Questions and Answers - PBM Amd 0007 of Solicitation 1605DC-18-R-00020.xlsx

Sheet1 Questions and Answers Submitted for

Pharmacy Benefits Management (PBM) Services

Department of Labor (DOL) Office of Workers’ Compensation Programs (OWCP)

Amendment 0007 - Solicitation Number 1605DC-18-R-00020

In accordance with Attachment 4 CA2 - Revised Technical and Net Discount Proposal Guidance ("Attachment 4 CA2"), please note the following with respect to each proposal Volume:

1. Volume I – Technical Approach - Scope and content of revisions: Only two PWS requirements have been amended: the Prior Authorization Portal (revised PWS 5.1.4) and the Drug Utilization Review (DUR) (revised PWS 5.1.4.4).

Accordingly, only those sections of your technical proposal which address those two PWS sections may be revised at this time. The evaluators will consider only those revisions which address those two PWS requirements (PWS 5.1.4 and 5.1.4.4).

2. Volume II – Past Performance - The corrective action will not include a reevaluation of Past Performance. In making a new selection decision, DOL will consider the findings from the earlier evaluation of your firm’s Past Performance.

3. Volume III – Price/Discount - Offerors are required to submit a revised net discount proposal (in the excel workbook) that includes discount rates and fees for all base and optional services as described in Attachment 6 CA2 - PBM Discount Calculation Workbook, Section B (Schedule of Supplies/Services), and Section L of the solicitation.

4. Volume IV – Mandatory Criteria - Offerors are required to submit a document indicating that the guaranteed discount from Average Wholesale Price (AWP), as defined in Part 2 of the Solicitation, will be at or below what is described in the table on Page 4 of Attachment 4 CA2.

NOTE: Offerors are not required to provide a written (tenure) statement confirming that the Respondent has been operating as a pharmacy benefits manager for a minimum of five (5) years.

4 Attachment 7 CA2 - PWS Changes Attachment 7 PWS Changes - page 2 of 2; 5.1.4.4.4 PWS States: "The contractor shall employ retrospective DUR tools, which identify and provide data on prescribers and pharmacies that prescribe or dispense in a manner outside the norm, present safety concerns, or might be engaged in potential waste, fraud, or abuse. Examples include, but are not limited to the prescribing and dispensing excessive quantities of controlled substances, and unusually high rates of compounded or brand name drug prescriptions with instructions to dispense as written. The tools employed shall provide full visibility of each claimant’s OWCP workers compensation medication history, including medications obtained from retail, mail order, compounding, and out-of-network pharmacies; through third-party billers; and dispensed by physicians."

Question: While the program will be mandatory once fully implemented, how does the Government plan to provide the full adjudication data on physician dispensed medications or other out of network bills that are submitted on a medical bill or otherwise and not through the point of sale process prior to full implementation?

Please clarify/confirm the number of cases per year on which we are to base our pricing for these CLINs.

According to your instructions, it seems the Government only wants an updated Pricing Workbook (Attachment 6).

Is this correct? Do we need to submit a redlined version of the Cost Narrative similar to what is being required in the Technical Volume?

DOL will allow Offerors to make changes to their Pricing Narrative document, if they deem it necessary.

Please be advised that: "You may NOT propose pricing for any required service outside the discounts and fees set forth in Attachment 6 CA2 - PBM Discount Calculation Workbook, Section B (Schedule of Supplies/Services), and Section L of the Solicitation. The Government will NOT consider and will NOT accept any separate prices, pricing rates, fees or any charges for DUR services, the Prior Authorization Portal, or any other PWS requirement. If an Offeror proposes to charge a separate fee, or to charge for a service, in any way that is separate from the Section B Schedule of Supplies/Services, DOL will consider that proposal to exclude such services and the proposal may be deemed deficient for that reason."

7 Attachment 4 CA2 - Revised Technical and Net Discount Proposal Guidance Technical Proposal The Instructions say: PLEASE NOTE THAT THERE IS NO PAGE LIMIT FOR VOLUME I – TECHNICAL APPROACH. Material submitted in excess of the page limits or noncompliance with printing parameters will be removed ..."

Please confirm that there are NO page limits for our revised Technical Approach Volume.

The contractor shall implement a secure interface to communicate alerts directly to OWCP with findings from the DUR process.

A “user interface” allows a user to interact with the computer and exchange information. Secure email transmission is not a secure interface. EDI is not a requirement in 5.1.4.4.2. Per the approval of the Government and at a date convenient for the Government in the future, an EDI solution may be developed for transmission of data, but the requirement at 5.1.4.4.2 requires a secure interactive interface.

11 Attachment 7 CA2 - PWS Changes Attachment 7 CA2 – Changes to Performance Work Statement (PWS) 5.1.4.4.3

Automated Prospective Drug Utilization Review (DUR)

• Hard Edits: Stops the pharmacy from processing a claim unless or until an override is entered or authorized by the PBM or DFEC.

• Soft Edits: Stops the pharmacy from processing a claim unless or until a pharmacist provides a DUR code at the pharmacy.

• Message Only Alerts: These alerts do not stop a claim from processing, but provide important clinical and/or coverage information to the pharmacy.

Or other strategies the PBM suggests.

12 Attachment 7 CA2 - PWS Changes Attachment 7 CA2 – Changes to Performance Work Statement (PWS) 5.1.4.4.5

The contractor shall provide clinical DUR services, to include at minimum clinical personnel (Pharmacists, Nurses, Nurse Practitioners, Physicians or a combination thereof) that will contact and engage prescribers and recommend interventions in up to 4,000 cases per year and provide in such cases advice regarding particular transactions and/or medication regimens.

Please specify what is defined as a "case." For example, is a case defined as:

• An injured worker (claimant)?

• A claim?

• Each DUR service where the PBM’s clinical personnel engage with prescribers and recommend interventions?

The contractor shall conduct interventions and ongoing support by either, or a combination of, a Pharmacist, Nurse, Nurse Practitioner or Physician. DOL will decide the combination on a case-by-case basis in response to the contractor’s clinical DUR recommendation.

Upon DOL direction, the Contractor shall proceed with the approved intervention and monitor progress at least monthly for 6 months or until achieving the expected outcome, whichever is sooner.

Which (if any) of the following services does the DOL consider to be part of DUR services and, therefore, require to be included in the PBM pricing:

• Peer to peer review (prescriber to prescriber)?

• Cognitive behavior therapy (CBT) or other psychological/social behavior management that influences patient behavior?

• Case management?

• Drug screening?

Any of those services may be included among the DUR services to be provided by the Offeror under the contract.

Any and all services, if offered by the PBM, should be included or wrapped into the PBM pricing and discount structure. Offerors should take this into consideration when selecting pricing and AWP discounts.

Please note: "In determining the discounts and fees to be proposed, you should consider all PWS requirements, including the requirement to provide clinical DUR services (per revised PWS 5.1.4.4) and a Prior Authorization Portal (per revised PWS 5.1.4)."