs | |
| C.8 | Describe the State of Nebraska specific website you will have available by July 1, 2026, through which members can, at a minimum, access and view eligibility, plan benefits, pharmacy and formulary information, locate a pharmacy, price a prescription specific to the State’s plan design, order a mail order refill, track a mail order shipment, and order a replacement card. This website will be linked to the State's internet home page. | Member Svcs | |
| C.9 | Describe your drug cost look-up tool on your member website that provides both the plan copay and full drug cost? | Member Svcs | |
| C.10 | Describe your mobile app features, availability, and capabilities. | Member Svcs | |
| D | FORMULARY AND REBATE MANAGEMENT | Formulary | RESPONSE |
| D.1 | Provide a copy of your current proposed formulary (both a detailed file in Excel and an abbreviated PDF version). Provide a listing of any excluded drugs along with the preferred clinical alternatives. | Formulary | |
| D.2 | If requested by the State, the PBM agrees to grandfather the current formulary (preferred) list and respective copayments for up to 90 days following the contract effective date with no impact on the minimum rebate guarantees. Confirm agreement. | Formulary | |
| D.3 | Complete and submit a formulary disruption analysis based on your proposed formulary and the provided claims data with drug exclusions that allows for prior authorization for medical necessity. Results to be included are the number of members that will require a change as well as the number of prescriptions associated with the formulary change. An Excel file that lists the specific drugs that will be negatively impacted (excluded or higher-cost tier) along with the total number of scripts and members impacted for each of these drugs should also be provided. Please provide a summary of your formulary disruption analysis using the table below: | Formulary | |
| a. No Change: | Formulary | ||
| # Members impacted | Formulary | ||
| % of Total Members | Formulary | ||
| Number of Scripts Impacted | Formulary | ||
| % of Total Scripts (including all brands and generics) | Formulary | ||
| b. Positive (higher-cost tier to lower tier): | Formulary | ||
| # Members impacted | Formulary | ||
| % of Total Members | Formulary | ||
| Number of Scripts Impacted | Formulary | ||
| % of Total Scripts (including all brands and generics) | Formulary | ||
| c. Negative (lower tier to higher-cost tier): | Formulary | ||
| # Members impacted | Formulary | ||
| % of Total Members | Formulary | ||
| Number of Scripts Impacted | Formulary | ||
| % of Total Scripts (including all brands and generics) | Formulary | ||
| d. Moving from covered to not covered/Excluded: | Formulary | ||
| # Members impacted | Formulary | ||
| % of Total Members | Formulary | ||
| Number of Scripts Impacted | Formulary | ||
| % of Total Scripts (including all brands and generics) | Formulary | ||
| D.4 | Are any generic drugs considered “non-preferred” on your proposed formulary (i.e., subject to the “non-preferred” copay)? If yes, please describe in detail and provide examples. | Formulary | |
| D.5 | Do your manufacturer agreements contain provisions that limit the amount the manufacturer can raise the AWP price of prescription drugs each year? If yes, please describe: | Formulary | |
| D.6 | What reporting will you provide to the State to demonstrate such manufacturer price limit agreements provide meaningful benefits to the State? | Formulary | |
| D.7 | Describe the process you will use to substitute biosimilar drugs for original brand specialty drugs and include a description of reporting you will provide to demonstrate plan cost savings of the biosimilar relative to the net of rebate brand specialty drug, and conversely the net of rebate brand cost relative to the biosimilar if the brand specialty drug remains on the formulary after biosimilar availability. | Formulary | |
| D.8 | Do you have a formulary appeal process in place to address member concerns regarding formulary alternatives or provider indications of medical necessity? If yes, explain the process: | Formulary | |
| D.9 | When do formulary changes typically occur? | Formulary | |
| D.10 | Do you agree to limit formulary deletions up to twice per year on 01/01 and 07/01? | Formulary | |
| D.11 | Explain how the State and affected members will be notified about formulary changes | Formulary | |
| E | CLINICAL MANAGEMENT PROGRAMS AND CAPABILITIES | CM | RESPONSE |
| E.1 | Confirm that you are proposing to administer the State’s clinical and other programs as outlined below. Please specify if any additional fees apply in your response below and in your response to the Financial Section of this document. | CM | |
| a. Prior Authorization | CM | ||
| b. Step Therapy | CM | ||
| c. Drug Quantity Limits | CM | ||
| d. Medication Therapy Management | CM | ||
| e. Specialty Pharmacy Program | CM | ||
| f. Diabetic Supplies Program | CM | ||
| g. Vaccine Administration | CM | ||
| E.2 | How will the State be kept informed of changes to clinical management rules? | CM | |
| E.3 | Provide a sample client management report that details clinical rule activity and savings. | CM | |
| E.4 | Provide a sample of your client clinical management performance report. | CM | |
| E.5 | Describe your PA, step therapy and quantity level limit program capabilities. Please attach a list of drug categories for which such programs can be applied. | CM | |
| E.6 | Provide your book-business prior authorization rate of denials for the following therapeutic categories: GLP-1, SGL-2, Specialty-Inflammatory; Specialty-Dermatology; Migraine. | CM | |
| E.7 | Does your firm use AI (artificial intelligence) for prior authorization approvals? If so, please provide a detailed explanation. | CM | |
| E.8 | Briefly describe your drug utilization review (DUR) process and indicate which point-of-sale edits can be overwritten and which are “hard” rejects. Include a list of your point-of-sale edits. | CM | |
| E.9 | Provide your detailed utilization management program list, including specific drugs names in each program. | CM | |
| E.10 | Provide a sample DUR report you produce and make available to clients. | CM | |
| E.11 | What was your overall average DUR savings as a percentage of plan cost in 2024? Please break-out savings by category (e.g. refill-too-soon, age restriction, etc.) | CM | |
| E.12 | Briefly summarize the DUR edits that detect fraud and/or abuse. | CM | |
| E.13 | Describe the “look-back” period (% of prescription days that must elapse) utilized for the refill-too-soon edit and indicate whether it includes only the previous claim or cumulative historical claims. Provide separately for retail and mail order. | CM | |
| E.14 | Can the State customize the above look back period? | CM | |
| E.15 | In addition to point-of-sale edits, describe any other tools or programs that are available to detect, prevent, and resolve fraud and/or abuse? Indicate whether such programs are optional and whether they entail a separate fee. | CM | |
| E.16 | Do you require a DEA or other identifier to be indicated to fill a controlled substance drug? If yes, how is the requirement enforced? | CM | |
| E.17 | Provide your standard prior authorization criteria for GLP-1 diabetes drugs. | CM | |
| E.18 | Describe your services to encourage drug adherence and list therapeutic categories targeted. | CM | |
| E.19 | Describe your policies for lost medication, vacation supplies, and overseas supplies for prescription early refills. | CM | |
| E.20 | Do you monitor individual physician prescribing patterns? If yes, what action is taken with physicians who have a high degree of non-compliance to improve their compliance? | CM | |
| E.21 | Briefly describe methods you currently have in place to influence prescribing behavior, if any. Can the State opt-in/out of these programs? | CM | |
| E.22 | Provide a copy of any physician score card or other reporting that is provided to clients. | CM | |
| E.23 | Describe your firm’s relationship with pharmaceutical and biotechnology companies. | CM | |
| E.24 | Provide aggregate net PMPM trend for commercial clients (> 1000 lives) by year for the last five (5) years. | CM | |
| F | NETWORK ACCESS AND MANAGEMENT | Network | RESPONSE |
| F.1 | Confirm that your proposal is based on your broadest network. | Network | |
| F.2 | What is the current number of retail pharmacies in your network? | Network | |
| F.3 | List any pharmacy chains excluded from your proposed retail pharmacy network. | Network | |
| F.4 | Confirm you will notify plan participants, in writing, with at least 45 days advance notice (or as much time as is feasible if the terminating Pharmacy gives the Contractor less than 45 days’ notice), in the event that the contract for a participant's network pharmacy (or pharmacy chain) terminates for any reason. For the purposes of this requirement, plan participant shall mean a member who has had a prescription filled within the last 90 calendar days or a member has an active refill on file with the affected pharmacy. | Network | |
| F.5 | Perform and provide a GeoAccess analysis based on your contracted pharmacy network using the Census File provided. The access standards in the table below will be utilized in the analysis. | Network | |
| a. Urban / Suburban Enrolls | Network | ||
| Pharmacy - 2 in 5 miles | Network | ||
| b. Rural Enrollees | Network | ||
| Pharmacy - 1 in 15 miles | Network | ||
| F.6 | Confirm you will be responsive to requests by the State to recruit additional pharmacies for the network, on a general, regional, or specific basis. | Network | |
| F.7 | What is the process to add a pharmacy to your network? | Network | |
| F.8 | Describe how you would work with the Plan Sponsor to maximize State of Nebraska employee prescriptions filled at pharmacies owned and operated by businesses in the State of Nebraska. | Network | |
| F.9 | Confirm you will have a network of retail pharmacies that have agreed to discount their charges for 90-day supplies of maintenance medications. PBM must provide this network through the entire term of the contract, including term extensions. | Network | |
| F.10 | Confirm you agree to apply MAC pricing to Retail Pharmacy 90-Day Network. The MAC price must be the same MAC as the Retail Network or better on an individual drug basis. | Network | |
| F.11 | Describe in detail any program available to identify and leverage low priced generic drugs available through on-line pharmacies, and how the State and members can take advantage of such pricing. | Network | |
| F.12 | Provide the number of participating retail pharmacies that were terminated from the network in the past 24 months: +when the termination is initiated by the PBM. ++when the termination is initiated by a pharmacy. | Network | |
| Termination Rates by Your Organization+: | Network | ||
| # of Pharmacies | Network | ||
| % of Pharmacies | Network | ||
| Reason for Terminations | Network | ||
| Termination Rates by Pharmacy++: | Network | ||
| # of Pharmacies | Network | ||
| % of Pharmacies | Network | ||
| Reason for Terminations | Network | ||
| F.13 | Confirm you will notify the State prior to anticipated major changes to the network. The State reserves the right to accept or decline proposed changes to the network and set the effective date of such changes. | Network | |
| F.14 | Using the Claims Repricing Data File that contains pharmacy utilization representative of the Rx utilization experience for the State’s membership, for each pharmacy listed, please indicate if the pharmacy is in the network (i.e., a participating provider) for the plan you are proposing | Network | |
| F.15 | Confirm you agree to pass through 100% of State-related audit recoveries identified through PBM's internal daily and ongoing retail network pharmacy audit compliance procedures. | Network | |
| F.16 | PBM must implement measures to recover overpayments made to pharmacies or members and employ a mechanism to ensure the State receives credit for these overpayments. Details of threshold recovery levels will be finalized at the time of contract award. Confirm agreement. | Network | |
| F.17 | List the specific network management processes currently in place to avoid fraud and abuse. | Network | |
| G | MAIL ORDER | Mail Order | RESPONSE |
| G.1 | Please describe locations of all of your Mail Order facilities nationwide. | Mail Order | |
| G.2 | Confirm prescriptions purchased via mail order will never be more expensive than those obtained via retail pharmacies. | Mail Order | |
| G.3 | Confirm you will not repackage prescriptions or otherwise change the NDC for any prescription or OTC products dispensed at mail order. | Mail Order | |
| G.4 | Confirm you will communicate via a telephone call or email any delays beyond two days in the delivery of prescriptions to the member. | Mail Order | |
| G.5 | Confirm you will send prescription orders to members that do not provide appropriate payments with their prescription order, up to three (3) times the Plans highest copayment for each enrollee. After the ceiling is reached, the Contractor may implement standard accounts receivable policies and procedures. | Mail Order | |
| G.6 | Confirm you will arrange and pay for a short-term retail supply of a delayed or incorrectly processed mail order prescription caused by your organization. In addition, PBM agrees not to charge the State’s members for expedited delivery of the mail order prescription if the prescription delay is caused by PBM’s organization. | Mail Order |
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