OWCP PBM services virtual industry day event questions.docx

OWCP PBM services industry day event questions

1. Do you have any concerns with meeting the PWS requirements and deliverables?

1. Are the OWCP performance metrics and requirements consistent with industry standards?

1. Are you able to receive referrals and case documents electronically and submit the reports electronically?

1. Does your pharmacy network cover all fifty states, the District of Columbia, and in all five permanently inhabited US territories?

1. What is your experience providing workers’ compensation PBM services?

1. Are you registered in SAM.gov? Do you have a GSA Schedule? If so, please provide your Unique Entity Identifier (UEI) number and GSA Schedule.

1. Are your IT systems Federal Risk and Authorization Management Program (FEDRAMP) compliant?

1. Can you implement PBM services for all three OWCP programs within one calendar year?

1. Do you have any concerns with integrating with the other government systems outlined in the contract?

1. Does your PBM system adjudicate a prescription for a claimant that has multiple cases with multiple accepted diagnoses? Does your PBM system adjudicate prescriptions based on ICD-9 and ICD-10 codes linked to specific injury-based formularies?

1. Can your PBM system set MED cumulative limits across multiple cases for a single claimant?

1. Does your PBM employ pharmacists to complete prior authorizations on behalf of payers?

1. Can you customize NCPDP edit functions?

1. Can you build and customize stakeholder web portals specific to the unique needs of the government?

1. Can you guarantee a per transaction cost that equals “the lesser of” the pharmacy submitted price, the most recent OWCP Pharmacy Fee Schedule price, the pharmacy usual and customary rate (U&C) rate, the generic maximum allowable cost (MAC), a guaranteed AWP discount plus the pharmacy dispensing fee plus a PBM service fee?

1. Can your organization stop a pharmacy from processing prescriptions if instructed to do so by the government?

1. Does your PBM system block specific NDCs and GPIs?

1. What potential fraud, waste, and abuse (FWA) identification tools does your organization use?

1. Describe your end-to-end workflow to identify FWA?

1. Give examples of FWA detected by your organization.

1. Does your PBM system use Medi-Span data elements to build a formulary?

1. What is your quality assurance (QA) process to ensure your data is validated and verified? How often is QA performed?

1. What core PBM services do you offer (formulary management, mail order services, specialty pharmacy services, drug utilization review, billing)? What kind of support services do you offer stakeholders and injured claimants (e.g., call center, pharmacist support, text-based questions, nurse case management)?

1. What clinical programs and clinician support do you offer?

1. Does your company pay pharmacies via Electronic Funds Transfer (EFT)? Does your company have the capability to pay claimants via EFT for prescriptions they may have purchased out-of-pocket?

1. DOL requires its PBM to ingest and store up to 7 years of prescription transaction data, and to use this data when adjudicating claims. Does your company have any limitations on the amount of historical prescription transaction data it can store in its system?

1. Does your PBM perform regular or annual market pricing checks and provide the results to your clients?

1. Do you provide manufacturer derived revenue back to your clients on a per transaction basis?

1. Do you have any concerns with the brand/generic categorization outlined in the contract for either reporting or pricing?

1. Can you provide real-time access to transaction data and customized reports?

1. If the PBM or the government identifies a system defect, does your company provide a “work around” solution while the defect is being fixed?

1. How will you staff this contract?

1. What are your plans for innovation and technology enhancements in the next 3-5 years?